This information is added by users of ASN. Neither ASN nor the Flight Safety Foundation are responsible for the completeness or correctness of this information.
If you feel this information is incomplete or incorrect, you can submit corrected information.
| Date: | Thursday 9 February 1989 |
| Time: | 03:00 LT |
| Type: |  McDonnell Douglas DC-9-32F |
| Owner/operator: | Evergreen International Airlines |
| Registration: | N935F |
| MSN: | 47220/296 |
| Total airframe hrs: | 37823 hours |
| Engine model: | P&W JT8D-9A |
| Fatalities: | Fatalities: / Occupants: 2 |
| Aircraft damage: | None |
| Category: | Accident |
| Location: | Salt Lake City, UT -
 United States of America
|
| Phase: | En route |
| Nature: | Unknown |
| Departure airport: | Ogden, UT (KHIF) |
| San Antonio, TX | |
| Investigating agency: | NTSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
AS 1ST OFFICER (FO) WAS FLYING ACFT, DRG CLB AFTER TKOF, CABIN WOULDN'T PRESSURIZE. HE BGN LVL OFF AT 16,000', BUT CAPT ORDERED HIM TO CONT CLBG TO ASSIGNED FLT LVL (FL 330), WHILE HE (THE CAPT) WENT AFT TO FND PRBLM. FO DISLIKED THE ORDER,BUT COMPLIED RATHER THAN CONFRONT CAPT. CAPT LEFT COCKPIT WITH PORTABLE 'ON DEMAND' OXYGEN (O2) SYS, WHICH HAD 15 MIN SUPPLY OF O2. WHEN CAPT DIDN'T RTRN, FO TRIED SIGNALING HIM. THO RELUCTANT TO COUNTERMAND CAPT'S ORDER, FO MADE SERIES OF DSCNTS TO 13,000'. AFTER ABT 30 MIN, HE LEFT COCKPIT & FND CAPT UNCONSCIOUS & UNRESPONSIVE IN FWD CARGO AREA WITH O2 MASK ON HIS FACE. CAPT'S FOOT WAS ENTANGLED IN CARGO NET WHICH CVRD A PALLET. FO TRIED TO REVIVE CAPT, TO NO AVAIL, THENDECLARED EMERG & LNDD AT LUBBOCK. CAPT WAS RUSHED TO HOSPITAL, BUT WAS DEAD ON ARRIVAL. EXAM REVEALED AFT PRESSURE BULK-HEAD WAS NOT INSTALLED. IT HAD BEEN REMOVED FOR MAINT BFR FLT. PORTABLE O2 SYS WAS STILL FULL, INDCG CAPT HAD LITTLE OR NO USE OF O2; IT WAS TESTED & FUNCTIONED NMLY. GROUP OF 8 FORENSIC PATHOLOGISTS CONCLUDED CAPT DIED FM HYPOXIC HYPOXIA.
Probable Cause: IMPROPER IN-FLIGHT PLANNING/DECISION BY THE CAPTAIN (PILOT-IN-COMMAND) AND HIS IMPROPER USE OF THE PORTABLE OXYGEN SYSTEM, WHICH RESULTED IN HIS INCAPACITATION DUE TO HYPOXIA. FACTORS RELATED TO THE ACCIDENT WERE: INADEQUATE MAINTENANCE/INSPECTION OF THE AIRCRAFT BY COMPANY MAINTENANCE BY FAILING TO REINSTALL THE AFT PRESSURE BULKHEAD HATCH (INSPECTION DOOR) AND POOR CREW COORDINATION.
Accident investigation:
 |
|
Sources:
NTSB FTW89MA047
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 24-Mar-2024 12:04 | ASN Update Bot | Added |
Corrections or additions? ... Edit this accident description
The Aviation Safety Network is an exclusive service provided by:
Quick Links:
| ASN Home | Send Correction / Feedback |
| FSF Home | Disclaimer | Copyright |
| Contact Us | Privacy Policy |
| Press / Media |
CONNECT WITH US:
©2024 Flight Safety Foundation