PB97-910401

NTSB/AAR-97/0l

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

WHEELS-UP LANDING

CONTINENTAL AIRLINES FLIGHT 1943

DOUGLAS DC-9 N10556

HOUSTON, TEXAS

FEBRUARY 19, 1996

6804

/
The National Transportation Safety Board is an independent Federal agency dedicated to

promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety.

Established in 1967, the agency is mandated by Congress through the Independent Safety

Board Act of 1974 to investigate transportation accidents, determine the probable causes of

the accidents, issue safety recommendations, study transportation safety issues, and evaluate

the safety effectiveness of government agencies involved in transportation. The Safety

Board makes public its actions and decisions through accident reports, safety studies, special

investigation reports, safety recommendations, and statistical reviews.

Information about available publications may be obtained by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(202)382-6735

(800)877-6799

Safety Board publications may be purchased, by individual copy or by subscription, from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(703)487-4600
NTSB/AAR-97/01 PB97-910401

NATIONAL TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

WHEELS-UP LANDING

CONTINENTAL AIRLINES FLIGHT 1943

DOUGLAS DC-9 N10556

HOUSTON, TEXAS

FEBRUARY 19, 1996

Adopted: February 11, 1997

Notation 6804

iii

CONTENTS

EXECUTIVE SUMMARY.......................................................................................................... vi

1. FACTUAL INFORMATION.................................................................................................. 1

1.1 History of Flight .................................................................................................................... 1

1.2 Injuries to Persons ................................................................................................................. 5

1.3 Damage to Airplane............................................................................................................... 5

1.4 Other Damage........................................................................................................................ 5

1.5 Personnel Information ........................................................................................................... 5

1.5.1 The Captain .................................................................................................................................6

1.5.1.1 Captain’s 72-Hour History Before the Accident................................................................................. 8

1.5.2 The First Officer..........................................................................................................................9

1.5.2.1 First Officer’s 72-Hour History Before Accident ............................................................................. 12

1.5.3 Flight Attendants .......................................................................................................................12

1.6 Airplane Information........................................................................................................... 13

1.6.1 Dispatch Information.................................................................................................................13

1.6.2 Hydraulic System ......................................................................................................................14

1.6.3 Landing Gear Indication and Warning System .........................................................................16

1.6.4 Ground Proximity Warning System ..........................................................................................16

1.7 Meteorological Information ................................................................................................ 17

1.8 Aids to Navigation .............................................................................................................. 17

1.9 Communications ................................................................................................................. 17

1.10 Airport Information ........................................................................................................... 18

1.11 Flight Recorders ................................................................................................................ 18

1.12 Wreckage and Impact Information.................................................................................... 20

1.13 Medical and Pathological Information .............................................................................. 21
iv

1.14 Fire .................................................................................................................................... 21

1.14.1 Airport Emergency Response..................................................................................................21

1.15 Survival Aspects................................................................................................................ 21

1.15.1 Flight Attendant Tailcone Training.........................................................................................24

1.16 Tests and Research ............................................................................................................ 25

1.16.1 Simulated Approach ................................................................................................................25

1.17 Organizational and Management Information................................................................... 26

1.17.1 Pilot Union Presence at COA..................................................................................................26

1.17.2 Recent COA Accidents and FAA Oversight ...........................................................................27

1.18 Additional Information...................................................................................................... 30

1.18.1 Pilot Observations Concerning DC-9/MD-80 Hydraulic System ...........................................30

1.18.2 COA Guidance to Pilots on the DC-9 Hydraulic System........................................................31

1.18.3 COA Crew Resource Management Training ..........................................................................32

1.18.4 COA Checklist Procedures......................................................................................................34

1.18.5 COA Standard Operating Procedures......................................................................................36

2. ANALYSIS.............................................................................................................................. 38

2.1 General ................................................................................................................................ 38

2.2 Flightcrew Performance ...................................................................................................... 39

2.2.1 Failure to Properly Complete the In-range Checklist................................................................39

2.2.2 Failure to Confirm Flap Function at the 5o

 Setting ...................................................................41

2.2.3 Failure to Determine the Cause of the Flap Extension Problem...............................................43

2.2.4 Failure to Perform Landing Checklist and Confirm Gear Position...........................................44

2.2.5 Failure to Discontinue the Approach ........................................................................................46

2.2.5.1 Role of the First Officer.................................................................................................................... 46

2.2.5.2 Role of the Captain ........................................................................................................................... 47

2.3 Role of Fatigue in Flightcrew Performance ........................................................................ 49
v

2.4 Adequacy of COA and FAA Oversight............................................................................... 50

2.5 Checklist Design ................................................................................................................. 52

2.6 Survival Factors................................................................................................................... 54

3. CONCLUSIONS .................................................................................................................... 55

3.1 Findings............................................................................................................................... 55

3.2 Probable Cause.................................................................................................................... 57

4. RECOMMENDATIONS....................................................................................................... 58

5. APPENDIXES ........................................................................................................................ 61

APPENDIX A—INVESTIGATION AND HEARING............................................................ 61

APPENDIX B—COCKPIT VOICE RECORDER TRANSCRIPT ....................................... 62

APPENDIX C—FLIGHT DATA RECORDER DATA PLOT .............................................. 92

APPENDIX D—COA DC-9 NORMAL CHECKLIST ........................................................... 93
vi

EXECUTIVE SUMMARY

On February 19, 1996, at 0902 central standard time, Continental Airlines (COA)

flight 1943, a Douglas DC-9-32, N10556, landed wheels up on runway 27 at the Houston

Intercontinental Airport, Houston, Texas. The airplane slid 6,850 feet before coming to rest in

the grass about 140 feet left of the runway centerline. The cabin began to fill with smoke, and

the captain ordered the evacuation of the airplane. There were 82 passengers, 2 flightcrew

members, and 3 flight attendants aboard the airplane. No fatalities or serious injuries occurred;

12 minor injuries to passengers were reported. The airplane sustained substantial damage to its

lower fuselage. The regularly scheduled passenger flight was operating under Title 14 Code of

Federal Regulations Part 121 and had originated from Washington National Airport about 3

hours before the accident. An instrument flight rules flight plan had been filed; however, visual

meteorological conditions prevailed for the landing in Houston.

The National Transportation Safety Board determines that the probable cause of

this accident was the captain’s decision to continue the approach contrary to COA standard

operating procedures that mandate a go-around when an approach is unstabilized below 500 feet

or a ground proximity warning system alert continues below 200 feet above field elevation. The

following factors contributed to the accident: (1) the flightcrew’s failure to properly complete

the in-range checklist, which resulted in a lack of hydraulic pressure to lower the landing gear

and deploy the flaps; (2) the flightcrew’s failure to perform the landing checklist and confirm

that the landing gear was extended; (3) the inadequate remedial actions by COA to ensure

adherence to standard operating procedures; and (4) the Federal Aviation Administration’s

(FAA) inadequate oversight of COA to ensure adherence to standard operating procedures.

Safety issues discussed in this report include checklist design, flightcrew training,

adherence to standard operating procedures, adequacy of FAA surveillance, and flight attendant

tailcone training. Safety recommendations concerning these issues were made to the FAA.
NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

WHEELS-UP LANDING

CONTINENTAL AIRLINES FLIGHT 1943

DOUGLAS DC-9-32, N10556

HOUSTON, TEXAS

FEBRUARY 19, 1996

1. FACTUAL INFORMATION

1.1 History of Flight

On February 19, 1996, at 0902 central standard time,1 Continental Airlines (COA)

flight 1943, a Douglas DC-9-32, N10556, landed wheels up on runway 27 at the Houston

Intercontinental Airport (IAH), Houston, Texas. The airplane slid 6,850 feet before coming to

rest in the grass about 140 feet left of the runway centerline. The cabin began to fill with smoke,

and the captain ordered the evacuation of the airplane. There were 82 passengers, 2 flightcrew

members, and 3 flight attendants aboard the airplane. No fatalities or serious injuries occurred;

12 minor injuries to passengers were reported. The airplane sustained substantial damage to its

lower fuselage. The regularly scheduled passenger flight was operating under Title 14 Code of

Federal Regulations (CFR) Part 121 and had originated from Washington National Airport

(DCA) about 3 hours before the accident. An instrument flight rules (IFR) flight plan had been

filed; however, visual meteorological conditions (VMC) prevailed for the landing in Houston.

The accident occurred on the second leg of a 2-day 2-leg sequence for the reserve

flightcrew. The captain flew the first leg on February 18, 1996, from IAH to DCA. The flight

departed IAH at 1745 and arrived in DCA at 2127 eastern standard time (EST). The flightcrew

then had a 9-hour 23-minute rest period in Washington, D.C.

The first officer performed pilot flying duties for the accident leg of the trip (flight

1943), which departed DCA at 0650 EST. According to both the captain and the first officer, the

takeoff, departure, and en route segments of the flight were uneventful.

 1

 Unless otherwise indicated, all times are central standard time, based on a 24-hour clock.
2

At 0840:42, air traffic control (ATC) at Houston Center issued a clearance to

flight 1943 to descend from the en route altitude of 35,000 feet to 13,000 feet mean sea level.2

The first officer began the descent, and at 0841:32, the cockpit voice recorder (CVR) recorded

the captain reading the descent checklist.3 At 0841:40, the first officer asked the captain to verify

that the calculation of 132 knots as the target airspeed for the approach to IAH was correct, to

which the captain replied in the affirmative.4 The descent checklist was called complete by the

captain at 0842:03.

At 0845:31, the first officer called for the in-range checklist. The data from the

digital flight data recorder (FDR) indicated that the airplane was descending through 19,000 feet

at this time. Between 0845:37 and 0846:10, the captain referred to each of the seven items on the

in-range checklist, in the correct order, except for the fourth item, “Hydraulics,” to which the

captain did not refer.5 The first officer responded “checked set” to the third item, “Flight

Instruments, Altimeters,” and “on” to the fifth item, “Shoulder Harness.”

Flight 1943 received clearance to descend to 10,000 feet at 0847:12. At 0848:39,

the captain made initial contact with the Houston Terminal Radar Approach Control Arrival East

controller and requested runway 27. At 0849:33, the controller cleared flight 1943 to descend to

7,000 feet. At 0853:23, the controller instructed flight 1943 to “join the two seven localizer” and

descend to 4,000 feet.

At 0854:49, the first officer called for the approach checklist. Between 0854:49

and 0855:18, the captain referred to the first four of the nine items on the checklist.6 At 0855:27,

the checklist was interrupted by the first officer informing the captain that he intended to use

manual spoilers and 40o of flaps for the landing. The captain resumed completing the checklist at

0855:56, and accomplished the next three items before he was interrupted again at 0856:06,

when the controller transmitted “Continental nineteen forty three, thirteen miles from the marker,

maintain two thousand till established on the localizer, cleared ILS two seven approach.” At

0857:02, the controller instructed flight 1943 to maintain a speed of 190 knots or faster to the

outer marker and to contact the tower. According to the captain, the ATC request to maintain

190 knots or faster to the marker was not unusual at IAH on a visual flight rules (VFR) day. In

his postaccident statement, the captain reported that at the time ATC made the request, the

airplane’s indicated airspeed was approximately 210 knots, so no speed adjustment was necessary.

 2

 Unless otherwise indicated, all altitudes are expressed in relation to mean sea level.

3

 See appendix B for a complete transcript of the CVR.

4

 The calculation of a target airspeed was one of the steps required to complete the last item of the

descent checklist, “Landing Data, Bugs.” A copy of COA’s DC-9 Normal Checklist is provided as appendix D.

5

 The following items, in consecutive order, are on the in-range checklist: “Fuel Boost Pumps,

Quantity,” “No Smoke & Seat Belt Signs,” “Flight Instruments, Altimeters,” “Hydraulics,” “Shoulder Harness,”

“Approach Briefing,” and “Sterile Cockpit Light.”

6

 The following items, in consecutive order, are on the approach checklist: “Altimeters & Bugs,”

“VOR/ADF Switches,” “Marker Switches,” “Radios,” “Course,” “Mode Selectors,” “RAT EPR/TRI,” “Air

Conditioning Auto-Shutoff,” and “Landing Announcement.”
3

After making the landing public address (PA) announcement, the captain contacted the Houston

Intercontinental Air Traffic Control Tower Local East controller, and at 0857:58, the flight was

cleared to land. At 0858:08, the captain said “now, where was I,” referred to the last two items

on the approach checklist, and stated “approach check complete.”

At 0858:48, the captain commented “aw shoot. I can’t play tennis when it’s like

this... well maybe this afternoon it’ll clear up. actually I’ve still got a lot of time.” At 0859:00,

the first officer said “go slats and five.” After the CVR recorded the sound of a click at 0859:03,

the captain stated “slats are going to five.” The captain later recalled that he felt the slats extend,

and the first officer recalled that the blue “SLATS EXTEND” light illuminated. Between

0859:14 and 0859:37, the captain engaged the first officer in nonessential conversation about the

weather. At 0859:50, the first officer initiated dialogue with the captain to clarify whether the

controller had asked them to maintain 190 knots to the outer or middle marker. The discussion

ended at 0900:00, when the first officer commented “heh” and then made two remarks, of which

only a few words were intelligible on the CVR recording. In a written statement submitted to the

Safety Board on January 27, 1997, the first officer reported that he had noticed the flap gauge

indicating 0o

 at 0900:00 and that his subsequent remarks had been in reference to the flap gauge.

At 0900:11, the captain reported the airport in sight.

At 0900:13, after crossing the outer marker, the first officer called for the flaps to

be extended to 15o. During an interview on February 20, 1996, and in his written statement dated

February 27, 1996, the first officer indicated that at this point he realized that the flaps had not

extended and touched the flap gauge to show the captain that it indicated zero. According to the

captain, he responded by confirming that the flap handle was positioned to 15o

. At 0900:33, the

captain said “I think the flaps *7.” At 0900:35, three intermittent sounds from the landing gear

warning horn were produced, according to the first officer, by the captain rapidly moving the

throttles back and forth. At 0900:37, the captain said “well we know that, you want the gear.”8

At 0900:38, the first officer called “gear down,” and 2 seconds later, the CVR recorded the sound

of a thump.9 At 0900:41, the first officer called for the landing checklist and the flaps to be

extended to 25o

. At 0900:46, the gear warning horn began to sound. During the next 12 seconds,

the first officer called for the flaps to be extended to 40o

 and then to 50o. At 0901:00, the first

officer stated “* I don’t have any flaps.” In his postaccident statement, the captain reported that

“the aircraft did not feel as though we had 50 flaps (didn’t balloon and aircraft didn’t slow).”

The CVR does not indicate that the landing checklist was ever started.

During postaccident interviews, neither pilot recalled seeing “any” landing gear

indicator lights; both pilots recalled the gear handle being moved to the down position. The first

 7

 When transcribing cockpit voice recordings, the Safety Board uses an asterisk to signify an

unintelligible word.

8

 After the accident, the first officer stated that he did not understand what the captain meant by the

comment, “well we know that.”

9

 According to the DC-9 pilots who were members of the CVR group, the thump sound recorded

by the CVR was similar to the sound produced by moving the gear handle on a DC-9 to the down position.
4

officer stated that he did not hear the landing gear warning horn. The captain stated that he heard

the horn sound momentarily and thought that it sounded because he put the flaps to 25o before

the gear was down and locked.

According to FDR data, at 0900:58, the airplane was traveling at 216 knots

indicated airspeed, approximately 504 feet above field elevation (AFE), and 34 seconds from

touchdown.10 At 0901:02, the first officer stated “want to take it around?” and the captain

replied “no, that’s alright. * keep your speed up here about uh.” Regarding his decision to

continue the approach, the captain later stated, “it was a VFR day, we had a 10,000 foot runway,

we had gear and flaps, I felt there was not a problem.” The first officer later stated that there was

no time for discussion with the captain because the approach was so fast.

At 0901:07, the landing gear warning horn stopped sounding. At 0901:08, the

first officer stated “I can’t slow it down here now,” and the captain replied “you’re alright.” At

0901:10, the first officer said “we’re just smokin’ in here.” At 0901:13, the ground proximity

warning system (GPWS) alerted “whoop whoop pull up” three times, and silenced at 0901:18.

During the second GPWS alert, at 0901:15, the landing gear warning horn resumed sounding and

continued to do so until after touchdown. According to the first officer, the captain reached up to

the overhead panel as the GPWS was alerting. The captain did not recall doing this and stated

that he had interpreted the GPWS alerts as a high sink rate warning.

At 0901:18, the first officer said “want to land it?” At 0901:20, the captain

replied “yeah” and, according to the first officer, took control of the airplane. According to the

captain, the first officer was “uncomfortable with the situation and relinquished the controls.”

The captain stated that at the time he took over, the airspeed was high, but he felt comfortable.

The transfer of control from the first officer to the captain occurred as the airplane was traveling

at 204 knots indicated airspeed, approximately 161 feet AFE, and 12 seconds from touchdown.

At 0901:24, the first officer asked the captain “you want it?” and the captain said “yeah.”

At 0901:32, the airplane touched down hard with the wheels up at 193 knots

indicated airspeed. As the airplane slid down the runway, two controllers on duty in the tower

and two airport groundskeepers observed smoke and fire coming from beneath the airplane. The

captain said that as the airplane slid down the runway, he was able to maintain directional control

with the rudder. The airplane came to a stop in the grass off to the left side of the runway.

The first officer stated that after the airplane came to rest, he made the PA

announcement, “remain seated, remain seated, remain seated.”11 According to the captain, he

called for the evacuation checklist, pulled both engine fire handles, and moved both fuel control

 10 See appendix C for a plot of all FDR parameters covering a 90-second period commencing at

0900:10.

11 The first officer’s PA announcement was not recorded by the CVR. The recording ended at

0902:05, before the evacuation.
5

levers to “OFF.” The first officer read the evacuation checklist, and the captain accomplished the

items.

The “A” flight attendant12 stated that after the airplane came to a stop, she entered

the cockpit and informed the flightcrew that smoke was in the cabin. She observed the

flightcrew shutting down the engines and returned to the cabin. When she heard, “easy victor,

easy victor, go out the main cabin door,” she opened the left forward cabin exit, inflated the slide,

and directed the passengers at the front of the cabin out this exit. The “B” flight attendant

directed passengers out the overwing exits. She stated that with the exception of one elderly man

who required assistance, all the passengers were evacuated in less than 1 minute. After the

passengers were evacuated, the flight attendants exited, followed by the flightcrew.

The accident occurred during the hours of daylight. The airplane came to rest

about 29°58’40” north latitude, 95°20’23” west longitude.

1.2 Injuries to Persons

Injuries Flightcrew Cabin Crew Passengers Other Total

Fatal 0 0 0 0 0

Serious 0 0 0 0 0

Minor 0 0 12 0 12

None 2 3 70 0 75

Total 2 3 82 0 87

1.3 Damage to Airplane

The airplane received substantial damage to its lower fuselage. Estimated repair

costs exceeded the airplane’s insured value of $2.56 million, and it was scrapped.

1.4 Other Damage

A total of 18 runway centerline lights and 3 taxiway lights were destroyed. The

estimated cost to replace the lights was $8,500.

1.5 Personnel Information

The flightcrew consisted of the captain and the first officer. Company records

indicated that the two pilots had not flown together before the accident pairing. Three flight

attendants were aboard the airplane.

 12 The “A,” “B,” and “C” flight attendants have specific duties to perform both during a routine

flight and in the event of an emergency evacuation. During an evacuation, the “A,” “B,” and “C” flight attendant’s

duty stations are at the front, middle, and rear of the cabin, respectively.
6

Safety Board investigators conducted individual interviews of the captain and first

officer on February 20, 1996, and again on September 25, 1996. In addition, all crewmembers

submitted written statements to the Safety Board.

1.5.1 The Captain

The captain, age 50, was hired by COA in 1984. He holds an airline transport

pilot certificate, with airplane multiengine land and airplane single-engine land ratings, and B727, B-737, and DC-9 type ratings. At the time of the accident, he possessed a first-class

medical certificate dated February 6, 1996, with the restriction, “Must possess near vision

glasses.” He had no Federal Aviation Administration (FAA) record of aircraft accidents,

incidents, or flight violations.

The captain’s total pilot time was approximately 17,500 hours. In the 24 hours

before the accident, he flew 6 hours. In the 30, 60, and 90 days before the accident, he flew 29,

60, and 87 hours, respectively.

The captain was a U.S. Air Force flight instructor during the Vietnam War.

Before joining COA, he was employed by the FAA as an aviation safety inspector and by Braniff

International as a flight engineer on DC-8 and B-727 airplanes. His first position at COA was as

a B-727 second officer. In July 1985, he upgraded to first officer on the B-727 and accumulated

approximately 5,000 hours in that position. He transitioned to the B-737 in 1993 and

accumulated approximately 1,100 hours as a B-737 first officer. In 1995, he upgraded to captain

on the B-737. As part of his upgrade training, he completed a 1-day crew resource management

(CRM) course in January 1995. He told investigators that he considered the CRM training to be

useful. Between March 1995 and June 1995, he accumulated approximately 119 hours as a B737 captain.

In late June 1995, the captain transitioned to the DC-9 and completed primary

systems training. He characterized this training as weak because of outdated course materials. In

July 1995, he completed DC-9 simulator training and participated in a line oriented flight training

(LOFT) simulator session. Following his initial operating experience (IOE), the captain

successfully completed a line check. The line check report13 indicated that the captain was rated

"above average" on two evaluation categories and "satisfactory" on the remaining thirteen. The

two categories with above average ratings were:

OVERALL TECHNICAL PROFICIENCY

Adhere to checklist, SOP, FARs, sterile cockpit, etc.

Demonstrate high level of basic flying skills

 13 The original line check report prepared by the check airman was destroyed in compliance with

COA policy, after record of satisfactory completion was entered in the computer data base. However, the check

airman retained a copy of the report.
7

Adept at normal and abnormal procedures

Thorough systems knowledge

LEADERSHIP AND TEAMWORK

Balance authority and assertiveness

Promote continual dialogue

Use all available resources

Share any doubts with others

The check airman also wrote on the form, “good check ride well prepared and

ready to fly as a DC-9 captain." The captain said that after his training, he felt comfortable in the

DC-9.

As a reserve14 captain on the DC-9, the captain accumulated approximately 220

flight hours from August 1995 to February 1996. At the time of the accident, he was the most

junior captain on the DC-9 at the Houston base. The captain indicated to Safety Board

investigators after the accident that he had been concerned with the regularity and amount of his

flying time in the DC-9 and frequently volunteered to pick up trips to build more time. He also

said that he did not feel comfortable in the aircraft, because he was not flying as often as he

would have liked.

In December 1995, the captain completed recurrent DC-9 systems and simulator

training. A review of the captain’s COA training records revealed no history of failures or retests.

Regarding his DC-9 training, the captain could not recall whether he had practiced

no-flap landings in the simulator or received specific simulator training on hydraulic system

problems. He did not remember having any previous events in the DC-9 concerning hydraulic

system configuration. He said that a “norm”15 existed for the first officer to make hydraulic

system configuration changes; he was aware that this was not standard operating practice, which

assigned the task to the pilot not flying at all times. He said he conducted his cockpit according

to standard operating practice, because he was new to the airplane, and he did not expect first

officers to configure the hydraulic pumps.

The chief pilot at Houston, who had flown with the captain when he was a first

officer on the B-727, said that the captain was conscientious, had an excellent record, and that

pilots liked flying with him. Several pilots who flew with the captain in the year before the

accident were interviewed. Many of them did not remember flying with him. First officers who

did remember flying with the captain described him as capable, competent, and personable. One

characterized the atmosphere in the cockpit while flying with the captain as light and jovial and

 14 Reserve pilots do not have enough seniority (time-in-service) to obtain a monthly trip schedule.

They are on call about 20 days each month, flying on an as-needed basis.

15 Norms are customary behaviors, not necessarily based on policy.
8

said he “wasn’t completely all business.” One indicated that the tone in the cockpit while flying

with the captain was closer to the “norm” developed on the line rather than standard operating

practice as taught during training. Two first officers who flew with the captain in the Fall of 1995

said that because the captain was new to the DC-9, he was a little slow at times, but that his

procedures and airplane handling skills were good. One first officer said that he did not enjoy

flying with the captain, but could only describe the reasons as a difference in style and “vague

discomforting things.”

A first officer who flew with the captain in early February described the first leg

of a trip in which the captain had difficulty making crossing restrictions16 while flying a standard

terminal arrival route into a busy airport in the northeast corridor. The first officer characterized

the captain’s behavior during the approach as “slow to develop with what was happening.” He

felt that the captain had mixed up step-down fixes on the arrival. He attributed this to the

captain’s lack of recent flying experience and lack of experience in northeast corridor operations.

According to the first officer, the captain’s remaining legs were routine.

The captain was domiciled in Houston throughout his career with COA. He was

married with two children. He said that his relationships with his wife and children were good.

He stated that no major family or personal events had occurred in the days and weeks before the

accident. A search of the National Driver Register indicated no history of driver’s license

revocation or suspension.

1.5.1.1 Captain’s 72-Hour History Before the Accident

The captain was off duty on February 16 and 17. He checked the scheduling

computer on Saturday evening, February 17, to determine the likelihood that he would get called

out. He began reserve phone availability at 0600 on the morning of February 18. He awoke at

0700, ate breakfast, and played tennis at 0845. He was called by crew scheduling at 1000 and

assigned the trip with a report time of 1645. He completed his tennis match and went home. He

reported normal activities and made no attempts to sleep that afternoon because he was not tired.

He arrived at the airport about 1630, performed routine paperwork, and met the crew at 1715.

The flight departed Houston at 1745 and arrived at DCA at 2127 EST.

The captain arrived at the hotel about 2220 EST, after what he described as a

longer-than-usual van ride, went straight to his room, and went to bed immediately. The captain

said it was an “unrestful night” describing it as a “short night, early wakeup.” He said that he

was awakened by traffic and outside noises during the night but did not remember how many

times. Hotel records indicate that he had a wake-up call scheduled for 0530 EST. He said that

he awoke at 0500 EST to prepare for the 0600 EST departure to the airport. The captain said that

he probably had coffee and sweet rolls in the hotel lobby while waiting for the van. He arrived at

the aircraft about 0620 EST.

 16 Crossing restrictions specify the altitude and/or airspeed an airplane is required to be at when

passing over a given location (fix).
9

The captain indicated that when he is off duty, he normally gets about 9 hours of

sleep each night and feels tired the next morning if he gets fewer. He said that he routinely

drinks one cup of coffee in the morning, but in the case of an early wakeup, he might consume

two cups of coffee. During his second interview with Safety Board investigators, the captain

made conflicting statements about whether he was tired on the morning of the accident. Early in

the interview, the captain said that he felt tired and indicated that the time-zone difference meant

it was an unusually early wakeup for him. Later, he stated that he was not fatigued or tired at the

time of the accident, and he believes that fatigue was not a factor in the accident. The captain

emphasized that nothing adversely affected his performance on the day of the accident and stated

that he would characterize his behavior on the accident trip as normal.

1.5.2 The First Officer

The first officer, age 37, was hired by COA in 1988. He holds an airline transport

pilot certificate, with an airplane multiengine land rating, and Lear Jet and Sabreliner type

ratings. At the time of the accident, he possessed a second-class medical certificate dated August

9, 1995, with no restrictions. He had no FAA record of aircraft accidents, incidents, or flight

violations.

The first officer had approximately 2,200 hours total pilot time. In the 24 hours

before the accident, the first officer flew 6 hours. In the 30, 60, and 90 days before the accident,

he flew 11, 51, and 111 hours, respectively.

Before becoming employed by COA, the first officer was a pilot in the U.S. Air

Force, where he flew F-4, Sabreliner, and Lear Jet aircraft. He was hired by COA as a B-747

second officer and accumulated approximately 575 hours in that position from April 1988 to

February 1989. In March of 1989, he accepted a 1-year company-offered leave of absence 17 to

fly A-3718 jets in the Air Force reserve. He extended this leave on an annual basis until 1993,

when his request for extension was denied at the chief pilot’s office because of “tight staffing.”

The first officer returned to COA in August 1993 and started his transition training

for the second officer position on the DC-10. He had difficulty completing the simulator training

in the DC-10 and had to repeat the curriculum, starting with primary systems (ground) school in

November 1993. The vice president of training for COA indicated that repeating training was

not unusual for a second officer coming back to line operations after a 4-year leave of absence.

In January 1994, the first officer completed his IOE and passed a line check. During line

operations in the DC-10, he accumulated approximately 78 hours from January to April 1994.

Because changes in COA’s DC-10 fleet usage would have forced him to leave the Houston base,

he transitioned to the Airbus 300 (A-300) in June 1994 to maintain his Houston domicile. The

transition was completed without difficulty, and he accumulated approximately 128 hours as an

 17 COA used this method of workforce reduction to prevent the furlough of excess pilots. Pilots

who accepted COLAs maintained certain company benefits such as travel passes and paid medical insurance.

18 The A-37 is an Air Force air-to-ground attack airplane.
10

A-300 second officer from June to September 1994.

In September 1994, while a second officer on the A-300, the first officer was

removed from the line for 60 days and sent for a fit-for-duty evaluation following an incident at

an IAH security checkpoint and an A-300 captain’s complaint about his cockpit behavior. While

proceeding to the gate for the first leg of a trip with the A-300 captain, the first officer failed to

respond to a request by security personnel that he pass through a second magnetometer. After

flying with him for six legs, the A-300 captain complained to the Houston chief pilot’s office,

and later to the FAA principal operations inspector (POI) for COA, that the first officer had

questioned his authority, demonstrated nonstandard behavior in the cockpit, and ignored security

personnel.

The first officer was removed from duty, and the Houston chief pilot started an

investigation and evaluation. No concerns about the first officer’s professional competence were

identified during the investigation. He underwent a fit-for-duty examination consisting of a

clinical interview by a psychiatrist lasting several hours, and a comprehensive psychological

evaluation consisting of a battery of personality and aptitude tests. The psychiatrist found nothing

wrong with the first officer and recommended to the assistant chief pilot that he be returned to

flight status without delay. After a proficiency check, the first officer was returned to duty.

The first officer told Safety Board investigators that the A-300 captain’s

complaint resulted from what he said was a “personality clash” precipitated by the security

checkpoint incident. He said a contributing factor was his status as a non-union reserve pilot

who had obtained a line19 to fly for the entire month. At the time, COA’s pilot union was at an

impasse in its contract negotiations with the company, and it recommended that pilots not fill

open time so that the company would have to call in extra pilots. The first officer did not support

the union and did not heed their recommendation. The A-300 captain was a union member.

 The first officer said this incident was “terribly damaging” to him personally and

professionally. After the incident he adopted what he described as a mode of “captain

management” to preclude a recurrence of another similar event. In this mode he would

constantly interpret what the captains he flew with really meant or really wanted. He indicated

that it was necessary for him to play along and “not stir the hornet’s nest.” Even though he had

been cleared of the accusations, and the record of the incident had been removed from his

personnel file, the first officer felt like he was being watched.

In November 1994, he transferred to the Greensboro, North Carolina, base and

upgraded to first officer on the DC-9. As part of his upgrade training, he completed a 1-day

CRM course. He said that it was his understanding that according to company CRM policy, the

captain has final authority, and there was not a company policy instructing first officers to take

control if necessary. The first officer failed to complete DC-9 simulator training on his first

attempt because of a slow instrument scan. He repeated all the simulator sessions and completed

 19 Monthly trip schedule.
11

the training in February 1995. The simulator instructor said the first officer was average and

stated that his problem was not unusual for pilots upgrading after extended time in the second

officer position. In March 1995, the first officer completed his IOE and passed a line check. The

captain who gave the first officer IOE said that he had good skills, improved over time, was

receptive to input, and eager to learn.

From February 1995 to February 1996, the first officer accumulated

approximately 450 hours as a reserve pilot on the DC-9. In December 1995, he completed DC-9

recurrent systems training. On February 16, 1996, the first officer participated in a recurrent

LOFT simulator session and completed a proficiency check. The instructor for the LOFT and

proficiency check said the first officer provided substantial input to the captain during the LOFT

session and did an "excellent" job in the proficiency check. He characterized the first officer as

"above average" and "more than qualified" at the time he saw him. The instructor was the same

one who had administered the first officer’s initial DC-9 simulator training a year before.

The first officer did not remember any instances in line operations or training on

the DC-9 where the hydraulic system was not configured for landing during the in-range

checklist. He remembered covering material about the hydraulic system configurations on the

DC-9 during ground school. He said that some captains had asked him to make hydraulic system

configuration changes even when he was the flying pilot and it was not his responsibility.

Several pilots who flew with the first officer in the year before the accident were

interviewed. Several captains described him as quiet, with good pilot skills and an adherence to

procedures that reflected his military training. Two captains described the first officer as

technically proficient but “meticulous,” and stated that his slow and deliberate approach to

cockpit procedures was frustrating. The lead line check airman on the DC-9 at Greensboro, who

had worked for 8 years as a CRM instructor, offered the following description of the first officer

based on their conversations:

if you bumped into him at a grocery store or on a flight deck, he’d probably

tend to be quiet, but very analytical, very judicial, very fair on a good day. On

a bad day, he might be too quiet, too inclined to keep issues to himself rather

than speak up, . . .

In the summer of 1995, a captain complained to the Greensboro chief pilot about

the first officer’s performance and lack of CRM skills in the cockpit. The captain had flown

about 40 legs with the first officer over a 1-month period. The Greensboro DC-9 lead line check

airman was tasked with evaluating the complaint and assigned a check airman to fly with the first

officer. The first officer was not aware of the complaint or that he was being evaluated. The

check airman reported that the first officer was still learning techniques, but overall was very

professional, communicated, and was part of the crew. Based on this report, no further action

was taken by the chief pilot’s office.

At the time of the accident, the first officer was single and lived alone in an

apartment in Greensboro. He moved to Greensboro from Houston about 1 year before the
12

accident. He said that near the time of the accident, a close relationship ended with someone

who had remained in Houston. A search of the National Driver Register indicated no history of

driver’s license revocation or suspension.

1.5.2.1 First Officer’s 72-Hour History Before Accident

Thursday night, February 15, 1996, the first officer studied for his proficiency

check and spoke for about 90 minutes to the Greensboro DC-9 lead line check airman about the

check ride. He described the proficiency check as a major life event. Friday, February 16, he

deadheaded20 from Greensboro to Houston and slept most of the trip. He completed the

proficiency check in the afternoon and spent the night at a hotel near the airport. On Saturday,

February 17, he deadheaded back to Greensboro and arrived in the afternoon.

Sunday, February 18, he awoke about 0900 EST, was contacted by crew

scheduling at 0930 EST, and assigned the accident trip pairing. He departed his home base in

Greensboro at 1455 EST and deadheaded to Houston, arriving at 1625. He proceeded directly to

the gate, and the flight departed at 1745. He ate a crew meal and drank some orange juice on the

flight. Upon arrival at DCA, after completing the termination checklist, he searched for, but

could not find, his overnight bag on the airplane. He arrived at the hotel about 2230 EST, where

he learned that a flight attendant had mistakenly given his bag to the station manager at DCA. At

his room, he called the station manager to locate his bag. The first officer said that he was

“miffed” about the missing bag. He went to sleep about 2330 EST and did not sleep very well.

He said he doesn’t sleep well the first night in a strange bed, and he was concerned about the loss

of his bag. He awoke at 0500 EST to prepare for the 0600 EST crew van. He said that it was an

early day and that there was no time for breakfast at the hotel. While en route to Houston, he

had some coffee and ate a crew meal.

The first officer described himself as an evening person and said that he usually

wakes up around 0900. He indicated that he does not drink coffee regularly, but uses it when he

needs its stimulating effect. The first officer stated that he was tired on the morning of the

accident, and he felt that fatigue affected his ability to make decisions at the end of the flight.

1.5.3 Flight Attendants

The “A” flight attendant had more than 11 years of service with COA. Her most

recent recurrent training before the accident was completed in March 1995. The “B” flight

attendant had 3 years of service with COA. Her most recent recurrent training before the

accident was completed in February 1995. The “C” flight attendant had more than 9 years of

service with COA. Her most recent recurrent training before the accident was completed in May

1995. Each of the flight attendants was qualified on DC-9, DC-10, B-727, B-737, B-747, B-757,

and A-300 airplanes.

 20 Flew in a nonactive crew status.
13

1.6 Airplane Information

N10556, a Douglas DC-9-32, serial number 47423, was manufactured on

March 9, 1970. It was powered by two Pratt & Whitney (P&W) JT8D-9A turbofan engines. The

airplane was put into service as part of COA’s fleet in January 1991. It had previously been

operated by Air Canada, Texas International, New York Air, and Eastern Airlines.

The airplane had accumulated 63,163 flight hours and 58,913 cycles at the time of

the accident. The last maintenance inspection performed was an "A" check21 on February 17,

1996.. No noteworthy discrepancies were found in the airplane’s maintenance records.

1.6.1 Dispatch Information

The dispatch paperwork for flight 1943 indicated that it was released from DCA

at a gross takeoff weight of 102,757 pounds. The maximum gross takeoff weight for the airplane

was 104,400 pounds. The center of gravity was calculated to be 16.9 percent mean aerodynamic

chord, which was within limits.

The planned fuel burn for the flight to Houston was 16,500 pounds; thus, 86,257

pounds was the estimated landing weight and also the estimated weight of the airplane at the time

of the accident.

The COA speed card for a landing weight of 86,000 pounds lists the following

reference speeds:

Flaps 40 degrees, slats extended 125 knots

Flaps 50 degrees, slats extended 121 knots

COA procedures call for final approach to be flown at a target airspeed of the

flaps 40 (or 50)o reference speed plus a wind additive. Using a wind additive of 7 knots (1/2 the

steady state wind of 14 knots), the following target airspeeds were calculated for flight 1943:

Flaps 40 degrees, slats extended 132 knots

Flaps 50 degrees, slats extended 128 knots

For a landing weight of 86,000 pounds, the COA DC-9 Flight Manual chart

entitled, “V-Speeds for Abnormal Landings,” listed the landing reference speed as 153 knots for

a flaps-up, slats-extended configuration.

 21 An "A" check is a comprehensive external inspection of the airplane performed by COA

maintenance personnel at intervals of 14 days.
14

1.6.2 Hydraulic System

Hydraulic power on the DC-9 is provided by two independent hydraulic systems.

Each system is normally pressurized by its respective engine-driven hydraulic pump. An

auxiliary electrically operated pump and an alternate motor pump provide backup pressure

sources. The output pressure of each engine-driven hydraulic pump is controlled by a 3-position

switch, which is located on the first officer’s instrument panel, but is accessible to both pilots.

(See figure 1.) In the “HI” position, pump output pressure is 3,000 pounds per square inch (psi).

The “LOW” position reduces the pressure to 1,500 psi. The “OFF” position depressurizes the

system. Switches controlling the auxiliary (AUX) and alternate (ALT) hydraulic pumps are also

located on the first officer’s instrument panel. Ground, takeoff, and landing operations are

conducted with the engine-driven hydraulic pump switches in the “HI” position and the AUX and

ALT switches “ON.” During in-flight operation, system pressures are reduced to 1,500 psi by

positioning the engine-driven pump switches to “LOW” and turning the AUX and ALT switches

“OFF.” COA procedures require changeover to the low pressure configuration during

completion of the after-takeoff checklist. The high pressure configuration is enabled before

landing, during completion of the in-range checklist.

Hydraulic components are classified as being either priority or non-priority based

on their operating pressure requirements and/or their function. Priority components are mainly

associated with normal flight operations and require lower operating pressures to function.

These components include spoilers, slats, rudder, flap/rudder stop, engine reversers, the elevator

augmentation system, and the ventral stair system. Non-priority components require a system

pressure of at least 2,000 psi to function normally and are required for all ground operations,

including takeoff and landing. Non-priority components include landing gear, brakes, flaps, nose

wheel steering, and the alternate gear pump. A priority valve in each system gates hydraulic

pressure between the priority and non-priority components. When the engine-driven pumps are

placed in the “HI” mode, the priority valves open as the system pressure exceeds 2,000 psi and

permit operation of non-priority components. Placing the engine-driven pumps in the “LOW”

mode reduces system pressure, closes the priority valves, and renders the non-priority

components, including the flaps and landing gear, inoperative.

Pressure gauges for each hydraulic system are located on the first officer’s

instrument panel immediately above the pump switches. The “LOW” range is indicated by a

green arc from 1,300 to 1,600 psi, and the “HI” range is indicated by a green arc from 2,800 to

3,100 psi. Each system has a “HYD PRESS LOW” annunciator light on the overhead panel that

illuminates when the respective system pressure drops to approximately 900 psi. The “MASTER

CAUTION” light will illuminate at the same time.

According to the Douglas Aircraft Company, as of December 31, 1996, 874 DC-9

(-10 through -50) and 1,009 MD-80 series airplanes were in service worldwide with the “HI,

LOW, OFF” hydraulic switch configuration. The MD-80 hydraulic system differs from the DC-9

system in that it does not incorporate priority valves. On the MD-80, system pressure is provided

to all components continually; however, normal operation of the non-priority components still
15

a

.bDm

z Oub ‘4

o e

MYO?Wo

9vuuntr

Upper Illustration - Hydraulic switch panel in high pressure configuration.

Bottom Photo - Photo of accident airplane’s hydraulic switch panel in low pressure

configuration (see section 1.12).

Figure 1 – Hydraulic switch panel.
16

requires hydraulic pressure greater than 2,000 psi. If the engine-driven pumps are in the “LOW”

mode, the function of the flaps and the landing gear will be impaired. Douglas provides an “ON,

OFF” hydraulic switch configuration as a customer option on the MD-80. Two operators have

chosen this option, and as of December 31, 1996, there were 126 MD-80 airplanes in service

worldwide with the “ON, OFF” switch configuration.

1.6.3 Landing Gear Indication and Warning System

Landing gear position indication on the DC-9 is provided by three green lights and

three red lights located on the forward instrument panel above the gear handle. A green gear

light indicates that the respective landing gear is down and locked. A red gear light indicates that

the respective gear is unsafe, neither full up nor full down. An amber light located just to the

right of the gear lights illuminates whenever the inboard main gear doors are not in the fully

closed position.

A landing gear warning horn will sound when the throttles are retarded to idle if

the landing gear is not down and locked.22 The pilots can silence the horn by depressing the horn

cutoff button located on the instrument panel. The warning horn will also sound, regardless of

throttle position, if the landing gear is not down and locked and the flap handle is moved beyond

the approach (15o

) setting. In this condition, the horn cannot be silenced and will continue to

sound until the gear is down and locked or the flap handle is retracted to a setting of 15o

 or less.

1.6.4 Ground Proximity Warning System

COA operates DC-9 airplanes equipped with Sundstrand Mark I and Mark II

GPWS units, which provide aural and visual warnings in response to aircraft configuration

and/or operation deficiencies. The GPWS computer receives input from the radio altimeter, air

data computer, glideslope receiver, landing gear handle position switch, and flap handle position

switch. The computer processes these inputs and, in the case of the Mark I system as installed in

N10556, generates a “whoop whoop pull up” aural warning and illuminates a red light labeled

“PULL UP” on the instrument panel when any of the following conditions are detected:

• Rate of descent exceeds certain threshold values.

• Terrain closure rate exceeds certain threshold values.

• Takeoff altitude loss.

• Below 500 feet above ground level (agl) with landing gear handle not in the

down position.

 22 The red gear lights on a COA DC-9 will not illuminate under these conditions. All COA DC-9

airplanes have been modified in accordance with Douglas Service Bulletin 32-170, entitled “LANDING GEAR -

Position and Warning - Deactivate Warning Lights During Throttle Retardation.” This modification is required for

compliance with United Kingdom Civil Aviation Authority requirements. Texas International (which merged with

COA in 1982) acquired DC-9 airplanes incorporating this modification from Air Canada and then performed the

modification on the remainder of its DC-9 airplanes to standardize the fleet.
17

• Between 500 and 200 feet agl with gear handle down, but flap handle not

selected to the landing position,23 and a rate of descent exceeding certain

values.

• Below 200 feet agl with gear handle down, but flap handle not selected to the

landing position.

•

If a pilot chooses to land with less-than-normal landing flaps, the flap configuration warning can

be disabled by activating a flap-override switch installed on the overhead panel. This switch

affects only the GPWS warnings associated with flap position; the other warning modes remain

active. All warnings are inhibited below 50 feet agl.

When an ILS frequency is selected by the pilot, the Mark I GPWS unit will sound

a “glideslope” warning and illuminate the “BELOW G/S” light on the instrument panel if the

airplane inadvertently descends below the glideslope. “Whoop whoop pull up” and “glideslope”

are the only verbal warnings available in the Mark I GPWS units. The Mark II units provide

verbal warnings that are more specific about the nature of the airplane deficiency. The expanded

warnings include “too low gear,” “too low flaps,” too low terrain,” “sink rate,” “don’t sink,” and

“minimums.”

1.7 Meteorological Information

Visual meteorological conditions prevailed at the time of the accident.

The IAH hourly weather observation at 0850 was 1,000 feet scattered, measured

ceiling 1,800 feet broken, 2,700 feet overcast; visibility 10 miles; temperature 68 oF; dew point

63 o

F; wind estimated 210o at 12 knots; altimeter setting 29.70 inches of Hg.

1.8 Aids to Navigation

There were no known difficulties with aids to navigation.

1.9 Communications

Before the airplane’s touchdown, there were no known difficulties with

communications. At 0901:56, the CVR recorded the captain making a radio call to IAH tower

requesting assistance. This call was not received by the tower.

The captain was using the airplane’s No. 1 communication radio to transmit.

Postaccident examination revealed that the antenna for this radio, which was mounted on the

belly of the airplane, was destroyed.

 23 Landing position is any flap setting greater than 15o

.
18

1.10 Airport Information

IAH is owned and operated by the city of Houston and is about 15 miles north of

Houston. The airport is served by four paved runways. (See figure 2.) It is certificated as an

aircraft rescue and fire fighting index E airport24 in accordance with the applicable provisions of

14 CFR Part 139.

Runway 9/27 is an asphalt runway, 9,999 feet long and 150 feet wide with 35-foot

asphalt non-weight bearing shoulders. Runway 27 is equipped with a Category II instrument

landing system and marked as a precision instrument runway, which includes high intensity

runway, runway centerline, and touchdown zone lights. The approach threshold elevation is 87

feet.

Runway 9/27 is surrounded by a runway safety area, which is 500 feet wide and

extends 1,000 feet beyond each runway threshold, and which conforms to FAA Advisory

Circular 150/5300-13, “Airport Design.” There are 4 drainage culverts located at 2,000- to

3,000-foot intervals 248 feet north of the runway centerline, with the first 15 feet of each culvert

tapered, which conforms to runway safety area requirements.

1.11 Flight Recorders

An FDR and a CVR were installed in the airplane. The two recorders were

removed from the airplane and sent to the Safety Board’s laboratory in Washington, D.C., for

readout.

The FDR was a Sundstrand model UFDR, SN 5442. The following six

parameters were recorded: time, indicated airspeed, pressure altitude, magnetic heading, vertical

acceleration, and very high frequency radio keying.25 The data indicated that at 0901:32, the

airplane touched down hard at an indicated airspeed of 193 knots. The recorded data ended when

power to the unit was interrupted while the airplane was still moving.

The CVR was a Fairchild model A-100, SN 4100. The recording consisted of four

channels of good quality26 audio information: the cockpit area microphone, the captain and first

 24 Title 14 CFR Part 139 requires, for scheduled air carrier service with aircraft at least 200 feet

long, that at a minimum the airport be equipped with at least three aircraft rescue and fire fighting vehicles with a

combined carrying capacity of at least 6,000 gallons of water for foam production.

25 The six-parameter FDR was permissible under an exception to the standard 11-parameter

requirement of 14 CFR Part 121.343 because the airplane did not meet Stage 2 noise levels, was to be retired by

1998, and was listed on the FAA Aircraft Retirement Schedule.

26 The Safety Board generally uses the following criteria to assess the quality of a CVR recording:

a “poor” recording is one in which a transcription is nearly impossible given that a large portion of the recording is

unintelligible; a “fair” recording is one in which a transcription is possible, but the recording is difficult to
Flight 1943 final location m

of airplane. w

m

m=

x

Flight 1943 approximate

point of touchdown.

Figure 2 – Houston Intercontinental Airport diagram.

difficult to understand; a “good’ recording is one in which few words are unintelligible; and an “excellent”

recording is very clear and easily transcribed.
20

officer audio panels, and the interphone/PA system. The recording started at 0831:16, with the

airplane in cruise flight at 35,000 feet. It continued through the descent, approach, and landing at

IAH, ending at 0902:05, when electrical power to the unit was interrupted. A transcript was

prepared of the entire 30-minute, 49-second recording (see appendix B).

1.12 Wreckage and Impact Information

Physical evidence indicated that the airplane touched down about 3,300 feet from

the approach end (beginning) of runway 27, almost directly on the runway centerline. A

continuous scrape mark started at this point and led down the runway to the location of the

airplane. The scrape mark remained close to the runway centerline for approximately 5,000 feet

and then diverged to the left, departing from the pavement about 6,730 feet after it began. About

10 feet further than that, both inboard main landing gear doors and the left forward nosegear door

were located. Small fragments of skin from the belly of the airplane were scattered along the

runway.

Examination of the cockpit revealed that the landing gear handle was in the down

position and the flap handle was set to 50o

. The left and right engine-driven hydraulic pump

switches were in the “LOW” position, and the ALT and AUX hydraulic pump switches were in

the “OFF” position. The left hydraulic system gauge indicated 1,600 psi, and the right gauge

indicated 0 psi (refer to figure 1). The safety wire on the GPWS flap override switch was found

broken; however, the switch was not in the “OVRD” position.

The airplane stopped on a magnetic heading of 255° about 6,850 feet from the

initial touchdown point. It came to rest on its lower fuselage in the grass adjacent to the takeoff

end of the runway about 140 feet left of the runway centerline.

Upon initial examination of the airplane, the leading edge slats were found

deployed, and the flaps were found extended to approximately 5o

. However, as time passed, the

flaps continued to extend until the trailing edges rested on the ground. When the airplane was

lifted by a crane, the landing gear extended and the flaps moved to full deflection (50o).27

After the airplane was removed to a hangar, the underside of the fuselage was

examined. Skin, stringers, and frames on the lower fuselage were damaged by contact erosion,

with the damage increasing in severity in the aft direction. There was a 15-inch diagonal tear in

the aft pressure bulkhead. The majority of the hydraulic piping and electrical wiring installed in

the lower fuselage was heavily damaged.

 27 According to Douglas, the gradual extension of the flaps, the extension of the landing gear, and

the 0 psi indication on the right hydraulic pressure gauge are all indications that the airplane’s hydraulic system had

been compromised during the slide down the runway.
21

1.13 Medical and Pathological Information

Six passengers reported that they sustained minor injuries, and six passengers

reported that they sustained smoke inhalation.28 One passenger was transported to a local

hospital with complaints of back pain and released the same day.

The captain and first officer submitted urine samples about 1015 on February 19,

1996, in accordance with COA’s drug testing program. The samples were tested at an

independent laboratory for amphetamines, phencyclidine, cocaine, cannabinoids, and opiates.

The results of the examinations were negative for both pilots. At 1220 on February 19, 1996, the

captain and first officer were administered a breath alcohol test, which tested negative for both

pilots.

1.14 Fire

According to passenger and flight attendant statements, after the airplane came to

a stop, smoke began to fill the midsection of the cabin. Several passengers reported that the

smoke appeared to be coming from beneath the cabin floor.

During postaccident examination of the airplane, scorched paint and burnt

electrical wiring were found in the center section dry bay located below the cabin midsection.

No evidence of a sustained fire was found.

1.14.1 Airport Emergency Response

At 0902, the Houston Fire Department was notified of the accident by ATC via

the airport emergency phone network and responded with four crash/rescue units and an

emergency medical vehicle. The aircraft rescue and fire fighting vehicles were positioned around

the airplane, ready to apply extinguishing agent. After some light smoke was observed

emanating from the rear cargo area, a hand-held hose line was placed in position while fire

fighters boarded the airplane to ensure that all occupants had been evacuated. Fire fighters

attempted to gain access to the aft cargo compartment using saws and hydraulic cutting tools, but

this proved to be too difficult because of the airplane’s position without its landing gear

extended, so they removed seats and flooring in the cabin to gain access. When access to the

cargo compartment was gained, no fire was found.

1.15 Survival Aspects

The cockpit was configured conventionally with two flightcrew member seats and

an observer jumpseat, which had not been occupied on the accident flight. The airplane was

configured with 103 passenger seats, which had been about 80 percent occupied. No lap children

 28 Passenger injuries were self-reported in statements to the Safety Board or on their COA

“Customer Incident Report.”
22

had been aboard. The “A” flight attendant had been seated on an aft-facing jumpseat that was

attached to the cockpit bulkhead adjacent to the forward entry door. The “B” and “C” flight

attendants were seated on a forward-facing double-occupancy jumpseat that was attached to the

tailcone access door.

Two floor-level exits were located in the forward cabin, four overwing exits were

located at seat rows 15 and 16, and a tailcone exit was located at the rear of the cabin. (See

figure 3.) Access to the tailcone was provided by a plug-type door in the center of the aft cabin

bulkhead.29 With this type tailcone access door, the shoulder harnesses for the flight attendants

occupying the aft jumpseat are mounted to the plug door, and the flight attendant lap belts are

attached to the aft cabin bulkhead. If one or more of the jumpseat shoulder harness straps are

buckled to the lap belt, this ties the plug door to the bulkhead and interferes with the removal of

the door during an emergency evacuation.

COA’s Inflight Manual, current at the time of the accident, provided the following

guidance to flight attendants for opening the plug-type door:

DC-9-30 aircraft #556 and #557 are equipped with a plug type door. At the

top of the door is a T-shaped handle. The door is opened from the customer

compartment by lifting the handle up and pulling the door inward, then lifting

it up and out of its frame. Place the door against the lavatory door.

The manual did not mention the need to ensure that the jumpseat shoulder harness straps are

unbuckled from the lap belts before attempting to remove the plug door.

According to the flight attendants, during the evacuation most of the passengers

exited the airplane by way of the overwing emergency exits. Other passengers exited through the

left forward (L-1) cabin exit. Access to the tailcone exit was blocked. One passenger stated that

the tailcone access plug door could not be fully opened because a seat belt restricted its

movement. The “C” flight attendant stated that she could not completely remove the plug door

because of the jumpseat shoulder harness. She redirected the passengers at the rear of the plane

to the overwing exits.

When Safety Board investigators examined the airplane, the evacuation slide at

the left forward exit was found deployed and inflated. The right forward exit was open, but the

slide was not deployed. All the overwing exit hatches and the tailcone access plug door were

found removed. According to fire department personnel, the right forward exit and the tailcone

plug door were opened during the postevacuation fire fighting activities.

 29 COA operates DC-9 airplanes with access to the tailcone exit via either a plug-type door or a

floor-level door. At the time of the accident, COA operated two airplanes with the plug-type tailcone access door:

one of these was the accident airplane and the other was ship #557.
23

coNTINEm& AIRLINEs

AIR~ SEAmG DIAGRAM

DC-9-30

Flight Attendant A

-.

Jumpseat

MainCabin Door/ Scrvi@Door/

Emrgency Exit EmergencyExit

EmergencyExit

EmergencyExit

Flight Attendant

Jumpseat on

Tailcone Access I

EmergencyExit

Plug Door

ErnagencyExit

Emrgency Exit

Figure 3 – Cabin configuration.
24

Subsequent to the accident, on September 16, 1996, COA issued “Inflight Safety

Bulletin #96-07” to all flight attendants. The subject of the bulletin was the “Aft Jumpseat

Harness on DC-9 Ship #557 (Plug Door).” The bulletin provided information on how to prevent

blocking a useable exit during an evacuation. It emphasized the need to fully rotate the release

knob when unfastening the jumpseat restraining harness to ensure that the shoulder straps release

and cautioned flight attendants never to leave the shoulder harness attached to the seat belt. On

October 16, 1996, COA issued a revision to the Inflight Manual that included the following note

concerning the plug door:

NOTE: When leaving the jumpseat ensure both shoulder harness straps

release from the lap belt, or removal of the door may be hindered.

1.15.1 Flight Attendant Tailcone Training

The Safety Board addressed the issue of flight attendant tailcone training in its

report on the ground collision of a DC-9 and a B-727, and the subsequent fire on the DC-9, at

Romulus, Michigan, on December 3, 1990.30 As a result of its investigation of that accident, in

which a flight attendant and a passenger died of smoke inhalation inside the DC-9 tailcone, the

Safety Board issued Safety Recommendation A-91-60, which asked the FAA to do the following:

Issue an Advisory Circular addressing acceptable methods for the design,

construction, operation, and maintenance of mockups used for exit training

during crewmember emergency training, and provide guidance to FAA

inspectors to ensure that emergency equipment training devices accurately

replicate the intended operational environment.

In response to this recommendation, on July 13, 1992, the FAA issued Air Carrier

Operations Bulletin (ACOB) 8-76-6, “Guidelines for Crewmember Training on Aircraft

Tailcones and Approval of Tailcone Training Devices.”31 The bulletin set forth acceptable means

for approving tailcone training devices and provided the following guidance concerning plug

door training devices:

(2) The ventral or plug door training device simulating the door at the pressure

bulkhead leading to the tailcone should approximate the size and shape of the

door on the actual aircraft. A door training device should approximate, within

10 percent, the weight of the actual door. If a shoulder harness is attached to

the door in the aircraft that might interfere with the opening of the door, one

should be similarly attached to the corresponding door in the training device.

 30 See Aircraft Accident Report—“Northwest Airlines, Inc., Flights 1482 and 299, Runway

Incursion and Collision, Detroit Metropolitan/Wayne County Airport, Romulus, Michigan, December 3, 1990”

(NTSB/AAR-91/05).

31 On January 6, 1993, the Safety Board classified A-91-60 “Closed—Unacceptable Action”

because the ACOB did not require that each flight attendant receive hands-on experience with every emergency exit.
25

On January 26, 1996, ACOB 8-76-6 was superseded by the issuance of Flight

Standards Handbook Bulletin (HBAT) 96-02, “Guidelines for Crewmember Training on Aircraft

Tailcones and Approval of Tailcone Training Devices.” HBAT 96-02 contained the same

language concerning plug door training devices as was found in ACOB 8-76-6. On February 8,

1996, the POI provided COA with a copy of HBAT 96-02, and on March 8, 1996, the director of

in-flight training and procedures for COA stated in a letter to the POI that COA “was in

compliance with all requirements” of the bulletin.

On July 25, 1996, Safety Board investigators visited COA’s Houston flight

attendant training facility and examined the DC-9 plug door training device. Although the trainer

used an actual plug door salvaged from an airplane, no shoulder harnesses or seat belts were

installed in the training device. According to the FAA cabin safety specialist for COA, the plug

door training device in Houston, as well as those at the flight attendant training facilities in

Newark, New Jersey, and Cleveland, Ohio, were approved by the FAA before her assignment to

COA in 1989.

The cabin safety specialist told Safety Board investigators that her 1992 file

photos of the plug door trainers currently located in Newark and Cleveland showed that shoulder

harnesses were installed on the plug doors. In addition, she pointed out what she considered to

be a deficiency in HBAT 96-02, in that COA’s trainers were equipped in accordance HBAT

96-02, which specifies only the installation of shoulder harnesses on the plug door; however, this

did not provide flight attendants with an opportunity to see how the shoulder harness could

interfere with the opening of the door, because no seat belts were installed on the trainer

bulkheads, and HBAT 96-02 does not specify the installation of seat belts. As of January 1997,

COA has equipped its plug door training devices in Houston, Newark, and Cleveland with

shoulder harnesses and seat belts.

1.16 Tests and Research

1.16.1 Simulated Approach

The approach segment of flight 1943 was reenacted in a COA DC-9 simulator.

According to COA training personnel, the simulator was programmed to accurately represent the

cockpit indications resulting from attempting to configure the airplane for landing with the

hydraulic pumps in the low pressure position. The simulator was positioned 12 miles outside the

outer marker on the IAH runway 27 localizer at 4,000 feet. The in-range checklist was

completed with the exception of the “Hydraulics” item.

A speed of 190 knots was maintained to the marker. When the glideslope was

intercepted, the slats were extended and the flaps were selected to 5o

. The “MASTER

CAUTION” light illuminated for a few seconds along with the “HYD PRESS LOW” light as the

slats extended. The blue “SLATS EXTEND” light came on, indicating that the slats were

extended. The flaps remained at 0o, and the flap gauge indicated zero.
26

When the landing gear handle was lowered and the flap handle placed to 25o, the

following indications were observed:

• No red landing gear warning lights.

• No green landing gear “down and locked” lights.

• No amber landing gear door light.

• Continuous landing gear warning horn that could not be silenced when the

flap handle was positioned to 25o.

1.17 Organizational and Management Information

COA was founded in 1934 as Varney Speed Lines and changed its name to

Continental Airlines in 1937. At the time of the accident, it operated 298 airplanes, on both

domestic and international flights. It had 31,952 employees, of whom 3,892 were pilots. It had

31 DC-9 series airplanes, flown by 215 DC-9 pilots. The FAA certificate holding office

(headquarters) is located in Houston, Texas.

The former Texas International, People Express, New York Air, and Frontier

Airlines have become part of COA. COA also acquired assets from former airlines—Muse,

Transtar, and Eastern. In its 62-year history, COA has twice filed to reorganize under Chapter 11

of the Federal Bankruptcy Code. The first was in 1983, and the company emerged in 1986; the

second was in 1990, and the company emerged in 1993. The company also experienced a

protracted labor strike from 1983 to 1985.

1.17.1 Pilot Union Presence at COA

Since July 1993, the pilots of COA have been represented by the International

Association of Continental Pilots (IACP), a union certified by the National Mediation Board. All

COA pilots, except those in management positions, are eligible for membership. Contractually

all COA pilots must pay IACP dues, but pilots are not required to join the union. About 85

percent of the pilots have elected to join the union.

Before the IACP was certified, COA pilots had last been represented by the Air

Line Pilots Association (ALPA) until the bankruptcy of 1983. From 1984 to 1993, the pilots

were represented by a COA-sponsored “operational group,” a form of participative management,

not sanctioned by the National Mediation Board. According to IACP officials, in 1991, the pilots

believed that more formal representation was needed because of a disparity between COA and

industry-standard pay and scheduling practices; a significant majority of pilots voted for union

representation. COA management offered the pilot group voluntary recognition of an

independent union. COA pilots elected to form the IACP instead of seeking representation by

ALPA. In August 1995, the first collectively bargained labor agreement since 1983 was signed.
27

1.17.2 Recent COA Accidents and FAA Oversight

On November 15, 1993, a COA B-727 was substantially damaged when it

contacted the runway during a go-around at Chicago’s O’Hare International Airport.32 None of

the 7 crewmembers or 79 passengers were injured. The go-around was initiated when the

flightcrew realized that the landing gear was not extended for landing. In postaccident

statements, the pilots reported that they were distracted by Traffic Alert Collision Avoidance

System alerts and forgot to lower the landing gear. The Mark I GPWS sounded a warning as the

airplane descended through 500 feet agl; it was not designed to, and did not, specifically

announce “too low gear” as would a Mark II GPWS. The GPWS warning ceased at 50 feet agl,

and at that time, the pilots realized they had not lowered the landing gear, so they initiated a goaround. The Safety Board determined that the probable cause of this accident was the following:

THE CAPTAIN’S FAILURE TO ASSURE THAT THE LANDING GEAR WAS EXTENDED

FOR LANDING. FACTORS RELATED TO THE ACCIDENT WERE: TRAFFIC ALERT

DISTRACTIONS, THE FLIGHT CREW’S FAILURE TO USE THE CHECKLIST, AND

INADEQUATE COMPANY SYSTEMS TRAINING.

In the Pilot/Operator Aircraft Accident Report submitted on December 14, 1993,

to the Safety Board, COA stated that it would “evaluate upgrading all “Mark I” GPWS units on

all aircraft to the “Mark II” standard.” As of January 1997, COA still had 53 airplanes in service

equipped with Mark I GPWS units.

FAA inspectors performed a focused inspection of COA operations during a 3-

week period in January and February 1994. Inspectors conducted from 40 to 55 en route flight

inspections. The stated results were that some pilots were found not to be following checklists

and standard operating procedures. According to the POI, he debriefed COA management

regarding these results, and the company committed to initiating remedial action.

On March 2, 1994, a COA MD-82 sustained substantial damage when the captain

rejected the takeoff from runway 13 at LaGuardia Airport, Flushing, New York, and the airplane

continued beyond the takeoff end of the runway.33 There were no fatalities, and 29 of the 110

passengers and 1 of the 6 crewmembers received minor injuries during the evacuation. The

Safety Board determined that the probable causes of this accident were the following:

The failure of the flightcrew to comply with checklist procedures to turn on an

operable pitot/static heat system, resulting in ice and/or snow blockage of the

pitot tubes that produced erroneous airspeed indications, and the flightcrew’s

 32 See Brief of Accident and Factual Report NTSB CHI94FA039.

33 See Aircraft Accident Report—“Runway Overrun Following Rejected Takeoff, Continental

Airlines Flight 795, McDonnell Douglas MD-82, N18835, LaGuardia Airport, Flushing, New York, March 2, 1994”

(NTSB/AAR-95/01).
28

untimely response to anomalous airspeed indications with the consequent

rejection of takeoff at an actual speed of 5 knots above V1.

In its final report the Safety Board stated the following:

The checklist deviations and other pilot procedural deficiencies noted by the

FAA during a special inspection, which included numerous en route

inspections about 1 month before the accident, suggest that the problems

identified in this accident regarding improper checklist procedures were

systemic at COA. If pilots fail to adhere to procedures during en route

inspections by FAA inspectors, they most likely behave in a similar manner

when no inspector is present. Despite the COA POI’s efforts to correct this

situation with COA management, the actions recommended in A-94-001 and -

00334 appear to be appropriate for COA.

According to the POI, there was no increased FAA surveillance of COA following

the La Guardia accident. In interviews with Safety Board investigators, COA personnel indicated

that the company placed additional emphasis during pilot training on the importance of checklists

and adhering to standard operating procedures.

In accordance with the National Aviation Safety Inspection Program (NASIP), a

team of FAA aviation safety inspectors conducted an inspection of COA from July 31, 1995,

through August 11, 1995. Compliance issues raised during the inspection were discussed with

company personnel and the FAA principal inspectors. Fourteen cockpit en route inspections

 34 These safety recommendations pertaining to flightcrew checklists were issued to the FAA on

February 2, 1994, as a result of the Safety Board’s study of flightcrew-involved major accidents (NTSB/SS-94/01):

Apply the results of research conducted to date on the design and use of checklists to improve the

error-tolerance of air carrier checklist procedures for taxi operations by enhancing flightcrew

monitoring/challenging of checklist execution, providing cues for initiating checklists, and

considering technological or procedural methods to minimize the omission of any items on a

checklist. Provide specific guidance to air carriers for implementing these procedures. (A-94-001)

Require U.S. air carriers operating under 14 [CFR] Part 121 to provide, for flightcrews not covered

by the advanced qualification program, line operational simulation training during each initial or

upgrade qualification into the flight engineer, first officer, and captain position that: (1) allows

flightcrews to practice, under realistic conditions, nonflying pilot functions, including monitoring and

challenging errors made by other crewmembers; (2) attunes flightcrews to the hazards of tactical

decision errors that are errors of omission, especially when those errors are not challenged; and (3)

includes practice in monitoring and challenging errors during taxi operations, specifically with

respect to minimizing procedural errors involving inadequately performed checklists. (Class II,

Priority Action) (A-94-003)

The FAA responded to A-94-003 by revising Advisory Circular 120-51B “Crew Resource

Management Training,” and the Safety Board classified this recommendation “Closed—Acceptable Alternate

Action.” The status of A-94-001 is discussed in section 2.5 of this report.
29

were performed to observe compliance with Federal regulations, company procedures, and FAAapproved programs. The inspection did not identify any deviations from Federal regulations or

noncompliance with company procedures during the en route phase of flight. In addition, the

POI told Safety Board investigators that he had seen no trends in the area of noncompliance with

Federal regulations or company procedures in the Program Tracking and Reporting System data

collected during his tenure as POI (1991 to present).

On February 20, 1996, a COA B-737 ran off the departure end of runway 36 and

onto the overrun after landing at DCA.35 None of the 5 crewmembers or 74 passengers were

injured. In postincident statements, the air traffic controllers working the flight reported that the

airplane was faster on the approach and touched down farther down the runway than other

airplanes that arrived at DCA around the time of the incident. Data retrieved from the FDR

indicated that the airplane touched down at approximately 180 knots indicated airspeed.

According to Boeing, the landing reference speed for the airplane as configured (flaps 25o,

weight 94,000 pounds) was 141 knots. The Safety Board determined that the probable cause of

this incident was the following:

[E]xcessive airspeed was maintained by the captain during the

approach/landing phase of the flight, which resulted in an overrun and an

encounter with soft/wet terrain. Factors relating to the incident were: the

pilot’s failure to attain the proper touchdown point, the wet runway condition,

and partial failure of the anti-skid brake system.

In 1996, COA participated in a National Aeronautics and Space Administration

(NASA)/University of Texas/FAA-sponsored Aerospace Crew Research Project. The program

had been coordinated before the flight 1943 accident; however, data collection did not start until

late spring. A series of internal line checks throughout the COA fleet were performed by the

research team as part of the project. The line checks focused on CRM, standard operating

procedures, and checklists. The NASA/University of Texas team briefed COA management on

the results of the line checks in July 1996. The research team noted violations of the sterile

cockpit rule and problems with checklist execution. The checklist problems observed included

checklists performed from memory, interrupted checklists not being completed properly, and

nonstandard checklist initiation.

According to COA management personnel, following the July 1996 briefing, the

company initiated a “bottoms-up” review of normal checklist usage and compliance throughout its

fleet. It also considered modifications to the physical form of checklists and checklist philosophy.

As one result of its ongoing checklist review, COA developed a “Checklist Discipline” training

module, which will be presented to all active flightcrew members during 1997 recurrent training.

The module highlights the importance of strict adherence to checklist procedures by using a

videotape that reviews recent COA accidents and incidents to elicit discussion among the class

participants.

 35 See Brief of Accident and Factual Report (NTSB IAD96IA044).
30

1.18 Additional Information

1.18.1 Pilot Observations Concerning DC-9/MD-80 Hydraulic System

A search of the Aviation Safety Reporting System (ASRS) data base produced one

report dated February 1995 relevant to this accident.36 In this report, the first officer of an MD80 series airplane described a landing approach during which the nosegear would not lower and

lock. After a go-around, diagnosis of the problem revealed that the crew had not performed the

in-range checklist, and the captain “had failed to turn the engine driven hydraulic pumps from

low to high and had also failed to turn on either AUX or transfer pumps.” The first officer, selfdescribed as “new to the aircraft,” reported being unaware that high pressure was necessary to get

the nosegear down. According to the first officer, the captain “commented that he had made this

mistake before.”

Several DC-9 pilots told Safety Board investigators that they remembered

instances where the pumps were not configured for landing during the performance of the inrange checklist in airplanes they were flying. They indicated that they learned of the

consequences of this action through personal experience. They said that the operating manuals

and training materials do not explicitly state that if the pumps are not switched to “HI,” the

landing gear will not extend and the flaps will not deploy.

Again, COA standard operating procedures direct that the pilot not flying, who is

performing the checklist, is responsible for manipulating the pump switches. Some captains and

first officers indicated the unofficial norm that delegated the first officer with the responsibility

for manipulating pump switches at all times was because although the switches were accessible

to the captain, the pump switches were closer to the first officer.

Pilots indicated that it was possible to forget to configure the hydraulic pumps for

landing if the approach was interrupted or rushed. They said the airplane’s behavior when

attempting to deploy the flaps and landing gear would clue them that the switches had not been

placed to “HI.” Several pilots stated that it is difficult to detect the difference between flaps 5o

and flaps 0o with slats extended using handling characteristics alone. One pilot said there is a

“rocking” pitch moment that occurs when the flaps and slats deploy, because they rarely extend

together. However, he indicated that he noticed the flaps were not operating when the flap

handle was positioned to 15o

 and no pitch change occurred. Another pilot indicated that he was

alerted that the pumps had not been configured for landing when the sounds associated with the

extension of the landing gear did not occur.

 36 See ASRS Report #296688. The ASRS is a NASA-sponsored project to maintain a data base of

voluntarily submitted reports addressing safety concerns in aviation. Identifying information, such as company

affiliation, is removed from the reports. Because of the voluntary nature of the data collection methods, the presence

of an event in the ASRS data base probably indicates that a number of such events are occurring.
31

1.18.2 COA Guidance to Pilots on the DC-9 Hydraulic System

COA’s FAA-approved training program requires that, within the preceding 12

months, all flightcrew members complete a recurrent systems review (RS) course. According to

the COA Flight Operations Training Manual, aircraft systems subjects are taught in a 3-year

cycle; the “Hydraulics” subject is taught in the first year of the cycle, and 1995 was the first year

of a cycle. The RS course includes 8 hours of classroom instruction and a home study module.

The 1995 home study material on hydraulics provides the following information on the system

priority valves:

Each system is divided into a priority and non-priority section by a priority

valve. This valve restricts available pressure to the priority section when

pump output is at or below 2000 psi. This valve allows free flow in the

opposite direction.

The text does not specifically list the priority or non-priority components;

however, a schematic diagram of the hydraulic system is provided from which this information

could be extracted. Regarding the engine-driven hydraulic pump switch positions, the home

study material states the following:

OFF-energizes solenoid to position pump to zero pressure output, hydraulic

fluid circulates through pump for lubrication.

LOW-allows pump to operate at approximately 1500 psi (lower green band).

HI-pump will now operate at approximately 3000 psi (upper green band).

NOTE: If electrical power is lost, pump will operate at full output

pressure regardless of switch position.

In addition, the section entitled “Hydraulic System, Landing Gear, Brakes, &

Anti-Skid,” in the COA DC-9 Flight Manual, provides the following guidance to the pilot under

the heading “Engine Driven Pumps”:

EACH ENGINE DRIVEN PUMP IS A VARIABLE DISPLACEMENT TYPE PUMP CAPABLE

OF PROVIDING 8 GALLONS PER MINUTE FLOW AT A MAXIMUM PRESSURE OF 3,000

PSI. THE PUMPS ARE SWITCH CONTROLLED AND SOLENOID OPERATED. THE 3-

POSITION SWITCHES ARE LOCATED ON THE FIRST OFFICER’S INSTRUMENT PANEL

AND CONTROL THE OUTPUT PRESSURE OF THE RESPECTIVE PUMPS.

IN THE “HIGH” MODE, PUMP OUTPUT PRESSURE IS 3,000 PSI. THE “LOW”

MODE REDUCES THE PRESSURE TO 1,500 PSI. THE “OFF” POSITION

ELECTRICALLY UNLOADS THE PUMP AND DEPRESSURIZES THE SYSTEM. THE

ENGINE DRIVEN PUMPS ARE “FAIL-SAFE” TO THE “HIGH” MODE OF OPERATION

IF ELECTRICAL POWER IS LOST.
32

Under the heading “System Priority and Priority Valves,” the manual states the following:

HYDRAULIC COMPONENTS ARE CATEGORIZED AS BEING EITHER PRIORITY OR

NON-PRIORITY, DEPENDING UPON THEIR OPERATING PRESSURE REQUIREMENTS

AND/OR THEIR FUNCTION DURING THE OPERATING REGIMES OF THE AIRCRAFT.

PRIORITY COMPONENTS ARE MAINLY ASSOCIATED WITH NORMAL FLIGHT

OPERATIONS, AND REQUIRE LOWER OPERATING PRESSSURES TO FUNCTION.

THESE COMPONENTS INCLUDE: SPOILERS; SLATS; RUDDER; FLAP/RUDDER

STOP; ENGINE REVERSERS; ELEVATOR AUGMENTATION SYSTEM; AND THE

VENTRAL STAIR SYSTEM (GROUND OPERATION ONLY).

NON-PRIORITY COMPONENTS INCLUDE: LANDING GEAR; BRAKES; FLAPS;

NOSE WHEEL STEERING; AND THE ALTERNATE GEAR PUMP. THESE

COMPONENTS REQUIRE A SYSTEM PRESSURE OF AT LEAST 2000 PSI TO FUNCTION

NORMALLY, AND ARE REQUIRED FOR ALL GROUND OPERATIONS, INCLUDING

TAKEOFF AND LANDING.

TO MAINTAIN SUFFICIENT HYDRAULIC FLUID SUPPLY AND PRESSURE FOR

PRIORITY COMPONENT OPERATION, A ONE-WAY RESTRICTOR VALVE, OR

PRIORITY VALVE, IS INSTALLED IN EACH SYSTEM. THE VALVE IS DESIGNED TO

PREVENT FLUID PASSAGE UNTIL 2000 PSI OR GREATER PRESSURE IS AVAILABLE.

IN FLIGHT, SYSTEM PRESSURE IS REDUCED TO 1500 PSI, WHILE TAKEOFF AND

LANDING OPERATIONS REQUIRE FULL SYSTEM PRESSURE OF 3000 PSI.

1.18.3 COA Crew Resource Management Training

Continental’s manager of human factors told Safety Board investigators that pilots

upgrading or downgrading at COA attend a 1-day CRM course known as “Crew Coordination

Concepts (CCC).” This course is conducted as a workshop with a CRM facilitator to elicit

discussion of crew coordination issues relevant to pilots changing their cockpit role. The course

includes role playing, discussion of personal experiences, review of industry accidents and

incidents, and evaluation of crew behavior from videotapes. The course also reviews the

importance of checklists and strict adherence to standard operating procedures. Safety Board

investigators attended a CCC workshop on August 29, 1996, and found that specific emphasis

was placed on the danger of accepting, during line operations, short-cuts or “norms” that deviate

from standard operating procedures.

According to the manager of human factors, check airmen at COA evaluate

flightcrews during line checks on technical proficiency and six “Crew Effectiveness Markers”

based on CRM principles. The evaluation form used by the check airmen, and reviewed with the

crew after a check ride, contains descriptions of each of the six areas. The six “Crew

Effectiveness Markers” are also presented in the COA DC-9 Flight Manual as follows:
33

The following Crew Effectiveness Markers were developed to assist crew

members in their understanding and practice of [CRM]. The markers were

structured in a checklist format for ease of use and recall. . . . They should be

reviewed periodically to improve CRM proficiency, just as emergency and

abnormal checklists are revisited from time to time. CRM will be evaluated in

training events, proficiency checks and line checks utilizing the Crew

Effectiveness Markers.

OVERALL TECHNICAL PROFICIENCY

 Set a professional example.

 Adhere to SOP, FAR’s, sterile cockpit, etc.

 Demonstrate high level of flying skills.

 Be adept at normal and abnormal procedures.

 Maintain thorough systems knowledge.

BRIEFING and COMMUNICATION

 Set an open tone.

 Fully brief operational/safety issues.

 Explicitly encourage participation.

 All are obligated to seek and give information.

 State how SOP deviations will be handled.

 Include cabin crew.

LEADERSHIP and TEAMWORK

 Balance authority and assertiveness.

 Promote continual dialogue.

 Adapt to the personalities of others.

 Use all available resources.

 Must share doubts with others.

SITUATIONAL AWARENESS

 Monitor developments (fuel, weather, ATC, etc.).

 Anticipate required actions.

 Ask the right questions.

 Test assumptions, confirm understanding.

 Monitor workload distribution and fellow crew members.

 Report fatigue, stress, and overload in self and others.

DECISION MAKING

 Fly the aircraft.

 Obtain all pertinent information.

 All crew members state recommendations.

 Better idea suggested? Abandon yours.

 Clearly state plan or intentions.
34

 Establish “Bottom Lines”.

 Resolve conflicts and doubts quickly.

CREW SELF-EVALUATION

 Debrief key events.

 Continuously provide information to self-correct.

 Openly discuss successes and mistakes.

 Ask, “How could we have done better?”.

 Discuss what is right, not who is right.

In addition, the COA DC-9 Flight Manual contains the following information

about CRM:

Effective [CRM] can substantially improve safety in line operations.

Technical proficiency, knowledge of aircraft systems and adherence to

standard operating procedures continue as the foundation of aviation safety. . .

. The practice of effective CRM is expected behavior among all crewmembers.

Pilots should routinely utilize effective CRM skills as discussed during the

[CCC] workshops. . . . Industry studies have shown that most airline mishaps

were attributable to poor CRM. Failure to follow standard operating

procedures, failure of non-flying pilots to monitor the flying pilot, and

unchallenged tactical decision errors by the Captain were the leading causes

identified. Effective CRM would have broken the chain of events leading to

an accident in the majority of mishaps studied.

According to COA training personnel, following this accident and the internal line

checks conducted in the spring of 1996, COA worked with human factors experts from NASA

and the University of Texas to design a new 1-day CRM course known as “Error Management.”

All active COA flightcrew members are scheduled to complete this course during 1997.

1.18.4 COA Checklist Procedures

The section entitled “Use of Checklists,” in the COA DC-9 Flight Manual,

provides the following guidance to the pilot regarding normal checklists:

The Pilot Flying will call for all checklists in flight. Each item will be

challenged out loud by the designated crewmember unless otherwise noted.

The responding crewmember will visually confirm that the challenged action

has been properly accomplished and will respond appropriately to the

challenge, confirming the action or describing the configuration. . . . When

responses are required by both crewmembers (C, F), the pilot responding to

the checklist replies first followed by a crosscheck and identical reply from the

other pilot. . . . Any action which has not been performed or completed when
35

challenged must be completed before the next challenge is read. If

performance of the challenged action cannot be completed immediately, the

crewmember responding will reply “Standby” or other suitable response to

indicate that further reading of the checklist will be suspended until the item

can be accomplished.

Both pilots are responsible for visual confirmation that all checklist items are

completed. Each checklist item will be treated separately, read in a command

tone, and answered only when the challenged action has been completed and

is in agreement with the appropriate response [emphasis in original]. When

the crewmember reading the checklist has ascertained that all items have been

completed, he will announce, “____ CHECKLIST COMPLETE.”

Continental’s vice president of training told Safety Board investigators that COA

instructs pilots to work through the flow required in a particular checklist and then use the

checklist to confirm the configuration of the aircraft. COA pilots are not required to physically

hold the checklist but are instructed to directly refer to the checklist; normal checklists are not to

be performed from memory. COA pilots are instructed to correct a pilot reading a checklist

using nonstandard phraseology. They are not specifically instructed to perform checklists in a

timely manner; however, if interrupted, pilots are instructed to state that the checklist has been

stopped and where it has been stopped. They are not required to use a placeholder, but if they

forget where the checklist was stopped, they are to resume the checklist from the start.

The COA normal checklists for the DC-9 are printed along two columns on two

sides of a laminated 8.5- by 11-inch card. The card was designed to be folded in half along its

longest dimension to isolate each column. Each column contains between two and five separate

checklists. During line operations, Safety Board investigators observed COA crews on the DC-9

and MD-80 routinely folding the card a second time, into quarters. The dimensions of the folded

card were about 4.25 by 5.5 inches, and crews stowed it in the sliding-window latch mechanism

while not in use or placed it for use on the yoke clipboard. Depending on the location of the

checklists on the card, the additional fold could cross a single checklist and require the card to be

turned over or unfolded to read the items on and after the fold.

COA’s expanded checklist procedure for the in-range checklist indicates that the

checklist “will be accomplished at 18,000 feet” and is to be conducted by “PNF [pilot not flying]

Challenge - PNF Respond.” Only one of the seven items on the checklist, “Flight Instruments,

Altimeters,” requires a response by both pilots. The fourth item on the checklist is “Hydraulics -

ON, HI, CHECKED.” The expanded procedure for this item states the following:

Place the L and R Eng Hyd Pumps switches to the HI position and check both

HYD Press gauges within 3000 PSI green arc. Check both Hyd Fluid

Quantity gauges for indication above red line.
36

Place Alt and Aux Hyd Pump switches to ON position. This is to provide an

additional source of hydraulic pressure in the event of an engine pump failure.

Verify brake pressure gauges are normal.

The expanded checklist procedure for the landing checklist indicated that the pilot

flying should call for the checklist in conjunction with the gear-down call and the pilot not flying

should complete the procedure and the checklist. Both pilots were required to “respond to the

gear challenge.” The first item on the checklist was “Gear - DOWN, 3 GREEN.” The expanded

procedure for this item states the following:

Placing landing gear handle to DOWN position and in the detent will put the

gear down and close the doors. The three green lights will come on indicating

that all three gear overcenter links are in place. The main landing gear doors

are closed and held closed by hydraulic pressure. The GEAR DOOR OPEN

light should be out.

1.18.5 COA Standard Operating Procedures

The Safety Board reviewed the operational procedures for landings contained in

the COA DC-9 Flight Manual. Under the heading “Stabilized Approach,” the manual states the

following:

A “stabilized” approach is defined as flight on the desired glide path (visual or

electronic) at a steady rate of descent, on the “target” speed in landing

configuration, in trim, and with the proper thrust setting. Approach planning

which results in a stabilized approach at and below 1,000 feet above field

elevation will provide the most consistent landing performance. Unstabilized

approaches must not be allowed to continue below 500 feet above field

elevation in VMC conditions, or below 1,000 feet above field elevation in

IMC conditions except as required for descent on non-precision approaches.

Under the heading “Final Approach,” the manual states the following:

Once landing flaps have been established, target speeds (under stable air

conditions) will be VREF +5 knots. . . . When landing in higher wind

conditions (above 10 knots), add 1/2 the steady wind and the full value of the

gust (if any).

The approach procedures section of the COA DC-9 Flight Manual provides the

following guidance to the pilot regarding GPWS warnings:

Under day IFR or night flight conditions, a GPWS terrain warning will be

responded to by application of thrust and a positive pull-up out of the danger

zone. Under day VFR flight conditions, the crew will evaluate conditions and

take appropriate corrective actions when a terrain warning is annunciated.
37

Any “Terrain”, “Pull-up”, or configuration warning that occurs or continues

below 200’ AFE mandates a go-around, regardless of flight conditions.

Additional information regarding GPWS warnings is contained in the section of

the manual entitled “Ground Proximity Warning System” and states the following, in part:

WARNING: Do not ignore short duration warnings. Take immediate and

aggressive action to correct the flight path.

Any “TERRAIN,” “PULL UP,” or configuration warning that

occurs or continues below 200’ AFE mandates a go around

regardless of flight conditions.
38

2. ANALYSIS

2.1 General

The two-member flightcrew and three flight attendants were trained and qualified

to conduct the flight in accordance with Federal regulations. There was no evidence of any

medical condition that might have affected the flightcrew’s performance.

VMC prevailed, and weather was not a factor in the accident. The Safety Board

considered the role that the ATC request to maintain 190 knots to the outer marker had in the

accident. The captain had substantial experience flying into IAH during his 12-year career at

COA. He told investigators that the ATC request was not unusual during VMC conditions at

IAH. The first officer demonstrated some confusion about the request, but his actions to

configure the airplane for landing were timely and appropriate upon passage of the outer marker.

The Safety Board concludes that the ATC request to maintain 190 knots to the outer marker did

not contribute to the accident because it did not affect crew actions, decisionmaking, or

situational awareness.

The airplane was certificated and equipped and maintained in accordance with

Federal regulations and approved procedures. There is no evidence that mechanical

malfunctions or failures of the airplane structures, flight control systems, or powerplants

contributed to the accident.

The evidence indicates that the airplane’s hydraulic system was not configured for

landing. Because the hydraulic system remained in the low pressure mode, hydraulic pressure

was not available to lower the landing gear and deploy the flaps. The flightcrew failed to detect

this configuration error and continued its approach into Houston. Comments on the CVR and

postaccident statements by the flightcrew indicate that both pilots recognized that the flaps did

not deploy after the flaps were selected to 15o

, but the flightcrew did not determine the cause of

this problem or execute a go-around.

The landing checklist was not performed, and the flightcrew did not confirm that

the gear was down and locked. The gear warning horn sounded during the approach, indicating

that the landing gear was not extended, but it was ignored. When the airplane descended through

500 feet AFE, it was traveling 84 knots faster than the target airspeed of 132 knots. Although,

under COA standard operating procedures, this excessive airspeed mandated that the approach be

discontinued, the captain rejected a go-around request from the first officer, who was the flying

pilot. The GPWS sounded an alert 19 seconds before impact and was ignored. Unaware that the

gear was not down, the captain assumed control of the airplane and made a wheels-up landing.

This analysis addresses flightcrew performance, including the role of fatigue in

the flightcrew’s performance, the adequacy of COA’s oversight of its pilots and the FAA’s

oversight of COA, checklist design, and survival factors.
39

2.2 Flightcrew Performance

Performance deficiencies exhibited by the flightcrew during this flight include: (1)

failure to configure the hydraulic system for landing during the performance of the in-range

checklist; (2) failure to detect initially that the flaps did not extend; (3) failure to determine the

reason the flaps did not extend after detection; (4) failure to perform the landing checklist and to

confirm the landing gear status; and (5) failure to discontinue the approach.

2.2.1 Failure to Properly Complete the In-range Checklist

Fifteen minutes before landing, as the airplane descended through 19,000 feet, the

captain omitted one item on the in-range checklist. The omitted item, “Hydraulics - ON & HI,

CHECKED,” would have enabled the high pressure configuration of the hydraulic system,

thereby providing pressure to operate the flaps and landing gear. Three steps were required to

complete this checklist item: movement of the AUX and ALT pump switches from “OFF” to

“ON,” movement of the left and right engine-driven hydraulic pump switches from “LOW” to

“HI,” and confirmation that system pressures were between 2,800 and 3,100 psi.

The Safety Board examined the following potential reasons for the captain’s

omission of the checklist item:

• The captain was interrupted or distracted.

• The checklist item, “Hydraulics,” was obscured by a fold in the checklist.

• The captain expected the first officer to complete the hydraulics item because

of the existence of an informal “norm.”

The results of line checks conducted in the weeks after the accident as part of

COA’s participation in the NASA/University of Texas/FAA-sponsored Aerospace Crew

Research Project found instances of checklist procedural violations, including improperly

completed checklists after interruptions. Interruptions during the in-range checklist could have

come from several sources including other flight tasks, system anomalies, scanning for traffic,

ATC communications, or nonessential conversation. However, there is no indication that any of

these events occurred during the captain’s performance of the in-range checklist.37 The captain

accomplished the checklist in less than 30 seconds, and there was no delay when he read items in

the list immediately before and after the skipped checklist item. There is no evidence that an

interruption or distraction contributed to the omission of the checklist item.

The in-range checklist contains seven items and is located approximately midpage on the left column on COA’s laminated 8.5- by 11-inch DC-9 normal checklist. The checklist

used by the captain was folded into quarters, and the horizontal fold bisected the in-range

 37 No ATC communications were directed to flight 1943. Routine ATC communications to other

aircraft were present and are a normal part of airline operations.
40

checklist. However, the fold was between the last two items of the checklist, “Approach

Briefing” and “Sterile Cockpit Light.” The captain referred to each of these items. The checklist

item, “Hydraulics,” was not obscured by the additional fold.

Regarding the informal norm assigning the first officer the responsibility to

manipulate the hydraulic pump switches at all times, even when the first officer was the flying

pilot, the captain said he did not adhere to the norm in his cockpit and did not expect the first

officer to work the hydraulic pump switches during the accident flight. Therefore, it is unlikely

that the norm contributed to the captain’s failure to properly configure the hydraulic system.

However, the existence of informal norms, the findings from the line checks conducted after the

accident, and the recent history of flightcrew-related accidents at COA raises concerns that an

operational climate may have existed in which crews occasionally deviated from standard

operating procedures. This significant issue is addressed in section 2.4 of this analysis.

In summary, the Safety Board found no evidence indicating that the captain was

interrupted or distracted during the performance of the in-range checklist, that the omitted

checklist item was obscured, or that the captain believed the first officer would configure the

hydraulic system. The Safety Board was unable to determine the specific reason for the captain’s

omission of the “Hydraulics” item on the in-range checklist.

The COA DC-9 Flight Manual states that both pilots are responsible for visual

confirmation that all checklist items are completed. The first officer’s response to two items on

the checklist, “Flight Instruments, Altimeters” and “Shoulder Harness,” indicates that he was

aware that the in-range checklist was being completed. However, the first officer did not detect

the captain’s omission of the “Hydraulics” item. The Safety Board concludes that because the

captain omitted the “Hydraulics” item on the in-range checklist and the first officer failed to

detect the error, hydraulic pressure was not available to lower the landing gear and deploy the

flaps.

The Safety Board is concerned that the normal in-flight operating procedure for

the DC-9 hydraulic system deactivates (or, in the case of the MD-80, impairs the operation of)

certain hydraulic components, including the landing gear and the flaps, without providing an

overt signal to the flightcrew of the non-functional status of those components. If the hydraulic

system is not configured properly during performance of the in-range checklist, the error can

initially only be determined by direct observation of the hydraulic pump switches and pressure

gauges. Because the flaps and landing gear are not typically extended until the later stages of an

approach, the next opportunity for the flightcrew to detect such an error occurs during a period of

higher workload when there is less time for problem diagnosis.

The February 1995 ASRS report and statements by other DC-9 pilots indicate that

failure to configure the hydraulic system for landing is not an uncommon occurrence.38 A review

of checklists from several DC-9 and MD-80 operators revealed that none of the checklists,

including the Douglas Aircraft Company’s checklist, emphasize the importance of the

 38 See discussion in section 1.18.1.
41

“Hydraulics” item by placing it as the first item on the in-range checklist or requiring mandatory

cross-check of the item by both pilots. Further, the item requires only an “ON & HI,

CHECKED” response to the challenge and does not require verbal notation of the pressure

values. NASA-sponsored research on checklist design39 indicates that critical items should be

placed first on a checklist because the probability of successfully accomplishing the first items on

a checklist is the highest. In addition, this research indicates that errors in checklist execution

can be reduced by designing checklists that incorporate redundancy through requiring crosscheck of items by both pilots, and that reduce ambiguity by requiring verbal responses stating the

actual value of an item.

The Safety Board concludes that the “Hydraulics” item is placed too low on the

in-range checklist, rendering it vulnerable to omission. Therefore, the Safety Board believes that

the FAA should require all DC-9 and MD-80 operators with the “HI, LOW, OFF” hydraulic

switch configuration to revise their checklists to emphasize the importance of the “Hydraulics”

item by placing it as the first item on the in-range checklist (or equivalent), and requiring that

both pilots verbally verify hydraulic pump switch settings and system pressures.

2.2.2 Failure to Confirm Flap Function at the 5o

 Setting

Because the flightcrew did not note the information displayed by the hydraulic

system pressure gauges and pump switches, the first opportunity to detect the configuration error

through abnormal system function came when the crew selected 5o of flaps. At 0859:00, the first

officer called “go slats and five,” and the captain moved the flap handle to the 5o setting. Only

the leading edge slats deployed because of the low hydraulic pressure. Although the captain

recalled that he felt the slats extend and the first officer recalled that the blue “SLATS

EXTEND” light illuminated, the flightcrew failed to detect that the flaps had not extended to 5o

.

The following cues were available to both pilots to signal abnormal system function:

During slat extension

• Momentary illumination of the “MASTER CAUTION” and “HYD PRESS

LOW” lights.

• Absence of pitch changes that normally occur when both flaps and slats

are in transition.

After slat extension

• Flap gauge pointer indicating zero at the 12-o’clock position, instead of 5o

at the 1-o’clock position.

 39 Degani, A. & Weiner, E. Human Factors of Flight-Deck Checklists: The Normal Checklist,

NASA Contractor Report 177549, May, 1990.
42

Because he was the flying pilot, the absence of normal pitch changes would have

been most perceptible to the first officer. However, as mentioned previously, DC-9 pilots

interviewed by Safety Board investigators stated that it is difficult to detect the difference

between flaps 5o and flaps 0o with slats extended using handling characteristics alone.

Nonetheless, the illumination of the “MASTER CAUTION” and “HYD PRESS LOW” lights,

even though momentary, should have alerted the flightcrew to a problem. The Safety Board

considered the possibility that both pilots were distracted, which prevented detection of the lights

and the zero indication on the flap gauge.

 At 0858:48, immediately before the first officer requested slats and 5o

 of flaps,

the captain commented “aw shoot. I can’t play tennis when it’s like this. . . . well maybe this

afternoon it’ll clear up. actually I’ve still got a lot of time.” After moving the flap handle, the

captain stated “slats are going to five,” paused for about 10 seconds, and then, contrary to the

sterile cockpit rule,40 continued to discuss with the first officer for about 30 seconds the weather

as it would affect his afternoon tennis. The first officer then initiated dialogue with the captain to

clarify whether ATC had asked them to maintain 190 knots to the outer or middle marker.

The topic of the captain’s conversation indicates that his attention was directed

outside the cockpit as he assessed the weather’s effect on his tennis plans. It would have been

unlikely for him to detect the momentary illumination of the “MASTER CAUTION” light,

especially if he was using a side window to view the rain on the ground. The first officer may

have been distracted by the captain’s statements, or by his own concern about the ATC speed

request. It is possible that he was examining an approach plate or the cockpit instruments to

evaluate his position relative to the outer marker. It is also possible that he detected the

momentary illumination of the “MASTER CAUTION” light, but assigned it no significance

because the blue “SLATS EXTEND” light was illuminated, providing a positive cue of system

function.

The failure of the flaps to extend to 5o

 was an important cue that the hydraulic

system was not properly configured. The detection and diagnosis of the flap problem at this

stage of flight could have prevented the accident. Although the Safety Board was unable to

determine the specific reason why the flightcrew failed to detect the momentary illumination of

the “MASTER CAUTION” light or the zero flap gauge indication, it concludes that the captain’s

distraction from his duties as pilot-in-command and his disregard for the sterile cockpit rule

contributed to the pilots’ failure to detect their hydraulic system configuration error when they

selected 5o

 of flaps. The captain’s disregard for the sterile cockpit rule also raises concerns that

 40 Title 14 CFR Part 121.542 states, “no flight crewmember may engage in, nor may any pilot in

command permit, any activity during a critical phase of flight which could distract any flight crewmember from the

performance of his or her duties or which could interfere in any way with the proper conduct of those duties.

Activities such as eating meals, engaging in non essential conversations within the cockpit and non essential

communications between the cabin and cockpit crews, and reading publications not related to the proper conduct of

flight are not required for the safe operation of the aircraft. Critical phases of flight include all ground operations

involving taxi, takeoff and landing, and all other flight operations below 10,000 feet, except cruise flight.”
43

an operational climate tolerant of nonstandard conduct may have existed at COA. As mentioned

previously, this issue will be addressed in section 2.4.

2.2.3 Failure to Determine the Cause of the Flap Extension Problem

There is evidence that both pilots recognized that the flaps had not extended

during the final minute of the flight. The first officer has indicated that he recognized that the

flaps had not extended somewhere between 1 minute and 1 minute 13 seconds after he first asked

for them to be extended. After the accident, the captain consistently stated that he felt the flaps

were extended. However, the following evidence suggests the captain also recognized the flaps

had not extended:

• His instruction at 0901:03 to the first officer to maintain speed was consistent

with an approach without flaps.

Further, in postaccident statements, the captain said the following:

• He recalled the first officer saying the flaps were zero.

• The airplane did not respond as it should have with the flaps at 50o.

• The 10,000-foot runway length was a factor in his decision to land.

Based on this evidence, the Safety Board concludes that both the captain and the first officer

recognized that the flaps had not extended after the flaps were selected to 15o.

As the pilot not flying, the captain had primary responsibility for initiating

diagnosis of the reason for the flap extension problem. The first officer communicated the

anomaly to the captain using nonverbal and verbal messages. The captain’s postaccident

statements indicate that he received the first officer’s message. However, the captain’s diagnosis

was limited to confirmation that the flap handle was positioned properly and making throttle

movements.41 These ineffective actions suggest that the captain was confused and not able to

comprehend the information that was available to him. This type of behavior is consistent with

the effects of fatigue, a topic that will be addressed in section 2.3 of this analysis.

Consistent with other DC-9 pilots who reported failing to properly configure the

hydraulic system, this crew detected a problem with flap deployment when the airplane did not

respond with pitch and speed changes as flaps were selected to 15o and beyond. However, this

crew did not recognize that the failure of the flaps to deploy was a symptom of improper

hydraulic system configuration. Neither the captain nor the first officer recalled events concerning

improper hydraulic system configuration in his previous DC-9 experience and, therefore, did not

 41 At 0900:33, the captain said, “I think the flaps *.” At 0900:35, there were three intermittent

sounds from the landing gear warning horn that, according to the first officer, were produced by the captain rapidly

moving the throttles back and forth. The throttle manipulation would not have provided the captain with diagnostic

information about the flaps.
44

possess firsthand knowledge to help recognize that the symptom he was experiencing was the

result of this error.

In addition, the Safety Board’s review of the information provided by COA to its

pilots concerning the DC-9 hydraulic system revealed that the flight manual and training

materials do not explicitly state that if the pumps are not switched to “HI,” the landing gear will

not extend and the flaps will not deploy. The Safety Board concludes that the pilots’ lack of

previous exposure, either through training or during line operations, to the consequences of

improper hydraulic system configuration contributed to their failure to detect their hydraulic

system configuration error.

The Safety Board believes that the FAA should require all POIs of 14 CFR Part

121 operators using DC-9 and MD-80 airplanes with the “HI, LOW, OFF” hydraulic switch

configuration to ensure that operating manuals and training programs include information about

the consequences of improper hydraulic system configuration, specifically that the flaps and

landing gear will not function normally if the engine-driven hydraulic pumps are not set to “HI.”

2.2.4 Failure to Perform Landing Checklist and Confirm Gear Position

In accordance with company procedures, the first officer called for the landing

checklist after the gear-down call. Although he placed the gear handle in the down position, the

captain never initiated the checklist.

Because the flaps remained stowed, the airplane did not slow during the approach.

Traveling at a speed of approximately 200 knots, the airplane covered the distance between the

outer marker and the runway threshold in about 75 seconds. If the target approach speed of 132

knots had been maintained, it would have taken about 115 seconds to cover this distance. The

increase in speed allowed the flightcrew very little time to address the flap problem and

configure the airplane for landing.

In the 27 seconds that elapsed from the time the captain said “I think the flaps *”

to the time the first officer stated “I don’t have flaps,” the captain manipulated the throttles and

then responded to the gear-down call, the flaps 25 call, the flaps 40 call, and the flaps 50 call.

The captain had very little time to react to the directives he was being given by the first officer.

The first officer’s rapid calls for 40o

 and then 50o of flaps probably interrupted the captain as he

was initiating the landing checklist. It is likely that the first officer was preoccupied flying the

approach at an unusually high rate of speed and was unaware that the checklist had not been

accomplished. Thus, neither pilot confirmed the landing gear was down and locked as required

by the first item in the checklist.

During postaccident interviews, both pilots recalled the gear handle being moved

to the down position.. Apart from the handle position, the following cues were available to

indicate to the flightcrew that the gear was not down:
45

• There was no increase in cockpit noise after the gear handle was placed in the

down position, as there would have been if the nosegear doors had opened and

the gear extended into the slipstream.

• The red gear unsafe lights and the amber gear door open light, which would

have illuminated when the gear were in transition, remained off.

• The green gear lights, which would have illuminated when the gear were

down and locked, remained off.

• The gear warning horn sounded almost continuously after the flap handle was

moved to 25o at 0900:46.42

Neither pilot was alerted to the status of the gear by the absence of the normal

cues (increase in noise and lights). However, detecting the absence of normal cues is often more

difficult than detecting the presence of abnormal cues. Nonetheless, neither crewmember

responded to the gear warning horn. The reason for this may be that the gear warning horn

frequently sounds during routine operations, and it can be perceived by pilots as a nuisance

alarm. For example, the horn sounds during approaches whenever the throttles are reduced to

idle and the landing gear is not down; a condition that is not always consistent with a dangerous

configuration. Research has shown that frequent alarms can lead to slower response times or

even disregard for a warning.43 In this case, however, the horn sounded after the gear handle was

placed down and the flap handle was moved to 25o

. These conditions were outside the

traditional “nuisance” envelope.

The first officer later stated that he did not hear the horn; the captain stated that

he heard the horn but thought it sounded because he put the flaps to 25o before the gear was

down and locked. It is possible that the horn’s constant tone lost its salience as a signal in the

environment because of the extended duration it sounded during the final minute of the approach.

However, it is more likely that the pilots failed to detect the numerous cues alerting them to the

status of the gear for the same reasons they failed to perform the landing checklist—

preoccupation with the flap extension problem and their high workload during the final minute of

the flight.

The Safety Board concludes that the pilots failed to perform the landing checklist

and to detect the numerous cues alerting them to the status of the landing gear as a result of their

focus on coping with the flap extension problem and the high level of workload because of the

rapid sequence of events in the final minute of the flight. The Safety Board also concludes that

had the landing checklist been properly performed, the flightcrew would have detected the failure

of the landing gear to extend.

 42 The landing gear warning horn stopped for 8 seconds from 0901:07 to 0901:15. This issue is

addressed in section 2.2.5.2.

43 See, for example, Getty, D.J., Swets, J.A., Pickett, R.M., & Gonthier, D., 1995, “System

Operator Response to Warnings of Danger: A Laboratory Investigation of the Effects of the Predictive Value of a

Warning on Human Response Time.” in Journal of Experimental Psychology: Applied, Vol. 1, Pages 19-33.
46

2.2.5 Failure to Discontinue the Approach

According to FDR data, 34 seconds before touchdown, the airplane was 504 feet

AFE and traveling at 216 knots indicated airspeed. Again, this speed was 84 knots faster than the

target airspeed of 132 knots established by the flightcrew during completion of the descent

checklist. In addition, the speed was 63 knots faster than the reference airspeed of 153 knots for

a flaps-up, slats-extended landing at a weight of 86,000 pounds. The COA DC-9 Flight Manual

current at the time of the accident described a stabilized approach as flight on the desired glide

path at a steady rate of descent, on the target speed in landing configuration, in trim, and with the

proper thrust setting. The manual stated that unstabilized approaches must not be allowed to

continue below 500 feet AFE. The approach was clearly unstabilized when the airplane

descended through 500 feet; yet, the flightcrew failed to discontinue the approach.

2.2.5.1 Role of the First Officer

The first officer told Safety Board investigators that his goal after recognizing that

the flaps were not extended was to get the captain to initiate a go-around. Thirty seconds before

touchdown, the first officer stated “want to take it around?” and the captain replied “no that’s

alright. * keep your speed up here about uh.” When the captain denied the first officer’s request

to go around and told him to keep his speed up, the first officer did not challenge the captain’s

statement. He also did not question the captain to determine his reason(s) for continuing the

approach. The first officer stated that there was no time for discussion with the captain because

the approach was so fast. The first officer’s failure to question the captain’s decision to continue

the approach was inconsistent with the CRM training he had received that emphasized the

importance of sharing doubts with other crewmembers and quickly resolving conflicts.

The first officer’s failure to assert himself and overtly challenge the captain’s

decision to continue the approach must be evaluated in the context of the strategy he had

developed after the A-300 incident in 1994 when he was removed from duty for 60 days and sent

to a psychiatrist for evaluation following a captain’s complaint. The first officer described the A300 incident as “terribly damaging” to him personally and professionally. He told Safety Board

investigators he believed his career would be in jeopardy if another captain complained to

management about him. Therefore, after the incident, he adopted a cautious and deferential

mode of interaction with captains to prevent a recurrence, even though this style of

communication could on occasion conflict with the CRM training he had received.

Although the first officer failed to overtly challenge the captain’s decision to

continue the approach, he did continue providing information to the captain about the quality and

stability of the approach. Five seconds after the captain rejected his go-around request by stating

“no you’re alright,” the first officer said “I can’t slow it down here now.” The captain again

stated “you’re alright,” and the first officer replied “we’re just smokin’ in here.” The Safety

Board concludes that although the first officer was unwilling to overtly challenge the captain’s

decision to continue the approach, he did attempt to communicate his concern about the

excessive speed of the approach to the captain.
47

Nonetheless, the Safety Board is concerned that a pilot was disinclined to

assertively challenge another pilot’s decision, despite having completed CRM training

advocating that he do so, because he feared reprisal. Therefore, the Safety Board believes that

the FAA should require all POIs of 14 CFR Part 121 carriers to ensure that the carriers establish

a policy and make it clear to their pilots that there will be no negative repercussions for

appropriate questioning in accordance with CRM techniques of another pilot’s decision or action.

In addition, the Safety Board believes that the FAA should require all POIs of 14 CFR Part 121

carriers to ensure that CRM programs provide pilots with training in recognizing the need for,

and practice in presenting, clear and unambiguous communications of flight-related concerns.

2.2.5.2 Role of the Captain

The captain’s rejection, without any discussion, of the first officer’s go-around

request was inconsistent with the CRM training concerning decisionmaking that he had received.

This training emphasized the importance of giving consideration to the recommendations of

other crewmembers and obtaining all pertinent information before committing to a course of

action. The first officer, because he was flying, had substantial information about the quality and

stability of the approach; however, the captain chose to ignore the first officer’s recommendation.

The captain stated after the accident that he was aware that the first officer was uncomfortable

with the approach, but that the captain felt comfortable continuing with the landing.

The GPWS warning that began sounding 19 seconds before touchdown was not

heeded by the captain. The warning began at 0901:13 when the airplane was 275 feet AFE and

continued until 0901:18 when the airplane was 172 feet AFE. The COA DC-9 Flight Manual

current at the time of the accident stated that any GPWS warning that occurred or continued

below 200 feet AFE mandated a go-around regardless of flight conditions.

There is also evidence that the captain may have attempted to silence the GPWS

warning. During the final 30 seconds of flight, the gear warning horn stopped sounding for 8

seconds. Because the landing gear was not down and locked, the only way the gear horn could

have been silenced at this point was by moving the flap handle to a setting of 15o

 or less. This

would have placed the airplane in a condition (gear handle down, flap handle not selected to the

landing position) enabling the GPWS to generate a flap configuration warning. Six seconds after

the gear warning horn stopped sounding, the GPWS alerted “whoop whoop pull up” three times.

During the second GPWS alert, the gear warning horn resumed sounding and continued to do so

until after touchdown.

The first officer stated that the captain reached up to the overhead panel as the

GPWS began alerting. The captain did not recall doing this. During examination of the cockpit

following the accident, the safety wire on the GPWS flap override switch was found broken;

however, the switch was not in the “OVRD” position. Moving the switch to the “OVRD”

position would have terminated the GPWS warning. Moving the flap handle to a setting greater

than 15o

 would also have terminated the GPWS warning. After the accident, the flap handle was

found in the 50o

 position. A possible explanation for the 8-second interruption of the gear

warning horn and the three GPWS alerts is that one of the pilots cycled the flap handle. It is
48

conceivable that this was an attempt to diagnose the cause of the flap extension problem. During

postaccident interviews, neither pilot recalled cycling the flap handle.

The GPWS unit installed in the airplane was a Mark I system, which only

provided a generic “pull up” warning and did not provide a specific message about the reason for

the alert. A Mark II system would have provided the warning “too low flaps.” The Safety Board

considers it unlikely that the captain’s decision to land would have been affected even if he had

received the more specific warning, as he was already aware that the flaps were not extended.

However, the captain’s statement that he interpreted the alerts as a high sink rate warning, and

not as a configuration warning, illustrates the potential for misinterpretation of the less specific

warning messages provided by the Mark I GPWS.

Another example of the inadequacy of the Mark I GPWS was provided by the

COA B-727 accident in November 1993.44 The Safety Board is disappointed that COA has not

replaced all its Mark I GPWS units, but it recognizes that there is currently no Federal regulation

mandating such replacement.

The Safety Board has addressed the need for improvements to the GPWS

equipment installed in 14 CFR Part 121 aircraft several times over the years. Most recently, on

October 16, 1996, the Safety Board issued Safety Recommendation A-96-101, which asked the

FAA to examine the effectiveness of enhanced ground proximity warning equipment, and if it

found the equipment to be effective, require its installation on all transport-category aircraft. The

features provided by enhanced GPWS equipment include aural messages that identify the reason

for a warning. On December 31, 1996, in its initial response to A-96-101, the FAA stated that it

has initiated an evaluation of the effectiveness of enhanced ground proximity warning

equipment. The FAA further stated that it will initiate appropriate action based on the results of

the evaluation, which it anticipates will be completed in March 1997.

There was no safety of flight reason for the captain to land the airplane, and there

was sufficient fuel on board to abort the landing and make another approach. Although the

captain made reference to an on-time arrival bonus,45 there was no system in place at COA

rewarding pilots for individual flight performance. Consequently, the Safety Board concludes

that there was no compelling reason for the captain’s decision to land the airplane; multiple

signals and guidance indicated that the approach should be discontinued, as did COA’s standard

operating procedures.

 44 See discussion in section 1.17.2.

45 At 0854:01, the captain said “surprise, you’re gonna make your on time,” and at 0854:10,

commented “I’m gonna give you another bonus check.” COA had a company-wide bonus system that provided a

$100 bonus to eligible employees, including pilots, for any month when the airline ranked first in on-time arrivals

based on U.S. Department of Transportation Air Travel Consumer Reports. The bonus was $65 when the airline

ranked second or third place. The staff vice president for safety and regulatory compliance told Safety Board

investigators that the bonus system was directed at gate agents and ramp personnel, not pilots.
49

The captain’s improper decision to land was consistent with his behavior as

recorded by the CVR during the final 30 minutes of the flight. His behavior was that of a

passive, distracted pilot and not that of an active member of the flightcrew ensuring the safety of

the flight. He repeatedly deviated from standard operating procedures, failed to adhere to the

sterile cockpit rule, ignored warnings, and did not utilize effective CRM techniques. This

behavior was in sharp contrast to the July 1995 line check report, which rated the captain above

average for “Overall Technical Proficiency” and “Leadership and Teamwork.” It also was

inconsistent with the descriptions of the captain as capable, competent, and personable made by

first officers he had flown with in the year before the accident.

On two separate occasions the captain was interviewed by Safety Board

investigators, and he offered no explanation for his behavior. During the second interview, the

captain emphasized that nothing affected his performance on the day of the accident and stated

that his behavior was normal. However, the Safety Board considered the possibility that fatigue

may have affected the captain’s behavior.

2.3 Role of Fatigue in Flightcrew Performance

Evidence that fatigue may have affected the behavior of flightcrew is available in

the following areas:

• Maximum sleep time available during the layover.

• Statements on the CVR.

• Postaccident statements by the flightcrew.

The flightcrew had a rest period the night before the accident of 9 hours 23

minutes, which was 38 minutes longer than COA’s minimum block-to-block rest period46 of 8

hours 45 minutes. However, because of travel to and from the hotel, the amount of sleep time

obtained by the flightcrew that night was less. The captain had the opportunity for 6 to 6.5 hours

of sleep, and because of his efforts to locate his crew bag, the first officer had the opportunity for

only 5.5 hours of sleep.

During the flight, at 0848:08, the captain indicated he had consumed two cups of

coffee. The captain told Safety Board investigators that he would consume two cups of coffee in

the morning only if it was an early wakeup. At 0857:22, the captain said to the first officer

“you’ve been up all night too.” This statement suggests the captain knew that neither pilot had

obtained a restful night’s sleep.

After the accident, the first officer said that he was tired and felt that fatigue

affected his ability to make decisions at the end of the flight. The captain made conflicting

 46 The block-to-block rest period for a crewmember starts when the last flight of the day for that

crewmember blocks in at the gate (arrives at the gate and parking brake is set) and stops when the first flight of the

next day for the crewmember blocks out (parking brake is released for push back from the gate).
50

statements about fatigue. He initially stated that he felt tired on the day of the accident, but later

he stated that he was not tired at the time of the accident and he did not believe that fatigue was a

factor in the accident.

The captain’s deficient decisionmaking at the end of the flight and his inability to

effectively process the rapidly changing information concerning abnormal system operation are

consistent with the effects of fatigue. There is evidence that obtaining 2 hours less sleep than

normally is required by an individual can degrade alertness and performance.47 Fatigue can

interfere with an individual’s capability to deal with rapidly changing events and to direct and

sustain attention, and can lead to the tendency to fixate.48 However, the captain’s ATC

communications were standard and not suggestive of impairment. The captain was experienced

in airline operations and therefore routine ATC communications were well-learned and processed

automatically. Automatic behaviors are less likely to show the same degradation with fatigue

that accompanies higher cognitive processes such as decisionmaking and problem solving.

The Safety Board found no evidence that the pilots had accumulated a sleep debt

over the days preceding the accident; therefore, the fatigue they may have experienced was not

long term. The Safety Board concludes that the flightcrew’s degraded performance is consistent

with the effects of fatigue, but there is insufficient information to determine the extent to which it

contributed to the accident.

2.4 Adequacy of COA and FAA Oversight

In its study of flightcrew-involved major accidents, the Safety Board documented

the significance of improperly completed checklists and failure to follow standard operating

procedures in accident causation.49 The COA flight 1943 accident was the third flightcrewinvolved accident at COA in 28 months.50 The frequency of these accidents suggests that the

company response and FAA oversight after the previous accidents may have been inadequate.

The 1995 NASIP findings appeared to show that COA had corrected deficiencies

identified after the previous accidents and FAA inspections. However, only 6 months later, the

flightcrew of the accident airplane consistently deviated from standard operating procedures,

including failing to properly perform checklists and engaging in nonessential conversation below

10,000 feet. In addition, the day after this accident, a COA B-737 overran the runway on landing

 47 See Special Investigation Report—“Commercial Space Launch Incident, Launch Procedure

Anomaly, Orbital Sciences Corporation, Pegasus/SCD-1, 80 Nautical Miles East of Cape Canaveral, Florida,

February 9, 1993” (NTSB/SIR-93/02).

48 See Aircraft Accident Report—“Uncontrolled Collision With Terrain, American International

Airways Flight 808, Douglas DC-8-61, N814CK, U.S. Naval Air Station, Guantanamo Bay, Cuba, August 18, 1993”

(NTSB/AAR-94/04).

49 See Safety Study—“A Review of Flightcrew-Involved, Major Accidents of U.S. Air Carriers,

1978 through 1990” (NTSB/SS-94/01).

50 See discussion in section 1.17.2.
51

at DCA, and again, the Safety Board found evidence of deviations from standard operating

procedures, specifically the captain’s failure to discontinue an unstabilized approach.

In the weeks following the accident, there was evidence of improper checklist

execution and sterile cockpit violations found and later reported by the NASA/University of

Texas/FAA-sponsored Aerospace Crew Research Project team. The Safety Board is especially

concerned that procedural violations were observed in the weeks after the accident, yet the FAA

NASIP inspection 6 months before the accident failed to detect any procedural deviations, and

the POI had seen no trends in the area of noncompliance with Federal regulations or company

procedures during his tenure as POI (1991 to present). Finally, during this investigation, Safety

Board investigators learned that some pilots at COA used operational norms that had been

developed on the line and were contrary to standard operating procedures acquired during

training. That COA management was aware of and apparently concerned by these norms, is

evident from a CRM course attended by Safety Board investigators in which the instructor

emphasized the importance of rejecting short-cuts and norms that deviate from standard

operating procedures.

Based on the findings of this investigation, the Safety Board concludes that there

were deficiencies in COA’s oversight of its pilots and the POI’s oversight of COA. In addition,

the Safety Board concludes that COA was aware of inconsistencies in flightcrew adherence to

standard operating procedures within the airline; however, corrective actions taken before the

accident had not resolved this problem.

During its investigation of USAir flight 1016, a DC-9-31 that crashed into terrain

during a missed approach at Charlotte, North Carolina, on July 2, 1994, the Safety Board found

evidence of systemic pilot procedural deviations.51 In the final report for USAir flight 1016, the

Safety Board stated the following, in part:

The Safety Board believes that the failure of flightcrews to adhere to standards

and procedures may reflect a general lack of professionalism that is not being

corrected by the training and checking programs at airlines. The findings of

this investigation, as well as many other investigations, suggest that there may

be a systemic problem of complacency and nonstandard conduct that adversely

affects the performance of flightcrews during critical phases of flight.

As a result of this investigation, the Safety Board issued Safety Recommendation A-95-46,

which recommended the following to the FAA:

Require that Principal Operations Inspectors (POIs) ensure that their

respective air carrier(s) adhere to the company's operating procedures, and

emphasize rigorous compliance to checklist procedures.

 51 See Aircraft Accident Report—“Flight Into Terrain During Missed Approach, USAir Flight

1016, DC-9-31, N954VJ, Charlotte/Douglas International Airport, Charlotte, North Carolina, July 2, 1994”

(NTSB/AAR-95/03).
52

The Safety Board classified A-95-46 “Closed—Acceptable Action” based on the

FAA’s issuance of Flight Standards Information Bulletin (FSIB) 95-20, which directed POIs to

reemphasize to their air carrier(s) the need for adherence to company operating procedures. The

action recommended in FSIB 95-20 appears to be appropriate for COA; furthermore, the Safety

Board believes the FAA should require COA to audit its internal oversight process and correct

deficiencies in that oversight process that allow deviations from standard operating procedures

and violations of Federal regulations to go uncorrected, and to develop a specific plan to

reinforce the importance of adherence to standard operating procedures among pilots. In

addition, the Safety Board believes that the FAA should audit its surveillance of COA en route

operations to determine if the surveillance is adequate to identify procedural deficiencies in

COA’s operations.

2.5 Checklist Design

In the summer of 1996, COA independently initiated a comprehensive evaluation

of checklist philosophy, usage, and format across its fleet. The evaluation is ongoing, and COA

has received guidance from experts on human factors in this effort. According to COA

management personnel, the company intends to modify its checklists to comply with guidelines

for checklist design and usage derived through NASA-sponsored research.52 These guidelines

are designed to help prevent crew omissions, promote redundancy, and prioritize safety-critical

information.

The Safety Board is encouraged by the steps that COA has taken to bring its

checklists into compliance with contemporary human factors research on checklist design and

usage. During its investigation, the Safety Board noted deficiencies in COA checklists that are

contrary to these guidelines and should be addressed in the checklist revisions. These

deficiencies included the following:

• checklists that could be folded by flightcrews to reduce the checklist size, but

the additional fold could interrupt a checklist or obscure a checklist item.

• normal checklists that are designed to be challenged and responded to by the

same pilot, thereby eliminating the redundancy inherent in the system in which

the challenge is made by one pilot and the response by another pilot.

The Safety Board has addressed the issue of inadequate checklist procedures by

airline pilots several times over the years. The Board issued Safety Recommendation A-94-001

(quoted in full in section 1.17.2), which specifically addressed the design of taxi checklists, as a

result of its study of flightcrew-related accidents.53 This recommendation asked the FAA to

 52 Degani, A. & Weiner, E. Human Factors of Flight-Deck Checklists: The Normal Checklist,

NASA Contractor Report 177549, May, 1990.

53 See Safety Study—“A Review of Flightcrew-Involved, Major Accidents of U.S. Air Carriers,

1978 through 1990” (NTSB/SS-94/01).
53

“apply the results of research conducted to date on the design and use of checklists to improve

the error-tolerance of air carrier checklist procedures for taxi operation” and to “provide specific

guidance to air carriers for implementing these procedures.”

In a December 18, 1996, letter the FAA responded to the Safety Board detailing

actions taken to address Safety Recommendation A-94-001. The FAA’s actions included: (1)

mandating CRM training for certificate holders required to comply with 14 CFR Part 121

training requirements, (2) revising Advisory Circular 120-51B “Crew Resource Management

Training” to address training in challenging errors involving inadequately completing checklists

and to provide clarifying CRM guidance in respect to checklist procedures, (3) issuing Flight

Standards Information Bulletin 95-20, which instructs POIs of 14 CFR Part 121 and 135 carriers

to reemphasize the need to strictly comply with standard operating procedures and in-flight

checklist procedures, and (4) issuing a report in January 1995 entitled “Human Performance

Considerations in the Use and Design of Aircraft Checklists,” which summarizes contemporary

human factors principles affecting the design and use of all aircraft checklists, not only taxi

checklists as stated in A-94-001. The report also provides guidance on checklist design.

On October 30, 1996, the report was distributed to all FAA headquarters, regional, and

field offices accompanied by a memorandum from the Director of Flight Standards Service

(AFS-1) stating the following, in part:

[this report] is a tool which can be used by operators in the design,

development, and use of new aircraft checklists. The report can also be used

in the revision of existing checklists, as needed. Several reports, for

employees and operators, are included with this memorandum.

Based on the FAA’s actions, including the production and distribution of this report, the

Safety Board now classifies A-94-001 “Closed—Acceptable Action.”

Although the Safety Board recognizes that the FAA has satisfied the intent of

A-94-001, the Board notes that to date, the FAA has not provided a mechanism to ensure that

checklists of air carriers comply with the guidance provided in the FAA’s recently issued report.

The Safety Board concludes that this accident demonstrates the need for all air carriers to bring

their checklists that apply to all phases of ground and flight operations into compliance with the

contemporary human factors principles of checklist design outlined in the FAA’s report. While it

appears that the current COA-initiated review of checklists and checklist procedures may

accomplish this end at COA, the Safety Board is concerned that other airlines’ checklists may not

benefit from the guidance set forth above. Therefore, the Safety Board believes that the FAA

should require that POIs review the checklists of air carriers operating under 14 CFR Parts 121

and 135 to ensure that they comply with the guidance presented in the FAA report entitled

“Human Performance Considerations in the Use and Design of Aircraft Checklists, ” and require

that any checklists that do not comply with the guidance be revised accordingly.

 
54

2.6 Survival Factors

The Safety Board concludes that the “C” flight attendant was unable to completely

remove the tailcone access plug door because one of the aft jumpseat shoulder harness straps was

buckled to the lap belt, which tied the plug door to the aft cabin bulkhead. Fortunately, the lack

of availability of the tailcone exit did not preclude a timely and successful evacuation.

When Safety Board investigators examined the DC-9 plug door training device at

COA’s Houston flight attendant training facility, they found that seat belts and shoulder

harnesses were not installed in the trainer. Therefore, it was not possible for flight attendants to

practice attempting to remove the plug door with the shoulder harness straps buckled to the seat

belt and gain hands-on experience with the problem this creates. In addition, the COA Inflight

Manual current at the time of the accident did not mention the need to ensure that the jumpseat

shoulder harness straps are unbuckled from the lap belts before attempting to remove the plug

door. The Safety Board concludes that COA flight attendants received inadequate information

and training on the operation of the DC-9 tailcone access plug door. As a result of the Safety

Board’s accident investigation, COA has equipped its DC-9 plug door trainer in Houston (as well

as those at its flight attendant training facilities in Newark, New Jersey, and Cleveland, Ohio)

with shoulder harnesses and seat belts. In addition, COA revised the Inflight Manual to include

information on the consequences of attempting to remove the plug door without first ensuring

that the shoulder harness straps are released.

HBAT 96-02 provides guidelines for approval of tailcone training devices by

FAA inspectors and states, “if a shoulder harness is attached to the door in the aircraft that might

interfere with the opening of the door, one should be similarly attached to the corresponding door

in the training device.” However, because of the omission of a requirement in HBAT 96-02 that

seat belts be installed in plug door trainers, the Safety Board believes that the FAA should amend

HBAT 96-02 to include a requirement that if any portion of a restraint system is attached to the

tailcone access plug door in the aircraft that might interfere with the opening of the door, the plug

door training device must be equipped with the entire restraint system.
55

3. CONCLUSIONS

3.1 Findings

1. The two-member flightcrew and three flight attendants were trained and

qualified to conduct the flight in accordance with Federal regulations. There was no evidence of

any medical condition that might have affected the flightcrew’s performance.

2. The air traffic control request to maintain 190 knots to the outer marker did not

contribute to the accident because it did not affect crew actions, decisionmaking, or situational

awareness.

3. The airplane was certificated and equipped and maintained in accordance with

Federal regulations and approved procedures. There is no evidence that mechanical malfunctions

or failures of the airplane structures, flight control systems, or powerplants contributed to the

accident.

4. Because the captain omitted the “Hydraulics” item on the in-range checklist

and the first officer failed to detect the error, hydraulic pressure was not available to lower the

landing gear and deploy the flaps.

5. The “Hydraulics” item is placed too low on the in-range checklist, rendering it

vulnerable to omission.

6. The captain’s distraction from his duties as pilot-in-command and his disregard

for the sterile cockpit rule contributed to the pilots’ failure to detect their hydraulic system

configuration error when they selected 5o of flaps.

7. Both the captain and the first officer recognized that the flaps had not extended

after the flaps were selected to 15o

.

8. The pilots’ lack of previous exposure, either through training or during line

operations, to the consequences of improper hydraulic system configuration contributed to their

failure to detect their hydraulic system configuration error.

9. The pilots failed to perform the landing checklist and to detect the numerous

cues alerting them to the status of the landing gear because of their focus on coping with the flap

extension problem and the high level of workload as a result of the rapid sequence of events in

the final minute of the flight.

10. Had the landing checklist been properly performed, the flightcrew would have

detected the failure of the landing gear to extend.
56

11. Although the first officer was unwilling to overtly challenge the captain’s

decision to continue the approach, he did attempt to communicate his concern about the

excessive speed of the approach to the captain.

12. There was no compelling reason for the captain’s decision to land the

airplane; multiple signals and guidance indicated that the approach should be discontinued, as did

Continental Airlines’ standard operating procedures.

13. The flightcrew’s degraded performance is consistent with the effects of

fatigue, but there is insufficient information to determine the extent to which it contributed to the

accident.

14. There were deficiencies in Continental Airlines’ (COA) oversight of its pilots

and the principal operations inspector’s oversight of COA. COA was aware of inconsistencies in

flightcrew adherence to standard operating procedures within the airline; however, corrective

actions taken before the accident had not resolved this problem.

15. This accident demonstrates the need for all air carriers to bring their

checklists that apply to all phases of ground and flight operations into compliance with the

contemporary human factors principles of checklist design outlined in the FAA’s report, “Human

Performance Considerations in the Use and Design of Aircraft Checklists.”

16. The “C” flight attendant was unable to completely remove the tailcone access

plug door, because one of the aft jumpseat shoulder harness straps was buckled to the lap belt,

which tied the plug door to the aft cabin bulkhead. Fortunately, the lack of availability of the

tailcone exit did not preclude a timely and successful evacuation.

17. Continental Airlines flight attendants received inadequate information and

training on the operation of the DC-9 tailcone access plug door.
57

3.2 Probable Cause

The National Transportation Safety Board determines that the probable cause of

this accident was the captain’s decision to continue the approach contrary to Continental Airlines

(COA) standard operating procedures that mandate a go-around when an approach is unstabilized

below 500 feet or a ground proximity warning system alert continues below 200 feet above field

elevation. The following factors contributed to the accident: (1) the flightcrew’s failure to

properly complete the in-range checklist, which resulted in a lack of hydraulic pressure to lower

the landing gear and deploy the flaps; (2) the flightcrew’s failure to perform the landing

checklist and confirm that the landing gear was extended; (3) the inadequate remedial actions by

COA to ensure adherence to standard operating procedures; and (4) the Federal Aviation

Administration’s inadequate oversight of COA to ensure adherence to standard operating

procedures.
58

4. RECOMMENDATIONS

As a result of the investigation of this accident, the National Transportation Safety

Board makes the following recommendations to the Federal Aviation Administration:

Require all DC-9 and MD-80 operators with the “HI, LOW, OFF” hydraulic

switch configuration to revise their checklists to emphasize the importance of

the “Hydraulics” item by placing it as the first item on the in-range checklist

(or equivalent), and requiring that both pilots verbally verify hydraulic pump

switch settings and system pressures. (A-97-3)

Require all principal operations inspectors of 14 CFR Part 121 operators using

DC-9 and MD-80 airplanes with the “HI, LOW, OFF” hydraulic switch

configuration to ensure that operating manuals and training programs include

information about the consequences of improper hydraulic system

configuration, specifically that the flaps and landing gear will not function

normally if the engine-driven hydraulic pumps are not set to “HI.” (A-97-4)

Require all principal operations inspectors of 14 CFR Part 121 carriers to

ensure that the carriers establish a policy and make it clear to their pilots that

there will be no negative repercussions for appropriate questioning in

accordance with crew resource management techniques of another pilot’s

decision or action. (A-97-5)

Require all principal operations inspectors of 14 CFR Part 121 carriers to

ensure that crew resource management programs provide pilots with training

in recognizing the need for, and practice in presenting, clear and unambiguous

communications of flight-related concerns. (A-97-6)

Require Continental Airlines to audit its internal oversight process and correct

deficiencies in that oversight process that allow deviations from standard

operating procedures and violations of Federal regulations to go uncorrected,

and to develop a specific plan to reinforce the importance of adherence to

standard operating procedures among pilots. (A-97-7)

Audit its surveillance of Continental Airlines (COA) en route operations to

determine if the surveillance is adequate to identify procedural deficiencies in

COA’s operations. (A-97-8)

Require that principal operations inspectors review the checklists of air

carriers operating under 14 CFR Parts 121 and 135 to ensure that they comply

with the guidance presented in the Federal Aviation Administration report

entitled “Human Performance Considerations in the Use and Design of

Aircraft Checklists, ” and require that any checklists that do not comply with

the guidance be revised accordingly. (A-97-9)
59

Amend Flight Standards Handbook Bulletin 96-02, “Guidelines for

Crewmember Training on Aircraft Tailcones and Approval of Tailcone

Training Devices,” to include a requirement that if any portion of a restraint

system is attached to the tailcone access plug door in the aircraft that might

interfere with the opening of the door, the plug door training device must be

equipped with the entire restraint system. (A-97-10)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

JAMES E. HALL

Chairman

ROBERT T. FRANCIS II

Vice Chairman

JOHN A. HAMMERSCHMIDT

Member

JOHN J. GOGLIA

Member

GEORGE W. BLACK

Member

February 11, 1997

61

5. APPENDIXES

APPENDIX A—INVESTIGATION AND HEARING

1. Investigation

The National Transportation Safety Board was initially notified of this accident

about 0930 on February 19, 1996, by the FAA. One investigator from the Safety Board’s South

Central Regional Office was immediately dispatched to the scene. Washington-based specialists

provided assistance in the areas of Human Performance, Survival Factors, and Flight Recorders.

Parties to the investigation were the FAA, COA, the Douglas Aircraft Company,

and the Independent Association of Continental Pilots.

2. Public Hearing

No public hearing was held in connection with this accident investigation.
62

APPENDIX B – COCKPIT VOICE RECORDER TRANSCRIPT

Transcript of a Fairchild A-100 cockpit voice recorder (CVR), s/n 4100, installed on an Continental Airlines DC-9-32, N10556, which was involved in a gear up landing at Houston Intercontinental Airport, Texas, on February 19, 1996.

LEGEND

RDO Radio transmission from accident aircraft

CAM Cockpit area microphone voice or sound source

INT Transmissions over aircraft interphone system

ATIS-1 Radio transmission from Houston ATIS heard through captain’s audio pannel.

OPS Radio transmission from Continental Houston operations

MTC Radio transmission from Continental Houston maintenance

1989 Radio transmission from Continental flight 1989

1677 Radio transmission from Continental flight 1677

CTR1 Radio transmission from 1st Houston center controller

CTR2 Radio transmission from 2nd Houston center controller

APR Radio transmission from Houston approach control

TWR Radio transmission from IAH control tower

UNK Radio transmission received from unidentified aircraft

PA Transmission made over aircraft public address system

NAV Morse code identifier heard over captain’s channel

-1 Voice identified as Pilot-in-Command (PIC)

-2 Voice identified as Co-Pilot

-3 Voice identified as female flight attendant

-4 Aircraft mechanical voice

-? Voice unidentified

* Unintelligible word

@ Non pertinent word

# Expletive

% Break in continuity

( ) Questionable insertion

[ ] Editorial insertion

.... Pause

Note 1: Times are expressed in central standard time (CST).

Note 2: Non pertinent conversation refers to conversation that does not directly concern the operation, control, or condition of the

aircraft, the effect of which will be considered along with other facts during the analysis of flight crew performance.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

START of RECORDING

START of TRANSCRIPT

0831:16

RDO-1 OK an, seventeen ninety, three three zero seven. we'll

give it a try.

0831:23

CAM-1 never works, but we'll give it a try.

0831:26

CAM-2 [sound of laughter]

0831:29

CAM-2 well who do we talk to.... ARINC?

0831:43

CAM-1 what? yeah, you could call ARINC. ** you know.

0832:01

CAM-1 thirty uh, one.

0832:03

CAM-2 thirty one one seven? I don't know, can we do that?

0832:07

CAM-1 sure.

0832:09

CAM-2 or do they have to go through the company for *?

0832:13

CAM-1 I'm off the air.

63
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0832:15

CAM-2 captain's prerogative, really. whatever you want to do.

0832:18

CAM-1 I want to go home.

0832:25

CAM-1 if I don't know what aircra, I can't do that, I don't know what

aircraft *** anything ***. I have to go... they're gonna say,

what's their call sign. Selcall. let me ask *.

0832:37

CAM-2 roger dodger.

0832:37

CAM-1 **** talk to the people.

0832:40

RDO-1 ah Houston uh, nineteen forty three.

0832:43

IAHOP ** nineteen forty three.

0832:45

RDO-1 yeah, right now looks like I'm gonna be there uh, 'bout five

after. need a wheel chair and electric cart.

0832:53

IAHOP copy five after sir, wheel chair electric cart. your gate today will be I eight, international eight and your equipment

uh, looks like you download and go off to the pad.

64
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0833:03

RDO-1 OK international eight and uh, we had a request from ATC

to try to get ahold of seventeen ninety and have 'em go on

Memphis uh, one thirty three zero seven an' is it possible

that you could uh, go through ARINC or somethin' to try to

get 'em?

0833:15

CTR1 * nineteen forty three, contact Houston one three three

point five seven, thirty three five seven.

0833:16

IAHOP OK, I copied the one thirty three point zero seven and

what was the flight number?

0833:19

RDO-1 seventeen ninety.

0833:22

IAHOP seventeen ninety, I'll se what we can do.

0833:21

RDO-2 one thirty three five seven and uh, we're working on the

other call.

0833:25

RDO-1 I appreciate it.

0833:25

CTR1 appreciate your help sir, good day.

0833:27

RDO-1 see ya.

0833:30

CAM-1 *** I - A - eight.

65
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0833:41

CAM-1 I'm off, gonna talk to maintenance.

0833:47

RDO-2 Houston center, Continental nineteen forty three level

three five zero.

0833:56

RDO-1 ah, Houston ah, maintenance Continental, nineteen forty

three.

0833:59

CTR2 Continental nineteen forty three, Houston center roger.

0834:11

CAM-2 *** in range check.

0834:16

RDO-1 Houston maintenance, nineteen forty three.

0834:21

MTC calling maintenance, go ahead.

0834:23

RDO-1 yeah aircraft uh, five five six gonna be at uh, IAB eight

here in about uh, five after the hour thirty minutes from

now and the cockpit door kick out plate uh, just will not

stay in place. it keeps falling out.

0834:40

MTC OK understand uh, five five six, I eight, five after and you

got the uh, cockpit kick out door that won't stay in place.

0834:48

RDO-1 affirmative, thank you.

66
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0834:50

MTC we'll see you on I eight.

0834:56

CAM-1 OK. *** twenty four oh five.

0835:04

ATIS-1 ... international terminal. runway one four left locator outer

marker out of service. advise on initial contact you have

Hotel....

0835:11

CAM-2 what happened the international terminal?

0835:15

ATIS-1 ... Houston Intercontinental airport information Hotel, one

three five zero Zulu weather. measured ceiling one thousand five hundred overcast, visibility one zero. temperature six eight. dew point six three. wind two one zero at

one four. altimeter two niner six seven. arriving aircraft

expect ILS runway one four left, ILS runway two six, ILS

runway two seven. simultaneous approaches in use. departing aircraft expect runway one four right. runway one

four left, runway two six. notice to airmen, crane three

hundred thirty one feet AGL south of the international terminal. runway one four left locator outer marker out of

service. advise on initial contact you have Hotel.

0836:11

CAM-1 well, let's see. sixteen seventeen, wow, we've lost that much,

eighty.

0836:34

CTR2 November six zero Delta you're cleared direct Midland.

0836:37

CAM-1 Midland? direct Midland?

67
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0836:42

CAM-? *.

0836:46

CAM-1 Midland, Odessa.

0836:55

CAM-1 *** that, we wrote that up..... you're cleared to three five oh.

0837:39

CAM-? they don't have us direct to Daisetta yet?

0837:44

CAM-2 we’re on the arrival. between uh, ** and Daisetta.

0837:53

CAM-1 oh very well.

0837:55

CAM-2 kinda sorta.

0837:56

CAM-1 ***.

0837:57

CAM-2 sorta.

0837:58

CAM-1 kinda.

0838:01

CAM-1 sort of did OK. now the pressure's off.

0838:06

CAM-2 sorta.

68
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0838:14

CAM-1 should I tell 'em about their long walk to where ever they want

to go? or just let them experience it and the joy of it when they

get there?

0838:22

CAM-2 dedicated to the joy of walking? in a terminal designed by...

0838:31

PA-1 ah ladies and gentlemen uh, should be at Houston approximately, thirty minutes from now. beginning our descent here

shortly. the weather in Houston's still overcast skies are sixty

eight degrees maybe a little warmer now, that temperature's

about forty five minutes old. the uh, wind's out of the southwest around uh, around ten to fifteen miles an hour. like we

say we should be in there approximately at the gate in thirty

minutes. like to thank you for flying with us today, and we hope

to see you again in the future.

0839:10

CAM-1 what good, what good's an electric, electric cart gonna do?

they don't have electric carts in the international terminal.

they're not allowed up there?

0839:19

CAM-2 of course there's a reason for that.

0839:21

CAM-1 they never stressed the building for it. ***. #.

0839:32

CAM-2 * building is not stressed for a heavy golf cart. uh.

0839:42

CAM-1 good planning. we can always get our ***. people get an electric cart, and they think, hey this is great and you bring her up

to the ramp and they get off and make them walk up the ramp.

69
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0839:57

CAM-1 [sound of laughter]

0840:11

CAM-2 ask him if he wants us at ten thousand at Daisetta.

0840:14

CAM-1 today?

0840:16

CAM [sound of four taps]

0840:17

CAM-2 if so, we gotta get on down.... he forgot about us.

0840:35

RDO-1 uh, Houston nineteen forty three uh, you need us to ddescend to ten over Daisetta?

0840:42

CTR2 Continental nineteen uh, forty three, descend and maintain one three thousand. Humble altimeter two niner six

eight.

0840:49

RDO-1 two nine six eight, down to one three thousand, Continental nineteen forty three.

0840:53

CAM [sound similar to altitude alert being adjusted]

0840:54

CAM [sound of beep]

0840:56

CAM-2 thank you sir.

0840:59

70 70
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

CAM-1 you know you can do it. he knows you're tough.

0841:02

CAM-2 * already, they give us two six also?

0841:09

CAM-1 [sound of whistling]

0841:14

CAM-1 aaah.

0841:17

CAM-1 we can do acro, we're good at it.

0841:32

CAM-1 it's alright ** pressurization. landing data bugs?

0841:40

CAM-2 if we have to at the earliest we uh, half of uh, fourteen is four

two, * make it one thirty two? is that right?

0841:51

CAM-1 correcto. elcorrecto, roger dodger.

0842:00

CAM-2 descent check please.

0842:03

CAM-1 fineto.

0842:04

CAM-2 roger.

0842:08

CTR2 Southwest fifteen twenty nine, turn fifteen degrees right.

intercept the Humble zero four five radial for the BASTN

three.

71
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0842:14

CAM-1 BASTN three? what the # is that?

0842:18

CAM-2 we're on Daisetta.

0842:24

ATIS-1 .... ILS one four left, ILS runway two six, ILS runway two

seven....

0842:44

CAM-1 ah, they're going to Hobby.

0842:50

CAM-1 ah oh. we're outta my * again.

0842:57

CAM-2 they have no **.

0843:08

CAM-2 I'll put you on Humble.

0843:09

CAM-1 Humble.

0843:20

CAM-1 yep, sounds like two five zero knots today.

0843:26

CAM-2 **.

0843:36

CAM-1 easy for you to say. if you were in a seven three it'd be a little

tough. [sound of laughter]

0843:41

CAM-2 really is that right? **.

72
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0843:42

CAM-1 they don't come down this good.

0843:44

CAM-2 I can do it.

0843:46

CAM-1 speed brake is kinda useless in that plane.

0843:49

CAM-2 is it, I think it's better than *.

0843:58

CAM-? we'll make up a little time here ***.

0844:04

CAM-? ** without a doubt. ***.

0844:08

CAM [sound of knocks]

0844:10

CAM-1 oh my #.

0844:12

CAM-3 l was just told, one wheel chair and one electric cart.

0844:15

CAM-1 yes but we're coming into international eight.

0844:20

CAM-3 oh my Lord. *** still need the wheel chair. ** can't walk at all.

0844:26

CAM-1 we're gonna have to push him the whole way.

73
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0844:27

CAM-3 wow, he's going to Guadalajara maybe *****.

0844:32

CAM-1 dump him off on the ramp.

0844:38

CAM-3 ***. thank you.

0844:39

CAM-1 alright.

0844:46

CAM-?  .

0844:51

CAM-1 [sound of whistling]

0844:58

CAM-1 let's see, we said eighty..... fifty seven ** *. let me check that.

fifty seven.

0845:04

ATIS-1 .. Hotel... Houston Intercontinental airport information

Hotel, one three five zero Zulu weather. measured ceiling

one thousand five hundred overcast, visibility one zero.

temperature six eight. dew point six three. wind two one

zero at one four. altimeter two niner six seven.....

0845:28

CAM-1 ** again.

0845:31

CAM-2 in range check please.

0845:33

CAM-1 ooh, ooh, ooh.

74
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0845:35

CAM-1 [sound of laughter]

0845:37

CAM-1 uh boost pumps we got. number four is on.

0845:41

CAM-2 no.

0845:43

CAM-1 number, four on. number one, one two three. whatever that

is.. they're on and checked... no smoke seat belt's on. flight

instruments and altimeters?

0845:52

CAM-1 checked set.

0845:54

CAM-1 shoulder harness on.

0845:56

CAM-2 on.

0845:59

CAM-1 approach briefing? why did they, remove the sterile cockpit off

of here but they left it on here?

0846:10

CAM-2 I, gotta go to....

0846:17

CAM-2 one three thousand right, not ten?

0846:19

CAM-1 correcto.

75
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0846:23

CAM-1 correcto.

0846:34

CTR2 Continental nineteen forty three, say speed.

0846:37

RDO-1 alright now doing uh, three ten. what do you need?

0846:39

CTR2 that will be fine.

0846:42

CAM-2 three twenty.

0846:44

CAM-1 one to go.

0846:45

CAM-? roger.

0846:46

CAM [sound of tone similar to altitude alert]

0846:52

CAM-2 ah.

0847:03

CAM-1 * everybody, they’re holding everybody up.

0847:06

CAM-2 yeah but we're too sharp for 'em.

0847:09

CAM-1 I guess they're assuming the headwind is stronger then the.....

76
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0847:12

CTR2 Continental nineteen forty uh, three, descend and maintain one zero thousand.

0847:16

RDO-1 down to ten, Continental nineteen forty three.

0847:29

CAM-2 actually he said descend to ten thousand but he didn't say

cross Daisetta at ten.

0847:34

CAM-1 that's correct.

0847:39

CAM-1 el correcto.

0847:43

CAM-2 we'll be there anyhow.

0847:55

CAM-1 come on, if you keep this bumpy I'm going to have to #.... I

was doin' alright till you started this.

0848:02

CAM-2 I thought, I thought you had a pretty good bladder I thought

****.

0848:08

CAM-1 ** two cups of coffee.

0848:09

CAM [sound of tone similar to altitude alert]

0848:10

CAM-2 damn.

0848:12

77
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

CAM-1 I don't normally last that long.

0848:15

CAM-2 amazing.

0848:18

CTR2 Continental nineteen forty three, contact Houston approach, one two zero point zero five.

0848:23

RDO-1 two uh, zero zero five, nineteen forty three.

0848:31

CAM-2 approach?

0848:39

RDO-1 approach, nineteen forty three uh, ten thousand Hotel, request two seven.

0848:42

APR nineteen forty three expect runway two six, I'll pass your

request on.

0848:48

CAM-2 boy. request... we want two six, no?

0848:52

CAM-1 naw.

0848:56

CAM-2 we're around the corner, huh?

0848:57

CAM-1 yeah.

0849:00

CAM-1 *** gate one *** we, back, fight the traffic.

78
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0849:08

CAM-2 alright.

0849:26

CAM-1 are you gonna be at sixty five?

0849:31

CAM-2 uuuuh, pretty close.

0849:33

APR * nineteen forty three, descend and maintain seven thousand.

0849:35

RDO-1 down to seven Continental nineteen forty three.

0849:36

CAM [sound of short tone]

0849:37

CAM-2 down to seven.

0849:40

CAM [sound similar to cabin chime]

0849:43

CAM-1 ten ten ten.

0849:45

CAM-1 [sound of tapping then whistling]

0850:22

CAM-1 [sound of singing] every body, loves a lover.

0850:33

CAM-2 uuuuuh.

79
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0850:34

APR Continental nineteen forty three, fly heading two two zero.

0850:37

RDO-1 two two zero, Continental nineteen forty three.

0850:39

CAM-1 oh very well. we can do that too.

0850:57

CAM-1 * got everybody lined up pretty well there.

0851:00

CAM-2 boy, I guess so ****.

0851:03

CAM-2 let's see, two six.

0851:06

CAM-1 we may not get it.

0851:09

CAM [sound of tone similar to altitude alert]

0851:11

CAM-1 one to go. eight for seven.

0851:25

CAM-2 I think we're in luck **.

0851:38

1989 Continental nineteen eighty nine, two seven zero, down to

seven.

0851:42

APR I’ll pass your request on.

80
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0851:45

CAM-1 pass it on. pass it on. pass it on. we'll be gone, we'll be gone,

we'll be gone.

0852:07

CAM-1 nine o'clock.

0852:10

CAM [sound of tapping]

0852:13

CAM-1 well, at least we won't have to go through customs.

0852:18

CAM-2 yep.

0852:27

CAM-1 well, quit dripping on me. what kind of plane is this? gettin' all

over me here.

0852:35

CAM-2 ** the ILS for two six. seventy one B one, fifteen September

ninety five. one oh nine point seven. two sixty four. *** seven

point five DME. Straight in ***** radar altimeter. we got uh,

good RV. we'll break it off for the visual once we get below the

weather down there. if he sends us around, climb to a thousand feet *** then climbing right turn as published.

0853:23

APR Continental nineteen forty three, turn right heading two

three zero. join the two seven localizer, maintain four

thousand.

0853:26

RDO-1 two three zero, down to four, and join the two seven localizer, nineteen forty three.

0853:32

81 81
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

CAM [sound of short tone]

0853:33

CAM-1 down to four and join the two seven localizer, which is ten nine.

0854:01

CAM-1 surprise, you're gonna make your on time.

0854:03

CAM-2 one ten nine, two sixty four. TANKS at six DME final approach

fix.

0854:10

CAM-1 I'm gonna give you another bonus check. I want you to go into

see %% and tell him, despite the odds against it...

0854:21

CAM-1 what's the matter with this thing? wow, why is it going down,

we caught it?

0854:27

CAM-2 it’s uh.

0854:32

CAM-1 how could we catch it if it's going down so slow? going down

too slow. oh well.

0854:49

CAM-2 approach check please when you're ready.

0854:50

CAM-1 ah yes, ah.

0854:54

CAM-1 altimeters and the bugs?

0854:56

82
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

CAM-2 niner six seven set right and one thirty two set right.

0855:03

CAM-1 VOR, ADF switches?

0855:06

CAM [sound of tone similar to altitude alert]

0855:07

CAM-1 set VOR, ADF whatever.

0855:09

CAM-1 marker's on.

0855:09

CAM-2 five for four.

0855:17

CAM-1 glide slope's alive.

0855:18

CAM-1 radios are ident ***.

0855:19

NAV-1 [sound of Morse code identifier "IGHI" starts and continues for twelve seconds]

0855:27

CAM-2 we'll go manual spoilers.

0855:29

CAM-1 oh, very well.

0855:31

CAM-2 forty flaps.

0855:32

83
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

CAM-1 forty flaps?

0855:34

CAM-2 roger dodger.

0855:35

CAM-2 #, you scared me half to death.

0855:39

CAM-1 I'm just tryin' to..

0855:56

CAM-1   mode selector .. yeah and **  two lights ****. *** and that's

not going to change much. I'll just leave it there.

0856:02

NAV-1 [sound of Morse code identifier "IGHI" starts and continues to end of the recording]

0856:06

APR Continental nineteen forty three, thirteen miles from the

marker, maintain two thousand till established on the localizer. cleared ILS uh, two seven approach.

0856:10

CAM [sound of short tone]

0856:13

RDO-1 two thousand till established, cleared for uh, two seven

approach, Continental nineteen forty three.

0856:19

CAM-2 I'm going to intercept the glide path up here... TANKS is at six.

84
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0856:38

CAM-1 ** crummy weather. what's this? # how can I play tennis if it's

raining.

0857:02

APR Continental nineteen forty three, on your speed uh, one

nine zero or faster to the marker and contact uh, the

tower, one two five three five.

0857:11

RDO-1 two five three five, Continental nineteen forty three.

0857:14

CAM-1 OK.

0857:15

CAM-2 they’re out of the way, huh?

0857:22

CAM-1 you've been up all night too.

0857:31

PA-1 we're about ah, ten miles outside the airport, flight attendants

be seated for arrival.

0857:37

CAM [sound of stabilizer trim-in-motion horn]

0857:47

CAM [sound similar to landing gear warning horn]

0857:49

CAM-? **.

0857:55

RDO-1 Continental nineteen forty three with you for two seven.

85
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0857:58

TWR Continental nineteen forty three, Houston tower runway

two seven. cleared to land, wind two four zero at seven.

0858:02

RDO-1 cleared to land two seven, Continental nineteen forty

three.

0858:04

CAM-2 cleared to land.

0858:06

CAM-1 cleared to lando.

0858:08

CAM-1 now, where was I. aah, b-b-b-b-b-b-aaaaah, air conditioning

auto shutoff is armed, briefing has been made. approach

check is completed.

0858:40

CAM [sound of tone similar to altitude alert]

0858:43

CAM-1 cleared to lando.

0858:44

CAM-2 cleared to land.

0858:48

CAM-1 aw shoot. I can't play tennis when it's like this... well maybe

this afternoon it'll clear up. actually I've still got a lot of time.

0859:00

CAM-2 go slats and five.

0859:03

CAM [sound of click]

86
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0859:03

CAM-1 slats are going to five.

0859:14

CAM-1 I was watching the news this morning and said it was going to

be nice out. they lied.

0859:30

CAM-1 look at the ground, it doesn't look like much rain. It's overcast.

0859:31

CAM-2 dismal.

0859:35

CAM-1 that's not too bad. we don't worry about.

0859:37

CAM-2 yeah. *** might be rather pleasant *.

0859:50

CAM-2 one ninety to the marker.

0859:51

CAM-1 [sound of whistling]

0859:52

CAM-2 the middle marker?

0859:53

CAM-1 to TANKS.

0859:55

CAM-2 one ninety to the middle marker or to TANKS?

0859:59

CAM-1 Tanks *** whatever you want.

0900:00

87 87
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

CAM-2 heh.

0900:01

CAM-2 well **. I wonder if ***.

0900:05

CAM-2 ******.

0900:11

CAM-1 runway in sighto.

0900:13

CAM-2 there's TANKS... so uh, flaps fifteen.

0900:16

CAM-1 **.

0900:33

CAM-1 I think the flaps *.

0900:35

CAM [three intermittent sounds similar to landing gear warning horn]

0900:37

CAM-1 well we know that, you want the gear.

0900:38

CAM-2 gear down.

0900:39

CAM [sound of tone similar to altitude alert]

0900:40

CAM [sound of thump]

0900:41

CAM-2 landing check, twenty five in (the green).

88
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0900:46

CAM [sound similar to landing gear warning horn starts and continues]

0900:50

CAM-2 (flaps forty).

0900:53

CAM [momentary interruption of sound similar to landing gear warning horn]

0900:56

CAM-2 (here comes) fifty.

0900:58

CAM-1 fifty flaps.

0901:00

CAM-2 * I don't have any flaps.

0901:01

CAM-1 ****.

0901:02

CAM-2 want to take it around?

0901:03

CAM-1 no, that's alright. * keep your speed up here about uh,

0901:07

CAM [sound similar to landing gear warning horn stops]

0901:08

CAM-2 I can't slow it down here now.

0901:10

CAM-1 you're alright.

89
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0901:10

CAM-2 .. we're just smokin’ in here.

0901:13

CAM-4 whoop whoop pull up, whoop whoop pull up, whoop whoop pull

up.

0901:15

CAM [sound similar to landing gear warning horn starts and continues to after impact]

0901:18

CAM-2 want to land it?

0901:19

CAM-1 yeah.

0901:20

CAM-2 your airplane. captain's airplane.

0901:24

CAM-2 you want it?

0901:25

CAM-1 yeah.

0901:32

CAM [sound of impact, loud rattling, rumbling starts and continues]

0901:56

RDO-1 tower, nineteen forty three on runway two seven needs

some help]

0902:01

CAM [sound of a one second tone]

90
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATION

TIME & TIME &

SOURCE CONTENT SOURCE CONTENT

FTW96FA018

0902:03

CAM [sound of loud rattling and rumbling stops]

0902:05

CAM [sound of a one second tone]

0902:06

END of RECORDING

END of TRANSCRIPT

91
Continental Airlines Flight 1943

DC-9-32, 02/19/96 FJW96FAI18 ~,

➤?eo l.j [

,,=~

m.io ma m.ma -40 ~ W.m mlo ~ ml:30 mol:40 ‘<

-~ S-O Tim

P1-OT 1

Revised November 27, 1996 National Transportation Safety Board/ VPR
93

APPENDIX D-COA DC-9 NORMAL CHECKLIST

AFTER TAKEOFF

PNF Challenge PNF Respond

Landing Gear . . . . . .. UPLATCH CHECKED, UP, LIGHTS OUT

Flaps, Slats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . UP, LIGHT OUT

Ignition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AS REQUIRED

Fuel Feed . . . . . . . . . . . . . . . . . . .FROM CENTER/MAIN TANKS

Air Conditioning Auto. Shutoff . . . . . . . . . . . . . . . . . . . . . ..OVRD

Annunciator Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHECKED

Hydraulics . . . . . . . . . . . . . . . . . . . . . . . . . . . . .OFF & LOW

DESCENT

PNF Challenge PNF Respond

Eng Sync . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OFF

Ice Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ON/OFF

Pressurization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. SET

Landing Data, Bugs . . . . . . . . . . . . . . . . . . CHECKED, SET (C,F)

I N RANGE

PNF Challenge PNF Respond

Fuel Boost Pumps, Quantity . . . . . . . . . . . . . . . #_ ON. CHECKED

No Smoke & Seat Belt Signs. . . . . . . . . . . . . . . . . . . . . . . . . . . ..ON

Flight Instrument, Altimeters . . . . . . . . . . .. CHECKED, SET (C,F)

Hydraulics . . . . . . . . . . . . . . . . . . . . . . . . . . ..ON & HI, CHECKED

Shoulder Harness . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . ..ON

Approach Bri i

efing . . . . . . . . . . . . . . . . . . . . . . . . . . . . COMPLETE

Sterile Cockpit Light . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . ..ON

APPROACH

PNF Challenge PNF Respond

Altimeters & Bugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SET (C,F)

VOR/ADF Switches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SET VOR/ADF

Marker Switches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. ON/OFF

Radios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TUNED, IDENTIFIED

Come . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..INBOUND

Mode Selectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .AS REQUIRED

RAT EPR/TRI . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . ..GA

Air Conditioning Auto-Shutoff . . . . . . . . . . . . . . . . . . . . . . . . . . . ..ARMED

Landing Announcement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . COMPLETE

LANDING

PNF Challenge PNF Respond

Gear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..DOWN, 3 GREEN (C,F)

Ignition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OVRD

Spoilers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . LIGHT OUT, ARMED

Flaps, Slats 0 

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ____ ,EXT

Annunciator Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHECKED

AFTER LANDING

F/O Challenge (SILENT) F / O Respond

Ignition & Pitot Heat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OF. F

Engine, Airfoil Anti-Ice . . . . . . . . . . . . .. . . . . . . . . . . . . . . . OFF/ON, OFF

Anti-Skid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OFF

Air Conditioning Auto. Shutoff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OVRD

Flaps, Slats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .UP, LIGHT OUT

DME, Radar, Transponder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OFF, STBY

Spoilers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . RETRACTED

Hydraulics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHECKED

Exterior Lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AS REQUIRED

APU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AS REQUIRED

Right Pack, Right Engine . . . . . . . . . . . . . . . . . . . . . . . ..OFF, SHUT DOWN

PARKING

F/O Challenge Capt Respond

Parking Brake . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. SET/OFF

Seat Belt & Sterile Cockpit Lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . OFF

APU/External power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .AS REQUIRED

Fuel Levers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OFF

Boost Pumps . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. SET

packs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AS REQUIRED

Beacon. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OFF

Aux, Alt Hydraulic Pumps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .OFF

Logbook & FOB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . COMPLETED

TERMINATION

Either Pilot Challenge Either Pilot Respond

Standby Hor izon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .OFF

Packs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OFF

APU Air Switch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OFF

Battery Charger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHECKED

Galley Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OFF

Emergency Exit Lights . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OFF

Windshield Heat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OFF

Exterior Lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OFF

Cockpit Lights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OFF

Radar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Transponder, TCAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 

Rudder Power Control Lever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .MANUAL

Manual Press Controller . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . AS REQUIRED

Radios . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .OFF

Pneumatic X-Feeds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CLOSED

Ground Service Electrical Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SET

APU Bus Switches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .OFF

APU Master Switch . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .OFF . 

Fuel Boost Preps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..OFF

Battery Switch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OFF

DC-9 NORMAL CHECKLIST

REV # 6/01/95 FAA Approved 10/16/95

Form #: 24.6013 M&E: 00-00732-3-0073