1987 — Nov 15, Continental Airlines Flight 1713 DC-9 takeoff crash, Denver, CO — 28

lornajarrettblanchard November 15, 1987

— 28 B3A (Geneva, Switzerland). Crash of a Douglas DC-9 in Denver: 28 killed.”

— 28 NTSB. AAR. Continental Airlines, Inc., Flight 1713…Stapleton International Airport…

Narrative Information

NTSB Executive Summary: “On November 15, 1987, Continental Airlines, Inc., flight 1713, a McConnell Douglas DC-9-14, N626TX, was operating as a regularly scheduled, passenger-carrying flight between Denver, Colorado, and Boise, Idaho. The airplane was cleared to take off following a delay of approximately 27 minutes after deicing. The takeoff roll was uneventful, but following a rapid rotation, the airplane crashed off the right side of runway 35 left. Both pilots, 1 flight attendant, and 25 passengers sustained fatal injuries. Two flight attendants and 52 passengers survived.

“The National Transportation Safety Board determines that the probable cause of this accident was the captain’s failure to have the airplane deiced a second time after a delay before takeoff that led to upper wing surface contamination and a loss of control during rapid takeoff rotation by the first officer. Contributing to the accident were the absence of regulatory or management controls governing operations by newly qualified flightcrew members and the confusion that existed between the flightcrew and air traffic controllers that led to the delay in departure.

“The safety issues discussed in this report include:

Pilot training;
Aircraft deicing procedures; and
Wingtip vortex generation and lifespan.

“Recommendations concerning these issues were addressed to the Federal Aviation Administration, the National Fire Protection Association, the American Association of Airport Executives, the Airport Operators Council International, and Continental Airlines, Inc.” (p. v.)

“….Medical and Pathological Information….Postmortem examinations were performed by the City and County of Denver’s Coroner’s Office. The autopsies revealed that 11 passengers (including an infant), the captain, the first officer, and 1 flight attendant died of multiple blunt force traumatic impact injuries; 5 passengers died of head injuries secondary to blunt trauma, and 9 passengers died of mechanical asphyxia….Two passengers died after being transported to the hospital….

“Interior Damage and Occupant Injuries. There was extensive damage to the forward left side of the airplane. The fuselage was missing on the left side from aft of the boarding door to about station 466. No one in a window set in rows 2-9 on the left side survived. Cabin dividers, overhead compartments, and passenger seats were ejected during the impact and were found along the wreckage path….Rows 10-15 were inverted and in an area of extreme compression. All occupants in this area required extrication. All survivors in this area had serious injuries and eight of the nine passengers who died of traumatic asphyxia were seated in this section…. [p. 20.] ….

“The Captain’s Actions. The Safety Board notes several decision-making deficiencies of the captain of flight 1713. The Safety Board believes that he should have realized that he was exposing the airplane to airfoil contamination for too long a period and should have returned to the deicing pad for another deicing before takeoff. In addition, he showed poor judgment in allowing an inexperienced first officer to attempt a takeoff in weather conditions such as those that existed at Denver. Further, from data recovered from the CVR and the FDR, it appears that he did not attempt to arrest the first officer’s rapid rotation of the airplane during the takeoff.

“Although the captain was an experienced pilot with apparently better than average flying skills, he was relatively inexperienced as a captain on air carrier turbojet airplanes, and he had very little total flying time in the DC-9. He was not seasoned in either the supervision or judgment of first officers, nor was he familiar with the unique characteristics of the DC-9-10 series airplane in icing conditions. Although he was taught about DC-9 cold weather operations during his ground training and simulator sessions, he had never actually encountered ground icing conditions in a DC-9 before the accident….In addition, he did not understand the intent of the company procedures concerning taxi from the gate through the deice pad and on to the runup pad. His failure to contact ground control for clearance to taxi to the deice pad precipitated a series of events that caused a portion of the 27-minute delay between deicing and takeoff. Following the accident, those procedures were modified to state that a flight should not taxi beyond the north side of concourse D until clearance is received from ground control.

“Company procedures also required the captain to inspect the airplane if the takeoff is delayed for more than 20 minutes after deicing. The captain did not examine the wings or cause the wings to be examined even after 27 minutes had elapsed….

“The captain had never flown with the first officer and knew nothing of his flying skills or background, although he did realize that the first officer was new to Continental.[1] He allowed the first officer to be the flying pilot on the first leg of this trip sequence into relatively poor weather, presumably so that he, the captain, would make the landing on the return leg to Stapleton, in perhaps equally poor weather. Although weather takeoffs are generally assumed to be less demanding than weather landings, and the general tradition is for two airline pilots to always ‘trade legs,’ a much wiser course of action would have been for the captain to have conducted the takeoff at Denver and then to have allowed the first officer to take over flying duties for the rest of that leg. The captain could then have flown the return leg and made the weather approach and landing back at Denver.” [p. 37.]

“Crew Pairing. The Safety Board believes that the captain’s basic inexperience as a DC-9 pilot together with his inexperience as a captain supervising the actions of first officers left him unprepared for the rapid rotation by the first officer into the aerodynamic stall regime. A more experienced DC-9 captain may have been better able to (a) notice that a rapid rotation was occurring, (b) arrest the rotation by blocking the yoke, and finally, (c) perhaps allow the airspeed to build up to the point where the takeoff could be successfully completed.

“In summary, the Safety Board believes that the pairing of pilots with limited experience in their respective positions can, when combined with other factors, such as adverse weather, be unsafe and is not acceptable. The Safety Board believes that although the pilots of flight 1713 had previously demonstrated competence in their duties, compromises in the decision-making process occurred as a result of inexperience in their respective positions. Subsequently, their pairing on the same flight was a factor in the accident….” [p. 38.]

“The Role of the Clearance Delivery and Ground Controllers and Continental Flight 594 in the Takeoff Delay of Flight 1713.

“The Safety Board believes that the air traffic control facility at Stapleton was unaware of the locations of Continental flights 594 and 1713 for extended periods of time after they began taxiing and that this lack of awareness contributed to the delay between deicing and takeoff for flight 1713. Procedural errors on the part of both flightcrews also contributed to this delay.

“The airport was not equipped with ASDE,[2] and the visibility varied somewhat but generally was such that tower personnel could not see beyond the ends of the terminal concourses at Stapleton. Not being able to in some manner see airplanes they are supposed to be controlling places a great burden on the controllers in the tower. Had the controllers been able to locate flights 594 and 1713 on the ramp via radar as they progressed to the takeoff position, the points of confusion and the subsequent takeoff delays may not have occurred. The Safety Board notes that Stapleton Airport is scheduled to have an SDE-3 installed in 1989, a slip from its original installation date of September 1988. The installation and certification of the equipment should take about 4 months according to FAA sources. The Board is concerned, then, that this airport will have gone without ASDE through two winter weather seasons with associated periods of low visibility since this accident….” [p. 39.] (NTSB)

Sources

B3A (Bureau of Aircraft Accidents Archives), Geneva, Switzerland. “Crash of a Douglas DC-9 in Denver: 28 killed.” Accessed 10-26-2016 at: http://www.baaa-acro.com/1987/archives/crash-of-a-douglas-dc-9-in-denver-28-killed/

National Transportation Safety Board. Aircraft Accident Report. Continental Airlines, Inc., Flight 1713, McDonnell Douglas DC-9-14, N626TX, Stapleton International Airport, Denver, Colorado, November 15, 1987 (NTSB/AAR-88/09). Washington, DC: NTSB, 9-27-1988, 90 pages. Accessed 10-26-2016 at: http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR8809.pdf

[1] In “Conclusions” section, p. 43, it is written as sixth “Finding” that “The first officer had a record of performance difficulties before joining Continental and continued to have difficulty in Continental’s DC-9 training program.”

[2] Airport Surface Detection Equipment.