NTSB Identification: FTW89MA047.
The docket is stored on NTSB microfiche number 39057.
Nonscheduled 14 CFR
Accident occurred Thursday, February 09, 1989 in SALT LAKE CITY, UT
Probable Cause Approval Date: 07/23/1991
Aircraft: MCDONNELL DOUGLAS DC-9-32F, registration: N935F
Injuries: 1 Fatal,1 Uninjured.

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report.

AS 1ST OFFICER (FO) WAS FLYING ACFT, DRG CLB AFTER TKOF, CABIN WOULDN'T PRESSURIZE. HE BGN LVL OFF AT 16,000', BUT CAPT ORDERED HIM TO CONT CLBG TO ASSIGNED FLT LVL (FL 330), WHILE HE (THE CAPT) WENT AFT TO FND PRBLM. FO DISLIKED THE ORDER,BUT COMPLIED RATHER THAN CONFRONT CAPT. CAPT LEFT COCKPIT WITH PORTABLE 'ON DEMAND' OXYGEN (O2) SYS, WHICH HAD 15 MIN SUPPLY OF O2. WHEN CAPT DIDN'T RTRN, FO TRIED SIGNALING HIM. THO RELUCTANT TO COUNTERMAND CAPT'S ORDER, FO MADE SERIES OF DSCNTS TO 13,000'. AFTER ABT 30 MIN, HE LEFT COCKPIT & FND CAPT UNCONSCIOUS & UNRESPONSIVE IN FWD CARGO AREA WITH O2 MASK ON HIS FACE. CAPT'S FOOT WAS ENTANGLED IN CARGO NET WHICH CVRD A PALLET. FO TRIED TO REVIVE CAPT, TO NO AVAIL, THENDECLARED EMERG & LNDD AT LUBBOCK. CAPT WAS RUSHED TO HOSPITAL, BUT WAS DEAD ON ARRIVAL. EXAM REVEALED AFT PRESSURE BULK-HEAD WAS NOT INSTALLED. IT HAD BEEN REMOVED FOR MAINT BFR FLT. PORTABLE O2 SYS WAS STILL FULL, INDCG CAPT HAD LITTLE OR NO USE OF O2; IT WAS TESTED & FUNCTIONED NMLY. GROUP OF 8 FORENSIC PATHOLOGISTS CONCLUDED CAPT DIED FM HYPOXIC HYPOXIA.

The National Transportation Safety Board determines the probable cause(s) of this accident to be:

IMPROPER IN-FLIGHT PLANNING/DECISION BY THE CAPTAIN (PILOT-IN-COMMAND) AND HIS IMPROPER USE OF THE PORTABLE OXYGEN SYSTEM, WHICH RESULTED IN HIS INCAPACITATION DUE TO HYPOXIA. FACTORS RELATED TO THE ACCIDENT WERE: INADEQUATE MAINTENANCE/INSPECTION OF THE AIRCRAFT BY COMPANY MAINTENANCE BY FAILING TO REINSTALL THE AFT PRESSURE BULKHEAD HATCH (INSPECTION DOOR) AND POOR CREW COORDINATION.

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