December 20, 2008
NTSB Number: AAR-10-04
NTIS Number: PB2010-910404
Addopted July, 2010
On December 20, 2008, about 1818 mountain standard time, Continental Airlines flight 1404, a Boeing 737-500, N18611, departed the left side of runway 34R during takeoff from Denver International Airport (DEN), Denver, Colorado. A postcrash fire ensued. The captain and 5 of the 110 passengers were seriously injured; the first officer, 2 cabin crewmembers, and 38 passengers received minor injuries; and 1 cabin crewmember and 67 passengers (3 of whom were lap-held children) were uninjured. The airplane was substantially damaged. The scheduled, domestic passenger flight, operated under the provisions of 14 Code of Federal Regulations Part 121, was departing DEN and was destined for George Bush Intercontinental Airport, Houston, Texas. At the time of the accident, visual meteorological conditions prevailed, with strong and gusty winds out of the west. The flight operated on an instrument flight rules flight plan.
The National Transportation Safety Board determines that the probable cause of this accident was the captain's cessation of rudder input, which was needed to maintain directional control of the airplane, about 4 seconds before the excursion, when the airplane encountered a strong and gusty crosswind that exceeded the captain's training and experience.
Contributing to the accident were the following factors: 1) an air traffic control system that did not require or facilitate the dissemination of key, available wind information to the air traffic controllers and pilots; and 2) inadequate crosswind training in the airline industry due to deficient simulator wind gust modeling.
The safety issues discussed in this report include the pilots' actions, training, and experience; air traffic controllers' obtaining and disseminating wind information; runway selection and use; crosswind training; simulator modeling; crosswind guidelines and limitations; certification and inspection of crew seats; and galley latches.
As a result of this investigation, the National Transportation Safety Board makes the following recommendations to the Federal Aviation Administration:
Conduct research into and document the effects of mountain wave and downslope conditions at airports, such as Denver International Airport, that are located downwind of mountainous terrain (including, for example, airports in or near Colorado Springs, Colorado; Anchorage, Alaska; Salt Lake City, Utah; and Reno, Nevada), identify potential mountain-wave-related hazards to ground operations at those airports, and disseminate the results to pilots and airport air traffic control personnel to allow for more informed runway selection decisions. (A-10-105)
Archive all low-level windshear alert system (LLWAS) data obtained from Denver International Airport and other airports that experience similar wind conditions and make those data available for additional research and the potential future development of an improved LLWAS algorithm for crosswind and gusty wind alerts on air traffic control tower ribbon display terminals. (A-10-106)
Modify Federal Aviation Administration Order 7110.65 to require air traffic controllers at airports with multiple sources of wind information to provide pilots with the maximum wind component, including gusts, that the flight could encounter. (A-10-107)
Review the required documentation for all low-level windshear alert system (LLWAS)-equipped air traffic control towers to ensure that a letter to airmen has been published and is easily accessible describing the location and designation of the remote sensors, the capabilities and limitations of the system, and the availability of current LLWAS remote sensor wind information on the request of a pilot, in compliance with Federal Aviation Administration Order 7210.3. (A-10-108)
Require air traffic control towers to locally develop and implement written runway selection programs that proactively consider current and developing wind conditions and include clearly defined crosswind components, including wind gusts, when considering operational advantage with respect to runway selection. (A-10-109)
Gather data on surface winds at a sample of major U.S. airports (including Denver International Airport) when high wind conditions and significant gusts are present and use these data to develop realistic, gusty crosswind profiles for use in pilot simulator training programs. (A-10-110)
Require 14 Code of Federal Regulations Part 121, 135, and 91K operators to incorporate the realistic, gusty crosswind profiles developed as a result of Safety Recommendation A-10-110 into their pilot simulator training programs. (A-10-111)
Once realistic, gusty crosswind profiles as asked for in Safety Recommendation A-10-110 are developed, develop a standard methodology including pilot-in-the-loop testing, for transport-category airplane manufacturers to establish empirically based, type-specific maximum-gusting-crosswind limitations for transport-category airplanes that account for wind gusts. (A-10-112)
Once a methodology as asked for in Safety Recommendation A-10-112 has been developed, require manufacturers of transport-category airplanes to develop type-specific, maximum-crosswind takeoff limitations that account for wind gusts. (A-10-113)
Until the actions described in Safety Recommendation A-10-113 are accomplished, require manufacturers of transport-category airplanes to provide operators with interim crosswind takeoff guidelines that account for wind gusts. (A-10-114)
Work with U.S. airline operators to review and analyze operational flight data to identify factors that contribute to encounters with excessive winds and use this information to develop and implement additional strategies for reducing the likelihood of wind-related runway excursions. (A-10-115)
Require cockpit crew seats installed in newly manufactured airplanes that were type certificated before 1988 to meet the crashworthiness standards contained in 14 Code of Federal Regulations 25.562. (A-10-116)
Require operators to perform periodic inspections on the Burns Aerospace model 2501-5 jumpseats for fatigue cracks within the jumpseat structure and replace the jumpseat if fatigue cracks are found. (A-10-117)
Require that operators of transport-category airplanes that use galley latches or latch plates secured solely by adhesives that may degrade over time modify the latches to include mechanical fasteners. (A-10-118)