FEBRUARY 19, 1996
NTSB Number: AAR-97-0l
NTIS Number: PB97-910401
Adopted February 11, 1997
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.
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)
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)