Ryan International Airlines Flight 590
Ryan International Airlines Flight 590 was a cargo flight carrying mail for the United States Postal Service from Greater Buffalo International Airport in Buffalo, New York, to Indianapolis International Airport in Indiana, with a stopover at Cleveland Hopkins International Airport in Cleveland, Ohio. On February 17, 1991, the McDonnell Douglas DC-9-15RC operating the flight crashed on takeoff from Cleveland during icing conditions. Both pilots, the aircraft's only occupants, were killed. The National Transportation Safety Board determined that the causes of the crash were the flight crew failing to deice their aircraft, and the inexperience of the Federal Aviation Administration, McDonnell Douglas, and Ryan International Airlines with icing condition on DC-9-10 aircraft.
Background
Aircraft
The aircraft involved was a 22-year-old McDonnell Douglas DC-9-15RC registered as N565PC. The -15 is a subvariant of the series 10 of DC-9s.The accident aircraft first flew in 1968 and was delivered to Continental Airlines as a passenger aircraft in July of that same year, registered as N8919. The aircraft operated with Continental for five years. In October 1973, the aircraft was delivered to Hughes Airwest and re-registered as N9351. In October 1980, the aircraft was transferred to Republic Airlines, which operated the aircraft until June 1984, when it was converted into a freighter and delivered to Purolater Courier. Three months later, the aircraft was registered as N565PC. In October 1987, the aircraft was transferred to Emery Worldwide Airlines. Ryan International Airlines began to operate the aircraft in 1989, though it was still owned by Emery Worldwide Airlines at the time of the accident.
Crew
The captain was 44-year-old David Reay. He had flown with Ryan Air International since 1989 and logged 10,505 flight hours, including 505 hours on the DC-9. Reay was described "as a pilot with average skills who took criticism well," and "having very good command authority and being smooth on the controls." However, Reay had been involved in disciplinary action at the airline twice. The first was in August 1990, when he landed an aircraft without computing the proper data. The second was when he gained access to the jumpseat of an aircraft operated by a different airline by using an unauthorized identity card. Reay received a written warning on the first offense and a verbal warning on the second. Reay had also been involved in a business venture where he distributed literature claiming that he was in a partnership with the airline. After a talk with the airline's president, Reay reclaimed the literature. Reay had previously made a similar claim with another flight position, which resulted in him being removed from it. Despite this activity, Reay had no criminal arrests, nor had he been involved any vehicular accidents.The first officer was 28-year-old Richard Duney Jr., who was far less experienced than captain Reay, having only been with the airline since January 28, 1991, less than a month before the accident. However, prior to joining RIA, he had been a pilot for a commuter airline from 1986 to 1989 and had served as a first officer on the DC-9 with USAir, but was laid off in 1991. Duney had 3,820 flight hours, with 510 of them on the DC-9.
The airline's chief pilot described Duney as "very personable and eager to do a good job." However, on March 28, 1990, Duney was involved in a car accident, though no charges were filed. Duney did not have any criminal history.
Weather
At 23:50, the National Weather Service issued the following weather report at CLE:The National Aviation Weather Unit warned pilots flying into Ohio that there were icing conditions and turbulence. No AIRMETs were in effect.
The NWS forecast at CLE was as follows:
In other words, the weather was dangerously cold with the temperature at, enough to cause ice to accumulate on aircraft, and the dew point at. There was light snow and strong winds blowing at, increasing the risk of windshear. Pilots could only operate under instrument flight rules until 14:00 the next day.
Accident
At 00:06 on February 17, first officer Duney requested departure clearance from air traffic control. The controller stated:At 00:08, due to the freezing temperatures and snow, the pilots activated the engine anti-ice system, which uses engine heat to prevent sensors from freezing, ensuring accurate instrument readings. The cockpit voice recorder recorded the following conversation snippet :
At 00:09, first officer Dunney requested taxi clearance. The tower controller instructed the flight to "taxi runway two three left via Juliet and the ramp." A minute later, the controller reminded the flight about the braking conditions :
At 00:14, Continental Airlines Flight 1238 informed the tower controller that they were on approach to the same runway. The controller cleared Flight 1238 to land, informing them about Flight 590's braking conditions. At 00:17 Flight 590 lined up on runway 23L, and one minute later, at 00:18, was cleared for takeoff:
At 00:18:24.6 Flight 590 commenced its takeoff roll from runway 23L. The engine anti-ice system was on during the takeoff roll. First officer Dunney was the pilot flying, and the following was recorded by the CVR:
Captain Reay called out "rotate" at 00:18:45.9 and the aircraft lifted off. Almost immediately after, however, the aircraft began to bank left, as indicated by the flight data recorder. This was also mentioned in statements from the tower controller and other witnesses. Several witnesses even went as far as to state that they saw an explosion before the aircraft crashed. According to the CVR, captain Reay called out "watch out" three consecutive times. Both engines began to experience compressor stalls and the stick shaker activated, both lasting for about three seconds. The aircraft rolled 90° to the left and entered a stall. At 00:18:57, the aircraft crashed back onto runway 23L, the left wing contacted the ground first, followed by the rest of the aircraft. The aircraft then flipped over and skidded along the runway, causing the cockpit and forward fuselage to separate and were destroyed. Both pilots were killed on impact by extreme trauma. The passengers and crew on Continental Airlines Flight 1238 witnessed the accident.
Investigation
Less than an hour after the accident occurred, the NTSB was notified about it. A go-team traveled to Cleveland four hours later. The United States Postal Service and airport workers recovered mail that had not been destroyed in the crash.The left wing and number-one engine were both destroyed during the accident sequence, but the right wing and number-two engine, were mainly intact. The number-one engine had a high rotation speed at the time of impact. The flaps were extended to 20° at the time of impact, though the flap handle was positioned near 30°. The horizontal stabilizer was at 34° nose up. The engine anti-ice heat switches were in the "ON" position at the time of impact. Despite witnesses stating that the aircraft was on fire or exploded before impact, the only fire and explosions had occurred during the impact sequence.
According to the CVR, the most notable information was during the takeoff sequence, including captain Reay's callouts, as well as the stick shaker and engine compressor stalls. According to the flight data recorder, the aircraft had reached a maximum airspeed of during its flight. The stick shaker had activated at. Flight 590 had experienced a sudden drop in normal acceleration to 0.7 g during its takeoff. The NTSB compared the takeoff of Flight 590 with another DC-9-10 in similar conditions. The acceleration of the comparison flights only dropped to almost 0.9 g during takeoff.
The NTSB examined other accidents that were involved icing, such as Ozark Air Lines Flight 982, Air Florida Flight 90, and Continental Airlines Flight 1713. Following the Flight 1713 accident, McDonnell Douglas presented a paper warning about ice accumulation on DC-9s. The FAA had also disagreed with a safety recommendation from the Flight 1713 accident, which recommended DC-9-10 series aircraft be de-iced with strong glycol during icing conditions.
Ryan International Airlines' DC-9s flight crew operations manual required the first officer to inspect the aircraft for ice after landing in icing conditions. However, according to ground witnesses, neither crew member left the aircraft while it was parked. The NTSB believed that this was because of the flight crew's previous experience with larger variants of the DC-9, which have leading edge devices and are less vulnerable to icing conditions, and possibly the fact that no other flight requested deicing before takeoff. The NTSB even considered fatigue as a reason the crew did not inspect the aircraft, the crew had been on the same flight schedule on the same route for six days and captain Reay may have been experiencing a cold; the demanding schedules can hamper illness recovery and contribute to fatigue. Nevertheless, the NTSB had insufficient evidence and was unable to determine if fatigue did indeed play a role in the accident.
The NTSB also noted that both Douglas and the FAA had been aware of previous DC-9 accidents in icing conditions, but had poor oversight. Ryan International Airlines was also unaware of these accidents when they purchased the DC-9s.
Conclusion
The NTSB published its final report nearly nine months later, stating:The NTSB determined that the accident had been caused by the icing contamination as a result of the flight crew failing to conduct an external examination of the aircraft after landing in cold weather, as well as the failure of the FAA, McDonnell Douglas, and Ryan International Airlines to respond appropriately from previous ice-related accidents, and their lack of understanding of icing condition of the DC-9-10 aircraft.
Six safety recommendations were issued to the FAA, and recommendation A-88-134 was reiterated.