United Airlines Flight 585

United Airlines Flight 585 was a scheduled passenger flight on March 3, 1991 from Denver to Colorado Springs, Colorado, carrying 20 passengers and 5 crew members on board. The plane experienced a rudder hardover while on final approach to runway 35 at Colorado Springs Municipal Airport, causing the plane to roll over and enter an uncontrolled dive. There were no survivors.[1]:xv

United Airlines Flight 585
N999UA, the aircraft involved in July 1986
Accident
Date3 March 1991 (1991-03-03)
SummaryLoss of control due to rudder hardover[1]
SiteWidefield Park, El Paso County
near Colorado Springs Municipal Airport, Colorado Springs, Colorado,
United States
38°44′09.4″N 104°42′42.4″W
Total fatalities25
Total injuries1
Aircraft
Aircraft typeBoeing 737-291
OperatorUnited Airlines
RegistrationN999UA
Flight originGreater Peoria Regional Airport
StopoverQuad City International Airport
Last stopoverStapleton International Airport
DestinationColorado Springs Municipal Airport
Occupants25
Passengers20
Crew5
Fatalities25
Survivors0
Ground casualties
Ground injuries1

The NTSB was initially unable to resolve the cause of the crash, but after similar accidents and incidents involving Boeing 737 aircraft, the crash was determined to be caused by a defect in the design of the 737's rudder power control unit.[1]:ix

Aircraft and flight crew

Flight 585 was operated by a Boeing 737-291, registered N999UA[2].[1]:7 The 737 was originally manufactured for Frontier Airlines in 1982 and was acquired by United Airlines in 1986 when the original Frontier Airlines went out of business (a new airline company with the same name formed eight years later).[1]:7 On the date of the accident, the aircraft had accumulated approximately 26,000 flight hours.[1]:7

The flight crew consisted of Captain Harold Green (52), First Officer Patricia Eidson (42), and 3 flight attendants. The captain, who had over 10,000 hours as a United Airlines pilot (including 1,732 hours on the Boeing 737), was regarded by colleagues as a conservative pilot who always followed standard operating procedures.[1]:5 The first officer had accumulated over 4,000 flight hours (including 1,077 hours on the Boeing 737), and she was considered by Captain Green to be a very competent pilot.[1]:6

Accident

Flight 585 was a regularly scheduled United Airlines Flight from General Wayne A. Downing Peoria International Airport in Peoria, Illinois to Colorado Springs, Colorado, making intermediate stops at Quad City International Airport in Moline, Illinois and the now-decommissioned Stapleton International Airport in Denver, Colorado. On March 3, 1991, the flight operated from Peoria to Denver without incident.[1]:1

At 09:23 AM Mountain Standard Time, Flight 585 departed Denver with 20 passengers and 5 crew members on board and was scheduled to arrive in Colorado Springs at 09:46 AM.[1]:2 At 09:37 AM, the aircraft was cleared for a visual approach to runway 35.[1]:2 The aircraft then suddenly rolled to the right and pitched nose down. The crew tried to initiate a go-around by selecting 15-degree flaps and an increase in thrust. The altitude decreased rapidly and acceleration increased to over 4G until the aircraft crashed into Widefield Park, less than four miles (6 km) miles from the runway threshold, at a speed of 245 miles per hour (395 km/h). The aircraft exploded on impact and an enormous fireball erupted as a result. According to the accident report, the resulting crash and explosion carved a crater 39 by 24 feet (12 m × 7.3 m) and 15 ft (5 m) deep.[1] Everyone on board was killed instantly, and an eight-year-old girl who lived nearby the tumbling jet was knocked to the ground by the force of the impact, suffering minor injuries.[3]

Investigation

Initial investigation

The National Transportation Safety Board (NTSB) commenced an investigation, which lasted for 21 months.[4]

Although the flight data recorder (FDR) outer protective case was damaged, the data tape inside was intact and all of the data was recoverable.[1]:38 Five parameters were recorded by the FDR: heading, altitude, airspeed, normal acceleration (G loads), and microphone keying. The FDR did not record rudder, aileron or spoiler deflection data, which could have aided the NTSB in reconstructing the plane's final moments.[4]:100 The data available proved insufficient to establish why the plane suddenly went into the fatal dive.[4]:102 The NTSB considered the possibilities of a malfunction of the rudder power control unit servo (which might have caused the rudder to reverse) and the effect that powerful rotor winds from the nearby Rocky Mountains may have had, but there was not enough evidence to prove either hypothesis.[4]:102

The cockpit voice recorder (CVR) was also damaged, but the data tape inside was also intact. However, the data tape had creases in it, resulting in the playback quality being poor.[4]:40 The CVR determined that the pilots made a verbal (and possible physical) response to the loss of control.[4]:102

The following is an excerpt of the last two minutes Flight 585 CVR, starting two minutes before impact (the full CVR recording started before Flight 585 took off from Stapleton):

Transcript of the last two minutes of United Airlines Flight 585's Cockpit Voice Recorder (Times are expressed in MST)
# = Expletive deleted; * = Unintelligible word; () = Questionable text; [] = Commentary; - = Break in continuity; Shading = Radio communication
Time Source Content
09:41:20 Captain Twenty five flaps.
09:41:23 Colorado Springs

tower control

 United five eighty-five, after landing hold short of runway three zero for departing traffic on runway… three zero.
09:41:25 [Sound similar to that of an engine power increase]
09:41:30 Captain Starting on down.
09:41:31 First officer (to Colorado Springs tower) We'll hold short of three zero, United five eighty five.
09:41:33 First officer That's all the way to the end of our runway not * doesn't mean a thing.
09:41:39 Captain No problem.
09:42:05 [Sound of "CO" ident on radio channel two]
09:42:08 First officer The marker's identified now it's really weak.
09:42:11 Captain No problem.
09:42:29 First officer (We had a) ten-knot change here.
09:42:31 Captain Yeah, I know… awful lot of power to hold that… airspeed.
09:42:38 First officer Runway is ah eleven thousand feet long
09:42:42 Captain Okay.
09:43:01 First officer Another ten knot gain.
09:43:03 Captain Thirty flaps.
09:43:03 [Sound similar to that of flap lever actuation]
09:43:08 First officer Wow.
09:43:09 [Sound similar to that of an engine power reduction]
09:43:28 First officer We're at a thousand feet.
09:43:32 First officer Oh god (flip)-
09:43:33 Captain Fifteen flaps.
09:43:34 First officer Fifteen.
09:43:34.4 First officer Oh.
09:43:34.7 Captain Oh! [Exclaimed loudly]
09:43:35.4 First officer #.
09:43:35.5 [Click sound similar to that of a flap lever actuation]
09:43:35.7 Captain #.
09:43:36.1 [Click sound similar to that of a flap lever actuation]
09:43:36.5 Captain No! [Very loud]
09:43:37.4 [Click sound similar to that of a flap lever actuation]
09:43:37.5 First officer Oh #.
09:43:38.2 Captain Oh #.
09:43:38.4 First officer Oh my god... [unidentifiable click sound] oh my god! [A scream]
09:43:40.5 Captain Oh no (#). [Exclaimed loudly]
09:43:41.5 [Sound of impact - end of tape]

Thus, the first NTSB report (issued on December 8, 1992) did not conclude with the usual "probable cause". Instead, it stated:[4]:102

The National Transportation Safety Board, after an exhaustive investigation effort, could not identify conclusive evidence to explain the loss of United Airlines flight 585.

This was only the fourth time in the NTSB's history that it published a final aircraft accident report with an undetermined probable cause.[5]

Intervening events
Main article: Boeing 737 rudder issues

Following the failure to identify the cause of Flight 585's crash, another Boeing 737 crash occurred under very similar circumstances when USAir Flight 427 crashed while attempting to land in Pennsylvania in 1994.[6]

Renewed investigation and probable cause

The NTSB reopened its investigation into Flight 585 in parallel with the Flight 427 investigation, due to the similar nature of the circumstances.[6]

During the NTSB's renewed investigation, it was determined that the crash of Flight 585 (and the later Flight 427 crash) was the result of a sudden malfunction of the aircraft's rudder power control unit. Another incident (non-fatal) that contributed to the conclusion was that of Eastwind Airlines Flight 517, which had a similar problem upon approach to Richmond on June 9, 1996.[7] On March 27, 2001, the NTSB issued a revised final report for Flight 585, which found that the pilots lost control of the airplane because of a mechanical malfunction. The renewed investigation concluded with a "probable cause" that stated:[1]:114

The National Transportation Safety Board determines that the probable cause of the United Airlines flight 585 accident was a loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder power control unit servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide.

The Discovery Channel Canada / National Geographic TV series Mayday dramatized the crash of Flight 585 and the subsequent 737 rudder investigation in a 2007 episode titled Hidden Danger.[5]

See also

References
  1. Aircraft Accident Report: Uncontrolled Descent and Collision With Terrain, United Airlines Flight 585, Boeing 737-200, N999UA, 4 Miles South of Colorado Springs Municipal Airport, Colorado Springs, Colorado, March 3, 1991 (PDF). National Transportation Safety Board. March 27, 2001. NTSB/AAR-01/01. Retrieved January 17, 2016.
  2. "FAA Registry (N999UA)". Federal Aviation Administration.
  3. "Jetliner Crashes Near Colorado Airport; 25 Die". Los Angeles Times. March 4, 1991. Retrieved September 7, 2019.
  4. Aircraft Accident Report: United Airlines Flight 585, Boeing 737-291, N999UA, Uncontrolled Collision With Terrain for Undetermined Reasons, 4 Miles South of Colorado Springs Municipal Airport, Colorado Springs, Colorado, March 3, 1991 (PDF). National Transportation Safety Board. December 8, 1992. NTSB/AAR-92/06. Retrieved January 17, 2016.
  5. "Hidden Danger". Mayday. Season 4. 2007. Discovery Channel Canada / National Geographic Channel.
  6. Aircraft Accident Report: Uncontrolled Descent and Collision With Terrain, USAir Flight 427, Boeing 737-300, N513AU, Near Aliquippa, Pennsylvania, September 8, 1994 (PDF). National Transportation Safety Board. March 24, 1999. NTSB/AAR-99/01. Retrieved January 17, 2016.
  7. Byrne, Gerry (2002). Flight 427: Anatomy of an Air Disaster. New York: Copernicus Books. pp. 207–210. ISBN 0-387-95256-X.

 This article incorporates public domain material from websites or documents of the National Transportation Safety Board.


This article is issued from Wikipedia. The text is licensed under Creative Commons - Attribution - Sharealike. Additional terms may apply for the media files.