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Atlas / NTSB / DCA91MA021

NTSB CAROL · Event

Event DCA91MA021

1991-02-17 CLEVELAND, Ohio, United States Airport · CLE Fatal 1 aircraft Status: Completed

Registry · N565PC

FAA Aircraft Registry record.

Make / Model

CIRRUS DESIGN SF50

Year of manufacture

2020

Engine

WILLIAMS FJ33-5A

Seats / Engines

7 seats · 1 engine

Last airworthiness date

20201209

ADS-B equipped

Yes — Mode-S A73AC5

Registrant of record

CAPITAL AVIATION LLC

Source: FAA Aircraft Registry (releasable master file).

Aircraft involved

Probable cause & findings

THE FAILURE OF THE FLIGHTCREW TO DETECT AND REMOVE ICE CONTAMINATION ON THE AIRPLANE'S WINGS, WHICH WAS LARGELY A RESULT OF A LACK OF APPROPRIATE RESPONSE BY THE FEDERAL AVIATION ADMINISTRATION, DOUGLAS AIRCRAFT COMPANY, AND RYAN INTERNATIONAL AIRLINES TO THE KNOWN CRITICAL EFFECT THAT A MINUTE AMOUNT OF CONTAMINATION HAS ON THE STALL CHARACTERISTICS OF THE DC-9 SERIES 10 AIRPLANE. THE ICE CONTAMINATION LED TO WING STALL AND LOSS OF CONTROL DURING THE ATTEMPTED TAKEOFF. (NTSB REPORT AAR-91/09)

Factual narrative

THE FLIGHT HAD FLOWN THROUGH WEATHER CONDUCIVE TO AIRFRAME ICE ABOUT 40 MIN PRIOR TO THE ACCIDENT DURING DESCENT INTO CLEVELAND. DURING THE 35-MINUTE TURNAROUND AT CLEVELAND THE CREW DID NOT EXIT THE AIRPLANE TO CONDUCT AN EXTERIOR PREFLIGHT INSPECTION TO VERIFY THAT THE WINGS WERE FREE OF ICE CONTAMINATION. IT WAS SNOWING WHILE THEY WERE ON THE GROUND. THE AIRPLANE STALLED AND ROLLED INTO THE GROUND IMMEDIATELY AFTER TAKEOFF. THERE WAS NO OPERATOR REQUIREMENT FOR THE PREFLIGHT. THE FLIGHT HAD NOT BEEN GIVEN TRAINING REGARDING THE EFFECTS OF WING CONTAMINATION ON THE AIRPLANE. THE FAA AND THE MANUFACTURER HAVE BEEN AWARE FOR SEVERAL YEARS OF THE PROPENSITY OF THE DC-9 SERIES 10 TO THE LOSS OF CONTROL CAUSED BY WING CONTAMINATION, BUT NEITHER OF THEM TOOK POSITIVE ACTION TO INCLUDE RELATED INFORMATION IN THE APPROVED AIRPLANE FLIGHT MANUAL. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12

Verbatim from NTSB's published report. Source file NTSB_1991_DCA91MA021.txt. Findings + structured fields enriched from FAA avall.mdb. Full investigation docket on data.ntsb.gov ↗.

Related research

What the literature says.

Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, loss of control). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.

Browse the full corpus — academia portal ↗