FlarePath
Cases › ERA10LA041 · Part 121 airline

BOEING 717-200Air Tran Airways

Pleasant Grove, NC, USA · 2009-10-26·N935AT

0
fatal
1
serious
Serious injury
highest injury
—
damage

What happened

NTSB summary, verbatim

During cruise descent the captain of the scheduled airline flight handed over control of the airplane to the first officer to make a public address announcement regarding turbulence. He had just turned on the fasten seatbelt sign when they received a resolution advisory (RA) from the onboard traffic alert and collision avoidance system (TCAS). The captain then took back control of the airplane and initiated an avoidance maneuver. During the avoidance maneuver, a flight attendant sustained serious injuries and a child passenger sustained a minor injury. Review of air traffic control radar data and data from the onboard flight data recorder revealed that 1.5 seconds after the TCAS RA occurred, the captain initiated a series of excessive control inputs which resulted in a positive vertical acceleration of approximately 1.6g. One second after the positive vertical acceleration the airplane sustained a maximum negative vertical acceleration of approximately .2g. A second after the negative vertical acceleration the airplane sustained another positive load of 1.4g after which the acceleration was dampened out. According to the TCAS manufacturer's published guidance, a flight crew should "promptly but smoothly" follow a TCAS RA and since the maneuvers are coordinated between aircraft, the crew should never maneuver in the opposite direction of the advisory. The advisories are always based on the "least amount of deviation from the flight path" while providing safe vertical separation. Typical RAs that would require a maneuver by a flightcrew only requires crew response within 5 seconds and g-forces of ±.25g. Review of the airline's training and guidance materials for the two different types of airplanes the airline operated revealed that this information was included in the training and guidance material for one of the airplane types in their fleet but was not included in the training and guidance materials for the accident airplane type.

Photographs

1the aircraft, and what the investigators found
The aircraft before the accident
Delta Air Lines B717-231, N935AT, MSN 5019 (04 2000), as DL 2392 Atlanta (ATL) - Gainesville (GNV), Flight time 0 43 (52701024298)
Charles from Port Chester, New York · CC BY 2.0 · Wikimedia Commons

Probable cause

the Board's determination
The captain's excessive maneuver in response to a traffic alert and collision avoidance system (TCAS) alert, which resulted in a serious injury to a flight attendant. Contributing to the accident was the operator's inadequate TCAS training and guidance.

Occurrence sequence

3 stepsNTSB coding · CICTT taxonomy
  1. 1 · Enroute-descent
    Collision avoidance alert
  2. 2 · Enroute-descent
    Abrupt maneuver
    defining event
  3. 3 · Enroute-descent
    Cabin safety event

Findings

5 causal · 0 contributing
  • CAUSE
    Personnel issues › Task performance › Use of equip/info › Use of equip/system — Pilot
  • CAUSE
    Personnel issues › Action/decision › Info processing/decision › Decision making/judgment — Pilot
  • CAUSE
    Personnel issues › Action/decision › Action › Incorrect action performance — Pilot
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Training — Operator
  • CAUSE
    Organizational issues › Support/oversight/monitoring › Documentation/record keeping — Operator

Sequence of events

5 timed eventsfrom the FDR factual report · claude-sonnet-5
  1. 1201 EDT (approximate)cruise-descentp.1
    Aircraft maneuvered to avoid another airplane during cruise-descent near Pleasant Grove, NC
  2. N/Acruisep.3
    TCAS resolution advisory occurred
  3. 1.5 seconds after TCAS RAcruisep.3
    Positive vertical acceleration of approximately 1.6 g's recorded
  4. 1 second after positive vertical acceleration peakcruisep.3
    Aircraft sustained a maximum negative vertical acceleration of approximately 0.2 g's
  5. 1 second after negative vertical accelerationcruisep.3
    Aircraft sustained another positive load of 1.4 g's after which the acceleration was dampened out

NTSB analysis

from the final report

During cruise descent the captain of the scheduled airline flight handed over control of the airplane to the first officer to make a public address announcement regarding turbulence. He had just turned on the fasten seatbelt sign when they received a resolution advisory (RA) from the onboard traffic alert and collision avoidance system (TCAS). The captain then took back control of the airplane and initiated an avoidance maneuver. During the avoidance maneuver, a flight attendant sustained serious injuries and a child passenger sustained a minor injury. Review of air traffic control radar data and data from the onboard flight data recorder revealed that 1.5 seconds after the TCAS RA occurred, the captain initiated a series of excessive control inputs which resulted in a positive vertical acceleration of approximately 1.6g. One second after the positive vertical acceleration the airplane sustained a maximum negative vertical acceleration of approximately .2g. A second after the negative vertical acceleration the airplane sustained another positive load of 1.4g after which the acceleration was dampened out. According to the TCAS manufacturer's published guidance, a flight crew should "promptly but smoothly" follow a TCAS RA and since the maneuvers are coordinated between aircraft, the crew should never maneuver in the opposite direction of the advisory. The advisories are always based on the "least amount of deviation from the flight path" while providing safe vertical separation. Typical RAs that would require a maneuver by a flightcrew only requires crew response within 5 seconds and g-forces of ±.25g. Review of the airline's training and guidance materials for the two different types of airplanes the airline operated revealed that this information was included in the training and guidance material for one of the airplane types in their fleet but was not included in the training and guidance materials for the accident airplane type.