Aviation Accident Summaries

Aviation Accident Summary DCA90MA017

ATLANTA, GA, USA

Aircraft #1

N44UE

BEECH A100

Aircraft #2

N8867E

BOEING 727

Analysis

DRG ARR AT NGT, BEECH A100 (KING AIR, N44UE) WAS CLRD FOR AN ILS RWY 26R APCH BEHIND CONTINENTAL FLT 9687, THEN EASTERN AIRLINE (EA) FLT 111 (BOEING 727, N8867E) WAS CLRD FOR THE SAME APCH BEHIND THE KING AIR. AFTER LNDG, FLT 9687 HAD A RADIO PROBLEM & THE TWR CTLR HAD DIFFICULTY COMMUNICATING WITH FLT 9687. MEANWHILE, THE KING AIR LNDD & ITS CREW HAD MOVED THE ACFT TO THE RGT SIDE OF THE RWY NR TWY-D (THE PRIMARY TWY FOR GEN AVN ACFT). THE TURNOFF FOR TWY-D WAS ABT 3800'FM THE APCH END OF RWY 26R. BEFORE THE KING AIR WAS CLR OF THE RWY, EA 111 LNDD & CONVERGED ON THE KING AIR. THE CREW OF EA 111 DID NOT SEE THE KING AIR UNTIL MOMENTS BFR THE ACDNT. THE CAPT TRIED TO AVOID A COLLISION, BUT THE BOEING'S RGT WING STRUCK THE KING AIR, SHEARING THE TOP OF ITS FUSELAGE & COCKPIT. SOME OF THE KING AIR'S STROBE/BEACON LGTS WERE INOP, THOUGH THEY MOST LIKELY WOULD HAVE BEEN EXTINGUISHED FOR THE IMC APCH. THE LOCAL CTLR DID NOT ISSUE A TFC ADZY TO EA 111 WITH THE LNDG CLNC. (SEE: NTSB/AAR-91/03)

Probable Cause and Findings

(1) FAILURE OF THE FEDERAL AVIATION ADMINISTRATION TO PROVIDE AIR TRAFFIC CONTROL PROCEDURES THAT ADEQUATELY TAKE INTO CONSIDERATION HUMAN PERFORMANCE FACTORS SUCH AS THOSE WHICH RESULTED IN THE FAILURE OF THE NORTH LOCAL CONTROLLER TO DETECT THE DEVELOPING CONFLICT BETWEEN N44UE AND EA 111, AND (2) THE FAILURE OF THE NORTH LOCAL CONTROLLER TO ENSURE THE SEPARATION OF ARRIVING AIRCRAFT WHICH WERE USING THE SAME RUNWAY. CONTRIBUTING TO THE ACCIDENT WAS THE FAILURE OF THE NORTH LOCAL CONTROLLER TO FOLLOW THE PRESCRIBED PROCEDURE OF ISSUING APPROPRIATE TRAFFIC INFORMATION TO EA 111, AND FAILURE OF THE NORTH FINAL CONTROLLER AND THE RADAR MONITOR CONTROLLER TO ISSUE TIMELY SPEED REDUCTIONS TO MAINTAIN ADEQUATE SEPARATION BETWEEN AIRCRAFT ON FINAL APPROACH.

 

Source: NTSB Aviation Accident Database

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