Individually Owned: 150,657
Corporate Owned: 137,281
Dallas-Fort Worth Intl Airport
Aircraft Accident/Incident Report
Dallas-Ft Worth, Texas 75261
Monday, February 27, 1995 20:54 CST
NTSB Narrative Summary Released at Completion of Accident
ON THE NIGHT OF THE INCIDENT, THE LOCAL CONTROLLER CLEARED AMERICAN FLT 2351, N1763, TO LAND ON RWY 35R. SEVEN SECONDS LATER THE SAME CONTROLLER INSTRUCTED LONE STAR FLT 1219, N355AE, TO TAXI INTO POSITION AND HOLD ON RWY 35R. NEITHER CREW HEARD THE OTHER'S CLEARANCE, NOR WAS EITHER ADVISED OF THE OTHER'S POSITION AS REQUIRED. THE TOWER CAB SUPERVISOR NOTICED THE CONFLICT & ALERTED THE CONTROLLER. THE CONTROLLER COULD NOT RECALL THE CALL SIGN FOR AA2351, AND ISSUED GO-AROUND INSTRUCTIONS USING INCORRECT CALL SIGNS AA1251 & AA1261. AA2351 OVERFLEW LS1219 BY ABOUT 35 FT BEFORE TOUCHING DOWN. THE LOCAL FREQUENCY WAS VERY BUSY, AND THE CONTROLLER'S WORKLOAD WAS CATEGORIZED AS 'HEAVY' BY ALL FLIGHTCREWS INTERVIEWED. REVIEW OF ATC TAPES CONFIRMED THOSE OBSERVATIONS. THE CONTROLLER WAS HANDLING TRAFFIC ON RWYS 35L, 35R, AND 31R, IN ADDITION TO RECEIVING INPUTS FROM THE DEPARTURE CONTROLLER. FIFTEEN MINUTES BEFORE THE INCURSION, THE CONTROLLER WAS GETTING UNCOMFORTABLE, AND INFORMED HIS SUPERVISOR THAT HE NEEDED A BREAK. THE SUPERVISOR LATER SAID THAT HE DID NOT NOTICE THAT THE CONTROLLER WAS GETTING OVERLOADED.
NTSB Probable Cause Narrative
THE LOCAL CONTROLLER'S TASK OVERLOAD, WHICH LED HIM TO FORGET TO ISSUE APPROPRIATE TRAFFIC ADVISORIES AND TO LOSE HIS AWARENESS OF THE TRAFFIC SITUATION, AND THE FAILURE OF THE CONTROLLER'S SUPERVISOR TO RECOGNIZE THAT THE CONTROLLER HAD REACHED OR EXCEEDED HIS MAXIMUM THRESHOLD OF WORKLOAD CAPABILITY AND TO TAKE APPROPRIATE ACTION.
Event Information
| Type of Event | Incident |
| Event Date | 2/27/1995 |
| Event Day of the Week | Monday |
| Time of Event | 2054 |
| Event Time Zone | Central Standard Time |
| Event City | DALLAS-FT WORTH |
| Event State | TEXAS |
| Event Country | -- |
| Zipcode of the event site | 75261 |
| Event Date Year | 1995 |
| Event Date Month | 2 |
| MidAir Collision Indicator | -- |
| On Ground Collision occurred ? | -- |
| Event Location Latitude | |
| Event Location Longitude | |
| Event Location Airport | DALLAS-FORT WORTH INTL |
| Event Location Nearest Airport ID | DFW |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | 562 |
| Weather Briefing Completeness | Full |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 2050 Central Standard Time |
| Direction of event from weather observation facility (degrees) | 0 |
| Weather Observation Facility ID | DFW |
| Elevation of weather observation facility | 562 |
| Distance of event from weather observation facility (units?) | 0 |
| Time Zone of the weather observation | CST |
| Lighting Conditions | Night/Dark |
| Lowest Ceiling Height | 0 |
| Lowest Non-Ceiling Height | 25000 |
| Sky/Lowest/Cloud Conditions | Scattered |
| Sky Condition for Lowest Ceiling | None |
| Visibility Runway Visual Range (Feet) | 0 |
| Visibility Runway Visual Value (Statute Miles) | 0 |
| Visibility (Statute Miles) | 15 |
| Air Temperature at event time (in degrees celsius) | 17 |
| Dew Point at event time (in degress fahrenheit) | 12 |
| Wind Direction (degrees magnetic) | 250 |
| Variable Wind Indicator | Unknown |
| Wind Speed (knots) | 6 |
| Wind Velocity Indicator | Unknown |
| Wind Gust Indicator | Not Gusting |
| Wind Gust (knots) | 0 |
| Altimeter Setting at event time (in. Hg) | 29 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | Unknown |
| METAR weather report | -- |
| Event Highest Injury | None |
| On Ground, Fatal Injuries | 0 |
| On Ground, Minor Injuries | 0 |
| On Ground, Serious Injuries | 0 |
| Injury Total Fatal | -- |
| Injury Total Minor | -- |
| Injury Total None | 78 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 5016 |
| NTSB Notification Source | -- |
| NTSB Notification Date | Mar 1 1995 12:00AM |
| NTSB Notification Time | 700 |
| Fiche Number and/or location -used to find docket information | IMAGE |
| Date of most recent change to record | Apr 9 2001 10:27AM |
| User who most recently changed record | dbo |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
||
|---|---|---|
Aircraft #1 |
Aircraft #2 |
|
| Aircraft Registration Number | N1763 | N355AE |
| NTSB Number | FTW95IA126A | FTW95IA126B |
| Missing Aircraft Indicator | N | N |
| Federal Aviation Reg. Part | Part 121: Air Carrier | Part 135: Air Taxi & Commuter |
| Type of Flight Plan filed | IFR | IFR |
| Flight plan Was Activated? | -- | -- |
| Damage | None | None |
| Aircraft Fire | None | None |
| Aircraft Explosion | None | None |
| Aircraft Manufacturer's Full Name | MCDONNELL DOUGLAS | FAIRCHILD |
| Aircraft Model | MD11 | SA227-AC |
| Aircraft Series Identifier | MD11 | SA227-AC |
| Aircraft Serial Number | 48533 | AC642 |
| Certified Max Gross Weight | 625000 | 14500 |
| Aircraft Category | Airplane | Airplane |
| Aircraft Registration Class | U.S. Registered/U.S. Soil | U.S. Registered/U.S. Soil |
| Aircraft is a homebuilt? | No | No |
| Flight Crew Seats | -- | -- |
| Cabin Crew Seats | -- | -- |
| Passenger Seats | -- | -- |
| Total number of seats on the aircraft | 249 | 21 |
| Number of Engines | 3 | 2 |
| Fixed gear or retractable gear | Retractable | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness | Continuous Airworthiness |
| Date of Last Inspection | Feb 24 1995 12:00AM | Feb 22 1995 12:00AM |
| Airframe hours since last inspection | 8691 | 35 |
| Airframe Hours | 8726 | 17725 |
| ELT Installed | No | Yes |
| ELT Activated | Unknown | No |
| ELT Aided Location of Event Site | Unknown | Unknown |
| ELT Type | -- | -- |
| Aircraft Owner Name | AMERICAN AIRLINES | MCDONNEL DOUGLAS FINANCE CORP |
| Aircraft Owner Street Address | P.O. BOX 61916 | 340 GOLDEN SHORE |
| Aircraft Owner City | DFW AIRPORT | LONG BEACH |
| Aircraft Owner State | TX | CA |
| Aircraft Owner Country | ||
| Aircraft Owner Zipcode | 75261 | 90802 |
| Operator is an individual? | -- | -- |
| Operator Name | EXEC EXPRESS II | |
| Operator Same as Owner? | Yes | No |
| Operator Is Doing Business As | -- | -- |
| Operator Address Same as Owner? | Yes | No |
| Operator Street Address | 131 EAST EXCHANGE AVENUE | |
| Operator City | FORT WORTH | |
| Operator State | TX | |
| Operator Country | ||
| Operator Zip code | 76106 | |
| Operator Code | EQGA | |
| Owner has at least one certificate | Yes - certificate holder | Yes - certificate holder |
| Other Operator of large aircraft? | No | No |
| Certified for Part 133 or 137 Operation | Unknown | Unknown |
| Operator Certificate Number | -- | -- |
| Indicates whether an air carrier operation was scheduled or not | Scheduled | Scheduled |
| Indicates Domestic or International Flight | Domestic | Domestic |
| Operator carrying Pax/Cargo/Mail | Passenger Only | Passenger Only |
| Type of Flying (Per_Bus / Primary) | Unknown | Unknown |
| Second Pilot on Board | Yes | Yes |
| Departure Point Same as Event | No | Yes |
| Departure Airport Code | ORD | DFW |
| Departure City | CHICAGO | |
| Departure State | IL | |
| Departure Country | ||
| Departure Time | 1856 | 0 |
| Departure Time Zone | CST | |
| Destination Same as Local Flt | crash at destination city | -- |
| Destination Airport Code | DFW | BPK |
| Destination City | MOUNTAIN HOME | |
| Destination State | AR | |
| Destination Country | ||
| Specific Phase of Flight | Landing | Standing |
| Report sent to ICAO? | -- | -- |
| Evacuation occurred | -- | -- |
| Date of most recent change to record | Jan 2 2001 10:30AM | Jan 2 2001 10:30AM |
| User who most recently changed record | dbo | dbo |
| Since inspection or accident | -- | -- |
| Event Location Runway Number and Location | 35R | 35R |
| Runway Length | 11388 | 11388 |
| Runway Width | 150 | 150 |
| Sight Seeing flight | No | No |
| Air Medical Flight | No | No |
| Medical Flight | -- | -- |