Aircraft Accident/Incident Report

Indianapolis, Indiana 46241
Sunday, May 12, 1996 20:25 CDT

NTSB Narrative Summary Released at Completion of Accident

Upon reaching a cruise altitude of 33,000 feet, the cabin altitude warning horn sounded. The captain noticed the right air conditioning pack was off and he, along with the flight engineer, attempted to reinstate the pack without using a checklist. The cabin altitude continued to climb to 14,000 feet at which time the warning lights illuminated and the oxygen masks deployed in the cabin. While attempting to correct the cabin altitude, the flight engineer inadvertently opened the outflow valve resulting in a rapid loss of cabin pressure. The captain, the flight engineer, and the lead flight attendant all subsequently became unconscious due to hypoxia. The captain had delayed donning his oxygen mask. The flight engineer became unconscious after reviving the flight attendant. The first officer, who had only 10 hours of flight time in the airplane, had donned his oxygen mask when the warning horn first sounded, maintained consciousness, and was able to initiate an emergency descent. During the emergency descent the captain, the flight engineer, and the attendant regained consciousness, and an emergency landing was made at Indianapolis, Indiana. The airplane was inspected and flight tested the next day. The airplane's pressurization system functioned with no anomalies.

NTSB Probable Cause Narrative

the failure of the captain and flight engineer to utilize a checklist to troubleshoot a pressurization system problem, and the flight engineer's improper control of the pressurization system which resulted in an inadvertent opening of the outflow valve and subsequent airplane decompression.

Event Information

Type of Event Incident
Event Date 5/12/1996
Event Day of the Week Sunday
Time of Event 2025
Event Time Zone Central Daylight Time
Event City INDIANAPOLIS
Event State INDIANA
Event Country --
Zipcode of the event site 46241
Event Date Year 1996
Event Date Month 5
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude
Event Location Longitude
Event Location Airport
Event Location Nearest Airport ID
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles --
Degrees magnetic from airport --
Airport Elevation --
Weather Briefing Completeness Unknown
Investigator's weather source Pilot
Time of the weather observation 0
Direction of event from weather observation facility (degrees) 0
Weather Observation Facility ID
Elevation of weather observation facility 0
Distance of event from weather observation facility (units?) 0
Time Zone of the weather observation
Lighting Conditions Night/Dark
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 0
Sky/Lowest/Cloud Conditions Clear
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 0
Air Temperature at event time (in degrees celsius) --
Dew Point at event time (in degress fahrenheit) 3
Wind Direction (degrees magnetic) 320
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) --
Density Altitude (feet) --
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury Minor
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal --
Injury Total Minor 11
Injury Total None 101
Injury Total Serious --
Injury Total All 11
Investigating Agency NTSB
NTSB Docket Number (internal use) 5015
NTSB Notification Source --
NTSB Notification Date May 13 1996 12:00AM
NTSB Notification Time 730
Fiche Number and/or location -used to find docket information IMAGE
Date of most recent change to record Dec 8 2000 9:59AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number N775AT
NTSB Number CHI96IA157
Missing Aircraft Indicator N
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed IFR
Flight plan Was Activated? --
Damage None
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Boeing
Aircraft Model 727-290
Aircraft Series Identifier 727-290
Aircraft Serial Number 21511
Certified Max Gross Weight 197700
Aircraft Category Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft 181
Number of Engines 3
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Dec 5 1995 12:00AM
Airframe hours since last inspection 1261
Airframe Hours 47305
ELT Installed No
ELT Activated Unknown
ELT Aided Location of Event Site Unknown
ELT Type --
Aircraft Owner Name GATX THIRD AIRCRAFT CORP.
Aircraft Owner Street Address FOUR EMBARCADERO STR. STE 200
Aircraft Owner City SAN FRANCISCO
Aircraft Owner State CA
Aircraft Owner Country
Aircraft Owner Zipcode 94111
Operator is an individual? --
Operator Name AMERICAN TRANS AIR
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? No
Operator Street Address 7337 W. WASHINGTON ST.
Operator City INDIANAPOLIS
Operator State IN
Operator Country
Operator Zip code 46231
Operator Code AMTA
Owner has at least one certificate Yes - certificate holder
Other Operator of large aircraft? No
Certified for Part 133 or 137 Operation Unknown
Operator Certificate Number --
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight Domestic
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) Unknown
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code MDW
Departure City CHICAGO
Departure State IL
Departure Country
Departure Time 2000
Departure Time Zone CDT
Destination Same as Local Flt --
Destination Airport Code PIE
Destination City ST. PETERSBURG
Destination State FL
Destination Country
Specific Phase of Flight Cruise
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Dec 20 2002 12:42PM
User who most recently changed record dbo
Since inspection or accident --
Event Location Runway Number and Location 0
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --