San Francisco International Airport
Aircraft Accident/Incident Report

San Francisco, California 94128
Wednesday, July 11, 2001 18:30 PDT

NTSB Narrative Summary Released at Completion of Accident

The air carrier transport airplane experienced an abrupt maneuver during its initial descent. The first officer reported that the flight crew had been cleared to descend from FL 390 to FL 330. The captain initiated the descent and the first officer began programming the flight management system. The first officer looked up as the airplane was flying past FL330 and queried the captain. The captain then immediately pulled the aircraft out of the descent and leveled off at FL330. Shortly thereafter, the flight crew was notified of a passenger injury resulting from the event. The captain reported to the passengers that they encountered turbulence. All of the flight attendants reported a smooth flight prior to the event. The captain had illuminated the fasten seat belt sign, but no one could remember an announcement accompanying the sign illumination. All of the flight attendants and an injured passenger, who was in the lavatory at the time of the event, described being pushed downward during the occurrence. There were no flight data recorders, cockpit voice recorders, or air traffic control recordings to review, because the Safety Board was not notified of the accident until almost 1 year after the event.

NTSB Probable Cause Narrative

the captain's excessive use of the flight controls to level off from a descent, which resulted in a passenger injury.

Event Information

Type of Event Accident
Event Date 7/11/2001
Event Day of the Week Wednesday
Time of Event 1830
Event Time Zone Pacific Daylight Time
Event City San Francisco
Event State CALIFORNIA
Event Country --
Zipcode of the event site 94128
Event Date Year 2001
Event Date Month 7
MidAir Collision Indicator No
On Ground Collision occurred ? No
Event Location Latitude 373708N
Event Location Longitude 1222229W
Event Location Airport San Francisco International
Event Location Nearest Airport ID SFO
Indicates whether the acc/inc occurred off or on an airport Off Airport/Airstrip
Distance from airport in statute miles 140
Degrees magnetic from airport 70
Airport Elevation 13
Weather Briefing Completeness Unknown
Investigator's weather source Weather Observation Facility
Time of the weather observation 1756 Pacific Daylight Time
Direction of event from weather observation facility (degrees) 250
Weather Observation Facility ID SFO
Elevation of weather observation facility 13
Distance of event from weather observation facility (units?) 140
Time Zone of the weather observation PDT
Lighting Conditions Day
Lowest Ceiling Height 2200
Lowest Non-Ceiling Height 2200
Sky/Lowest/Cloud Conditions Thin Broken
Sky Condition for Lowest Ceiling Broken
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) 10
Air Temperature at event time (in degrees celsius) 17
Dew Point at event time (in degress fahrenheit) 11
Wind Direction (degrees magnetic) 230
Variable Wind Indicator Wind direction could be determined
Wind Speed (knots) 18
Wind Velocity Indicator --
Wind Gust Indicator Gusting
Wind Gust (knots) 23
Altimeter Setting at event time (in. Hg) 30.02
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury Serious
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor 1
Injury Total None 98
Injury Total Serious 1
Injury Total All 2
Investigating Agency NTSB
NTSB Docket Number (internal use) 15531
NTSB Notification Source
NTSB Notification Date Jun 5 2002 12:00AM
NTSB Notification Time 1030
Fiche Number and/or location -used to find docket information DMS
Date of most recent change to record Jun 3 2004 1:28PM
User who most recently changed record NTSB\MONR
Basic weather conditions Visual Meteorological Cond
FAA District Office WP-OAK-FSDO

Aircraft Involved

Aircraft #1

Aircraft Registration Number N644DL
NTSB Number LAX01LA307
Missing Aircraft Indicator --
Federal Aviation Reg. Part Part 121: Air Carrier
Type of Flight Plan filed IFR
Flight plan Was Activated? Yes
Damage None
Aircraft Fire None
Aircraft Explosion None
Aircraft Manufacturer's Full Name Boeing
Aircraft Model 757-232
Aircraft Series Identifier --
Aircraft Serial Number 23998
Certified Max Gross Weight 232000
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 189
Number of Engines 2
Fixed gear or retractable gear Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness
Date of Last Inspection Jun 23 2001 12:00AM
Airframe hours since last inspection --
Airframe Hours 43432
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type --
Aircraft Owner Name DELTA AIRLINES, INC.
Aircraft Owner Street Address HARTSFIELD ATLANTA AIRPORT
Aircraft Owner City ATLANTA
Aircraft Owner State GA
Aircraft Owner Country USA
Aircraft Owner Zipcode 30320
Operator is an individual? No
Operator Name --
Operator Same as Owner? Yes
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State --
Operator Country --
Operator Zip code --
Operator Code DALA
Owner has at least one certificate --
Other Operator of large aircraft? --
Certified for Part 133 or 137 Operation --
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) --
Second Pilot on Board Yes
Departure Point Same as Event No
Departure Airport Code CVG
Departure City CINCINNATI
Departure State OH
Departure Country USA
Departure Time --
Departure Time Zone --
Destination Same as Local Flt crash at destination city
Destination Airport Code SFO
Destination City SAN FRANCISCO
Destination State CA
Destination Country USA
Specific Phase of Flight Descent
Report sent to ICAO? No
Evacuation occurred No
Date of most recent change to record Apr 13 2004 5:00PM
User who most recently changed record COOS
Since inspection or accident --
Event Location Runway Number and Location NA
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --