Individually Owned: 150,657
Corporate Owned: 137,281
Aircraft Accident/Incident Report
Pleasant Grove, North Carolina 23518
Monday, October 26, 2009 12:02 EDT
NTSB Narrative Summary Released at Completion of Accident
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.
NTSB Probable Cause Narrative
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.
Event Information
| Type of Event | Accident |
| Event Date | 10/26/2009 |
| Event Day of the Week | Monday |
| Time of Event | 1202 |
| Event Time Zone | Eastern Daylight Time |
| Event City | Pleasant Grove |
| Event State | NORTH CAROLINA |
| Event Country | -- |
| Zipcode of the event site | 23518 |
| Event Date Year | 2009 |
| Event Date Month | 10 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 365340N |
| Event Location Longitude | 0761204W |
| 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 | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1251 Eastern Daylight Time |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | ORF |
| Elevation of weather observation facility | 26 |
| Distance of event from weather observation facility (units?) | -- |
| Time Zone of the weather observation | EDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | 12000 |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | -- |
| 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) | 16 |
| Dew Point at event time (in degress fahrenheit) | 9 |
| Wind Direction (degrees magnetic) | 70 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 11 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Gusting |
| Wind Gust (knots) | 17 |
| Altimeter Setting at event time (in. Hg) | 30.23 |
| 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 | 120 |
| Injury Total Serious | 1 |
| Injury Total All | 2 |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 28612 |
| NTSB Notification Source | Pilot Union |
| NTSB Notification Date | -- |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | -- |
| Date of most recent change to record | Sep 14 2011 8:14AM |
| User who most recently changed record | rows |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
|
|---|---|
Aircraft #1 |
|
| Aircraft Registration Number | N935AT |
| NTSB Number | ERA10LA041 |
| 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 | 717-200 |
| Aircraft Series Identifier | -- |
| Aircraft Serial Number | 55069 |
| Certified Max Gross Weight | 120000 |
| Aircraft Category | Airplane |
| Aircraft Registration Class | -- |
| Aircraft is a homebuilt? | No |
| Flight Crew Seats | 3 |
| Cabin Crew Seats | 3 |
| Passenger Seats | 117 |
| Total number of seats on the aircraft | 123 |
| Number of Engines | 2 |
| Fixed gear or retractable gear | Retractable |
| Aircraft, Type of Last Inspection | Continuous Airworthiness |
| Date of Last Inspection | Sep 4 2009 12:00AM |
| Airframe hours since last inspection | -- |
| Airframe Hours | 23031 |
| ELT Installed | No |
| ELT Activated | Unknown |
| ELT Aided Location of Event Site | Unknown |
| ELT Type | -- |
| Aircraft Owner Name | WELLS FARGO BANK NORTHWEST NA TRUSTEE |
| Aircraft Owner Street Address | -- |
| Aircraft Owner City | SALT LAKE CITY |
| Aircraft Owner State | UT |
| Aircraft Owner Country | USA |
| Aircraft Owner Zipcode | 84111-2263 |
| Operator is an individual? | No |
| Operator Name | Air Tran Airways |
| Operator Same as Owner? | No |
| Operator Is Doing Business As | -- |
| Operator Address Same as Owner? | No |
| Operator Street Address | -- |
| Operator City | Orlando |
| Operator State | FL |
| Operator Country | USA |
| Operator Zip code | 32764 |
| Operator Code | ZZDA |
| Owner has at least one certificate | Yes - certificate holder |
| Other Operator of large aircraft? | No |
| Certified for Part 133 or 137 Operation | -- |
| Operator Certificate Number | ZZDA612U |
| 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 | MCO |
| Departure City | Orlando |
| Departure State | FL |
| Departure Country | USA |
| Departure Time | 1043 |
| Departure Time Zone | EDT |
| Destination Same as Local Flt | -- |
| Destination Airport Code | HPN |
| Destination City | White Plains |
| Destination State | NY |
| Destination Country | USA |
| Specific Phase of Flight | -- |
| Report sent to ICAO? | -- |
| Evacuation occurred | -- |
| Date of most recent change to record | Sep 13 2011 4:23PM |
| User who most recently changed record | broda |
| Since inspection or accident | Time of Accident |
| Event Location Runway Number and Location | N/A |
| Runway Length | -- |
| Runway Width | -- |
| Sight Seeing flight | No |
| Air Medical Flight | No |
| Medical Flight | -- |