Aircraft Accident/Incident Report

80 Se Of Jfk (Atlantic Ocean), New York
Thursday, January 20, 2011 22:35 EST

NTSB Narrative Summary Released at Completion of Accident

A near-midair collision occurred between a Boeing 777-200 and a flight of two US Air Force C-17s as the result of an operational error by controllers at the New York air route traffic control center (ZNY). The airplanes responded to traffic collision avoidance system (TCAS) advisories, and both controllers immediately provided traffic advisories and turned each aircraft to resolve the conflict. According to recorded radar data, the three airplanes passed within approximately 0 feet vertically and .38 miles laterally from each other. The air traffic data controller, who was the coordinator between two radar controllers, told the controller working the 777 to stop the airplane at flight level (FL) 210. Following that coordination and while still on an open line with that controller, the data controller leaned toward the controller working the two-C17s and told him to stop his flight at FL220. The controller working the 777 overheard the portion of the communication where the data controller said to stop at FL220 and believed that the instruction was meant for the 777. Therefore, the controller instructed the 777 to climb to FL220, while at the same time the controller instructed the C17s to descend to FL220. Additionally, the investigation revealed that the radar data blocks for each of the airplanes displayed incorrect assigned altitude data. The data block for the 777 indicated that the airplane was cleared to climb to FL230 and the data block for the C17s indicated that the flights were cleared to descent to 10,000 feet. Both of these were incorrect: the radar data block for all involved airplanes should have reflected the assigned altitudes of FL220.

NTSB Probable Cause Narrative

Incomplete and incorrect coordination between air traffic controllers that resulted in the 777 and the two C17s being cleared to maintain the same altitude. Contributing to the incident was the controllers’ non-adherence to established communications phraseology and incorrect data entry into the radar data blocks for each aircraft.

Event Information

Type of Event Incident
Event Date 1/20/2011
Event Day of the Week Thursday
Time of Event 2235
Event Time Zone Eastern Standard Time
Event City 80 SE of JFK (Atlantic Ocean)
Event State NEW YORK
Event Country --
Zipcode of the event site --
Event Date Year 2011
Event Date Month 1
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 --
Investigator's weather source Pilot
Time of the weather observation
Direction of event from weather observation facility (degrees) --
Weather Observation Facility ID --
Elevation of weather observation facility --
Distance of event from weather observation facility (units?) --
Time Zone of the weather observation --
Lighting Conditions Night/Dark
Lowest Ceiling Height --
Lowest Non-Ceiling Height --
Sky/Lowest/Cloud Conditions Unknown
Sky Condition for Lowest Ceiling Unknown
Visibility Runway Visual Range (Feet) --
Visibility Runway Visual Value (Statute Miles) --
Visibility (Statute Miles) --
Air Temperature at event time (in degrees celsius) --
Dew Point at event time (in degress fahrenheit) --
Wind Direction (degrees magnetic) --
Variable Wind Indicator --
Wind Speed (knots) --
Wind Velocity Indicator --
Wind Gust Indicator --
Wind Gust (knots) --
Altimeter Setting at event time (in. Hg) --
Density Altitude (feet) --
Intensity of Precipitation --
METAR weather report --
Event Highest Injury --
On Ground, Fatal Injuries --
On Ground, Minor Injuries --
On Ground, Serious Injuries --
Injury Total Fatal --
Injury Total Minor --
Injury Total None --
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 30359
NTSB Notification Source FAA
NTSB Notification Date --
NTSB Notification Time --
Fiche Number and/or location -used to find docket information --
Date of most recent change to record Oct 25 2012 12:32PM
User who most recently changed record broda
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft Registration Number --
NTSB Number OPS11IA246
Missing Aircraft Indicator --
Federal Aviation Reg. Part --
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 777
Aircraft Series Identifier 200
Aircraft Serial Number --
Certified Max Gross Weight --
Aircraft Category --
Aircraft Registration Class --
Aircraft is a homebuilt? No
Flight Crew Seats --
Cabin Crew Seats --
Passenger Seats --
Total number of seats on the aircraft --
Number of Engines --
Fixed gear or retractable gear Fixed
Aircraft, Type of Last Inspection --
Date of Last Inspection --
Airframe hours since last inspection --
Airframe Hours --
ELT Installed Yes
ELT Activated No
ELT Aided Location of Event Site No
ELT Type Unknown
Aircraft Owner Name --
Aircraft Owner Street Address 4333 Amon Carter Boulevard
Aircraft Owner City Fort Worth
Aircraft Owner State TX
Aircraft Owner Country USA
Aircraft Owner Zipcode 76155
Operator is an individual? No
Operator Name --
Operator Same as Owner? No
Operator Is Doing Business As --
Operator Address Same as Owner? Yes
Operator Street Address --
Operator City --
Operator State TX
Operator Country USA
Operator Zip code --
Operator Code --
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 --
Indicates whether an air carrier operation was scheduled or not Scheduled
Indicates Domestic or International Flight International
Operator carrying Pax/Cargo/Mail Passenger Only
Type of Flying (Per_Bus / Primary) --
Second Pilot on Board Yes
Departure Point Same as Event Yes
Departure Airport Code --
Departure City 81 SE of JFK
Departure State NY
Departure Country USA
Departure Time --
Departure Time Zone EST
Destination Same as Local Flt --
Destination Airport Code SBGR
Destination City Sao Paulo
Destination State --
Destination Country USA
Specific Phase of Flight --
Report sent to ICAO? --
Evacuation occurred --
Date of most recent change to record Oct 25 2012 12:30PM
User who most recently changed record broda
Since inspection or accident --
Event Location Runway Number and Location N/A
Runway Length --
Runway Width --
Sight Seeing flight No
Air Medical Flight No
Medical Flight --