Boeing 727-123 – N1965 – Air Crash Data

Incident Overview

Date: Sunday 23 June 1985

Aircraft Type: Boeing 727-123

Owner/operator: American Airlines

Registration Number: N1965

Location: South Haven, MI – ÿ United States of America

Phase of Flight: En route

Casualties: Fatalities: 0 / Occupants: 69

Component Affected: Radar Data and ATC ProceduresRadar Data and ATC Procedures

Investigating Agency: NTSBNTSB

Category: Accident

This incident report details a serious aviation collision involving an American Flight 803 (Boeing 727) and a Canadian Cessna 421C (N1200L) on 4/12/84. The Cessna was flying FM, approaching 13,000 to 12,000 feet, when it was detected by the American Flight 803’s radar. The Cessna then turned sharply to avoid a collision. The pilot of the Cessna, Captain Saawa, initiated a hard over to avoid a collision. Subsequently, the Cessna passed each other within 50-100 feet, resulting in a restrained passenger and a serious injury to two passengers. After landing, the pilot of the Flight 803, Pilot at-hand (FA), was navigating with a Transponder XP, experiencing intermittent communication issues. The Transponder was transmitting 3 MHz on 4/12/84, and was not actively used. The ATC personnel were not adequately monitoring the radar data, leading to a delayed and inadequate response. The pilot of the Flight 803, Pilot in Command (PIC), delayed remedial actions, resulting in further delays. The pilot of the Cessna was using the second transponder, and the ATC personnel were not properly utilizing the radar data. The pilot’s seat belt was not used, and the passenger was restrained. The incident was exacerbated by clouds and inadequate weather conditions.This incident report details a serious aviation collision involving an American Flight 803 (Boeing 727) and a Canadian Cessna 421C (N1200L) on 4/12/84. The Cessna was flying FM, approaching 13,000 to 12,000 feet, when it was detected by the American Flight 803’s radar. The Cessna then turned sharply to avoid a collision. The pilot of the Cessna, Captain Saawa, initiated a hard over to avoid a collision. Subsequently, the Cessna passed each other within 50-100 feet, resulting in a restrained passenger and a serious injury to two passengers. After landing, the pilot of the Flight 803, Pilot at-hand (FA), was navigating with a Transponder XP, experiencing intermittent communication issues. The Transponder was transmitting 3 MHz on 4/12/84, and was not actively used. The ATC personnel were not adequately monitoring the radar data, leading to a delayed and inadequate response. The pilot of the Flight 803, Pilot in Command (PIC), delayed remedial actions, resulting in further delays. The pilot of the Cessna was using the second transponder, and the ATC personnel were not properly utilizing the radar data. The pilot’s seat belt was not used, and the passenger was restrained. The incident was exacerbated by clouds and inadequate weather conditions.

Description

WHILE EN ROUTE ON AN IFR FLT PLAN (1ST OFFICER AT CTLS), AMERICAN FLT 803 (A BOEING 727, N1965) BGN A DSCNT FM FL 190 TO9000′. THE SEAT BELT SIGN WAS TURNED ON AT 18,000′. WHILE DSCNDG BTN CLD LAYERS, AT APRX 13,000 TO 12,000′, THE CAPT SAWA CESSNA 421C, N1200L, CONVERGING FM OPPOSITE DRCTN. HE TOOK CTL & ‘EXECUTED A HARD NOSE OVER’ TO AVOID A COLLISION. THECESSNA PLT RPRTD HE WAS CRUISING IN VFR CONDS AT 12,500′ WHEN HE SAW THE BOEING DSCNDG OUT OF SCAT CLDS. HE BGN DSCNDG, THEN ENTERED AN ABRUPT CLBG TURN TO AVOID COLLIDING. RPRTDLY, THE ACFT PASSED EACH OTHER W/I 50 TO 100′. AN UNRESTRAINEDPAX & 1 FLT ATNDNT (FA) WERE SERIOUSLY INJURED; 2 FA’S RECEIVED MINOR INJURIES. AFTER LNDG, WRINKLES & SKIN DMG WERE FNDON THE CESSNA’S HORIZONTAL STABILIZERS. THE CESSNA PLT WAS USING HIS #2 TRANSPONDER (XP); ARTCC WAS RECEIVING ITS REPLY INTERMITTENTLY; IT WAS FND TRANSMITTING 3 MHZ (MAX LMT) ABV THE DESIRED FREQ. ON 4/12/84, XP’S WERE CHKD & WRITTEN UP AS’#2 OFF FREQ HIGH.’ AFTER THE NR COLLISION, THE ARTCC CTLR NOTED THE ‘ALL PRIMARY’ FEATURE OF HIS RADAR WAS NOT IN USE. Findings 1. (F) OPERATION WITH KNOWN DEFICIENCIES IN EQUIPMENT – PERFORMED – PILOT OF OTHER AIRCRAFT 2. (F) IDENTIFICATION OF AIRCRAFT ON RADAR – NOT ATTAINED – ATC PERSONNEL(ARTCC) 3. (F) IMPROPER USE OF PROCEDURE – ATC PERSONNEL(ARTCC) 4. (F) WEATHER CONDITION – CLOUDS 5. SEAT BELT SIGN – SELECTED 6. (C) VISUAL LOOKOUT – INADEQUATE – COPILOT/SECOND PILOT 7. (C) REMEDIAL ACTION – DELAYED – PILOT IN COMMAND 8. (C) REMEDIAL ACTION – INADEQUATE – PILOT OF OTHER AIRCRAFT 9. MANEUVER – INTENTIONAL 10. (C) SEAT BELT – NOT USED – PASSENGER

Primary Cause

Inadequate radar monitoring and delayed remedial actions by ATC personnel, leading to a lack of timely response and a heightened risk of collision.Inadequate radar monitoring and delayed remedial actions by ATC personnel, leading to a lack of timely response and a heightened risk of collision.

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