Incident Overview

Date: Monday 26 October 2009
Aircraft Type: Boeing 717-231
Owner/operator: AirTran Airways
Registration Number: N935AT
Location: Pleasant Grove, NC – ÿ United States of America
Phase of Flight: En route
Casualties: Fatalities: 0 / Occupants: 122
Component Affected: CAS (Collision Avoidance System) – Specifically the TCAS system and its guidance protocols.CAS (Collision Avoidance System) – Specifically the TCAS system and its guidance protocols.
Investigating Agency: NTSBNTSB
Category: Accident
During a scheduled cruise descent, the captain initiated a series of maneuvers to respond to a traffic alert and collision avoidance system (TCAS) alert. After receiving the RA, the captain immediately initiated an avoidance maneuver, resulting in a positive vertical acceleration exceeding 1.6g and a subsequent maximum negative vertical acceleration. The excessive control inputs triggered a significant lateral acceleration, potentially leading to a serious injury to a flight attendant and a minor injury to a passenger. The incident highlights a failure in the TCAS system’s guidance and the crew’s response to the advisory, compounded by inadequate training and inadequate oversight.During a scheduled cruise descent, the captain initiated a series of maneuvers to respond to a traffic alert and collision avoidance system (TCAS) alert. After receiving the RA, the captain immediately initiated an avoidance maneuver, resulting in a positive vertical acceleration exceeding 1.6g and a subsequent maximum negative vertical acceleration. The excessive control inputs triggered a significant lateral acceleration, potentially leading to a serious injury to a flight attendant and a minor injury to a passenger. The incident highlights a failure in the TCAS system’s guidance and the crew’s response to the advisory, compounded by inadequate training and inadequate oversight.

Description

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 ñ.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. Probable Cause: 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.

Primary Cause

Inadequate TCAS training and guidance, specifically regarding the immediate response to a traffic alert and collision avoidance system (RA) and the crew’s response to the resulting maneuvers.Inadequate TCAS training and guidance, specifically regarding the immediate response to a traffic alert and collision avoidance system (RA) and the crew’s response to the resulting maneuvers.

Share on:

Leave a Reply

Your email address will not be published. Required fields are marked *