# NTSB CEN11LA092: Embraer EMB-145LR, N678AE, Madison, WI, November 23, 2010 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: November 23, 2010, 13:40 local (19:40 UTC) - Place: Madison, WI - Coordinates: 43.139999, -89.337501 - Nearby events: https://openairdocs.org/map.md?lat=43.1400&lon=-89.3375&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) not oper: Cabin safety event](https://openairdocs.org/ntsb-events/110) - Highest injury: Serious injuries - Injuries: 1 serious, 48 uninjured - Status: Completed, report October 17, 2011 - Report: Approved by Office Director - NTSB office: Central Region - Parties: FAA- Milwaukee FSDO - NTSB case key (mKey): 77931 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CEN11LA092 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/77931/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=77931 - Page: https://openairdocs.org/ntsb/CEN11LA092 ## Probable cause The passenger's decision to deplane without assistance despite having a preexisting condition that limited her mobility. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action](https://openairdocs.org/ntsb-findings/02041000): Personnel issues › Action/decision · Passenger (probable cause); cases with it: [Embraer EMB-145LR, 1 case](https://openairdocs.org/ntsb-findings/02041000/cases.md?model=3260212), [All aircraft, 111 cases](https://openairdocs.org/ntsb-findings/02041000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Standing-engine(s) not oper: Cabin safety event](https://openairdocs.org/ntsb-events/110) (defining event); cases with it: [Embraer EMB-145LR, 2 cases](https://openairdocs.org/ntsb-events/110/sequence.md?model=3260212), [All aircraft, 151 cases](https://openairdocs.org/ntsb-events/110/sequence.md) ## Analysis A wheelchair-designated passenger wearing an ankle brace was instructed to remain seated and wait for assistance that would be provided after the other passengers had deplaned. Despite these instructions, the passenger attempted to deplane without assistance and without the aid of her crutches, which had been stowed in the crew closet for the flight. While walking down the aisle of the airplane's cabin, the passenger fell near the forward galley and broke both of her ankles. ## Factual narrative On November 23, 2010, about 1340 central standard time, a passenger received serious injuries while deplaning from an Embraer EMB-145LR, N678AE, registered to and operated by American Eagle Airlines under the provisions of 14 Code of Federal Regulations Part 121 as a scheduled domestic passenger flight on an instrument flight rules flight plan. The airplane was piloted by an airline transport pilot. Except for the one passenger injury, there were no injuries to the other passengers or crewmembers. The flight originated from the Dallas/Fort Worth International Airport (DFW), Dallas-Fort Worth, Texas, at 1140, and had arrived at the Dane County Regional Airport-Truax Field (MSN), Madison, Wisconsin. According to crew statements, the injured passenger was designated as a wheelchair passenger and had boarded the airplane wearing an ankle brace. The passenger was seated in seat 9A. According to the gate agent, the passenger had been instructed to remain seated and wait for assistance which would be provided after the other passengers had deplaned. The flight attendant reported seeing the passenger walking down the cabin aisle during passenger deplaning without her crutches. The crutches had been stowed in the crew closet of the airplane for the flight. The flight attendant reported that the passenger fell in the aisle of the airplane's cabin near the forward galley. After falling, the passenger complained of pain in her right foot. Paramedics were called and assisted the injured passenger off of the airplane using a wheelchair. It was later determined that the injured passenger had broken both of her ankles and required surgery. ## Aircraft - Registration: [N678AE](https://openairdocs.org/aircraft/N678AE), registered now, S/N 14500813, built 2004 (OpenAirDocs) - Reported make and model: EMBRAER EMB-145LR - Registry model: [Embraer EMB-145LR](https://openairdocs.org/model/embraer-emb-145lr) (registry code 3260212) (OpenAirDocs) - Registry engine: [Rolls-Royce AE3007 series](https://openairdocs.org/engine/rolls-royce-ae3007-series) (registry code 54582, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 14500813 - Engines: ROLLS-ROYC AE3007 SER 7200 horsepower turbo fan; ROLLS-ROYC AE3007 SER 7200 horsepower turbo fan - Damage: No damage - Flight: Part 121 - Operator: American Eagle Airlines Inc - Registered owner: American Eagle Airlines Inc - Airworthiness certificate: Standard, Transport - Departed: DFW, Dallas, TX - Destination: MSN, Madison, WI - Flight plan: IFR - Airport: MSN, Dane County Regional Airport ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 62; injuries: none; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, with waivers/limitations; last flight review July 17, 2010; seat: left; flight hours: 14,974 total, 8,308 as pilot in command - Co-pilot; age 27; injuries: none; commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review April 12, 2010; seat: right; flight hours: 1,394 total ## Weather - Conditions: Visual (VMC), Day - Wind: 360° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 30 °F, dew point 14 °F - Altimeter: 30.21 inHg - Observed at: MSN ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20101123052839A](https://openairdocs.org/incident/20101123052839A), Nov 23, 2010: Embraer EMB-145LR, Madison, WI, No damage. American eagle airlines [sima] flight #2704 dfw-msn was parked at the msn terminal gate with the main engines shut down and the wheel chocks/brakes set when a… ## Docket (2 files) The files NTSB released with the investigation on September 7, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=77931. 683 KB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 669 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352929&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Crew statements (item 2, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40352930&FileExtension=.PDF&FileName=Crew%20statements-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.