CHI89IA179

NTSB incident investigation · Boeing 767-231 · Knox, IN · September 5, 1989

Incident · Minor injuriesIncident investigationFinal report
Date
September 5, 1989, 17:52 local (21:52 UTC)
Place
Knox, IN
Injuries
6 minor, 156 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N608TWBoeing 767-231
Weather
Instrument (IMC) · Day
Status
Completed · report October 8, 1992
Report
Approved by Office Director
Case key
14289

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

The radar controlller's failure to maintain radar separation. Factors contributing to the incident were: misunderstanding of an ATC instruction by the pilot of the incident airplane, and unclear phraseology used in the instructions issued by the radar controller.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Near collision between aircraftCruise - normal
Interpretation of instructions - not understoodPilot in commandFactor
Information unclear(phraseology)Atc personnel(artcc)Factor
Radar separation - not maintainedAtc personnel(artcc)Cause

Analysis

This airplane was involved in a near collision with another airplane while in positive control airspace. Both airplanes took evasive action. Visibility was reported by both flight crews as being reduced by the presence of Cirrus clouds with no visible horizon. This airplane had acknowledged and responded to a turn instruction issued to a third airplane with a similar call sign, and turned to a heading which put the two involved airplanes on an intersecting course. The turn instruction was challenged by the airplane for whom it was intended, but the incident airplane was never turned back to its original heading. The error was discovered a short time later by the manual controller and pointed out to the radar controller. He issued turn and climb instructions to the incident airplane along with a traffic advisory. Correlation of the two dfdr readouts with radar track data show, that at the point of closest approach, vertical separation was between 95 and 200 ft.

Aircraft

Registration
N608TW
Reported as
Boeing 767-231
Category
Airplane
Engine
P&W JT9D-7R4D, turbo fan
Damage
No damage
Flight
Part 121
Operator
Trans World Airlines Inc.
Departed
STL · St Louis, MO
Destination
Paris, France, OF
Flight plan
IFR
Airport
NONE

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown

Weather

Conditions
Instrument (IMC) · Day
Temperature
-0 °F, dew point -0 °F