DCA02MA054

NTSB accident investigation · Boeing 727-232 · Tallahassee, FL · July 26, 2002

Accident · Serious injuriesClass 1 · MajorFinal report
Date
July 26, 2002, 05:37 local (09:37 UTC)
Place
Tallahassee, FL
Injuries
3 serious
Damage
Destroyed
Phase of flight
Approach
Aircraft
N497FEBoeing 727-232
Weather
Visual (VMC) · Night/dark
Status
Completed · report October 28, 2004
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20020726030569A
Case key
55303

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

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Probable cause

The captain's and first officer's failure to establish and maintain a proper glidepath during the night visual approach to landing. Contributing to the accident was a combination of the captain's and first officer's fatigue, the captain's and first officer's failure to adhere to company flight procedures, the captain's and flight engineer's failure to monitor the approach, and the first officer's color vision deficiency.

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.

In flight collision with objectApproach
Light condition - dark nightFactor
Proper glidepath - not attainedFlightcrewCause
FatigueFlightcrewFactor
Crew/group coordination - inadequateCause
In flight collision with terrain/waterDescent - uncontrolled
Terrain condition - runway

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-04/02.

On July 26, 2002, at 0537 eastern daylight time, a FedEx Boeing 727, N497FE, crashed during landing at Tallahassee, Florida. The airplane was operating as Flight 1478 from Memphis, Tennessee, to Tallahassee. The airplane crashed short of the runway, and was subsequently destroyed by fire. All three crewmembers were seriously injured.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/publictn/publictn.htm. The Aircraft Accident Report number is NTSB/AAR-04/02.

On July 26, 2002, at 0537 eastern daylight time, a FedEx Boeing 727, N497FE, crashed during landing at Tallahassee, Florida. The airplane was operating as Flight 1478 from Memphis, Tennessee, to Tallahassee. The airplane crashed short of the runway, and was subsequently destroyed by fire. All three crewmembers were seriously injured.

Aircraft

Registration
N497FE
Reported as
Boeing 727-232
Category
Airplane
Serial number
20866
Airframe hours
37,980
Engine
Pratt & Whitney JT8D-15, 15,500 lbs thrust, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Part 121
Registered owner
Federal Express Corp
Airworthiness certificate
Standard, Transport; Standard, Normal
Departed
NE64 · Memphis, NE
Destination
TLH · Tallahassee, FL
Flight plan
IFR
Airport
TLH · Tallahassee Regional Airport, runway 09, 8,000 × 150 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Weather

Conditions
Visual (VMC) · Night/dark
Wind
120° at 5 knots
Visibility
9 statute miles
Lowest ceiling
None
Temperature
72 °F, dew point 72 °F
Altimeter
30.10 inHg
Observed at
TLH, 1 nm away

Docket · 184

The files NTSB released with the investigation on January 10, 2003, on NTSB’s docket system: statements, records, photos and specialists’ reports. 102 MB in all.

Operations 2 - Factual Report of Group ChairmanItem 1 · .PDF · 77 KBOperations 2 - Attachment A - Interview SummariesItem 2 · .PDF · 666 KBOperations 2 - Attachment B - Flight Crew's Trip ScheduleItem 3 · .PDF · 83 KBOperations 2 - Attachment C - Airport Diagrams and Approach ChartsItem 4 · .PDF · 971 KBOperations 2 - Attachment D - Flight 1478 Flight Plan/ReleaseItem 5 · .PDF · 250 KBOperations 2 - Attachment E - Airplane Weight and BalanceItem 6 · .PDF · 1.7 MBOperations 2 - Attachment F - Excerpts from FedEx Flight Operations Manual (FOM)Item 7 · .PDF · 645 KBOperations 2 - Attachment G - Excerpts from the FedEx B-727 Flight Manual, Volume 1Item 8 · .PDF · 384 KBOperations 2 - Attachment H - Excerpts from the FedEx B-727 Flight Manual, Volume 2Item 9 · .PDF · 146 KBOperations 2 - Attachment I - Excerpts from the FedEx B-727 Flight Manual, Volume 3Item 10 · .PDF · 1.2 MBOperations 2 - Attachment J - Excerpts from the FedEx 727 Instructor GuideItem 11 · .PDF · 454 KBOperations 2 - Attachment K - Excerpts from First Officer Frye's B-727 IOE Pilot Training RecordItem 12 · .PDF · 356 KBOperations 2 - Attachment L - FAA FSDO 25 Staffing ChartItem 13 · .PDF · 119 KBOperations 2 - Attachment M - FedEx Threat and Error Management CardItem 14 · .PDF · 316 KBOperations 2 - Attachment N - Excerpts from the FedEx B-727 Instructor Briefing GuideItem 15 · .PDF · 794 KBOperations 2 - Attachment O - Excerpts from the Regional Aviation Safety Inspection ProgramItem 16 · .PDF · 266 KBOperations 2 - Attachment P - Excerpts from the National Aviation Safety Inspection ProgramItem 17 · .PDF · 427 KBOperations 2 - Attachment Q - Excerpts from the Office Safety Inspection ProgramItem 18 · .PDF · 678 KBATC 3 - Factual Report of Group ChairmanItem 19 · .PDF · 37 KBATC 3 - Attachment 1: ZJX Sector 28 TranscriptItem 20 · .PDF · 224 KBATC 3 - Attachment 3: Copy of FDX1478 Flight StripItem 21 · .PDF · 45 KBATC 3 - Attachment 4: Minimum Instrument Altitude chart for ZJX R28 AreaItem 22 · .PDF · 114 KBATC 3 - Attachment 5: ZJX Daily Record of Facility OperationsItem 23 · .PDF · 80 KBATC 3 - Attachment 6: TLH Airport DiagramItem 24 · .PDF · 95 KBATC 3 - Attachment 7: Horace Davis Medical QualificationItem 25 · .PDF · 64 KBATC 3 - Attachment 8: Horace Davis Controller StatementItem 26 · .PDF · 114 KBATC 3 - Attachment 9: ZJX Sector 28 Sign-on / Sign-off LogItem 27 · .PDF · 158 KBATC 3 - Attachment 10: ZJX West Area Personnel LogItem 28 · .PDF · 293 KBATC 3 - Attachment 11: TLH-Related Notices to AirmenItem 29 · .PDF · 288 KBATC 3 - Attachment 12: TLH Page - FAA Airport/Facility DirectoryItem 30 · .PDF · 851 KBATC 3 - Attachment 14: TLH ATCT Daily Record of Facility OperationsItem 31 · .PDF · 66 KBATC 3 - Attachment 15: TLH Airport Lighting System LogItem 32 · .PDF · 23 KBMeteorology 5 - Factual Report of Group ChairmanItem 33 · .PDF · 4.1 MBSurvival Factors 6 - Factual Report of Group ChairmanItem 34 · .PDF · 91 KBSurvival Factors 6 - Errata to Factual Report of Group ChairmanItem 35 · .PDF · 6 KBSurvival Factors 6 - Addendum to factual report 1203Item 36 · .PDF · 9 KBSurvival Factors 6 - Factual Report errata/addendaItem 37 · .PDF · 37 KBSurvival Factors 6 - Factual report Attachment 1: Aircraft ConfigurationItem 38 · .PDF · 37 KBSurvival Factors 6 - Factual Report Attachment 2: Airport layout planItem 39 · .PDF · 86 KBSurvival Factors 6 - Factual Report Attachment 3: Notices to Airmen (NOTAMs)Item 40 · .PDF · 224 KBSurvival Factors 6 - Factual report Attachment 4: TLH runway inspection logItem 41 · .PDF · 173 KBSurvival Factors 6 - Factual report Attachment 5: TLH airport lighting activation logItem 42 · .PDF · 85 KBSurvival Factors 6 - Factual Report Attachment 6: FAA Flight Inspection ReportsItem 43 · .PDF · 153 KBSurvival Factors 6 - Factual Report Attachment 7: Annual Airport Certification Inspection Checklist and letters of Correction for 2002Item 44 · .PDF · 209 KBSurvival Factors 6 - Factual report Attachment 8: Runway survey data plotItem 45 · .PDF · 23 KBSurvival Factors 6 - Factual Report Attachment 9: Tallahassee Fire Department dispatch logItem 46 · .PDF · 567 KBSurvival Factors 6 - Factual Report Attachment 10: Tallahassee Memorial emergency medical services logItem 47 · .PDF · 146 KBSurvival Factors 6 - Factual Report Attachment 11: Tallahassee Police Department radio logItem 48 · .PDF · 147 KBSurvival Factors 6 - Factual Report Attachment 12: Leon County Sheriff's Office of Emergency Management logItem 49 · .PDF · 27 KBSurvival Factors 6 - Factual Report Attachment 13: Syllabus for TKH airport administration ARFF trainingItem 50 · .PDF · 57 KBSurvival Factors 6 - Factual Report Attachment 14: Letter of Approval from FAA to Jacksonville Fire and Rescue DepartmentItem 51 · .PDF · 47 KBSurvival Factors 6 - Factual Report Attachment 15: Training records for TFD ARFF personnelItem 52 · .PDF · 211 KBSurvival Factors 6 - Factual Report Attachment 16: Hazmat documentsItem 53 · .PDF · 67 KBSurvival Factors 6 - Factual Report Attachment 17: PhotographsItem 54 · .PDF · 254 KBSurvival Factors 6 - Factual Report - Attachment 18 - FAA CertAlert No. 02-08Item 55 · .PDF · 36 KBStructures 7 - Factual Report of Group ChairmanItem 56 · .PDF · 130 KBStructures 7 - Appendix "A" Wreckage DistributionItem 57 · .PDF · 2.8 MBStructures 7 - Appendix "B" Photo 1 - Aerial View of the Main WreckageItem 58 · .PDF · 217 KBStructures 7 - Appendix "B" Photo 2 - Aerial View of the Wreckage PathItem 59 · .PDF · 215 KBStructures 7 - Appendix "B" Photo 3 - View Showing Tree Swath and RunwayItem 60 · .PDF · 225 KB
All 184 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.