DCA15FA085

NTSB accident investigation · Mcdonnell Douglas MD 88 · New York, NY · March 5, 2015

Accident · No injuriesClass 1 · FieldFinal report
Date
March 5, 2015
Place
New York, NY
Injuries
132 uninjured
Damage
Substantial damage
Phase of flight
Landing
Aircraft
N909DLMcdonnell Douglas MD 88
Defining event
Landing-landing roll: Loss of control on ground
Weather
Instrument (IMC) · Day
Status
Completed · report March 3, 2017
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
20150305023949A
Case key
90822

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

On this page

Probable cause

the captain's inability to maintain directional control of the airplane due to his application of excessive reverse thrust, which degraded the effectiveness of the rudder in controlling the airplane's heading. Contributing to the accident were the captain's (1) situational stress resulting from his concerns about stopping performance and (2) attentional limitations due to the high workload during the landing, which prevented him from immediately recognizing the use of excessive reverse thrust.

Findings · 8

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

Performance/control parameters: powerplant parametersAircraft › Aircraft oper/perf/capability · Incorrect use/operationMcdonnell Douglas MD-88: 1 caseAll aircraft: 81 casesProbable cause
Aircraft capabilityAircraft › Aircraft oper/perf/capability · Capability exceededMcdonnell Douglas MD-88: 1 caseAll aircraft: 57 casesProbable cause
Workload management: task overloadPersonnel issues › Task performance · PilotMcdonnell Douglas MD-88: 1 caseAll aircraft: 18 casesProbable cause
Policy/procedureOrganizational issues › Management · OperatorMcdonnell Douglas MD-88: 1 caseAll aircraft: 15 cases
Personnel issuesPersonnel issues › Task performance · Cabin crewMcdonnell Douglas MD-88: 1 caseAll aircraft: 137 cases
Policy/procedureOrganizational issues › Management · ManufacturerMcdonnell Douglas MD-88: 1 caseAll aircraft: 15 cases

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

NTSB investigators traveled in support of this investigation and used data obtained from various sources to prepare this aircraft accident report. The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-16/02. On March 5, 2015, at 1102 eastern standard time, Delta Air Lines flight 1086, a Boeing MD-88, N909DL, was landing on runway 13 at LaGuardia Airport, New York, New York, when it departed the left side of the runway, contacted the airport perimeter fence, and came to rest with the airplane's nose on an embankment next to Flushing Bay. The 2 pilots, 3 flight attendants, and 98 of the 127 passengers were not injured; the other 29 passengers received minor injuries. The airplane was substantially damaged. Flight 1086 was a regularly scheduled passenger flight from Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia, operating under the provisions of 14 Code of Federal Regulations Part 121. An instrument flight rules flight plan had been filed. Instrument meteorological conditions prevailed at the time of the accident.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/investigations/AccidentReports/Pages/AccidentReports.aspx. The Aircraft Accident Report number is NTSB/AAR-16/02. On March 5, 2015, at 1102 eastern standard time, Delta Air Lines flight 1086, a Boeing MD-88, N909DL, was landing on runway 13 at LaGuardia Airport, New York, New York, when it departed the left side of the runway, contacted the airport perimeter fence, and came to rest with the airplane's nose on an embankment next to Flushing Bay. The 2 pilots, 3 flight attendants, and 98 of the 127 passengers were not injured; the other 29 passengers received minor injuries. The airplane was substantially damaged. Flight 1086 was a regularly scheduled passenger flight from Hartsfield-Jackson Atlanta International Airport, Atlanta, Georgia, operating under the provisions of 14 Code of Federal Regulations Part 121. An instrument flight rules flight plan had been filed. Instrument meteorological conditions prevailed at the time of the accident.

Aircraft

Registration
N909DL
Reported as
Mcdonnell Douglas MD 88 (88)
Category
Airplane
Serial number
49540
Built
1987
Airframe hours
71,195
Engines
Pratt & Whitney JT8D-219, 21,000 lbs thrust, turbo fanPratt & Whitney JT8D-219, 21,000 lbs thrust, turbo fan
Damage
Substantial damage
Flight
Part 121
Operator
Delta Air Lines
Registered owner
Wilmington Trust Company Trustee
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 3, 2015
Departed
ATL · Atlanta, GA
Destination
LGA · New York, NY
Flight plan
IFR
Airport
LGA · La Guardia, runway 13, 7,003 × 150 ft, asphalt
Equipment
Stall warning system, Auto-pilot, Data recorder, Electronic flight bag or handheld device, Electronic multifunction display

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.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
56
Injuries
None
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Last flight review
October 19, 2014
Seat
Left
Restraint
4-point
Flight hours
15,203 total · 11,687 in this make and model · 150 in the last 90 days · 4 in the last 24 hours
Role
Co-pilot
Age
46
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Unknown
Last flight review
January 11, 2015
Seat
Right
Restraint
4-point
Flight hours
4,708 total · 2,937 in this make and model · 185 in the last 90 days · 4 in the last 24 hours

Weather

Conditions
Instrument (IMC) · Day
Wind
100° at 8 knots
Visibility
0.25 statute miles
Temperature
27 °F, dew point 23 °F
Altimeter
30.12 inHg
Observed at
KLGA

Docket · 81

The files NTSB released with the investigation on May 27, 2016, on NTSB’s docket system: statements, records, photos and specialists’ reports. 58.1 MB in all.

Operations Group Chairman's Factual ReportItem 1 · .PDF · 423 KBOperations Attachment 1 - Interview SummariesItem 2 · .PDF · 684 KBOperations Attachment 2 - Flight ReleaseItem 3 · .PDF · 256 KBOperations Attachment 3 - Enroute ACARS CommunicationsItem 4 · .PDF · 91 KBOperations Attachment 4 - Landing TOLD CardItem 5 · .PDF · 225 KBOperations Attachment 5 - MD88 Runway Condition - Braking Action ChartItem 6 · .PDF · 197 KBOperations Attachment 6 - MD88 Landing Distance ChartItem 7 · .PDF · 490 KBOperations Attachment 7 - Crosswind GuidanceItem 8 · .PDF · 156 KBOperations Attachment 8 - Throttles, Reverse Levers and IndicatorsItem 9 · .PDF · 140 KBOperations Attachment 9 - Flight Control LocationItem 10 · .PDF · 76 KBOperations Attachment 10 - Spoiler-Speed Brake LeverItem 11 · .PDF · 81 KBOperations Attachment 11 - Auto Brake System ControlsItem 12 · .PDF · 106 KBOperations Attachment 12 - Airport Diagram and Approach ProceduresItem 13 · .PDF · 624 KBOperations Attachment 13 - Airport View and Pier DimensionsItem 14 · .PDF · 477 KBOperations Attachment 14 - Slippery Runway Landing PerformanceItem 15 · .PDF · 86 KBOperations Attachment 15 - Reverse Thrust OperationItem 16 · .PDF · 191 KBOperations Attachment 16 - Reverse Thrust and CrosswindItem 17 · .PDF · 121 KBOperations Attachment 17 - Evacuation ChecklistItem 18 · .PDF · 52 KBOperations Attachment 18 - Captain and FO Duties - EvacuationItem 19 · .PDF · 58 KBOperations Attachment 19 - Boeing All Operators Letter AOL-9-058Item 20 · .PDF · 141 KBOperations Attachment 20 - Boeing MD80 Service BulletinsItem 21 · .PDF · 330 KBOperations Attachment 21 - Boeing Flight Operations Bulletin MD-80-02-03Item 22 · .PDF · 142 KBOperations Attachment 22 - ASRS Thrust Reverser Related Loss of Directional Control EventsItem 23 · .PDF · 255 KBOperations Attachment 23 - Flight Test Figures from MDC-J9005Item 24 · .PDF · 2.3 MBOperations Attachment 24 - Crew Statements of Preceding FlightsItem 25 · .PDF · 260 KBOperations Attachment 25 - Wind DisplayItem 26 · .PDF · 4.5 MBOperations Attachment 26 - Stabilized ApproachItem 27 · .PDF · 3.4 MBSurvival Factors 6 - Survival Factors Group Chairman's Factual ReportItem 28 · .PDF · 358 KBSurvival Factors 6 - Attachment 1 - Flight Attendant StatementsItem 29 · .PDF · 61 KBSurvival Factors 6 - Attachment 2 - Flight Attendant Training RecordsItem 30 · .PDF · 2.5 MBSurvival Factors 6 - Attachment 3 - Flight Attendant SchedulesItem 31 · .PDF · 160 KBSurvival Factors 6 - Attachment 4 - Flight Attendant Interview SummaryItem 32 · .PDF · 105 KBSurvival Factors 6 - Attachment 5 - Passenger StatementItem 33 · .PDF · 83 KBSurvival Factors 6 - Attachment 6 - Inflight Service Onboard Manual (OBM) ExcerptsItem 34 · .PDF · 913 KBSurvival Factors 6 - Attachment 7 - Flight Attendant Training OverviewItem 35 · .PDF · 170 KBSurvival Factors 6 - Attachment 8 - Cabin Safety Inspector Interview SummaryItem 36 · .PDF · 63 KBSurvival Factors 6 - Attachment 9 - Safety Alert for Operators - Info 08040Item 37 · .PDF · 80 KBSurvival Factors 6 - Attachment 10 - Delta Air Lines Airport Customer Service Personnel Interview SummaryItem 38 · .PDF · 52 KBSurvival Factors 6 - Attachment 11 - Delta Air Lines Inflight Training and Procedure Personnel Interview SummaryItem 39 · .PDF · 68 KBSurvival Factors 6 - Attachment 12 - Passenger PhotographsItem 40 · .PDF · 5 photos · 1.5 MBSurvival Factors 6 - Attachment 13 - Passenger VideosItem 41 · .PDF · 27 KBSurvival Factors 6 - Attachment 13A - Passenger VideoItem 42 · .PDF · 21 KBSurvival Factors 6 - Attachment 13B - Passenger VideoItem 43 · .PDF · 21 KBSurvival Factors 6 - Attachment 14 - Delta Air Lines Airport Customer Service Reference ManualItem 44 · .PDF · 595 KBMaintenance RecordsItem 45 · .PDF · 335 KBAirport Operations - Factual Report of the Group ChairmanItem 46 · .PDF · 1.3 MBAirport Operations - Attachment 1 - LGA Snow LogItem 47 · .PDF · 355 KBAirport Operations - Attachment 2 - Timeline of EventsItem 48 · .PDF · 236 KBAirport Operations - Attachment 3 - NTSB Interview TranscriptsItem 49 · .PDF · 433 KBAirport Operations - Attachment 4 - FAA Letter and Port Authority MemorandumItem 50 · .PDF · 158 KBAirport Operations - Attachment 5 - Delta Air Lines StatementItem 51 · .PDF · 48 KBAirport Operations - Attachment 6 - Delta Air Lines Survey ResultsItem 52 · .PDF · 233 KBAirport Operations - Attachment 7 - LGA/FAA ATCT Letter of AgreementItem 53 · .PDF · 172 KBAirport Operations - Attachment 8 - Video Clip of LGA Snow Training CourseItem 54 · .PDF · 22 KBAirport Operations - Attachment 9 - NTSB Interview SummaryItem 55 · .PDF · 72 KBAirport Operations - Attachment 10 - ASDE-X Video Playback (1540-1610)Item 56 · .PDF · 22 KBAirport Operations - Attachment 11 - LGA Emergency Alert Notification System Audio FileItem 57 · .PDF · 17 KBAirport Operations - Attachment 12 - ARFF StatementsItem 58 · .PDF · 1.1 MBSystems 10 - Airworthiness Group Chairman's Factual ReportItem 59 · .PDF · 10 photos · 934 KBSystems 10 - Airworthiness Group Chairman's Factual Report - Attachment 1Item 60 · .PDF · 74 KB
All 81 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.