DCA24LA316

NTSB accident investigation · Boeing 757-224 · Dunnigan, CA · September 19, 2024

Accident · Serious injuriesClass 4 · LimitedFinal report
Date
September 19, 2024, 12:47 local (19:47 UTC)
Place
Dunnigan, CA
Injuries
2 serious, 2 minor, 151 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N12125Boeing 757-224
Defining event
Enroute-descent: Near midair/TCAS alert/loss of separation
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Investigation class
Class 4 - Basic report with no Prelim publish
NTSB office
Major Investigations Division
Parties
Boeing, FAA, United Airlines
FAA report
20240919022419A
Case key
195189

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 abrupt pitch control input by the flight crew in response to a TCAS resolution advisory resulted in two serious passenger injuries.

Findings · 2

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.

Object/animal/substance: aircraftEnvironmental issues › Physical environment · Effect on equipmentBoeing 757-224: 1 caseAll aircraft: 116 cases
Object/animal/substance: aircraftEnvironmental issues › Physical environment · Effect on personnelBoeing 757-224: 1 caseAll aircraft: 116 casesProbable cause

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

United Airlines (UA) flight 2428 received a traffic alert and collision avoidance system (TCAS) resolution advisory (RA) while descending to flight level FL310 when enroute to San Francisco International Airport (SFO), San Francisco, California. Two passengers were seriously injured, and two cabin crewmembers sustained minor injuries as a result of the aircraft response to the TCAS alert. The flight was a regularly scheduled domestic passenger flight from Newark Liberty International Airport (EWR), Newark, New Jersey to SFO. UA2428 was instructed by air traffic control to descend and maintain FL310 for their arrival into SFO. About 500 ft above level off at FL310, the crew received a TCAS traffic alert “traffic, traffic” for an aircraft crossing 1,500 feet below to which, the first officer, as pilot flying, reduced vertical speed on the mode control panel in response. A TCAS RA then immediately annunciated for the same traffic. The pilot flying responded by disengaging the autopilot and auto throttle and pitched the aircraft up following the pitch guidance on the primary flight display. Flight data show pitch increased by about 3° over 1 second and the aircraft descent arrested. Vertical acceleration ranged from 2.3 to 0.6 (g) over 2 seconds during the maneuver. The seatbelt sign had been turned on in the cabin shortly prior to the TCAS annunciation, however passengers still remained in the lavatories at the time of the maneuver. Two flight attendants were in the forward galley cleaning in preparation for the initial descent announcement. These two flight attendants fell to the floor during the maneuver and sustained minor injuries. There were two passengers in the aft lavatories at the time of the maneuver. One passenger flew upwards and landed forward fracturing the L2 spinal vertebrae. The other passenger was exiting the lavatory when he flew upwards and landed on his leg resulting in a fractured ankle. Following the event, the aircraft landed uneventfully. Paramedics met the aircraft at the gate and transported the passengers to the hospital for treatment.

Aircraft

Registration
N12125
Reported as
Boeing 757-224
Category
Airplane
Serial number
28967
Built
1998
Airframe hours
94,715
Engines
Rolls-Royc RB-211 SERIES, 22,000 lbs thrust, turbo fanRolls-Royc RB-211 SERIES, 22,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
United Airlines Inc
Registered owner
United Airlines Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · October 6, 2024
Departed
EWR · Newark, NJ
Destination
SFO · San Fransisco, CA
Flight plan
IFR
Equipment
Angle of attack indicator, Auto-pilot, Data recorder, Electronic flight bag or handheld device, Electronic multifunction display, Electronic primary flight display, Onboard weather, ADS-B, Satellite tracking device, Stall warning system

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
49
Injuries
None
Certificate
Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
May 16, 2024
Seat
Left
Restraint
5-point
Flight hours
16,899 total · 1,440 in this make and model · 5,936 as pilot in command · 221 in the last 90 days · 64 in the last 30 days
Role
Co-pilot
Age
35
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Helicopter, Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
August 30, 2024
Seat
Right
Restraint
3-point
Flight hours
2,646 total · 33 in this make and model · 588 as pilot in command · 119 in the last 90 days · 38 in the last 30 days

Weather

Conditions
Visual (VMC) · Day
Wind
110° at 15 knots
Temperature
-47 °F

Docket · 5

The files NTSB released with the investigation on March 27, 2025, on NTSB’s docket system: statements, records, photos and specialists’ reports. 34.2 MB in all.

FAA reports on this event · 1

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

Other investigations on N12125 · 1

Matched to the same aircraft by N-number and date.