# NTSB DCA90MA017: Beech A100, N44UE, Atlanta, GA, January 19, 1990 - Type: NTSB accident investigation - Classification: Accident · Fatal · Class 1 · Major · Final report - Date: January 18, 1990, 19:04 local (Jan 19, 1990, 00:04 UTC) - Place: Atlanta, GA - Location: 33.6367° N, 84.4279° W: Placed by OpenAirDocs at HARTSFIELD/JACKSON ATLANTA INTL (ATL), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=33.6367&lon=-84.4279&mi=10 - Phase of flight: [Landing](https://openairdocs.org/ntsb-phases/550) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 1 serious, 157 uninjured - Status: Completed, report May 3, 1993 - Report: Board-adopted at Board Meeting - Investigation class: Class 1 - NTSB office: Major Investigations Division - Safety recommendations: Yes - NTSB case key (mKey): 15933 - NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA90MA017.aspx - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/15933/pdf - Board report AAR9103 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9103.pdf - Page: https://openairdocs.org/ntsb/DCA90MA017 ## Probable cause (aircraft 2) (1) FAILURE OF THE FEDERAL AVIATION ADMINISTRATION TO PROVIDE AIR TRAFFIC CONTROL PROCEDURES THAT ADEQUATELY TAKE INTO CONSIDERATION HUMAN PERFORMANCE FACTORS SUCH AS THOSE WHICH RESULTED IN THE FAILURE OF THE NORTH LOCAL CONTROLLER TO DETECT THE DEVELOPING CONFLICT BETWEEN N44UE AND EA 111, AND (2) THE FAILURE OF THE NORTH LOCAL CONTROLLER TO ENSURE THE SEPARATION OF ARRIVING AIRCRAFT WHICH WERE USING THE SAME RUNWAY. CONTRIBUTING TO THE ACCIDENT WAS THE FAILURE OF THE NORTH LOCAL CONTROLLER TO FOLLOW THE PRESCRIBED PROCEDURE OF ISSUING APPROPRIATE TRAFFIC INFORMATION TO EA 111, AND FAILURE OF THE NORTH FINAL CONTROLLER AND THE RADAR MONITOR CONTROLLER TO ISSUE TIMELY SPEED REDUCTIONS TO MAINTAIN ADEQUATE SEPARATION BETWEEN AIRCRAFT ON FINAL APPROACH. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - On ground/water collision with object, landing - roll - light condition - dark night - exterior light(s) - inoperative - control tower service - inadequate, atc personnel(lcl/gnd/clnc) (contributing factor) - ifr separation standards - not maintained, atc personnel(lcl/gnd/clnc) (cause) - procedure inadequate, faa(other/organization) (cause) - On ground/water collision with object, landing - roll - light condition - dark night - control tower service - inadequate, atc personnel(lcl/gnd/clnc) (contributing factor) - ifr separation standards - not maintained, atc personnel(lcl/gnd/clnc) (cause) - procedure inadequate, faa(other/organization) (cause) ## Analysis (aircraft 2) DRG ARR AT NGT, BEECH A100 (KING AIR, N44UE) WAS CLRD FOR AN ILS RWY 26R APCH BEHIND CONTINENTAL FLT 9687, THEN EASTERN AIRLINE (EA) FLT 111 (BOEING 727, N8867E) WAS CLRD FOR THE SAME APCH BEHIND THE KING AIR. AFTER LNDG, FLT 9687 HAD A RADIO PROBLEM & THE TWR CTLR HAD DIFFICULTY COMMUNICATING WITH FLT 9687. MEANWHILE, THE KING AIR LNDD & ITS CREW HAD MOVED THE ACFT TO THE RGT SIDE OF THE RWY NR TWY-D (THE PRIMARY TWY FOR GEN AVN ACFT). THE TURNOFF FOR TWY-D WAS ABT 3800'FM THE APCH END OF RWY 26R. BEFORE THE KING AIR WAS CLR OF THE RWY, EA 111 LNDD & CONVERGED ON THE KING AIR. THE CREW OF EA 111 DID NOT SEE THE KING AIR UNTIL MOMENTS BFR THE ACDNT. THE CAPT TRIED TO AVOID A COLLISION, BUT THE BOEING'S RGT WING STRUCK THE KING AIR, SHEARING THE TOP OF ITS FUSELAGE & COCKPIT. SOME OF THE KING AIR'S STROBE/BEACON LGTS WERE INOP, THOUGH THEY MOST LIKELY WOULD HAVE BEEN EXTINGUISHED FOR THE IMC APCH. THE LOCAL CTLR DID NOT ISSUE A TFC ADZY TO EA 111 WITH THE LNDG CLNC. (SEE: NTSB/AAR-91/03) ## Aircraft 1 - Registration: [N44UE](https://openairdocs.org/deregistered/N44UE-1990-10-23), registration cancelled 1990-10-23, S/N B140 (OpenAirDocs) - Reported make and model: BEECH A100 - Registry model: [Beech A100](https://openairdocs.org/model/beech-a100) (registry code 1152915) (OpenAirDocs) - Category: Airplane - Serial number: B-140 - Engines: P&W PT6A-28 680 horsepower turbo prop - Damage: Destroyed - Flight: Positioning, Part 91 - Registered owner: Eps Air Service - Departed: PEACHTREE ARPT, GA - Destination: ATL, ATLANTA, GA - Flight plan: IFR - Airport: ATL, Hartsfield-Atlanta Intl, runway 26R, 9,000 × 150 ft, concrete ## Aircraft 2 - Registration: [N8867E](https://openairdocs.org/deregistered/N8867E-2009-02-17), registration cancelled 2009-02-17, S/N 20823, built 1973 (OpenAirDocs) - Reported make and model: BOEING 727 - Registry model: [Boeing 727-225](https://openairdocs.org/model/boeing-727-225) (registry code 1384077) (OpenAirDocs) - Registry engine: [Pratt & Whitney JT8D-9 series](https://openairdocs.org/engine/pratt-whitney-jt8d-9-series) (registry code 52048, turbo-jet) (OpenAirDocs) - Category: Airplane - Serial number: 20823 - Engines: P&W JT8D-15 15500 lbs thrust turbo fan - Damage: Substantial damage - Flight: Part 121 - Operator: Eastern Airlines, doing business as Eastern Airlines - Registered owner: Wilmington Trust Co Trustee - Airworthiness certificate: Standard, Transport - Departed: LGA, NEW YORK, NY - Destination: ATL, ATLANTA, GA - Flight plan: IFR - Airport: ATL, Hartsfield-Atlanta Intl, runway 26R, 9,000 × 150 ft, concrete ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N44UE; age 30; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 1,653 total - Pilot, aircraft N8867E; age 49; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 13,320 total, 7,432 in this make and model, 215 in the last 90 days ## Weather - Conditions: Visual (VMC), Night/dark - Wind: 290° at 3 knots - Visibility: 3 statute miles - Lowest ceiling: 10,000 ft overcast - Temperature: 63 °F, dew point 61 °F - Altimeter: 30.00 inHg ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19900118000712A](https://openairdocs.org/incident/19900118000712A), Jan 18, 1990: Beech A100, Atlanta, GA, Destroyed, 1 fatal. On landing roll was struck by N8867E also landing on same runway. ATC failed to separate. Anti collision light inop - [Accident 19900118000711A](https://openairdocs.org/incident/19900118000711A), Jan 18, 1990: Boeing 727225, Atlanta, GA, Substantial damage. On landing roll struck N44UE also rolling out on runway with inop ati collision lights. ATC failed to separate. 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.