DCA97MA049

NTSB accident investigation · Airbus Industrie A300B4-605R · West Palm Beach, FL · May 12, 1997

Accident · Serious injuriesMajor investigationFinal report
Date
May 12, 1997, 15:29 local (19:29 UTC)
Place
West Palm Beach, FL
Injuries
1 serious, 1 minor, 163 uninjured
Damage
Minor damage
Phase of flight
Enroute
Aircraft
N90070Airbus Industrie A300B4-605R
Weather
Instrument (IMC) · Day
Status
Completed · report February 11, 2000
Report
Approved by Office Director
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19970512012989A
Case key
11024

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 flightcrew's failure to maintain adequate airspeed during leveloff which led to an inadvertent stall, and their subsequent failure to use proper stall recovery techniques. A factor contributing to the accident was the flightcrew's failure to properly use the autothrottle.

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.

Loss of control - in flightDescent - normal
Airspeed - not maintainedFlightcrewCause
Autopilot - improper use ofFlightcrewFactor
Stall - inadvertentFlightcrewCause
Altitude deviation,uncontrolledDescent - uncontrolled
Remedial action - improperFlightcrewCause

Analysis

The flight was assigned an airspeed of 230 knots and cleared to descend from FL240 to 16,000 feet in preparation for landing at Miami. The FDR indicated that while the autopilot was engaged in the descent, the power levers moved from the mechanical autothrottle limit of 44 degrees to the manual limit of 37 degrees. As the aircraft leveled at 16,000 feet the airspeed decreased. The F/O began a right turn to enter a holding pattern and added some power, which stabilized the airspeed at 178 knots. However, the right bank and the resultant angle of attack (AOA) continued to increase, despite left aileron input by the autopilot. As the autopilot reached the maximum input of 20 degrees, bank angle increased past 50 degrees, and the AOA increased rapidly from 7 degrees to 12 degrees. At this point the stick shaker activated, the autopilot independently disconnected, the power was increased, and full left rudder was used to arrest the roll. The bank angle reached 56 degrees, and the AOA reached 13.7 degrees at 177 knots. The aircraft then pitched down, and entered a series of pitch, yaw, and roll maneuvers as the flight controls went through a period of oscillations for about 34 seconds. The maneuvers finally dampened and the crew recovered at approximately 13,000 feet. One passenger was seriously injured and one flight attendant received minor injuries during the upset. According to wind tunnel and flight test data the A300 engineering simulator should adequately represent the aircraft up to 9 degrees AOA. Unlike the accident aircraft; however, the simulator recovered to wings level promptly when the lateral control inputs recorded by the FDR were used. The roll disagreement between the simulator and accident aircraft began at 7 degrees AOA, and it appears that some effect not modeled in the simulator produced the roll discrepancy. Just prior to the upset the accident aircraft entered a cloud deck. The winds were approximately 240 degrees, 35 knots, and the ambient air temperature was approximately minus 4 degrees C. An atmospheric disturbance or asymmetric ice contamination were two possible explanations considered, but unproven.

Factual narrative

On May 12, 1997, about 1529 eastern daylight time, an Airbus A300B4-605R, N90070, flight 903, registered to Wilmington Trust Company Trustee, operated by American Airlines Inc., as a 14 CFR Part 121 scheduled domestic passenger flight, experienced an inflight loss of control, about 10 miles north of HEATT intersection in the vicinity of West Palm Beach, Florida. Instrument meteorological conditions prevailed and an IFR flight plan was filed. The airplane sustained minor damage. The airline transport pilot-in-command (PIC), commercial pilot first officer, 6 flight attendants, and 155 passengers sustained no injuries. One passenger sustained serious injuries, and one flight attendant received minor injuries. The flight originated from General Edward Lawrence Logan International Airport, Boston, Massachusetts, about 2 hours 16 minutes before the accident.

According to American Airlines safety personnel, the PIC stated the cabin seatbelt signs were illuminated, and they were level at 16,000 feet. They had received an air traffic control (ATC) clearance to hold at HEATT intersection located southeast of West Palm Beach. Weather was depicted in the vicinity of the holding fix on the weather radar. They requested and received clearance from ATC to hold north of the holding fix. As they were approaching the holding fix, they encountered a loss of control. The airplane pitched up and down, rolled to the left and right, and descended rapidly. The flightcrew initiated the "Escape" procedure and recovered the airplane. The PIC was advised of passenger injuries by the flight attendants. He declared an emergency with ATC and landed at Miami International Airport, Miami, Florida, without further incident.

Aircraft

Registration
N90070
Reported as
Airbus Industrie A300B4-605R (A300B4-605)
Category
Airplane
Serial number
513
Engine
unknown
Damage
Minor damage
Flight
Part 121
Operator
American Airlines
Registered owner
Wilmington Trust Company
Airworthiness certificate
Standard, Normal
Departed
BOS · Boston, MA
Destination
MIA · Miami, FL
Flight plan
IFR

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
41
Certificates
Flight engineer, Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Left
Flight hours
12,000 total · 500 in this make and model · 7,000 as pilot in command
Role
Co-pilot
Age
38
Injuries
None
Certificates
Private, Commercial, Flight engineer
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Seat
Right

Weather

Conditions
Instrument (IMC) · Day
Wind
200° at 4 knots
Visibility
10 statute miles
Lowest ceiling
2,500 ft broken
Temperature
73 °F, dew point 72 °F
Altimeter
29.00 inHg
Observed at
PBI

Docket · 80

The files NTSB released with the investigation on April 10, 1998, on NTSB’s docket system: statements, records, photos and specialists’ reports. 73.1 MB in all.

Operations 2 - Group Chairman Factual ReportItem 1 · .PDF · 4.5 MBOperations 2 - Attachment 1 - Activity Summary (Texas - June 3-5, 1997)Item 2 · .PDF · 1.4 MBOperations 2 - Attachment 2 - Interview Summary (Florida - June 27-28, 1997)Item 3 · .PDF · 9.1 MBOperations 2 - Attachment 3 - Interview Summary (Texas - July 8-10, 1997)Item 4 · .PDF · 7.1 MBOperations 2 - Attachment 4 - Heatt Five ArrivalItem 5 · .PDF · 79 KBOperations 2 - Attachment 5 - Approach To Stall Training Instructor Guide ExcerptItem 6 · .PDF · 256 KBOperations 2 - Attachment 6 - ACARS TransmissionsItem 7 · .PDF · 3.6 MBOperations 2 - Attachment 7 - Flight Crew StatementsItem 8 · .PDF · 141 KBOperations 2 - Attachment 8 - Non-Revenue Pilot Witness StatementsItem 9 · .PDF · 86 KBOperations 2 - Attachment 9 - Flight PapersItem 10 · .PDF · 670 KBOperations 2 - Attachment 10 - Captain Hinton's RepudiationItem 11 · .PDF · 52 KBOperations 2 - Attachment 11 - Selections from ATC TranscriptItem 12 · .PDF · 614 KBOperations 2 - Attachment 12 - American Airlines - Human Factors PolicyItem 13 · .PDF · 93 KBOperations 2 - Attachment 13 - American Airlines - Cockpit ManagementItem 14 · .PDF · 103 KBOperations 2 - Attachment 14 - American Airlines - Aircraft AutomationItem 15 · .PDF · 97 KBOperations 2 - Attachment 15 - American Airlines - Airplane Incident and AccidentItem 16 · .PDF · 122 KBOperations 2 - Attachment 16 - American Airlines - Deactivation of Cockpit Voice RecorderItem 17 · .PDF · 148 KBOperations 2 - Attachment 17 - High Altitude Buffet Margin Training Instructor Guid ExcerptItem 18 · .PDF · 103 KBOperations 2 - Attachment 18 - Unusual Attitude RecoveryItem 19 · .PDF · 79 KBOperations 2 - Attachment 19 - Windshear/Microburst Escape ProcedureItem 20 · .PDF · 110 KBOperations 2 - Attachment 20 - Autoflight/Autothrottle Systems ExcerptsItem 21 · .PDF · 362 KBOperations 2 - Attachment 21 - Post-Accident Training and RequalificationItem 22 · .PDF · 1.6 MBOperations 2 - Attachment 22 - Capt. Post-Acident TrainingItem 23 · .PDF · 363 KBMeteorology 5 - Group Chairman Factual ReportItem 24 · .PDF · 930 KBMeteorology 5 - Errata to Group Chairman Factual ReportItem 25 · .PDF · 49 KBMeteorology 5 - Attachment 1 - KMIA radiosonde sounding data for 1200 UTC May 12 and 0000 UTC May 13Item 26 · .PDF · 175 KBMeteorology 5 - Attachment 2 - KMIA Skew-T Log for 1200 UTC May 12 and 0000 UTC May 13Item 27 · .PDF · 48 KBMeteorology 5 - Attachment 3 - KAMX WSR-88D PPI base reflectivity product for 1919:34 - 1924:32 UTCItem 28 · .PDF · 58 KBMeteorology 5 - Attachment 4 - KAMX WSR-88D PPI base reflectivity product for 1924:39 - 1929:35 UTCItem 29 · .PDF · 55 KBMeteorology 5 - Attachment 5 - KAMX WSR-88D PPI base reflectivity product for 1929:42 - 1934:38 UTCItem 30 · .PDF · 77 KBMeteorology 5 - Attachment 6 - KAMX WSR-88D PPI four panel base reflectivity product for 1919:34 - 1924:32 UTCItem 31 · .PDF · 109 KBMeteorology 5 - Attachment 7 - KAMX WSR-88D PPI four panel base reflectivity product for 1924:39 - 1929:35 UTCItem 32 · .PDF · 110 KBMeteorology 5 - Attachment 8 - KAMX WSR-88D PPI four panel base reflectivity product for 1929:42 - 1934:38 UTCItem 33 · .PDF · 111 KBMeteorology 5 - Attachment 9 - KAMX WSR-88D PPI base velocity product for 1919:34 1924:32 UTCItem 34 · .PDF · 72 KBMeteorology 5 - Attachment 10 - KAMX WSR-88D PPI base velocity product for 1924:39 - 1929:35 UTCItem 35 · .PDF · 77 KBMeteorology 5 - Attachment 11 - KAMX WSR-88D PPI base velocity product for 1929:42 - 1934:38 UTCItem 36 · .PDF · 76 KBMeteorology 5 - Attachment 12 - KAMX WSR-88D PPI base spectrum width product for 1919:34 - 1924:32 UTCItem 37 · .PDF · 72 KBMeteorology 5 - Attachment 13 - KAMX WSR-88D PPI base spectrum width product for 1924:39 - 1929:38 UTCItem 38 · .PDF · 79 KBMeteorology 5 - Attachment 14 - KAMX WSR-88D PPI base spectrum width product for 1929:42 - 1934:38 UTCItem 39 · .PDF · 83 KBMeteorology 5 - Attachment 15 - KAMX WSR-88D VAD wind profiles for 1947 -2002 UTCItem 40 · .PDF · 54 KBMeteorology 5 - Attachment 16 - KAMX WSR-88D mesocyclone product for 1924 UTCItem 41 · .PDF · 51 KBMeteorology 5 - Attachment 17 - KAMX WSR-88D mesocyclone product for 1929 UTCItem 42 · .PDF · 53 KBMeteorology 5 - Attachment 18 - KAMX WSR-88D severe weather probability product for 1924 UTCItem 43 · .PDF · 59 KBMeteorology 5 - Attachment 19 - KAMX WSR-88D severe weather probability product for 1929 UTCItem 44 · .PDF · 52 KBMeteorology 5 - Attachment 20 - GOES-8 visible satellite image for 1902 UTCItem 45 · .PDF · 30 KBMeteorology 5 - Attachment 21 - GOES-8 visible satellite image (2X magnification) for 1902 UTCItem 46 · .PDF · 39 KBMeteorology 5 - Attachment 22 - GOES-8 visible satellite image for 1915 UTCItem 47 · .PDF · 29 KBMeteorology 5 - Attachment 23 - GOES-8 visible satellite image (2X magnification) for 1915 UTCItem 48 · .PDF · 46 KBMeteorology 5 - Attachment 24 - GOES-8 visible satellite image for 1932 UTCItem 49 · .PDF · 35 KBMeteorology 5 - Attachment 25 - GOES-8 visible satellite image (2X magnification) for 1932 UTCItem 50 · .PDF · 49 KBMeteorology 5 - Attachment 26 - GOES-8 infrared satellite image (4X magnification) for 1902Item 51 · .PDF · 47 KBMeteorology 5 - Attachment 27 - GOES-8 infrared satellite image (4X magnification) for 1915 UTCItem 52 · .PDF · 131 KBMeteorology 5 - Attachment 28 - GOES-8 infrared satellite image (4X magnification) for 1932 UTCItem 53 · .PDF · 112 KBMeteorology 5 - Attachment 29 - Lightning data for 1920 - 1930 UTCItem 54 · .PDF · 26 KBMeteorology 5 - Attachment 30 - Pilot Reports for 1500 - 2100 UTCItem 55 · .PDF · 102 KBMeteorology 5 - Attachment 31 - Convective SIGMETs for 1300 - 2000 UTCItem 56 · .PDF · 253 KBMeteorology 5 - Attachment 32 - McIDAS Convective SIGMETs plots for 22E, and 24EItem 57 · .PDF · 52 KBMeteorology 5 - Attachment 33 - Tornado Watch Number 278 and 279Item 58 · .PDF · 44 KBMeteorology 5 - Attachment 34 - McIDAS Tornado Watch plotsItem 59 · .PDF · 43 KBMeteorology 5 - Attachment 35 - ZMA CWSU Meteorologist StatementItem 60 · .PDF · 67 KB
All 80 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.

Other investigations on N90070 · 1

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