IAD00IA032

NTSB incident investigation · Boeing 767-332 · New York City, NY · March 31, 2000

Incident · No injuriesIncident investigationFinal report
Date
March 30, 2000, 20:25 local (Mar 31, 2000, 01:25 UTC)
Place
New York City, NY
NTSB coordinates
38.8093, -77.4597 (estimated), outside the stated state
Injuries
225 uninjured
Damage
No damage
Phase of flight
Enroute
Aircraft
N182DNBoeing 767-332
Weather
Visual (VMC) · Night/dark
Status
Completed · report May 8, 2001
Report
Approved by Office Director
FAA report
20000330001789I
Case key
51169

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

On this page

Probable cause

The NTSB’s determination of the probable cause, and any contributing factors.

The first officer's failure to maintain control of the airplane during climb out over water at night, which was a result of spatial disorientation. Factors in the incident were the cloud layer and dark night.

Analysis

During climb out at night over water, the airplane was straight and level and heading towards an intersection. The first officer was hand flying the airplane and the auto-pilot was not engaged. While climbing through 6,500 feet, the airplane rolled to the right and reached a maximum of 65.5 degrees. The first officer used left aileron, followed by left rudder input and returned to level flight. The crew declared an emergency, dumped 20,000 pounds of fuel and landed uneventfully at the departure airport. The captain reported there were no traffic collision avoidance system alerts or engine indication and crew alerting system warnings. The captain reported there was a thin deck of clouds at 6,500 feet, and it was a dark night with no moon. The international relief pilot stated there was no discernable horizon, and the first officer stated there was no horizon, stars, or moon, and all he saw was darkness. An examination of the airplane's systems revealed there were no mechanical or computer related discrepancies. The digital flight data recorder data revealed the rolls to the right were initiated by control wheel input.

Factual narrative

The factual narrative1,332 words

History of flight

On March 30, 2000, about 2025 Eastern Standard Time, a Boeing 767-332, N182DN, operated by Delta Airlines as flight 106, was not damaged when it rolled to the right while climbing through 6,500 feet, 15 miles southeast of John F. Kennedy International (JFK) Airport, New York, New York. There were no injuries to the 13 crew members and 212 passengers. Visual meteorological conditions prevailed and an instrument flight rules flight plan was filed for the passenger flight conducted under 14 CFR Part 121. The flight departed JFK destined for Frankfurt, Germany.

The incident occurred during the hours of night over water at about 40 degrees north latitude, and 73 degrees west longitude.

In the cockpit were the certificated airline transport pilot rated captain, first officer (FO), and the international relief pilot (IRP). The FO was the flying pilot and was hand flying the airplane. The auto-pilot was not engaged. Air traffic control (ATC) had cleared flight 106 to fly a heading of 155 degrees after departure, and was then assigned to fly direct to BETTE intersection. BETTE intersection was located 35 nautical miles east-southeast of JFK

The three crew members were interviewed on April 6, 2000, in Atlanta, Georgia, by a Safety Board investigator.

According to the captain, ATC instructed the crew to proceed direct to BETTE intersection. The captain entered BETTE into the Flight Management System (FMS), hit the "execute" button, and engaged the lateral navigation (L-NAV) mode on the flight director, which showed a left turn about 20-25 degrees. He then turned his attention to organizing his departure and en route charts.

Shortly after, the FO said something and the captain looked up and saw the FO "wrestling" with the airplane. The captain looked at the attitude director indicator (ADI) and it was "lying on its side" right wing down. The FO had the control wheel in the full left aileron position, attempting to level the airplane.

The captain stated there was a thin deck of clouds about 6,500 feet, and it was a dark night with no moon. He also reported that they were no traffic collision avoidance system (TCAS) alerts or engine indication and crew alerting system (EICAS) warnings.

According to the FO, after BETTE intersection was entered into the FMS, he made a control input to follow the flight director, which indicated a left turn. He looked outside the airplane to scan for traffic as the turn was made. He then checked the instruments and the ADI indicated a 60 degree bank turn to the right. He responded with full left aileron followed by left rudder, which returned the airplane to level flight. He stated that from the time BETTE intersection was entered into the FMS, to the time he noted the right bank on the ADI, 5-6 seconds had elapsed.

The FO looked outside the captain's left forward window to scan for traffic. He stated there was no horizon, stars, or moon, and all he saw was darkness. He did not recall seeing any clouds.

According to the IRP, he was sitting in the jump seat between the two pilots reviewing the flight plan, when he felt the airplane yaw then roll to the right. He looked up and saw the ADI pointer at 60 degrees right wing down. At that time, he saw ground lights and a scattered cloud layer below out of the right window. He noted there was no discernable horizon. He saw the FO trying to level the airplane and suggested the use of left rudder to level the airplane.

The airplane was returned to level flight. The crew declared an emergency, dumped 20,000 pounds of fuel, and returned to JFK without incident.

Personnel information

The captain had been employed with Delta Airlines since February 2, 1973, and was type-rated in both the B-767 and B-757 airplane. He reported a total time of 19,500 hours; 700 hours in make and model, of which 220 hours were in the last 90 days. He completed his last proficiency check in the B-767/757 in January, 2000. Prior to his transition into the B-767/757, the captain flew the Convair 880, B-727, DC-9, DC-8, L-1011, and B-737.

Five years prior to his employment with Delta, the captain flew P-3 airplanes for the Navy.

The FO had been employed with Delta Airlines since April 20, 1989, and was type-rated in both the B-767 and B-757 airplane. He reported a total of 9,000 total flight hours; 404 hours in make and model, of which 103 hours were in the last 90 days. He completed his initial B-767/757 operational experience in July, 1999. Prior to his transition into the B-767/757, the FO flew the B-737 from 1990 to 1999, and the B-727 in 1989.

Prior to his employment with Delta, the first officer served as a officer in the United States Air Force (USAF), where he was trained in both the T-38 and F-15 aircraft.

The FO reported that he had undergone unusual attitude training in the B-767/757 during his initial qualification at Delta Airlines, and had received extensive exposure to unusual attitudes during his tenure with the USAF.

Meteorological information

The weather reported at JFK, at 2051, was wind from 350 degrees at 15 knots gusting to 22 knots, visibility 10 miles, ceiling 8,000 feet broken, temperature 9 degrees Celsius, dew point -3 degrees Celsius, and altimeter setting 29.97 inches of Hg.

Radar data

Examination of radar data revealed there were no large transport category aircraft that had crossed along flight 106's route which could have resulted in a wake turbulence upset.

Flight recorders

A Fairchild model A-100 cockpit voice recorder (CVR) was brought to the Safety Board audio laboratory on April 3, 2000. The 30-minute recording was found to have no data relating to the event's period of time; therefore, no transcript was prepared.

Raw data information from the Digital Flight Data Recorder (DFDR) was extracted by Delta Airlines at its playback facility in Atlanta, Georgia, and provided to the Safety Board. According to the Safety Board's DFDR Group Chairman's report:

From 20:24:59 to 20:25:28 , the airplane's heading was maintained between 98 degrees and 100 degrees as the altitude increased from 5,100 feet to 6,300 feet.

At 20:25:29, the control wheel began a turn to the right. The right aileron was deflected and the airplane began a roll to the right. The control wheel input continued to increase to the right for the next 3.5 seconds until it reached a peak value of 63.7 degrees right wing down, at which time the bank angle reached 39.4 degrees right wing down. The other flight controls remained steady during this period.

At 20:25:33, the control wheel switched between right inputs and left inputs. The control wheel was manipulated from 63.7 degrees to the right at 20:25:32.5, to 20 degrees left at 20:25:33, then 34 degrees left at 20:25:33.5. At the same time, the elevator was moved to a 2 degree nose down position. The roll angle reached 48 degrees right at 20:25:33.5.

At 20:25:34, the control wheel was switched from a left to right position, and over the next 3-seconds the control wheel was moved between 18.8 degrees right to 40.7 degrees left, trending toward the left by the end of the period. During this 3-second period, the airplane's roll value increased from 62.9 degrees to 65.5 degrees right wing down.

The first indication of a left rudder application was recorded at 20:25:37.3. Over the next 6-seconds, rudder values changed from a steady value of 1.6 degrees right to 4.9 degrees left as the roll angles decreased from 65.5 degrees right wing down to approximately wings level. Also during this period, the control wheel values varied between 3.4 degrees and 34.1 degrees left wing down. With the application of nose up control inputs, the pitch attitude values increased from 5 degrees nose down to 0.9 degrees nose up and the decrease in altitude values stopped.

The DFDR parameters did not display any unusual or anomalous characteristics

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.

Abrupt maneuverClimb
Light condition - dark nightFactor
Aircraft control - not maintainedCopilot/second pilotCause
Spatial disorientationCopilot/second pilot
Weather condition - cloudsFactor

Aircraft

Registration
N182DN
Reported as
Boeing 767-332
Category
Airplane
Serial number
25987
Airframe hours
5,514
Engine
P&W PW 4060, 60,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Delta Airlines, doing business as Commercial Airline
Registered owner
Wilmington Trust Company
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · March 29, 2000
Departed
JFK · New York, NY
Destination
FRA · Frankfurt
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

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
54
Certificate
Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Front
Flight hours
19,500 total · 637 in this make and model

Weather

Conditions
Visual (VMC) · Night/dark
Wind
350° at 15 knots, gusting 22
Visibility
10 statute miles
Lowest ceiling
8,000 ft broken
Temperature
48 °F, dew point 37 °F
Altimeter
29.00 inHg
Observed at
JFK, 35 nm away

Docket · 11

The files NTSB released with the investigation on April 6, 2001, on NTSB’s docket system: statements, records, photos and specialists’ reports. 4.1 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 N182DN · 1

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