# NTSB MIA01FA029: Airbus Industrie A300B4-605R, N14056, Miami, FL, November 20, 2000 - Type: NTSB accident investigation - Classification: Accident · Fatal · Field investigation · Final report - Date: November 20, 2000, 12:22 local (17:22 UTC) - Place: Miami, FL - Coordinates: 25.815, -80.296669 - Nearby events: https://openairdocs.org/map.md?lat=25.8150&lon=-80.2967&mi=10 - Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping) - Highest injury: Fatal - Injuries: 1 fatal, 3 serious, 19 minor, 110 uninjured - Status: Completed, report February 28, 2006 - Report: Approved by Office Director - Parties: Airbus Industrie, Association of Professional Flight Attendants, American Airlines, U.S. Customs, Transport Workers Union, Allied Pilot's Association, Federal Aviation Administration - Safety recommendations: Yes - NTSB case key (mKey): 50666 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA01FA029 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/50666/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=50666 - Page: https://openairdocs.org/ntsb/MIA01FA029 ## Probable cause The failure of the flight crew to perform the cabin pressurization manual control abnormal checklist after experiencing a pressurization system malfunction and switching to manual pressurization control, and the failure of the flight crew to perform the emergency landing checklist prior to landing, resulting in the airplane having an excessive cabin pressure level after landing which led to a rapid decompression of the airplane when a flight attendant opened door and was ejected out of the airplane during emergency evacuation that was initiated by the captain. Contributing to the accident was the failure of operator maintenance personnel to ensure that insulation blankets around the forward and aft outflow valves were properly secured in accordance with airplane manufacturer's data, resulting in a malfunction of the pressurization system. Other contributing factors include the absence of FAA requirements that each emergency exit door has a system to relieve pressure or contain specific warnings (such as lights, placards, or other indications that clearly identify the danger of opening the emergency exit doors when the airplane is over pressurized); the absence of FAA technical specifications for lavatory ionization smoke detectors; the absence of a requirement in the airplane's ground/emergency evacuation checklist for the flight crew to ensure that the cabin differential pressure is zero pounds per square inch before signaling flight attendants to begin an emergency evacuation; and the absence of a mechanical stop in the negative direction on the cabin altimeter gauge. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Airframe/component/system failure/malfunction, climb - to cruise - maintenance,installation - improper, company maintenance personnel (cause) - air cond/heating/pressurization,outflow valve - blocked(partial) - air cond/heating/pressurization - failure,partial - Decompression, standing - engine(s) not operating - checklist - not followed, flightcrew (cause) - fuselage,cabin - pressure excessive - evacuation - initiated, pilot in command - door,passenger - exploded - fuselage,cabin - decompression - miscellaneous, flight attendant ## Analysis After takeoff from Miami, the flight experienced a pressurization system malfunction, which the captain identified as the airplane depressurizing. The flight attendants and passengers complained of pain in their ears at that time. The flight crew placed the pressurization system into manual control, turned off the autopilot and autothrottle systems, and began a descent to return to Miami. During the return to Miami, several lavatory smoke alarms activated and the captain call light illuminated in the cabin; however, no evidence of fire or smoke was found. The flight crew did not complete the checklists for manual pressurization control and emergency landing during the return to Miami, both of which called for the airplane to be depressurized prior to landing. After landing and stopping on a taxiway, the captain also noticed an aft baggage compartment fire loop light illuminated, prompting him to evacuate the airplane. After the captain ordered the evacuation, the flight attendants attempted to open the doors. The doors would not open. The flight attendant/purser at the L1 (front left passenger) door continued to attempt to open the door, and the door explosively opened, ejecting the flight attendant/purser from the airplane to the ground, causing fatal injuries. The remainder of the doors opened and the airplane was evacuated. The emergency evacuation checklist did not call for the flight crew to check for depressurization of the airplane prior to commanding an evacuation. Post-accident examination of the airplane revealed that insulation blankets, which had been manufactured and replaced by the airplane operator's maintenance personnel, had not been properly secured per the airplane manufacturer's data. The blanket had migrated over to, and partially blocked, the forward and aft pressurization outflow valves, leading to the pressurization system malfunction. The forward outflow valve was found 3/8-open and the aft outflow valve was found fully closed. The lavatory smoke alarms were found to activate when subjected to abnormal pressure. There were no FAA technical standards for the lavatory smoke detectors. A sensor in the aft cargo compartment was found out of tolerance and also activated when subjected to abnormal pressure. The cabin doors were found to have no means for relieving pressure prior to opening the doors. The cabin altimeter in the cockpit did not have a mechanical stop in the negative direction, and under excessive pressure conditions, allowed the needle to move past the negative range into the high positive range. The aircraft manufacturer stated that when the pressurization system is in the manual mode, the outflow valves do not automatically open during landing and that a person cannot open a door if the airplane is pressurized above approximately 1.5 psi differential. As result of this investigation, the Safety Board previously issued 18 safety recommendations to the FAA. ## Factual narrative HISTORY OF FLIGHT On November 20, 2000, about 1222 eastern standard time, an Airbus Industrie A300B4-605R, N14056, registered to Wilmington Trust Company, and operated by American Airlines, Inc., as flight 1291, a Title 14 CFR Part 121 scheduled international passenger flight, from Miami, Florida, to Port Au Prince, Haiti, had a flight attendant receive fatal injuries during an emergency evacuation after the flight returned to Miami. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The aircraft received minor damage and the airline transport-rated pilot, first officer, 5 flight attendants, 3 other crewmembers, and 100 passengers were not injured. One flight attendant received fatal injuries, 3 passengers received serious injuries, and 1 flight attendant and 18 passengers received minor injuries. The flight originated from Miami, Florida, the same day, about 1149. According to American Airlines, Inc. records, the captain reported for the accident flight at 1010 and the first officer reported at 1020. The flight crew received departure paperwork for the flight that included airplane information, weight and balance information, NOTAMS and weather information. Flight 1291 departed the gate at 1120 and was airborne at 1149. The first officer was the pilot flying. At 1156, during the climb to flight level 230, at about 16,000 feet above mean sea level (msl), the captain stated to the copilot that the airplane was depressurizing and for him to get the airplane down. The first officer disconnected the autopilot and began a descent. The flight crew notified Miami Air Route Traffic Control Center of a pressurization problem and requested a descent to 10,000 feet. Miami Center cleared flight 1291 to descend to 10,000 feet. The captain switched to manual pressurization control. At about 1159, after leveling at 10,000 feet, the flight crew advised the controller that they were unable to control pressurization and requested a clearance to return to Miami. The controller assigned a heading of 115 degrees and instructed the flight crew to contact Miami Approach Control. At about 1214, after being cleared to land by the Miami Air Traffic Control Tower, the captain declared an emergency, requested fire equipment to stand-by and stated to the tower controller: "we are getting some warnings of a fire, although there is no evidence of a fire at this time." Flight 1291 landed in Miami at about 1218. Total flight time for this abbreviated flight segment was 29 minutes. Shortly after landing, the airplane stopped on the taxiway and the flight crew requested fire personnel to inspect the exterior of the airplane for any visible evidence of fire. At about 1220, after being cleared to taxi to the ramp, a flight attendant called the captain on the intercom and reported a smell of smoke in the middle lavatory. She said it smelled like rubber burning. Immediately following this communication, the captain stated that he noticed that one of the cargo compartment fire detection loop lights was illuminated. He informed the ground controller, "we have a fire and we are going to evacuate right here." The flight attendants experienced difficulty opening the cabin doors when the emergency evacuation was initiated. The captain was notified of this difficulty. While the captain was evaluating the problem, he said he heard a "whoosh" sound and then the cabin doors opened, emergency slides deployed and passengers evacuated the airplane. At the captain's command to evacuate, the purser went to the L1 door and tried to open it, using one hand. The door would not open. The purser went back to the cockpit to tell the flight crew. The purser then came out of the cockpit and tried to open the door using both hands. He also heard someone from the back of the airplane state that the doors were not opening. Also, the number three and number four flight attendants stated their doors would not open. He was watching the purser out of the corner of his eye when all of a sudden there was an explosion. He was being pulled toward the L1 door and hit the corner of the lavatory and the L1 jump seat. He fell to the floor and blacked out momentarily. When he awoke the L1 door was open and the purser was on the ground about 60 feet from the airplane. PERSONNEL INFORMATION The captain held an Airline Transport Pilot certificate last issued on May 2, 1996, with airplane multiengine land, and instrument airplane ratings. He also held type ratings in the Airbus A-300B4-605R/A-310, Boeing 757 and 767, and Lockheed 300. At the time of the accident, the captain held an Federal Aviation Administration (FAA) first class medical certificate dated June 15, 2000. American Airlines hired the captain on February 8, 1985. A review of FAA records found no accident, incident or enforcement action. The captain last received a proficiency check in the Airbus A-300B4-605R on October 24, 2000. The first officer held an FAA Airline Transport Pilot certificate last issued on June 22, 1999, with airplane single engine land, airplane multiengine land, rotorcraft helicopter, and instrument airplane and helicopter ratings. He also held type ratings in the A-300B4-605R/A-310 and the Lockheed L-382. At the time of the accident, the first officer held an FAA first class medical certificate dated, May 31, 2000, with no restrictions. American Airlines hired the first officer on June 29, 1998. A review of FAA records found no accident, incident or enforcement action. The first officer last received a proficiency check in the Airbus A-300B4-605R on June 13, 2000. AIRCRAFT INFORMATION The airplane was an Airbus Industrie A-300B4-605R, serial number 463, U.S. registration N14056, manufactured in 1988. The airplane was equipped with two General Electric CF6-80C2A5 engines, which are rated at 61,500 pounds of takeoff thrust each. At the time of the accident, the airplane had accumulated 34,346 total flight hours. Logbook records show the airplane was last inspected on September 28, 2000, 345 flight hours before the accident, when the airplane received a "B" check in accordance with the American Airlines continuous airworthiness program. On November 9, 2000, the aft pressurization outflow valve was changed. WEIGHT AND BALANCE The following information was obtained from the flight departure paperwork: Basic Operating Weight 206669 lbs. Passenger Weight 21780 lbs. Baggage Weight 11177 lbs. Zero Fuel Weight 239626 lbs. Maximum Zero Fuel Weight Allowed 288800 lbs. Fuel 55600 lbs. Ramp Weight 296626 lbs. Maximum Ramp Weight Allowed 380500 lbs. Taxi Fuel Burn 1400 lbs. Actual Takeoff Weight 295226 lbs. Maximum Takeoff Weight Allowed 323800 lbs. Estimated Fuel Burn to PAP 18965 lbs. Estimated Landing Weight 267000 lbs. Maximum Landing Weight Allowed 308600 lbs. Takeoff center of gravity (CG) was 26.1 percent of the mean aerodynamic chord (MAC) and was within the approved limits of the airplane. METEOROLOGICAL INFORMATION The Miami International Airport 1238 surface weather observation was winds from 330 degrees at 8 knots, visibility 10 statute miles, clouds scattered at 2,500 feet above ground level, temperature 83 degrees F, dew point temperature 70 degrees F, altimeter setting 30.09 inches Hg. Visual meteorological conditions prevailed at the time. FLIGHT RECORDERS The cockpit voice recorder (CVR) was a Fairchild model A-100A s/n 50909. The CVR was brought to the audio laboratory of the National Transportation Safety Board (NTSB) on November 21, 2000. The CVR Group convened on November 29, 2000. A transcript was prepared of the entire 30:59-minute recording. The solid state flight data recorder (FDR), Fairchild model FA2100 (serial number 00857), was removed from the aircraft and sent to the National Transportation Safety Board's laboratory in Washin ## Aircraft - Registration: [N14056](https://openairdocs.org/deregistered/N14056-2011-09-15), registration cancelled 2011-09-15, S/N 463, built 1988 (OpenAirDocs) - Reported make and model: Airbus Industrie A300B4-605R (A300B4-605) - Registry model: [Airbus Industrie A300 B4-605R](https://openairdocs.org/model/airbus-industrie-a300-b4-605r) (registry code 3930308) (OpenAirDocs) - Registry engine: [GE CF6-80 series](https://openairdocs.org/engine/ge-cf6-80-series) (registry code 30025, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 463 - Airframe hours: 34346 - Engines: General Electric CF6-80C2A5 61500 lbs thrust turbo fan - Damage: Minor damage - Flight: Part 121 - Operator: American Airlines - Registered owner: Wilmington Trust Company - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, September 28, 2001, 345 hours before - Departed: MIA, MIAMI, FL - Destination: MTPP, PORT AU PRINCE - Flight plan: IFR - Airport: KMIA, Miami International, runway 30, 9,354 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 44; injuries: none; airline transport, flight engineer; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review October 24, 2000; seat: left; toxicology performed; flight hours: 13,043 total, 4,650 in this make and model, 8,612 as pilot in command, 135 in the last 90 days, 48 in the last 30 days, 7 in the last 24 hours - Co-pilot; age 36; injuries: none; flight engineer, commercial, airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; last flight review June 13, 2000; seat: right; toxicology performed; flight hours: 3,598 total, 634 in this make and model, 1,670 as pilot in command, 111 in the last 90 days, 31 in the last 30 days, 7 in the last 24 hours ## Weather - Conditions: Visual (VMC), Day - Wind: 330° at 8 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 82 °F, dew point 70 °F - Altimeter: 30.09 inHg - Observed at: MIA, 1 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20001120044009A](https://openairdocs.org/incident/20001120044009A), Nov 20, 2000: Airbus A300B4605R, Miami, FL, Minor damage, 1 fatal. (-23) After departure from mia, aal 1291 experienced pressurization problems. The captain stated that neither automatic pressurization controller could control… ## Docket (64 files) The files NTSB released with the investigation on January 22, 2002, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=50666. 42.2 MB in all. - Operations 2 - Factual Report of Group Chairman (item 1, .PDF, 5.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469639&FileExtension=.PDF&FileName=Operations%202%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Survival Factors 6 - Factual Report of Group Chairman (item 2, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152413&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Survival Factors 6 - Attachment 1 - American Airlines A300 Door/Slide Operation (item 3, .PDF, 115 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152414&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%201%20-%20American%20Airlines%20A300%20Door%2FSlide%20Operation-Master.PDF - Survival Factors 6 - Attachment 2 - Photographs (item 4, .PDF, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152415&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%202%20-%20Photographs-Master.PDF - Survival Factors 6 - Attachment 3 - Passenger Questionnaires (item 5, .PDF, 3.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469640&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%203%20-%20Passenger%20Questionnaires-Master.PDF - Survival Factors 6 - Attachment 4 - NTSB Materials Laboratory Factual Report No 01-089 (item 6, .PDF, 314 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469641&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%204%20-%20NTSB%20Materials%20Laboratory%20Factual%20Report%20No%2001-089-Master.PDF - Survival Factors 6 - Attachment 5 - American Airlines Passenger Safety Briefing Card (item 7, .PDF, 635 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152418&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%205%20-%20American%20Airlines%20Passenger%20Safety%20Briefing%20Card-Master.PDF - Survival Factors 6 - Attachment 6 - Description of Injuries (item 8, .PDF, 257 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152419&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%206%20-%20Description%20of%20Injuries-Master.PDF - Survival Factors 6 - Attachment 7 - Metropolitan Dade County Fire/Rescue Division of Miami International Airport - Fire Rescue Reports (item 9, .PDF, 514 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469642&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Attachment%207%20-%20Metropolitan%20Dade%20County%20Fire%2FRescue%20Division%20of%20Miami%20International%20Airport%20-%20Fire%20Rescue%20Reports-Master.PDF - Survival Factors 6 - Addendum A to Factual Report of Group Chairman (item 10, .PDF, 172 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152421&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%20A%20to%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Survival Factors 6 - Addendum A - Attachment 1 (item 11, .PDF, 78 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469643&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%20A%20-%20Attachment%201-Master.PDF - Survival Factors 6 - Addendum B to Factual Report of Group Chairman (item 12, .PDF, 129 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152423&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%20B%20to%20%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Survival Factors 6 - Addendum B - Attachment 1 - Photographs (item 13, .PDF, 20 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152424&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%20B%20-%20Attachment%201%20-%20Photographs-Master.PDF - Survival Factors 6 - Addendum B - Photo 1. View of the 4L evacuation slide/raft from the opposite end of the deceleration panels. Note: The 4L slide/raft was inflated at Air Cruisers, Inc. in Belmar, New Jersey. (item 14, .PDF, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152425&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%20B%20-%20Photo%201.%20View%20of%20the%204L%20evacuation%20slide%2Fraft%20from%20the%20opposite%20end%20of%20the%20deceleration%20panels.%20%20Note%3A%20The%204L%20slide%2Fraft%20was%20inflated%20at%20Air%20Cruisers,%20Inc.%20in%20Belmar,%20New%20Jersey.-Master.PDF - Survival Factors 6 - Addendum B - Photo 2. View of the 4L emergency evacuation slide/raft data tag. (item 15, .PDF, 31 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152426&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%20B%20-%20Photo%202.%20View%20of%20the%204L%20emergency%20evacuation%20slide%2Fraft%20data%20tag.-Master.PDF - Survival Factors 6 - Addendum 6 - Photo 3. View of the 4L evacuation slide/raft from the deceleration panel end of the slide. (item 16, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152427&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%206%20-%20Photo%203.%20View%20of%20the%204L%20evacuation%20slide%2Fraft%20from%20the%20deceleration%20panel%20end%20of%20the%20slide.-Master.PDF - Survival Factors 6 - Addendum B - Photo 4. View of the 4L forward deceleration panel. (item 17, .PDF, 32 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152428&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%20B%20-%20Photo%204.%20View%20of%20the%204L%20forward%20deceleration%20panel.-Master.PDF - Survival Factors 6 - Addendum B - Photo 5. View of the 4L aft deceleration panel. (item 18, .PDF, 30 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152429&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%20B%20-%20Photo%205.%20View%20of%20the%204L%20aft%20deceleration%20panel.-Master.PDF - Survival Factors 6 - Addendum B - Photo 6. View of the new evacuation slide/raft deceleration panels that were compared with the 4L slide for resistance. (item 19, .PDF, 23 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152430&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%20B%20-%20Photo%206.%20View%20of%20the%20new%20evacuation%20slide%2Fraft%20deceleration%20panels%20that%20were%20compared%20with%20the%204L%20slide%20for%20resistance.-Master.PDF - Systems 9 - Factual Report of Group Chairman (item 20, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152431&FileExtension=.PDF&FileName=Systems%209%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Flight Data Recorder 10 - Factual Report of Group Chairman (item 21, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469644&FileExtension=.PDF&FileName=Flight%20Data%20Recorder%2010%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Cockpit Voice Recorder 12 - Factual Report of Group Chairman (item 22, .PDF, 487 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469645&FileExtension=.PDF&FileName=Cockpit%20Voice%20Recorder%2012%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - Witness Statements (item 23, .PDF, 120 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469646&FileExtension=.PDF&FileName=Witness%20Statements-Master.PDF - Transcript of Radio Communications (item 24, .PDF, 391 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469647&FileExtension=.PDF&FileName=Transcript%20of%20Radio%20Communications-Master.PDF - Reports from Federal Agencies: ATC Controller Statements (item 25, .PDF, 900 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469648&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%3A%20ATC%20Controller%20Statements-Master.PDF - Reports from Local Agencies: Miami-Dade County Fire Department Report (item 26, .PDF, 640 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469649&FileExtension=.PDF&FileName=Reports%20from%20Local%20Agencies%3A%20Miami-Dade%20County%20Fire%20Department%20Report-Master.PDF - Other Pertinent Forms and Reports: Recorded Radar Data (item 27, .PDF, 1.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469650&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%3A%20Recorded%20Radar%20Data-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 28, .PDF, 443 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469651&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Other Pertinent Forms and Reports: Captain's Airplane Logbook Entry (item 29, .PDF, 63 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152440&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports%3A%20Captain%27s%20Airplane%20Logbook%20Entry-Master.PDF - Reports from Federal Agencies: ATC Information (item 30, .PDF, 313 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152441&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%3A%20ATC%20Information-Master.PDF - Reports from Local Agencies: Miami-Dade County Police Department Report (item 31, .PDF, 1.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469652&FileExtension=.PDF&FileName=Reports%20from%20Local%20Agencies%3A%20Miami-Dade%20County%20Police%20Department%20Report-Master.PDF - Reports from Local Agencies: Miami-Dade County Aviation Department Report (item 32, .PDF, 265 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469653&FileExtension=.PDF&FileName=Reports%20from%20Local%20Agencies%3A%20Miami-Dade%20County%20Aviation%20Department%20Report-Master.PDF - Photo: FDR Report Page 11 (item 33, .PDF, 207 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152444&FileExtension=.PDF&FileName=Photo%3A%20FDR%20Report%20Page%2011-Master.PDF - Photo: FDR Report Page 12 (item 34, .PDF, 284 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152445&FileExtension=.PDF&FileName=Photo%3A%20FDR%20Report%20Page%2012-Master.PDF - Photo: FDR Report Page 13 (item 35, .PDF, 271 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152446&FileExtension=.PDF&FileName=Photo%3A%20FDR%20Report%20Page%2013-Master.PDF - Photo: FDR Report Page 14 (item 36, .PDF, 300 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40152447&FileExtension=.PDF&FileName=Photo%3A%20FDR%20Report%20Page%2014-Master.PDF - Toxicological Report (item 37, .PDF, 25 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469663&FileExtension=.PDF&FileName=Toxicological%20Report-Redacted.PDF - Reports from Federal Agencies: U.S. Customs (item 38, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469654&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%3A%20U.S.%20Customs-Master.PDF - Statement of Party Representatives to NTSB Investigation (item 39, .PDF, 158 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469655&FileExtension=.PDF&FileName=Statement%20of%20Party%20Representatives%20to%20NTSB%20Investigation-Master.PDF - Witness Statement: American Airlines Mechanics (item 40, .PDF, 228 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469656&FileExtension=.PDF&FileName=Witness%20Statement%3A%20American%20Airlines%20Mechanics-Master.PDF - Correspondence: Submission from Allied Pilots Association (item 41, .PDF, 1.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469657&FileExtension=.PDF&FileName=Correspondence%3A%20Submission%20from%20Allied%20Pilots%20Association-Master.PDF - Correspondence: Submission from Airbus Industrie (item 42, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469658&FileExtension=.PDF&FileName=Correspondence%3A%20Submission%20from%20Airbus%20Industrie-Master.PDF - Correspondence: Airbus response to Allied Pilots Association Submission (item 43, .PDF, 126 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469659&FileExtension=.PDF&FileName=Correspondence%3A%20Airbus%20response%20to%20Allied%20Pilots%20Association%20Submission-Master.PDF - Reports from Parties to the Investigation (item 44, .PDF, 712 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177399&FileExtension=.PDF&FileName=Reports%20from%20Parties%20to%20the%20Investigation-Master.PDF - Survival Factors 6 - Addendum C - Additional Questionnaires (item 45, .PDF, 593 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469660&FileExtension=.PDF&FileName=Survival%20Factors%206%20-%20Addendum%20C%20-%20Additional%20Questionnaires-Master.PDF - Aircraft Maintenance Records (item 46, .PDF, 10.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177400&FileExtension=.PDF&FileName=Aircraft%20Maintenance%20Records-Master.PDF - Release of Aircraft Wreckage, NTSB Form 6120.15 (item 47, .PDF, 235 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469661&FileExtension=.PDF&FileName=Release%20of%20Aircraft%20Wreckage,%20NTSB%20Form%206120.15-Master.PDF - Photo 1: Cockpit pressurization panel after accident. Digital Photo. (item 48, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177919&FileExtension=.PDF&FileName=Photo%201%3A%20Cockpit%20pressurization%20panel%20after%20accident.%20Digital%20Photo.-Master.PDF - Photo 2: View of separated L-1 door slide. Digital Photo. (item 49, .PDF, 101 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177930&FileExtension=.PDF&FileName=Photo%202%3A%20View%20of%20separated%20L-1%20door%20slide.%20Digital%20Photo.-Master.PDF - Photo 3: View of left side of aircraft after accident. Digital Photo. (item 50, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177932&FileExtension=.PDF&FileName=Photo%203%3A%20View%20of%20left%20side%20of%20aircraft%20after%20accident.%20Digital%20Photo.-Master.PDF - Photo 4: View of right side of aircraft after accident. Digital Photo. (item 51, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177933&FileExtension=.PDF&FileName=Photo%204%3A%20View%20of%20right%20side%20of%20aircraft%20after%20accident.%20Digital%20Photo.-Master.PDF - Photo 5: View of Captain's open Airplane Operations Manual after accident. Digital Photo. (item 52, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177934&FileExtension=.PDF&FileName=Photo%205%3A%20View%20of%20Captain%27s%20open%20Airplane%20Operations%20Manual%20after%20accident.%20Digital%20Photo.-Master.PDF - Photo 6: View of ECAM page after accident. Digital Photo. (item 53, .PDF, 83 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177935&FileExtension=.PDF&FileName=Photo%206%3A%20View%20of%20ECAM%20page%20after%20accident.%20Digital%20Photo.-Master.PDF - Photo 7: View of ECAM page after accident. Digital Photo. (item 54, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177936&FileExtension=.PDF&FileName=Photo%207%3A%20View%20of%20ECAM%20page%20after%20accident.%20Digital%20Photo.-Master.PDF - Photo 8: View of pressurization panel after accident. Digital Photo. (item 55, .PDF, 98 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177937&FileExtension=.PDF&FileName=Photo%208%3A%20View%20of%20pressurization%20panel%20after%20accident.%20Digital%20Photo.-Master.PDF - Photo 9: View of aft pressurization valve. after accident. Digital Photo. (item 56, .PDF, 93 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177938&FileExtension=.PDF&FileName=Photo%209%3A%20View%20of%20aft%20pressurization%20valve.%20after%20accident.%20Digital%20Photo.-Master.PDF - Photo 10: Aft compartment where aft pressurization valve is located. Note insulation blankets out of place. Digital Photo. (item 57, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177939&FileExtension=.PDF&FileName=Photo%2010%3A%20Aft%20compartment%20where%20aft%20pressurization%20valve%20is%20located.%20Note%20insulation%20blankets%20out%20of%20place.%20Digital%20Photo.-Master.PDF - Photo 11: View of insulation blanket over aft pressurization valve. Digital Photo. (item 58, .PDF, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177940&FileExtension=.PDF&FileName=Photo%2011%3A%20View%20of%20insulation%20blanket%20over%20aft%20pressurization%20valve.%20Digital%20Photo.%20-Master.PDF - Photo 12: Outside view of aft pressurization valve after accident. Note valve is closed. Digital Photo. (item 59, .PDF, 95 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177941&FileExtension=.PDF&FileName=Photo%2012%3A%20Outside%20view%20of%20aft%20pressurization%20valve%20after%20accident.%20Note%20valve%20is%20closed.%20Digital%20Photo.%20-Master.PDF - Photo 13: View of forward pressurization valve and insulation blanket blocking valve. Digital Photo. (item 60, .PDF, 105 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177942&FileExtension=.PDF&FileName=Photo%2013%3A%20View%20of%20forward%20pressurization%20valve%20and%20insulation%20blanket%20blocking%20valve.%20Digital%20Photo.-Master.PDF - Photo 14: View of aft pressurization valve. FAA Digital Photo. (item 61, .PDF, 44 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177943&FileExtension=.PDF&FileName=Photo%2014%3A%20View%20of%20aft%20pressurization%20valve.%20FAA%20Digital%20Photo.-Master.PDF - Photo 15: View of insulation blanket with securing holes poked into material. FAA Digital Photo. (item 62, .PDF, 29 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40177944&FileExtension=.PDF&FileName=Photo%2015%3A%20View%20of%20insulation%20blanket%20with%20securing%20holes%20poked%20into%20material.%20FAA%20Digital%20Photo.-Master.PDF - Other Pertinent Forms and Reports (item 63, .PDF, 371 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40469662&FileExtension=.PDF&FileName=Other%20Pertinent%20Forms%20and%20Reports-Master.PDF - Drawings (engineering sketches): Airbus Insulation Blanket Process (item 64, .PDF, 622 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40180722&FileExtension=.PDF&FileName=Drawings%20(engineering%20sketches)%3A%20Airbus%20Insulation%20Blanket%20Process-Master.PDF 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.