MIA84IA054

NTSB incident investigation · Mcdonnell Douglas DC-10-30 · Atlantic Ocean (Atlantic Ocean) · January 1, 1984

Incident · Minor injuriesIncident investigationFinal report
Date
January 1, 1984, 15:54 local (20:54 UTC)
Place
Atlantic Ocean (Atlantic Ocean)
Injuries
1 minor, 495 uninjured
Phase of flight
Enroute
Aircraft
N82NAMcdonnell Douglas DC-10-30N656PABoeing 747-121
Weather
Visual (VMC) · Day
Status
Completed
Report
Approved by Office Director
Case key
31029

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

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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.

Near collision between aircraftCruise - normal
Ifr separation standards - not maintainedAtc personnel(artcc)Cause
Crew/group coordination - inadequateAtc personnel(artcc)Cause
Abrupt maneuverCruise - normal
Near collision between aircraftCruise - normal
Ifr separation standards - not maintainedAtc personnel(artcc)Cause
Crew/group coordination - inadequateAtc personnel(artcc)Cause

Analysis

Acft nearly collided with paa N82NA at FL370 about 200 mi east of miami when acft passed about 300 ft from each other ina nonradar environment. Both acft were at their assigned flight level & were operating on routes approved & issued by miami ARTCC. The D72 controller(ctlr) failed to coordinate the alt of N656PA with the D81 ctlr, failed to note conflict when he approved FL370 for N82NA, & placed flt progress strip for N82NA in wrong bay at sector 72 position. Additionally, D81 & R81 ctlrs failed to detect conflict between the two acft. The R72 ctlr did not carefully read the strip when he found it. The board also found the quality assurance efforts at the miami ARTCC to be deficient.

Acft nearly collided with paa N656PA at FL370 about 200 mi east of miami when acft passed about 300 ft from each other in a nonradar environment. Both acft were at their assigned flight level & were operating on routes approved & issued bymiami ARTCC. The D72 controller(ctlr) failed to coordinate the alt of N656PA with the D81 ctlr, failed to note conflict when he approved FL370 for N82NA, & placed flt progress strip for N82NA in wrong bay at sector 72 position. Additionally, D81 & R81 ctlrs failed to detect conflict between the two acft. The R72 ctlr did not carefully read the strip when he found it. The board also found the quality assurance efforts at the miami ARTCC to be deficient.

Aircraft · 2

Registration
N82NA
Reported as
Mcdonnell Douglas DC-10-30
Category
Airplane
Serial number
46713
Engine
GE CF6, 6 horsepower, turbo fan
Damage
No damage
Flight
Part 121
Registered owner
Pan American World Airways Inc
Airworthiness certificate
Standard, Transport
Departed
JFK · New York, NY
Destination
PJM · St. Maarten, OF
Flight plan
IFR
Registration
N656PA
Reported as
Boeing 747-121
Category
Airplane
Serial number
20351
Engine
P&W JT9D, turbo jet
Damage
No damage
Flight
Part 121
Operator
Pan American World Airways Inc
Registered owner
Bankers Trust Co. Trustee
Airworthiness certificate
Standard, Transport
Departed
EGLN · London, England, OF
Destination
MIA · Miami, FL
Flight plan
IFR

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot, aircraft N82NA
Age
40
Certificates
Airline transport, Flight instructor
Airplane ratings
Multi-engine land, Single-engine sea, Multi-engine sea, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--no waivers/lim.
Seat
Left
Role
Pilot, aircraft N656PA
Age
53
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 2, Valid Medical--w/ waivers/lim
Seat
Left

Weather

Conditions
Visual (VMC) · Day
Wind
30° at 15 knots
Lowest ceiling
None
Temperature
72 °F, dew point 54 °F
Altimeter
30.00 inHg
Observed at
MYNN, 60 nm away