# NTSB MIA90IA039: Boeing 727, N64339, Ormond Beach, FL, December 15, 1989

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: December 15, 1989, 10:23 local (15:23 UTC)
- Place: Ormond Beach, FL
- Location: 29.2858° N, 81.0559° W: Placed by OpenAirDocs: center of Ormond Beach, FL, within about 6 miles (OpenAirDocs)
- Nearby events: https://openairdocs.org/map.md?lat=29.2858&lon=-81.0559&mi=10
- Phase of flight: [Enroute](https://openairdocs.org/ntsb-phases/400) (OpenAirDocs' grouping)
- Highest injury: No injuries
- Injuries: 59 uninjured
- Status: Completed, report September 30, 1992
- Report: Approved by Office Director
- NTSB case key (mKey): 32575
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA90IA039
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/32575/pdf
- Page: https://openairdocs.org/ntsb/MIA90IA039

## Probable cause (aircraft 2)

FAILURE OF THE PILOT IN COMMAND IN THE BEECH 300 TO COMPLY WITH AN ATC CLEARANCE IN A TIMELY MANNER, WHILE DIVERTING HIS ATTENTION, AND FAILURE OF THE ATC CONTROLLER TO ASSURE THAT IFR SEPARATION WAS MAINTAINED.

## Probable cause (aircraft 1)

FAILURE OF THE PILOT IN COMMAND IN THE BEECH 300 TO COMPLY WITH AN ATC CLEARANCE IN A TIMELY MANNER, WHILE DIVERTING HIS ATTENTION, AND FAILURE OF THE ATC CONTROLLER TO ASSURE THAT IFR SEPARATION WAS MAINTAINED.

## Sequence of events

In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf).

- Near collision between aircraft, descent
  - atc clearance - not followed, pilot of other aircraft (cause)
  - diverted attention, pilot of other aircraft (cause)
  - ifr separation standards - not maintained, atc personnel(artcc) (cause)
- Near collision between aircraft, descent
  - atc clearance - not followed, pilot in command (cause)
  - diverted attention, pilot in command (cause)
  - ifr separation standards - not maintained, atc personnel(artcc) (cause)

## Analysis (aircraft 2)

AN FAA BEECH 300, CALL SIGN; FLT CHECK 72 (FLC72), WAS HDG SE ON J79 AT FL260, WHILE TWA FLT 393 WAS HDG SOUTH ON J45 AT FL310. BOTH HAD IFR CLNCS & WERE BEING CTLD BY THE R58 CTLD AT JACKSONVILLE ARTCC. AT THAT TIME, THE CTLR WAS BUSY WORKING A NUMBER OF OTR ACFT. FLC72 REQUESTED A DSCNT, BUT THE DSCNT WAS DELAYED WHILE THE CTLR COORDINATED TFC WITH ANOTHER CTLR. IN THE MEANTIME, FLT 393 WAS CLRD TO DSCND TO FL240. ABT 90 SEC LTR, FLC72 WAS TOLD TO FLY A HDG OF 195 DEG & TO DSCND & MAINT 16,000'.  FLC72 ACKNOWLEDGED, BUT DID NOT DSCND IN A TIMELY MANNER, NOR DID THE CTLR NOTE THE ANOMALY. SUBSEQUENTLY, FLC72 & FLT 393 CONVERGED TO ABT .8 MI MI HORIZONTAL SEPN AT THE SAME ALT. THIS OCCURRED WHEN THE CAPT OF FLC72 ALLOWED THE COPLT TO LEAVE THE COCKPIT & LET ANOTHER FAA EMPLOYEE OCCUPY THE COPLT'S SEAT. THE CAPT RPRTD THAT HE MAY HAVE BECOME DISTRACTED WHILE BRIEFING THE EMPLOYEE.

## Analysis (aircraft 1)

AN FAA BEECH 300, CALL SIGN: FLT CHECK 72 (FLC72), WAS HDG SE ON J79 AT FL260, WHILE TWA FLT 393 WAS HDG SOUTH ON J45 AT FL310.  BOTH HAD IFR CLNCS & WERE BEING CTLD BY THE R58 CTLR AT JACKSONVILLE ARTCC.  AT THAT TIME, THE CTLR WAS BUSY WORKING A NUMBER OF OTR ACFT.  FLC72 REQUESTED A DSCNT, BUT THE DSCNT WAS DELAYED WHILE THE CTLR COORDINATED TFC WITH ANOTHER CTLR. IN THE MEANTIME, FLT 393 WAS CLRD TO DSCND TO FL240.  ABT 90 SEC LTR, FLC72 WAS TOLD TO FLY A HDG OF 195 DEG & TO DSCND & MAINT 16,000'.  FLC72 ACKNOWLEDGED, BUT DID NOT DSCND IN A TIMELY MANNER, NOR DID THE CTLR NOTE THE ANOMALY. SUBSEQUENTLY, FLC72 & FLT 393 CONVERGED TO ABT .8 MI HORIZONTAL SEPN AT THE SAME ALT. THIS OCCURRED WHEN THE CAPT OF FLC72 ALLOWED THE COPLT TO LEAVE THE COCKPIT & LET ANOTHER FAA EMPLOYEE OCCUPY THE COPLT'S SEAT. THE CAPT RPRTD THAT HE MAY HAVE BECOME DISTRACTED WHILE BRIEFING THE EMPLOYEE.

## Aircraft 1

- Registration: [N64339](https://openairdocs.org/deregistered/N64339-2013-08-08), registration cancelled 2013-08-08, S/N 20844, built 1974 (OpenAirDocs)
- Reported make and model: BOEING 727
- Registry model: [Boeing 727-231](https://openairdocs.org/model/boeing-727-231) (registry code 1384079) (OpenAirDocs)
- Registry engine: [Pratt & Whitney JT8D-5](https://openairdocs.org/engine/pratt-whitney-jt8d-5) (registry code 52046, turbo-jet) (OpenAirDocs)
- Category: Airplane
- Serial number: 20844
- Engines: P&W JT8D 15500 lbs thrust turbo fan
- Damage: No damage
- Flight: Part 121
- Registered owner: Trans World Airways
- Airworthiness certificate: Standard, Transport
- Departed: LGA, NEW YORK, NY
- Destination: MCO, ORLANDO, FL
- Flight plan: IFR

## Aircraft 2

- Registration: [N72](https://openairdocs.org/aircraft/N72), registered now, S/N FF-7, built 1988 (OpenAirDocs)
- Reported make and model: BEECH 300
- Registry model: [Beech 300](https://openairdocs.org/model/beech-300) (registry code 1152930) (OpenAirDocs)
- Registry engine: [Pratt & Whitney Canada PT6A-60A](https://openairdocs.org/engine/pratt-whitney-canada-pt6a-60a) (registry code 52043, turbo-prop) (OpenAirDocs)
- Category: Airplane
- Serial number: FF-7
- Engines: P&W PT6A 1050 horsepower turbo prop
- Damage: No damage
- Flight: Public aircraft, Public use
- Registered owner: Federal Aviation Admin.
- Airworthiness certificate: Standard, Normal
- Departed: FTY, ATLANTA, GA
- Destination: X47, BUNNELL, FL
- Flight plan: IFR

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot, aircraft N64339; age 52; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 15,000 total
- Pilot, aircraft N72; age 53; airline transport; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; flight hours: 14,000 total

## Weather

- Conditions: Visual (VMC), Day
- Wind: 180° at 6 knots
- Visibility: 7 statute miles
- Lowest ceiling: none
- Temperature: 61 °F, dew point 37 °F
- Altimeter: 30.00 inHg
- Observed at: CRG, 13 nm away

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.

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