# NTSB MIA99LA272: Boeing 767-332, N196DN, Atlanta, GA, September 27, 1999 - Type: NTSB accident investigation - Classification: Accident · Serious injuries · Limited investigation · Final report - Date: September 27, 1999, 15:30 local (19:30 UTC) - Place: Atlanta, GA - Location: 33.7490° N, 84.3880° W: Placed by OpenAirDocs: center of Atlanta, GA, within about 7 miles (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=33.7490&lon=-84.3880&mi=10 - Phase of flight: [Maneuvering](https://openairdocs.org/ntsb-phases/450) (OpenAirDocs' grouping) - Highest injury: Serious injuries - Injuries: 1 serious, 201 uninjured - Status: Completed, report November 30, 2000 - Report: Approved by Office Director - NTSB case key (mKey): 47488 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=MIA99LA272 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/47488/pdf - Page: https://openairdocs.org/ntsb/MIA99LA272 ## Probable cause FAA approach/departure controller's improper service and failure to coordinate and resolve a conflict between aircraft prior to effecting a frequency change, and the improper application of visual separation rules to a flight in the clouds, resulting the crew being required to make an abrupt maneuver to avoid the traffic, causing serious injury to a flight attendant. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Abrupt maneuver, maneuvering - approach/departure control service - improper, atc personnel(dep/apch) (cause) - crew/group coordination - not attained, atc personnel(dep/apch) (cause) - visual separation - improper use of, atc personnel(dep/apch) (cause) - Abrupt maneuver, maneuvering - radar separation - not maintained, atc personnel(dep/apch) (cause) - evasive maneuver - initiated, pilot in command ## Analysis The crew of DAL147 said that they were inbound to land at Atlanta and was at 12,000 feet, on a heading 227 degrees, in sequence for runway 08 when the flight was switched to the south runway. They were told to turn to 180 degrees when able, and to look for traffic at 11,000 feet. DAL147 was in the clouds executing the turn to 180 degrees when they responded to the TARH controller that they had the traffic on TCAS, climbing out of 11,000 feet, approaching their altitude. The crew further stated that the TCAS indicated that the traffic was climbing to 14,000 feet. The pilot flying turned off the autopilot to make the turn quicker to avoid the traffic, and when the autopilot came off, a flight attendant in the back of the airplane was seriously injured. FAA transcript of communications revealed that the TARH controller told DAL147 that the traffic would be leveling at eleven and instructed the crew to maintain visual separation from the traffic. The transcripts also show that at 1902:43 the traffic, a Continental Airlines flight (COA66), was climbing in the clouds, and had been cleared to 14,000 feet instead of 11,000 feet. ## Factual narrative On September 27, 1999, about 1530 eastern daylight time, a Boeing 767-332, N196DN, registered to and operated by Delta Air lines Inc., as DAL147, had a flight attendant sustain an injury while on a Title 14 CFR Part 121 scheduled international passenger flight from Vienna, Austria, to Atlanta, Georgia. Visual meteorological conditions prevailed in the area at the time, and an instrument flight rules flight plan was filed. The airline transport-rated pilot, first officer, reserve pilot, 8 flight attendants, and 199 passengers were not injured, but 1 flight attendant received a serious injury. The flight originated from Vienna, the same day, about 1115. The flightcrew stated that as they made the descent into the Atlanta area, they were on the Macey arrival with a clearance to cross Logan at 12,000 feet, and had asked air traffic control (ATC) for, and had received approval to deviate to avoid numerous cloud buildups. The aircraft was heading 227 degrees, and the flight was being seqenced for runway 08, when the north arrivals controller told them that they would be switched to the south runway, and to contact the approach controller on 127.9. When the crew contacted the approach controller, they informed the controller that they were leveling at 12,000 feet, and the controller told them to turn to 180 degrees as soon as able. The approach controller told them shortly thereafter that traffic was at 11,000 feet. The crew noted the traffic on the TCAS, and that the traffic was climbing out of 11,000 feet and rapidly approaching their altitude. The captain, the pilot flying, had begun the turn to a heading of 180 degrees requested by the controller, when they received a traffic advisory from the TCAS system, followed by the dot on the TCAS screen changing color to yellow. While in the turn, the captain disconnecting the autopilot to make a quicker turn to get away from the traffic, and as the autopilot disconnected, the airplane pitched up and climbed about 200 feet. A flight attendant in the aft end of the airplane sustained a serious injury during the maneuver. The flight crew never received a resolution advisory from the TCAS, and never saw the traffic since they were in the clouds at the time. The seat belt sign had been on for some time previously, and the no smoking light had been cycled due to weather. A review of the FAA transcript of communications revealed that at 1902:31 the Atlanta Approach Terminal Arrival - H (TARH) controller stated to DAL147 that the northbound traffic would be leveling at 11,000 feet. At 1902:37 DAL147 responded saying that they had the traffic, and the TAR-H controller then instructed DAL147 to maintain visual separation. This instruction from TARH was given to DAL147 while the flight was in the clouds. At 1902:43 DAL147 said "okay he's *(fourteen) he's on icas showing (garbled) turn right turn right." At 1903:12 DAL147 said to TARH, "...i thought you said he was at eleven." At 1903:18 TARH replied saying, "...I thought they had stopped him at eleven." The FAA transcript of communications also revealed that at 1901:46 the traffic, a Continental Airlines flight (COA66), was climbing in the clouds, and had been cleared to 14,000 feet by Atlanta Departure Control (DRN). ## Aircraft - Registration: [N196DN](https://openairdocs.org/aircraft/N196DN), registered now, S/N 28453, built 1997 (OpenAirDocs) - Reported make and model: Boeing 767-332 - Registry model: [Boeing 767-332](https://openairdocs.org/model/boeing-767-332) (registry code 1385101) (OpenAirDocs) - Registry engine: [Pratt & Whitney PW4000 series](https://openairdocs.org/engine/pratt-whitney-pw4000-series) (registry code 52119, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 28453 - Airframe hours: 9737 - Engines: P&W PW4060 60000 lbs thrust turbo fan - Damage: No damage - Flight: Part 121 - Registered owner: Delta Airlines Inc. - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, September 3, 1999, 9,755 hours before - Departed: VIE, VIENNA/AUSTRIA, OF - Destination: ATL, ATLANTA, GA - Flight plan: IFR ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 58; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; flight hours: 19,000 total, 4,561 in this make and model, 202 in the last 90 days ## Weather - Conditions: Instrument (IMC), Day - Wind: 140° at 3 knots - Visibility: 10 statute miles - Lowest ceiling: 6,500 ft broken - Temperature: 77 °F, dew point 70 °F - Altimeter: 30.00 inHg - Observed at: ATL, 32 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 19990927041979A](https://openairdocs.org/incident/19990927041979A), Sep 27, 1999: Boeing 767332, Atlanta, GA. (-23) Delta flt 147 was maintaining 12,000 ft with the autopilot engaged. A turn was commenced to 180. A degree heading and a TCAS traffic advisory was… ## Other investigations on N196DN (2) 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. - [NTSB DCA21LA229](https://openairdocs.org/ntsb/DCA21LA229), Sep 1, 2021: Boeing 767-332 (N196DN), Seattle, WA, no damage. Probable cause: The flightcrew’s failure to set the hydraulic panel correctly during the execution of the pushback checklist, and when the hydraulic panel setting was corrected, that resulted in the airplane coming… - [NTSB ENG10IA038](https://openairdocs.org/ntsb/ENG10IA038), Jun 16, 2010: Boeing 767 (N196DN), Athens, Greece, incident, minor damage. Probable cause: A short circuit involving the light in position L3 on the squib test panel. The specific cause of the short circuit could not be determined. 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.