NYC04LA174

NTSB accident investigation · Bombardier CL-600 · Snow Hill, VA · July 21, 2004

Accident · Serious injuriesLimited investigationFinal report
Date
July 21, 2004, 08:15 local (12:15 UTC)
Place
Snow Hill, VA
Injuries
1 serious, 4 uninjured
Damage
No damage
Phase of flight
Maneuvering
Aircraft
N995CABombardier CL-600
Weather
Visual (VMC) · Day
Status
Completed · report March 28, 2006
Report
Approved by Office Director
Parties
FAA/FSDO
FAA report
20040721017019A
Case key
59797

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

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Probable cause

The pilot's excessive maneuvering in response to a TCAS alert, which resulted in a serious injury to the flight attendant.

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.

Miscellaneous/otherManeuvering
Collision avoidance system - activated
Maneuver - excessivePilot in commandCause

Analysis

The flight crew received a traffic advisory (TA) alert from the Traffic Alert and Collision Avoidance System (TCAS), followed shortly by an aural resolution advisory (RA) warning to "CLIMB, CLIMB." The first officer (FO) then disconnected the autopilot and initiated a climb, at a rate of ascent of 1,500 feet per minute. The captain then announced he was taking the controls and proceeded to pitch the airplane at a greater angle. As the airplane ascended, the flight attendant fell to the floor and broke her ankle. Once the TCAS announced, "clear of conflict," the captain leveled the airplane at 30,000 feet. He then returned the controls to the FO, and the airplane was descended back to an assigned altitude of FL 290. A review of radar data and air traffic control information, revealed that the accident airplane was climbing at a rate of 2,500 feet per minute and an airspeed of 483 knots. The airplane which caused the traffic alert for the accident airplane was an MD-80, which was climbing at 2,000 feet per minute, and an airspeed of 433 knots. The closest proximity between the two aircraft was 1.54 nautical miles, and 1,500 feet. According to the operator's Flight Standards Manual, "the correct response to a corrective RA is to fly from the red zone into the green zone. This maneuver requires a response within 5 seconds of the advisory using approximately a 0.25g maneuver". A performance review of the radar data revealed the flight crew's maneuver in response to the TCAS alert included a 1,000-foot climb, followed immediately by a descent back to the airplane’s assigned altitude. The maneuver described by the radar data could be performed using an initial 1.15 G pull-up to start the climb, followed by a 0.05 push-over to arrest the climb and start the descent, followed by a 1.4 G pull-up to level the airplane at the assigned altitude. In this sequence, the time between the 0.05 G push-over and the 1.4 G level-off was about 5 seconds.

Factual narrative

On July 21, 2004, at 0815 eastern daylight time, a Bombardier CL-600, N995CA, operated by Comair Airlines Inc., as flight 5645, was not damaged during a climb to avoid traffic near Snow Hill, Virginia. The two certificated airline transport pilots, and two non-revenue passengers were not injured. One flight attendant was seriously inured. Visual meteorological conditions prevailed for the flight that departed from the Charleston International Airport (CHS), Charleston, South Carolina, destined for the John F. Kennedy International Airport (JFK), New York, New York. An instrument flight rules flight plan was filed for the scheduled passenger flight conducted under 14 CFR Part 121.

According to the first officer (FO), while in cruise flight at flight level (FL) 290, the crew received an audible traffic advisory (TA) alert from the traffic collision avoidance system (TCAS). The multi-functional display depicted an aircraft at the 12-to 1-o'clock position, about 2,000 feet below, and climbing about 500 feet per minute. As the conflicting aircraft reached approximately 1,400 feet below the CL-600, the first officer visually observed the airplane, announced "traffic in sight, " and alerted the captain to the traffic.

At the same time as the captain instructed the FO to climb, the crew received an aural resolution advisory (RA) warning to "CLIMB, CLIMB" from the TCAS. The FO then disconnected the autopilot and initiated a climb, while advancing the thrust levers. The captain continued his instruction to climb and the vertical speed indicator displayed a rate of ascent of 1,500 feet per minute.

The captain then announced he was taking the controls and proceeded to pitch the airplane at a greater angle. Once the TCAS announced, "clear of conflict," the captain leveled the airplane at 30,000 feet. He then returned the controls to the FO, and the airplane was descended back to FL 290.

After the airplane was level, the captain was informed that the flight attendant was hurt. The flight continued to JFK, where the flight crew requested that paramedics meet the flight to assess the flight attendant's injury.

According to the flight attendant, she was performing a walk-through of the cabin, when she "felt pressure on herself, " and fell to the floor. Two jumpseating passengers in the cabin assisted her to a seat, and retrieved ice for her ankle. After landing, she was transported to an urgent care facility, and diagnosed with a broken ankle.

A review of radar data and air traffic control information provided by the Federal Aviation Administration (FAA), revealed that the Comair flight was climbing at a rate of 2,500 feet per minute and an airspeed of 483 knots. The airplane which caused the traffic alert for the Comair crew was an MD-80, which was climbing at 2,000 feet per minute, and an airspeed of 433 knots. The closest proximity between the two aircraft was 1.54 nautical miles and 1,500 feet.

According to the Comair CL-600 Flight Standards Manual, "the correct response to a corrective RA is to fly from the red zone into the green zone. This maneuver requires a response within 5 seconds of the advisory using approximately a 0.25g maneuver. Listed below [is one] possible corrective RA aural warning:

- 'CLIMB, CLIMB,' - Climb at the rate shown on the VSI, normally 1,500 FPM."

A performance review of the radar data revealed the flight crew response to the TCAS alert included a 1000-foot climb, followed immediately by a descent back to the airplane’s assigned altitude. The entire maneuver lasted about a minute and a half. While the nature of the radar data that tracked the flight did not allow the load factors in the cabin to be computed with certainty, the maneuver described by the radar data could be performed using an initial 1.15 G pull-up to start the climb, followed by a 0.05 push-over to arrest the climb and start the descent, followed by a 1.4 G pull-up to level the airplane at the assigned altitude. In this sequence, the time between the 0.05 G push-over and the 1.4 G level-off was about 5 seconds.

According to Comair training documents, flight crews receive initial TCAS training, during simulator LOFTs. During recurrent training, TCAS training/demonstrations may be built into specific LOFT scenarios.

Aircraft

Registration
N995CA
Reported as
Bombardier CL-600
Category
Airplane
Serial number
7229
Airframe hours
15,817
Engine
General Electric CF34-3A1, 9,220 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Registered owner
Comair Inc
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · July 1, 2004
Departed
CHS · Charleston, SC
Destination
JFK · New York, NY
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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
35
Injuries
None
Certificates
Airline transport, Commercial
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Without waivers/limitations
Last flight review
July 1, 2004
Seat
Left
Flight hours
6,530 total · 4,570 in this make and model · 197 in the last 90 days
Role
Co-pilot
Age
27
Injuries
None
Certificate
Commercial
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
October 1, 2003
Seat
Right
Flight hours
2,213 total · 1,179 in this make and model · 953 as pilot in command

Weather

Conditions
Visual (VMC) · Day
Wind
350° at 5 knots
Visibility
4 statute miles
Lowest ceiling
None
Temperature
81 °F, dew point 68 °F
Altimeter
30.00 inHg
Observed at
WAL, 7 nm away

Docket · 5

The files NTSB released with the investigation on January 11, 2006, on NTSB’s docket system: statements, records, photos and specialists’ reports. 1.1 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.