# NTSB NYC92FA009: Mcdonnell Douglas MD-80, N498AA, Newark, NJ, October 17, 1991 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Field investigation · Final report - Date: October 16, 1991, 21:07 local (Oct 17, 1991, 01:07 UTC) - Place: Newark, NJ - Location: 40.6925° N, 74.1687° W: Placed by OpenAirDocs at NEWARK LIBERTY INTL (EWR), within about a mile (OpenAirDocs) - Nearby events: https://openairdocs.org/map.md?lat=40.6925&lon=-74.1687&mi=10 - Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 36 minor, 134 uninjured - Status: Completed, report July 14, 1993 - Report: Approved by Office Director - NTSB case key (mKey): 37040 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=NYC92FA009 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/37040/pdf - Page: https://openairdocs.org/ntsb/NYC92FA009 ## Probable cause (aircraft 2) FAILURE OF THE CREW OF THE B-737, N7385F, TO MAINTAIN ADEQUATE VISUAL LOOKOUT WHILE TAXIING, AND FAILURE BY AIR TRAFFIC CONTROLLERS TO PROVIDE TRAFFIC INFORMATION AND/OR ISSUE WARNINGS TO EITHER FLIGHTCREW. A FACTOR WAS THE AFTER-LANDING TASK SATURATION OF BOTH FLIGHTCREWS. ## Probable cause (aircraft 1) FAILURE OF THE CREW OF THE B-737, N7385F, TO MAINTAIN ADEQUATE VISUAL LOOKOUT WHILE TAXIING, AND FAILURE BY AIR TRAFFIC CONTROLLERS TO PROVIDE TRAFFIC INFORMATION AND/OR ISSUE WARNINGS TO EITHER FLIGHTCREW. A FACTOR WAS THE AFTER-LANDING TASK SATURATION OF BOTH FLIGHTCREWS. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - On ground/water collision with object, taxi - from landing - visual lookout - inadequate, pilot of other aircraft (cause) - identification of aircraft visually - not obtained, pilot of other aircraft (cause) - excessive workload (task overload), pilot in command (contributing factor) - information - not issued, atc personnel(lcl/gnd/clnc) (cause) - diverted attention, atc personnel(lcl/gnd/clnc) - object - aircraft moving on ground - On ground/water collision with object, taxi - from landing - visual lookout - inadequate, pilot in command (cause) - identification of aircraft visually - not obtained, pilot in command (cause) - excessive workload (task overload), pilot in command (contributing factor) - information - not issued, atc personnel(lcl/gnd/clnc) (cause) - diverted attention, atc personnel(lcl/gnd/clnc) - object - aircraft moving on ground ## Analysis (aircraft 2) BOTH AIRPLANES LANDED IN SEQUENCE ON RUNWAY 4R, AND WERE PROCEEDING TO THEIR RESPECTIVE GATES. THE AMERICAN MD-80 LANDED FIRST. THE CONTINENTAL BOEING 737 WAS TOLD TO CROSS RUNWAY 4L AND CONTACT GROUND AFTER CROSSING. THE COLLISION OCCURRED AT THE INTERSECTION OF TAXIWAYS 'R' AND 'K'. BOTH FLIGHT CREWS WERE OCCUPIED WITH COCKPIT DUTIES AND DID NOT SEE EACH OTHER PRIOR TO THE COLLISION. NEITHER CREW RECEIVED TRAFFIC INFORMATION OR A WARNING FROM ATC PRIOR TO THE IMPACT. THE ATC SPECIALISTS IN THE TOWER WERE DISTRACTED BY A MAINTENANCE AIRPLANE TAXING NEAR RUNWAY 11. THE LOCAL AND GROUND CONTROLLERS SAID THEY THOUGHT THE AIRPLANES WOULD NOT COLLIDE, SO THEY DID NOT ISSUE A WARNING OR TRAFFIC INFORMATION. THE ACCIDENT HAPPENED ON A CLEAR NIGHT AND WEATHER WAS NOT A FACTOR. ## Analysis (aircraft 1) BOTH AIRPLANES LANDED IN SEQUENCE ON RUNWAY 4R, AND WERE PROCEEDING TO THEIR RESPECTIVE GATES. THE AMERICAN MD-80 LANDED FIRST. THE CONTINENTAL BOEING 737 WAS TOLD TO CROSS RUNWAY 4L AND CONTACT GROUND AFTER CROSSING. THE COLLISION OCCCURRED AT THE INTERSECTION OF TAXIWAYS 'R' AND 'K'. BOTH FLIGHT CREWS WERE OCCUPIED WITH COCKPIT DUTIES AND DID NOT SEE EACH OTHER PRIOR TO THE COLLISION. NEITHER CREW RECEIVED TRAFFIC INFORMATION OR A WARNING FROM ATC PRIOR TO THE IMPACT. THE ATC SPECIALISTS IN THE TOWER WERE DISTRACTED BY A MAINTENANCE AIRPLANE TAXING NEAR RUNWAY 11. THE LOCAL AND GROUND CONTROLLERS SAID THEY THOUGHT THE AIRPLANES WOULD NOT COLLIDE, SO THEY DID NOT ISSUE A WARNING OR TRAFFIC INFORMATION. THE ACCIDENT HAPPENED ON A CLEAR NIGHT AND WEATHER WAS NOT A FACTOR. ## Aircraft 1 - Registration: [N498AA](https://openairdocs.org/deregistered/N498AA-2020-08-03), registration cancelled 2020-08-03, S/N 49736, built 1989 (OpenAirDocs) - Reported make and model: MCDONNELL DOUGLAS MD-80 - Registry model: [Mcdonnell Douglas DC-9-82(MD-82)](https://openairdocs.org/model/mcdonnell-douglas-dc-9-82-md-82) (registry code 3022082) (OpenAirDocs) - Registry engine: [Pratt & Whitney JT8D series](https://openairdocs.org/engine/pratt-whitney-jt8d-series) (registry code 52053, turbo-jet) (OpenAirDocs) - Category: Airplane - Serial number: 49736 - Airframe hours: 6034 - Engines: P&W JT8-217-C 20850 lbs thrust turbo fan - Damage: Substantial damage - Flight: Part 121 - Operator: American Airlines, Inc., doing business as American Airlines - Registered owner: Wilmington Trust Company - Airworthiness certificate: Standard, Transport - Last inspection: AAIP, January 2, 2000 - Departed: RDU, RALEIGH/DURHAM, NC - Flight plan: IFR - Airport: EWR, Newark Intl ## Aircraft 2 - Registration: N7385F (not matched to a registry record) - Reported make and model: BOEING 737-291 - Category: Airplane - Serial number: 21069 - Airframe hours: 44541 - Engines: P&W JT8D 14500 lbs thrust turbo fan - Damage: Substantial damage - Flight: Part 121 - Operator: Continental Airlines - Registered owner: P.C. Flowers Inc. - Airworthiness certificate: Standard, Transport - Last inspection: Continuous airworthiness, October 7, 1991, 75 hours before - Departed: PIT, PITTSBURG, PA - Flight plan: IFR - Airport: EWR, Newark Intl, runway 4R, 9,300 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot, aircraft N498AA; age 47; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1, valid medical--no waivers/lim.; seat: left; toxicology performed; flight hours: 16,500 total, 3,146 in this make and model, 150 in the last 90 days, 8 in the last 24 hours - Pilot, aircraft N7385F; age 57; airline transport, flight engineer; airplane ratings: multi-engine land, single-engine land; instrument ratings: airplane; medical: class 1, valid medical--w/ waivers/lim; seat: left; toxicology performed; flight hours: 19,993 total, 198 in the last 90 days, 66 in the last 30 days, 4 in the last 24 hours ## Weather - Conditions: Visual (VMC), Night/bright - Wind: 20° at 7 knots - Visibility: 20 statute miles - Lowest ceiling: 20,000 ft broken - Temperature: 54 °F, dew point 37 °F - Altimeter: 30.00 inHg - Observed at: EWR, 1 nm away ## FAA reports on this event (2) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Incident 19911016051121I](https://openairdocs.org/incident/19911016051121I), Oct 16, 1991: Doug DC982, Newark, NJ, Minor damage. Collided with CAL554 while taxiing to gate. Aircraft met at an intersection. - [Incident 19911016051122I](https://openairdocs.org/incident/19911016051122I), Oct 16, 1991: Boeing 737291, Newark, NJ, Minor damage. Collided with ALL826 while taxiing to gate. Aircraft met at an intersection. 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.