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Aviation safety reports, made easier to study

NTSB Reports is an independent research and search tool for public aviation accident and incident records. It brings NTSB aviation reports, structured fields, docket files, extracted figures, photos, videos, and update history into one searchable interface.

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NTSB Report

September 5, 1989 · Boeing 767-231 · N608TW

Knox, IN

Overview

Report Status
Probable Cause
Event Type
Incident
Date
September 5, 1989
Injury Outcomes
6 injuries (6 minor injuries), 156 uninjured
Location
Knox, IN
Aircraft
Boeing 767-231
Tail Number
N608TW
Operator
Trans World Airlines
Injuries
Minor
NTSB Number
CHI89IA179

This airplane was involved in a near collision with another airplane while in positive control airspace. Both airplanes took evasive action. Visibility was reported by both flight crews as being reduced by the presence of cirrus clouds with no visible horizon. This airplane had acknowledged and responded to a turn instruction issued to a third airplane with a similar call sign, and turned to a heading which put the two involved airplanes on an intersecting course. The turn instruction was challenged by the airplane for whom it was intended, but the incident airplane was never turned back to its original heading. The error was discovered a short time later by the manual controller and pointed out to the radar controller. He issued turn and climb instructions to the incident airplane along with a traffic advisory. Correlation of the two DFDR readouts with radar track data show that at the point of closest approach, vertical separation was between 95 and 200 ft.

NTSB Probable Cause

THE RADAR CONTROLLLER'S FAILURE TO MAINTAIN RADAR SEPARATION. FACTORS CONTRIBUTING TO THE INCIDENT WERE: MISUNDERSTANDING OF AN ATC INSTRUCTION BY THE PILOT OF THE INCIDENT AIRPLANE, AND UNCLEAR PHRASEOLOGY USED IN THE INSTRUCTIONS ISSUED BY THE RADAR CONTROLLER.

Full Narrative

THIS AIRPLANE WAS INVOLVED IN A NEAR COLLISION WITH ANOTHER AIRPLANE WHILE IN POSITIVE CONTROL AIRSPACE. BOTH AIRPLANES TOOK EVASIVE ACTION. VISIBILITY WAS REPORTED BY BOTH FLIGHT CREWS AS BEING REDUCED BY THE PRESENCE OF CIRRUS CLOUDS WITH NO VISIBLE HORIZON. THIS AIRPLANE HAD ACKNOWLEDGED AND RESPONDED TO A TURN INSTRUCTION ISSUED TO A THIRD AIRPLANE WITH A SIMILAR CALL SIGN, AND TURNED TO A HEADING WHICH PUT THE TWO INVOLVED AIRPLANES ON AN INTERSECTING COURSE. THE TURN INSTRUCTION WAS CHALLENGED BY THE AIRPLANE FOR WHOM IT WAS INTENDED, BUT THE INCIDENT AIRPLANE WAS NEVER TURNED BACK TO ITS ORIGINAL HEADING. THE ERROR WAS DISCOVERED A SHORT TIME LATER BY THE MANUAL CONTROLLER AND POINTED OUT TO THE RADAR CONTROLLER. HE ISSUED TURN AND CLIMB INSTRUCTIONS TO THE INCIDENT AIRPLANE ALONG WITH A TRAFFIC ADVISORY. CORRELATION OF THE TWO DFDR READOUTS WITH RADAR TRACK DATA SHOW, THAT AT THE POINT OF CLOSEST APPROACH, VERTICAL SEPARATION WAS BETWEEN 95 AND 200 FT.

Flight

Event TypeIncident
Event Time17:52 EDT
Nearest Airport0nm N
Runway0
Runway Length0
Runway Width0
Flight Plan FiledIFR
Aircraft FireNo
Aircraft ExplosionNo

Aircraft

AircraftBoeing 767-231
Tail NumberN608TW
Aircraft CategoryAir
OperatorTrans World Airlines
Operating RulePart 121
Engines2
Engine TypeTurbofan
Engine DetailsP&W · JT9D-7R4D · Turbofan

People & Injuries

Injury Summary6 injuries (6 minor injuries), 156 uninjured
Fatal0
Serious0
Minor6
Uninjured156
Total162
Crew 1First Class

Conditions

ConditionsIMC
LightDaylight
WindCalm
CeilingNone
Temperature / Dew Point0 C / 0 C
Altimeter0
Weather SourcePILO

Appendix: Source Data