Pilot Debrief

EMBRAER ERJ 170 100 SE near Summit, MS — 2010-08-09

Final reportDCA10LA083
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Date
2010-08-09
Location
Summit, MS, USA
Aircraft
EMBRAER ERJ 170 100 SE
Registration
N856RW
Category
Airplane
Highest injury
Serious
Fatalities
0
Phase of flight
Cruise

Probable cause

the abrupt maneuver that was appropriately initiated to comply with the TCAS resolution advisory caused by the momentary projected loss of separation from converging traffic. Contributing to the accident was a passenger's decision to disregard the seatbelt sign.

NTSB narrative

The rapid climb and descent of FAST13 within 30 seconds exceeded the radar systems capability to accurately track and display the altitude changes. Accordingly, the air traffic controller providing services to TCF7530 and FAST13 did not observe FAST13 climb above the assigned altitude of FL280 nor did the controller receive a conflict alert from the radar system. The reason for FAST 13's deviation from assigned altitude was not determined. The TCAS onboard TCF7630 alerted as expected and the first officer appropriately initiated a climb in response to the RA. The seat belt sign was on prior to the TCAS alert because the flight attendants were preparing the cabin for landing. Shortly before the event, a passenger elected to go to the lavatory even though a flight attendant advised the passenger to return to his seat. The passenger was in the lavatory when the TCAS RA occurred resulting in him receiving a serious injury.

Analysis

Primary failure mode
Human factors
First missed decision gate
FAST13's altitude change was not communicated to TCF7630 or ATC.

NTSB coding

Evidence available

  • CVR
  • FDR / data
  • 10 docket documents
View NTSB final reportView NTSB docket

Docket documents10