National Transportation Safety Board Printed on : 1/3/2011 3:15:09 PM

Washington, DC 20594

Brief of Accident

Adopted 03/28/2006

NYC04LA174
File No. 19404 07/21/2004 Snow Hill, VA Aircraft Reg No. N995CA Time (Local): 08:15 EDT

Make/Model: Bombardier / CL-600 Fatal Serious Minor/None

Engine Make/Model: General Electric / CF34-3A1 Crew 0 1 2
Aircraft Damage: None Pass 0 0 2
Number of Engines: 2
Operating Certificate(s): Flag Carrier/Domestic
Name of Carrier: COMAIR INC
Type of Flight Operation: Scheduled; Domestic; Passenger Only
Reg. Flight Conducted Under: Part 121: Air Carrier

Last Depart. Point: CHARLESTON, SC Condition of Light: Day

Destination: NEW YORK, NY Weather Info Src: Weather Observation Facility
Airport Proximity: Off Airport/Airstrip Basic Weather: Visual Conditions
Lowest Ceiling: None
Visibility: 4.00 SM
Wind Dir/Speed: 350 / 005 Kts
Temperature (°C): 27
Precip/Obscuration:

Pilot-in-Command Age: 35 Flight Time (Hours)

Certificate(s)/Rating(s) Total All Aircraft: 6530

Airline Transport; Commercial; Multi-engine Land; Single-engine Land Last 90 Days: 197
Total Make/Model: 4570
Instrument Ratings Total Instrument Time: UnK/Nr
Airplane

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.
 Brief of Accident (Continued)

NYC04LA174
File No. 19404 07/21/2004 Snow Hill, VA Aircraft Reg No. N995CA Time (Local): 08:15 EDT

Occurrence #1: MISCELLANEOUS/OTHER

Phase of Operation: MANEUVERING

Findings
1. COLLISION AVOIDANCE SYSTEM - ACTIVATED
2. (C) MANEUVER - EXCESSIVE - PILOT IN COMMAND

Findings Legend: (C) = Cause, (F) = Factor

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The National Transportation Safety Board determines the probable cause(s) of this accident as follows.
The pilot's excessive maneuvering in response to a TCAS alert, which resulted in a serious injury to the flight attendant.