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American McDonnell Douglas MD11 incident

27 Feb 1995 · DALLAS-FT WORTH, TX, United States

McDonnell Douglas MD11 and Exec Express II Fairchild SA227-AC · Incident: near collision between aircraft during landing

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Event

NTSB case
FTW95IA126
Event typeAccident: someone killed or seriously injured, or the aircraft substantially damaged (NTSB definition). Incident: an occurrence that affected or could have affected safety, short of that. Glossary
Incident
InvestigationHow far the investigation had got when the record was published: preliminary, ongoing, final or completed. Unknown where the source does not say. Glossary
Completed
API-reported fatalities
0 · all aircraft and ground
Ground fatalities
0
OperationWhat kind of flying it was, grouped by the rules it flew under: airline (US Part 121), air taxi and commuter (Part 135), general aviation (Part 91 and similar), military or government. Glossary
Airline
WeatherVisual meteorological conditions (VMC): good enough to fly by looking outside. Instrument conditions (IMC): cloud or low visibility, flying by instruments. Glossary
Visual Meteorological Cond

Aircraft 1 · McDonnell Douglas MD11

Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N1763
Operator
American
Onboard fatalities
Unknown
Route
From Chicago O'Hare International Airport (ORD), Chicago, ILTo Dallas Fort Worth International Airport (DFW)
Aircraft age
Not recorded
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 121: Air Carrier
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Landing · flare/touchdown
First occurrenceThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Near collision between aircraft
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
None

Aircraft 2 · Fairchild SA227-AC

Aircraft type
Fairchild SA227
Category
Airplane
RegistrationThe aircraft's tail number, such as N12345 or G-ABCD. Registrations are reissued, so the same one years apart can be a different aircraft. Glossary
N355AE
Onboard fatalities
Unknown
Route
From Dallas Fort Worth International Airport (DFW)To Ozark Regional Airport (BPK), Mountain Home, AR
Aircraft age
Not recorded
Flight rulesThe regulations the flight operated under: in the US, Part 91 (general aviation), Part 121 (airlines), Part 135 (air taxi and commuter) and others; for flights abroad, the NTSB's coarser commercial or non-commercial code. Glossary
Part 135: Air Taxi & Commuter
Phase of flightThe stage of the flight when things started to go wrong: standing, taxi, takeoff, initial climb, en route, maneuvering, approach or landing. Glossary
Standing · engine(s) operating
First occurrenceThe single coded event the NTSB judges best describes what happened (records from 2008 on). Older records name the first occurrence in the sequence instead. Glossary
Near collision between aircraft
DamageDestroyed: beyond practical repair. Substantial: damage that affects the structure, performance or handling and normally needs major repair. Minor: less than that. Glossary
None

Cause areas

  • Atc personnel(lcl/gnd/clnc) › Control tower service, improper
  • Atc personnel(lcl/gnd/clnc) › Excessive workload (task overload)
  • Atc personnel(supervisor) › Supervision, inadequate

Not plotted · Location withheld: coordinates are missing, conflicting, invalid, or have no accepted acquisition method. No substitute location has been invented.

NTSB narrative

ON THE NIGHT OF THE INCIDENT, THE LOCAL CONTROLLER CLEARED AMERICAN FLT 2351, N1763, TO LAND ON RWY 35R. SEVEN SECONDS LATER THE SAME CONTROLLER INSTRUCTED LONE STAR FLT 1219, N355AE, TO TAXI INTO POSITION AND HOLD ON RWY 35R. NEITHER CREW HEARD THE OTHER'S CLEARANCE, NOR WAS EITHER ADVISED OF THE OTHER'S POSITION AS REQUIRED. THE TOWER CAB SUPERVISOR NOTICED THE CONFLICT & ALERTED THE CONTROLLER. THE CONTROLLER COULD NOT RECALL THE CALL SIGN FOR AA2351, AND ISSUED GO-AROUND INSTRUCTIONS USING INCORRECT CALL SIGNS AA1251 & AA1261. AA2351 OVERFLEW LS1219 BY ABOUT 35 FT BEFORE TOUCHING DOWN. THE LOCAL FREQUENCY WAS VERY BUSY, AND THE CONTROLLER'S WORKLOAD WAS CATEGORIZED AS 'HEAVY' BY ALL FLIGHTCREWS INTERVIEWED. REVIEW OF ATC TAPES CONFIRMED THOSE OBSERVATIONS. THE CONTROLLER WAS HANDLING TRAFFIC ON RWYS 35L, 35R, AND 31R, IN ADDITION TO RECEIVING INPUTS FROM THE DEPARTURE CONTROLLER. FIFTEEN MINUTES BEFORE THE INCURSION, THE CONTROLLER WAS GETTING UNCOMFORTABLE, AND INFORMED HIS SUPERVISOR THAT HE NEEDED A BREAK. THE SUPERVISOR LATER SAID THAT HE DID NOT NOTICE THAT THE CONTROLLER WAS GETTING OVERLOADED.

Probable cause

THE LOCAL CONTROLLER'S TASK OVERLOAD, WHICH LED HIM TO FORGET TO ISSUE APPROPRIATE TRAFFIC ADVISORIES AND TO LOSE HIS AWARENESS OF THE TRAFFIC SITUATION, AND THE FAILURE OF THE CONTROLLER'S SUPERVISOR TO RECOGNIZE THAT THE CONTROLLER HAD REACHED OR EXCEEDED HIS MAXIMUM THRESHOLD OF WORKLOAD CAPABILITY AND TO TAKE APPROPRIATE ACTION.

Verbatim NTSB analysis and probable cause from the NTSB dataset

Sources

NTSB record FTW95IA126
Event ID
20001207X02958
Case number
FTW95IA126
Dataset
historical-pre2008
Source SHA-256
89e2df6d848e7ab3b42e7d7c7a03ff403303057a26ca04c95b3ea67201c3ce74
Source notes (5)
  • Unreviewed is an editorial label, not an investigation status. API-sourced is not report-checked or human-reviewed. Explicit event totals are used without summing aircraft injury tables; onboard allocation is withheld. Unknown values remain unknown. The operation category is mapped from the NTSB-reported FAR part and has not been reviewed.
  • Filled from the NTSB case API where the bulk record had no value: local date, investigation status, damage. Values present in the bulk record are kept.
  • The date is the local date; the NTSB stores the UTC date 1995-02-28.
  • API snapshot SHA-256: 84934e077af7814a85f15daffd2652fe78e2268d9fda2c63869e5949f88767e6; retrieved 2026-09-18T18:03:17.500Z.
  • Corrected after a review of the NTSB narrative, which states these values explicitly: operator. The NTSB narrative names the operator: "THE LOCAL CONTROLLER CLEARED AMERICAN FLT 2351, N1763, TO LAND ON RWY 35R"