NTSB Identification: FTW95IA126A
Scheduled 14 CFR AMERICAN AIRLINES
Incident occurred Monday, February 27, 1995 in DALLAS-FT WORTH, TX
Probable Cause Approval Date: 12/12/1995
Aircraft: MCDONNELL DOUGLAS MD11, registration: N1763
Injuries: 78 Uninjured.

NTSB investigators used data provided by various sources and may not have traveled in support of this investigation to prepare this aircraft incident report.

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.

The National Transportation Safety Board determines the probable cause(s) of this incident to be:

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.

Full narrative available

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