MIA94FA169
MIA94FA169

HISTORY OF THE FLIGHT

On June 29, 1994, about 0023 eastern daylight time, a McDonnell-Douglas MD-11, N1752K, registered to American Airlines, Inc., operating as American Airlines flight 901, experienced altitude deviation in cruise flight over the Caribbean Sea just south of the Cuban coast, resulting in injuries to passengers and crew. The flight was a 14 CFR Part 121 scheduled international passenger flight from Miami, Florida, to Buenos Aires, Argentina. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan was filed. The airplane received minor damage. One passenger and 1 flight attendant received serious injuries, 12 passengers and 3 flight attendants received minor injuries, and 67 passengers and 10 flight attendants were not injured. The airline transport-rated captain, first officer, and reserve first officer were not injured. The flight originated at Miami, Florida, on June 28, 1994, at 2333.

The flightcrew stated the captain was in the main cabin taking a rest period. They were in cruise flight and the seatbelt sign was off. Passengers had been requested to keep their seatbelts on when seated. The reserve first officer occupied the captain's seat and the regular first officer was flying the airplane from the right seat. A flight attendant entered the cockpit with a container of beverages. The reserve first officer instructed her to place the container on the footrest of the center observer's seat.

The reserve first officer noticed the flight attendant was having trouble doing this and realized the first officers seat was in the way. The reserve first officer reached across the cockpit and activated the horizontal movement switch of the first officer's seat, without his knowledge, to move it forward out of the flight attendant's way. The first officer had his legs crossed behind the control column and as his seat was moved forward his legs pushed forward on the column. The autopilot turned off and the aircraft responded to the forward control column input and nosed down. The first officer then took the aircraft controls and returned the aircraft to level flight.

The captain returned to the cockpit and the flight attendants reported that some unrestrained passengers and flight attendants had been injured when the aircraft nosed over. The captain instructed the first officer to continue toward Kingston, Jamaica for a possible landing. The captain contacted American Airlines flight dispatch and it was determined that emergency assistance was not available in Kingston, for they could not reach anyone on the phone. The captain then elected to return to Miami, Florida, where the aircraft landed at 0205.

PERSONNEL INFORMATION

Information on the three flight crewmembers is contained in this report under Pilot Information, and in attachments to this report.

AIRCRAFT INFORMATION

Information on the aircraft is contained in this report under Aircraft Information.

METEOROLOGICAL INFORMATION

Visual meteorological conditions prevailed at the time of the accident. Additional meteorological information is contained in this report under Weather Information, and in attachments to this report.

FLIGHT RECORDERS

The cockpit voice recorder continued to operate after the accident and recordings for the time of the accident were recorded over after thirty minutes.

Readout and evaluation of the digital flight data recorder from N1752K was performed by Thomas R. Jacky, Aerospace Engineer, NTSB, Washington, D.C. Readout information indicated the aircraft was at an altitude of 33,000 feet, on a heading of 159 degrees, and at position of 20.58 degrees north and 78.50 degrees west, at the time of the accident. About 800 feet of altitude was lost during the nose over and the occupants were subjected to a minimum of -0.37 G's and a maximum of +1.85 G's. See attached Factual Report of Investigation Digital Flight Data Recorder.

MEDICAL AND PATHOLOGICAL INFORMATION

One passenger received serious internal injuries as a result of the altitude deviation. One flight attendant received a serious rib injury as a result of the altitude deviation. The remainder of the passengers and flight attendants who reported injuries sustained minor cut, contusion, and strain injuries.

About 5 hours after the accident the three flight members submitted to toxicology testing in accordance with the American Airlines drug and alcohol testing program. The tests were negative for drugs and alcohol. (See attached toxicology reports.)

ADDITIONAL INFORMATION

The aircraft was released to American Airlines on June 29, 1994, at 0530. The flight data recorder and cockpit voice recorder, which was retained by NTSB after the accident, was returned to American Airlines in September 1994.

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