NTSB CAROL · Event
Event NYC92FA009
Aircraft involved
Probable cause & findings
FAILURE OF THE CREW OF THE B-737, N7385F, TO MAINTAIN ADEQUATE VISUAL LOOKOUT WHILE TAXIING, AND FAILURE BY AIR TRAFFIC CONTROLLERS TO PROVIDE TRAFFIC INFORMATION AND/OR ISSUE WARNINGS TO EITHER FLIGHTCREW. A FACTOR WAS THE AFTER-LANDING TASK SATURATION OF BOTH FLIGHTCREWS.
Factual narrative
BOTH AIRPLANES LANDED IN SEQUENCE ON RUNWAY 4R, AND WERE PROCEEDING TO THEIR RESPECTIVE GATES. THE AMERICAN MD-80 LANDED FIRST. THE CONTINENTAL BOEING 737 WAS TOLD TO CROSS RUNWAY 4L AND CONTACT GROUND AFTER CROSSING. THE COLLISION OCCCURRED AT THE INTERSECTION OF TAXIWAYS 'R' AND 'K'. BOTH FLIGHT CREWS WERE OCCUPIED WITH COCKPIT DUTIES AND DID NOT SEE EACH OTHER PRIOR TO THE COLLISION. NEITHER CREW RECEIVED TRAFFIC INFORMATION OR A WARNING FROM ATC PRIOR TO THE IMPACT. THE ATC SPECIALISTS IN THE TOWER WERE DISTRACTED BY A MAINTENANCE AIRPLANE TAXING NEAR RUNWAY 11. THE LOCAL AND GROUND CONTROLLERS SAID THEY THOUGHT THE AIRPLANES WOULD NOT COLLIDE, SO THEY DID NOT ISSUE A WARNING OR TRAFFIC INFORMATION. THE ACCIDENT HAPPENED ON A CLEAR NIGHT AND WEATHER WAS NOT A FACTOR. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1991_NYC92FA009.txt.
Findings + structured fields enriched from FAA avall.mdb.
Full investigation docket on
data.ntsb.gov ↗.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (maintenance). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- Embry-Riddle Scholarly Commons 2026 · Journal article (IJAAA)
From Reactive to Predictive: A hybrid Trust-Mediated Adoption Framework for Data-Driven Maintenance in Distributed-Authority Aviation Environments
Modern aviation maintenance operates within increasingly data-intensive technological environments, yet the operational integration of predictive maintenance into routine decision-making remains incon…
- Semantic Scholar 2025 · Article (Applied Sciences)
Decision-Making Framework for Aviation Safety in Predictive Maintenance Strategies
The implementation of predictive maintenance (PM) in aviation presents unique challenges due to strict safety requirements, complex operational environments, and regulatory constraints.
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
Low-Resource Automatic Speech Recognition Domain Adaptation – A Case-Study in Aviation Maintenance
With timeliness and efficiency being critical in the aviation maintenance industry, the need has been growing for smart technological solutions that optimize and streamline the different underlying ta…
- Embry-Riddle Scholarly Commons 2024 · Journal article (JAAER)
A New Trajectory in UAV Safety: Leveraging Reinforcement Learning for Distance Maintenance Under Wind Variations
In the field of aviation, safety is a critical cornerstone, and the operation of Unmanned Aerial Vehicle (UAV) systems is deeply connected with this principle.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Just Culture in Aviation: A Metaphorical Study on Aircraft Maintenance Students
Just Culture, a sub-dimension of safety culture, has been a prominent and debated topic in aviation safety in recent years.
- Embry-Riddle Scholarly Commons 2024 · Journal article (IJAAA)
Performance PRISM: A Comprehensive Framework For Performance Measurement In Aircraft Maintenance
Aircraft maintenance is governed by rigorous safety requirements and high operational complexity, demanding robust performance measurement frameworks to ensure optimal maintenance practices.
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