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Accidents · NTSB OPS10IA001 · Final report

Boeing 767 incident near Atlanta Hartsfield Intl. Apt. (Katl), Georgia, October 19, 2009

On October 19, 2009 at about 10:05 am local time, a Boeing 767, registered N185DN, was involved in an incident during landing near Atlanta Hartsfield Intl. Apt. (Katl), Georgia (Atlanta Hartsfield Internation). It was flown under scheduled airline rules (Part 121). No one was hurt; 194 people were on board or involved. The weather was visual conditions (good weather).

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The NTSB's probable cause their words, unchanged

The flight crew’s failure to identify the correct landing surface due to fatigue. Contributing to the cause of the incident were (1) the flight crew’s decision to accept a late runway change, (2) the unavailability of the approach light system and the instrument landing system for the runway of intended landing, and (3) the combination of numerous taxiway signs and intermixing of light technologies on the taxiway.

Source: NTSB aviation accident database, copy made October 4, 2026. Docket and reports at the NTSB.

What the record shows

Date
October 19, 2009 · about 10:05 am local time
Place
Atlanta Hartsfield Intl. Apt. (Katl), Georgia · Atlanta Hartsfield Internation
Type
Incident · collision on the ground
Injuries
No one was hurt; 194 people were on board or involved.
Weather
visual conditions (good weather)
Aircraft
Boeing 767 332 · all 767s on the register
Registration
N185DN · registry record · serial 27961
Damage
Not recorded
Flight
Flight · scheduled airline rules (Part 121)

The NTSB's narrative final · quoted from the NTSB record

During the flight one of the three required flight deck crew members became ill and was considered to be incapacitated. The remaining two crew members conducted the entire night flight without the benefit of a customary break period. Throughout the flight the crew made comments indicating that they were fatigued and identified fatigue as their highest threat for the approach, but did not discuss strategies to mitigate the consequences of fatigue. At the time of the incident, the crew had been on duty for about 12 hours and the captain had been awake for over 22 hours, while the first officer had been awake for at least 14 hours. During the descent and approach, the flight crew was assigned a number of runway changes; the last of which occurred near the final approach fix for runway 27L. While the flight was on final approach, the crew was offered and accepted a clearance to sidestep to runway 27R for landing. Although the flight crew had previously conducted an approach briefing for two different runways, they had not briefed the approach for runway 27R and were not aware that the approach light system and the instrument landing system (ILS) were not available to aid in identifying that runway. When the crew accepted the sidestep to runway 27R, the captain, who was the flying pilot, saw the precision approach path indicator and lined the airplane up on what he said were the brightest set of lights he could see. During the final approach, the first officer was preoccupied with attempting to tune and identify the ILS frequency for runway 27R. Just prior to the airplane touching down, the captain realized they were landing on a taxiway. The airplane landed on taxiway M, 200 feet north of, and parallel to, runway 27R. Postincident flight evaluations of the airport lighting indicated that there were a number of visual cues that could have misguided the captain to align with taxiway M instead of runway 27R while on final approach. These cues included numerous taxiways signs along the sides of taxiway M which, from the air, appeared to be white and could be perceived as runway edge lights. In addition, the blue light emitting diode (LED) lights used on the eastern end of taxiway M were perceived to be brighter than the adjacent incandescent lights on the airfield and the alternating yellow and green lights in the ILS critical area provided the appearance of a runway centerline. The postincident flight evaluations indicated that when the approach lights or the ILS for runway 27R were available and used, it was clearlyevident when the airplane was not aligned with the runway.

The complete narrative as the NTSB published it. The NTSB's docket holds the report as a PDF and any photographs, statements and other documents from the investigation.

The factual record from the NTSB's investigation tables, in plain English

What happened, in order

  1. Airport occurrence during approach
  2. Wrong surface or wrong airport during landing defining event
  3. Medical event during enroute

The NTSB's findings

  • cause Personnel issues › Action/decision › Info processing/decision › Identification/recognition › Flight crew
  • factor Personnel issues › Action/decision › Info processing/decision › Decision making/judgment › Flight crew
  • factor Environmental issues › Operating environment › Approach aid coverage/avail › Localizer › Availability of related info
  • factor Environmental issues › Operating environment › Approach aid coverage/avail › Approach lighting › Availability of related info
  • factor Environmental issues › Operating environment › Airport facilities/design › Taxiway lighting › Contributed to outcome
  • factor Environmental issues › Operating environment › Airport facilities/design › Taxiway markings/signage › Decision related to condition
  • Personnel issues › Physical › Impairment/incapacitation › Illness/injury › Instructor/check pilot
  • cause Personnel issues › Physical › Alertness/Fatigue › (general) › Flight crew
  • Environmental issues › Operating environment › Radar services/coverage › Surface/taxi › Not specified

Pilot

  • Certificate: airline transport pilot
  • Ratings: multi-engine land; single-engine land
  • Flight time: 9,122 hours in all; 3,131 in this make and model; 71 in the last 90 days
  • Last flight review: December 6, 2008
  • Medical certificate: Class 1
  • Seat: left
  • Injury: no injuries

Crew member

  • Certificate: airline transport pilot
  • Ratings: multi-engine land; single-engine land
  • Flight time: 4,000 hours in all; 1,591 in this make and model; 145 in the last 90 days
  • Last flight review: April 9, 2009
  • Medical certificate: Class 1
  • Seat: rgt
  • Injury: no injuries

The aircraft

  • Airframe total time: 70,009 hours
  • Last inspection: continuous airworthiness programme, February 22, 2009
  • Maximum gross weight: 412,000 lb
  • Seats: 230
  • Landing gear: retractable
  • Engine 1: Pratt & Whitney PW4000 Series (turbofan); 0 hours total
  • Engine 2: Pratt & Whitney PW4000 Series (turbofan); 0 hours total
  • Operator: Delta Air Lines, Inc.

The flight

  • Departed from: SBGL Rio De Janeiro at 11:40 pm
  • Destination: KATL Atlanta GA
  • Flight plan: IFR
  • A second pilot was aboard

Weather at the time

  • Light: night
  • Visibility: 10 statute miles
  • Sky: clear
  • Temperature: 37°F (3°C), dew point 0°F (-18°C)
  • Altimeter: 30.28 inHg
  • Observation at 9:52 am from ATL

Injuries

FatalSeriousMinorNone
Cabi9
Flig3
Passengers182

Documents from the investigation the NTSB's docket: the evidence folder behind the report

The docket, the folder of records gathered during an investigation (maintenance records, photographs, witness statements, examinations), has not been read from the NTSB for this case yet; the list appears here once it has. Open the docket at the NTSB.

Other NTSB records under N185DN the same tail number, which may have belonged to a different aircraft at the time

2011-07-14DCA11CA084 · accident near Boston, MA · minor damage · no injuries
1996-06-25NYC96IA131 · incident near Jamaica, NY · minor damage · no injuries

About this page

Everything above comes from the NTSB's public accident database: the narrative, probable cause and findings are the NTSB's own words, and the coded tables behind its report (pilot, aircraft, flight, weather, injuries, sequence of events) are written out in plain English. Pilots' ages, home towns and medical details are left out on purpose. The documents and photographs are the NTSB's docket, the folder of records gathered during the investigation, shown as the NTSB released them (the NTSB redacts some personal details first) and listed under the NTSB's own titles. This site's own text never names pilots, passengers or anyone else involved. A preliminary report describes what is known soon after the event and can change; the final report, with the probable cause, usually follows one to two years later and this page is refreshed when it does. Case number OPS10IA001.