Boston Airport
Aircraft Accident/Incident Report

Boston, Massachusetts 02128
Sunday, November 13, 1988 20:12 EST

NTSB Narrative Summary Released at Completion of Accident

THE TOWER CONTROLLER CLEARED PAN AM FLT 543 (BOEING 727, N555PE) INTO POSITION & HOLD ON RWY 22R, THEN HE CLEARED THE 727 FOR TAKEOFF. THE CONTROLLER THEN CLEARED PRECISION FLT 649 (DORNIER DO-228, N238RP) INTO POSITION & HOLD ON RUNWAY 22R. THE CONTROLLER DID NOT REALIZE THE DORNIER WAS AT AN INTERSECTION, 4200 FT DOWN THE RUNWAY, RATHER THAN AT THE APPROACH END. HE HAD FAILED TO NOTICE THAT THE TAKEOFF STRIP WAS MARKED WITH A RED 'T' INDICATING AN INTERSECTION TAKEOFF. ALSO, THE GROUND CONTROLLER DID NOT ADEQUATELY COORDINATE WITH THE LOCAL CONTROLLER, WHEN HE CLEARED THE DORNIER TO TAXI TO THE INTERSECTION FOR AN INTERSECTION DEPARTURE. THE 727 FLIGHT CREW SAW THE DORNIER ON THE RUNWAY & MADE AN EARLY ROTATION, MISSING THE DORNIER. THERE WAS NO CONTACT BETWEEN AIRCRAFT OR INJURIES. THE 727 FLT CREW RETURNED FOR A LANDING TO CHECK THE ENGINES, WHICH HAD BEEN OVERBOOSTED AFTER MAXIMUM POWER WAS APPLIED TO CLEAR THE DORNIER. THE DORNIER WAS TAXIED CLEAR OF THE RUNWAY & BACK TO THE RAMP TO ASSURE THERE WAS NO DAMAGE.

NTSB Probable Cause Narrative

FAILURE OF THE LOCAL CONTROLLER TO DETECT THE RED T ON THE DEPARTURE STRIP ON PRE659 WHEN HE CLEARED HIM INTO POSITION AND HOLD. FACTORS RELATED TO THE ACCIDENT WERE: DARKNESS AND THE LACK OF POSITIVE COORDINATION BETWEEN THE GROUND CONTROLLER AND LOCAL CONTROLLER.

Event Information

Type of Event Incident
Event Date 11/13/1988
Event Day of the Week Sunday
Time of Event 2012
Event Time Zone Eastern Standard Time
Event City BOSTON
Event State MASSACHUSETTS
Event Country --
Zipcode of the event site 02128
Event Date Year 1988
Event Date Month 11
MidAir Collision Indicator --
On Ground Collision occurred ? --
Event Location Latitude
Event Location Longitude
Event Location Airport BOSTON
Event Location Nearest Airport ID BOS
Indicates whether the acc/inc occurred off or on an airport On Airport
Distance from airport in statute miles 0
Degrees magnetic from airport 0
Airport Elevation 20
Weather Briefing Completeness Not pertinent
Investigator's weather source Weather Observation Facility
Time of the weather observation 1950 Eastern Standard Time
Direction of event from weather observation facility (degrees) 0
Weather Observation Facility ID BOS
Elevation of weather observation facility 20
Distance of event from weather observation facility (units?) 0
Time Zone of the weather observation EST
Lighting Conditions Night/Dark
Lowest Ceiling Height 0
Lowest Non-Ceiling Height 900
Sky/Lowest/Cloud Conditions Scattered
Sky Condition for Lowest Ceiling None
Visibility Runway Visual Range (Feet) 0
Visibility Runway Visual Value (Statute Miles) 0
Visibility (Statute Miles) 15
Air Temperature at event time (in degrees celsius) 9
Dew Point at event time (in degress fahrenheit) 9
Wind Direction (degrees magnetic) 240
Variable Wind Indicator Unknown
Wind Speed (knots) 8
Wind Velocity Indicator Unknown
Wind Gust Indicator Unknown
Wind Gust (knots) 0
Altimeter Setting at event time (in. Hg) 29
Density Altitude (feet) 0
Intensity of Precipitation Unknown
METAR weather report --
Event Highest Injury None
On Ground, Fatal Injuries 0
On Ground, Minor Injuries 0
On Ground, Serious Injuries 0
Injury Total Fatal --
Injury Total Minor --
Injury Total None 144
Injury Total Serious --
Injury Total All --
Investigating Agency NTSB
NTSB Docket Number (internal use) 5030
NTSB Notification Source --
NTSB Notification Date Nov 13 1988 12:00AM
NTSB Notification Time 2345
Fiche Number and/or location -used to find docket information 39509
Date of most recent change to record Apr 9 2001 10:27AM
User who most recently changed record dbo
Basic weather conditions Visual Meteorological Cond
FAA District Office --

Aircraft Involved

Aircraft #1

Aircraft #2

Aircraft Registration Number N555PE N238RP
NTSB Number NYC89IA028A NYC89IA028B
Missing Aircraft Indicator N N
Federal Aviation Reg. Part Part 121: Air Carrier Part 135: Air Taxi & Commuter
Type of Flight Plan filed IFR IFR
Flight plan Was Activated? -- --
Damage Minor None
Aircraft Fire None None
Aircraft Explosion None None
Aircraft Manufacturer's Full Name BOEING DORNIER
Aircraft Model 727-227 DO-228-202
Aircraft Series Identifier 727-227 DO-228-202
Aircraft Serial Number 8138
Certified Max Gross Weight 172600 13669
Aircraft Category Airplane Airplane
Aircraft Registration Class U.S. Registered/U.S. Soil U.S. Registered/U.S. Soil
Aircraft is a homebuilt? No No
Flight Crew Seats -- --
Cabin Crew Seats -- --
Passenger Seats -- --
Total number of seats on the aircraft 163 19
Number of Engines 3 2
Fixed gear or retractable gear Retractable Retractable
Aircraft, Type of Last Inspection Continuous Airworthiness Continuous Airworthiness
Date of Last Inspection -- Nov 12 1988 12:00AM
Airframe hours since last inspection -- 5
Airframe Hours 36075 1800
ELT Installed No Yes
ELT Activated No No
ELT Aided Location of Event Site No No
ELT Type -- --
Aircraft Owner Name PAN AMERICAN WORLD AIRWAYS STATE STREET BANK & TRUST
Aircraft Owner Street Address 200 PARK AVE. 225 FRANKLIN ST.
Aircraft Owner City NEW YORK BOSTON
Aircraft Owner State NY MA
Aircraft Owner Country
Aircraft Owner Zipcode 02101
Operator is an individual? -- --
Operator Name PRECISION VALLEY AVIATION, INC
Operator Same as Owner? Yes No
Operator Is Doing Business As -- --
Operator Address Same as Owner? No No
Operator Street Address JFK INTL ARPT, BLD 53 841 GALAXY WAY
Operator City JAMAICA MANCHESTER
Operator State NY NH
Operator Country
Operator Zip code 11430 03103
Operator Code PAA PREA
Owner has at least one certificate Yes - certificate holder Yes - certificate holder
Other Operator of large aircraft? No No
Certified for Part 133 or 137 Operation Unknown Unknown
Operator Certificate Number -- --
Indicates whether an air carrier operation was scheduled or not Scheduled Scheduled
Indicates Domestic or International Flight Domestic Domestic
Operator carrying Pax/Cargo/Mail Passenger/Cargo Passenger/Cargo
Type of Flying (Per_Bus / Primary) Unknown Unknown
Second Pilot on Board Yes Yes
Departure Point Same as Event Yes Yes
Departure Airport Code BOS BOS
Departure City BOSTON
Departure State MA
Departure Country
Departure Time 2011 0
Departure Time Zone EST
Destination Same as Local Flt -- --
Destination Airport Code LGA ISP
Destination City FLUSHING ISLIP
Destination State NY NY
Destination Country
Specific Phase of Flight Takeoff Takeoff
Report sent to ICAO? -- --
Evacuation occurred -- --
Date of most recent change to record Dec 20 2002 12:42PM Jan 2 2001 10:30AM
User who most recently changed record dbo dbo
Since inspection or accident -- --
Event Location Runway Number and Location 222 22
Runway Length 7860 7860
Runway Width 150 150
Sight Seeing flight No No
Air Medical Flight No No
Medical Flight -- --