Individually Owned: 151,845
Corporate Owned: 143,699
Chicago O'hare International A Airport
Aircraft Accident/Incident Report
Chicago, Illinois 60018
Tuesady, March 21, 2006 16:20 EST
NTSB Narrative Summary Released at Completion of Accident
Certified professional controller (CPC) providing on-the-job training working North Local Control position for 24 minutes responsible for 8 aircraft. Plan X in effect (landing and departing runways 4 and 9). Developmental controller (DEV) is certified on all positions except local control (has 150 hours of the allotted 180.) Lufthansa (DLH) flight 437, A319, was instructed to taxi-into-position-and-hold on runway 4L to wait for the previous arrival to exit the runway. Chautauqua (CHQ) flight 7826, E145, was issued taxi-into-position-and-hold runway 9L and was advised traffic (DLH437) would be departing runway 4L. (It is approximately 1,900 feet from the Runway 9L threshold to the intersection of Runway 4L.) When the runway 9L traffic exited, DLH437 was cleared for takeoff. Thirty-five seconds later the DEV cleared CHQ7826 for takeoff on runway 9L. The Local Monitor and the CPC did not hear the DEV clear CHQ7826 for takeoff. Shortly thereafter, the Local Monitor noticed both aircraft were rolling and told the North Local Controller CPC who canceled takeoff instructions to both aircraft. Closest proximity 100 feet when both aircraft stopped at the runway intersection. AMASS did not have crossing runway logic installed and did not alarm. The pilot of DLH437 called the tower later and said they observed the E145 and was aborting takeoff when the controller told him to stop.
NTSB Probable Cause Narrative
The probable cause of this incident is the local controller's failure to ensure proper separation between Lufthansa (DLH) flight 437 andChautauqua (CHQ) flight 7826. Contributing to the probable cause was the local controller's failure to monitor the situation and advise the local controller that DLH437 had not departed prior to the controller issuing the takeoff clearance to CHQ7826.
Event Information
| Type of Event | Incident |
| Event Date | 3/21/2006 |
| Event Day of the Week | Tuesday |
| Time of Event | 1620 |
| Event Time Zone | Eastern Standard Time |
| Event City | Chicago |
| Event State | ILLINOIS |
| Event Country | -- |
| Zipcode of the event site | 60018 |
| Event Date Year | 2006 |
| Event Date Month | 3 |
| MidAir Collision Indicator | No |
| On Ground Collision occurred ? | No |
| Event Location Latitude | 415872N |
| Event Location Longitude | 0875428W |
| Event Location Airport | Chicago O'Hare International A |
| Event Location Nearest Airport ID | KORD |
| Indicates whether the acc/inc occurred off or on an airport | On Airport |
| Distance from airport in statute miles | -- |
| Degrees magnetic from airport | -- |
| Airport Elevation | 668 |
| Weather Briefing Completeness | -- |
| Investigator's weather source | Weather Observation Facility |
| Time of the weather observation | 1356 Central Daylight Time |
| Direction of event from weather observation facility (degrees) | -- |
| Weather Observation Facility ID | ORD |
| Elevation of weather observation facility | 668 |
| Distance of event from weather observation facility (units?) | -- |
| Time Zone of the weather observation | CDT |
| Lighting Conditions | Day |
| Lowest Ceiling Height | 3200 |
| Lowest Non-Ceiling Height | -- |
| Sky/Lowest/Cloud Conditions | Unknown |
| Sky Condition for Lowest Ceiling | Broken |
| Visibility Runway Visual Range (Feet) | -- |
| Visibility Runway Visual Value (Statute Miles) | -- |
| Visibility (Statute Miles) | 10 |
| Air Temperature at event time (in degrees celsius) | -1 |
| Dew Point at event time (in degress fahrenheit) | -7 |
| Wind Direction (degrees magnetic) | 10 |
| Variable Wind Indicator | Wind direction could be determined |
| Wind Speed (knots) | 25 |
| Wind Velocity Indicator | -- |
| Wind Gust Indicator | Unknown |
| Wind Gust (knots) | -- |
| Altimeter Setting at event time (in. Hg) | 30.13 |
| Density Altitude (feet) | -- |
| Intensity of Precipitation | -- |
| 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 | 78 |
| Injury Total Serious | -- |
| Injury Total All | -- |
| Investigating Agency | NTSB |
| NTSB Docket Number (internal use) | 22751 |
| NTSB Notification Source | FAA |
| NTSB Notification Date | Mar 22 2006 12:00AM |
| NTSB Notification Time | -- |
| Fiche Number and/or location -used to find docket information | DMS |
| Date of most recent change to record | Nov 30 2007 3:42PM |
| User who most recently changed record | NTSB\lema |
| Basic weather conditions | Visual Meteorological Cond |
| FAA District Office | -- |
Aircraft Involved |
||
|---|---|---|
Aircraft #1 |
Aircraft #2 |
|
| Aircraft Registration Number | -- | -- |
| NTSB Number | OPS06IA006A | OPS06IA006B |
| Missing Aircraft Indicator | -- | -- |
| Federal Aviation Reg. Part | -- | -- |
| Type of Flight Plan filed | IFR | IFR |
| Flight plan Was Activated? | Yes | Yes |
| Damage | None | None |
| Aircraft Fire | None | None |
| Aircraft Explosion | None | None |
| Aircraft Manufacturer's Full Name | Airbus Industrie | Embraer |
| Aircraft Model | 319 | 145EP |
| Aircraft Series Identifier | -- | -- |
| Aircraft Serial Number | DAPAC | N977RP |
| Certified Max Gross Weight | -- | -- |
| Aircraft Category | Airplane | Airplane |
| Aircraft Registration Class | -- | -- |
| Aircraft is a homebuilt? | No | No |
| Flight Crew Seats | -- | -- |
| Cabin Crew Seats | -- | -- |
| Passenger Seats | -- | -- |
| Total number of seats on the aircraft | -- | -- |
| Number of Engines | -- | -- |
| Fixed gear or retractable gear | Retractable | Retractable |
| Aircraft, Type of Last Inspection | -- | -- |
| Date of Last Inspection | -- | -- |
| Airframe hours since last inspection | -- | -- |
| Airframe Hours | -- | -- |
| ELT Installed | Yes | Yes |
| ELT Activated | No | No |
| ELT Aided Location of Event Site | No | -- |
| ELT Type | -- | -- |
| Aircraft Owner Name | -- | -- |
| Aircraft Owner Street Address | -- | -- |
| Aircraft Owner City | -- | -- |
| Aircraft Owner State | -- | -- |
| Aircraft Owner Country | -- | -- |
| Aircraft Owner Zipcode | -- | -- |
| Operator is an individual? | -- | No |
| Operator Name | -- | -- |
| Operator Same as Owner? | -- | No |
| Operator Is Doing Business As | -- | -- |
| Operator Address Same as Owner? | -- | Yes |
| Operator Street Address | Airport Terminal A | -- |
| Operator City | Dusseldorf | -- |
| Operator State | -- | -- |
| Operator Country | GE | -- |
| Operator Zip code | -- | -- |
| Operator Code | L7AY | CHQA |
| Owner has at least one certificate | -- | -- |
| Other Operator of large aircraft? | -- | -- |
| Certified for Part 133 or 137 Operation | -- | -- |
| Operator Certificate Number | -- | -- |
| Indicates whether an air carrier operation was scheduled or not | Scheduled | Scheduled |
| Indicates Domestic or International Flight | International | Domestic |
| Operator carrying Pax/Cargo/Mail | Passenger Only | Passenger Only |
| Type of Flying (Per_Bus / Primary) | -- | -- |
| Second Pilot on Board | -- | -- |
| Departure Point Same as Event | Yes | Yes |
| Departure Airport Code | KORD | KORD |
| Departure City | Chicago | Chicago |
| Departure State | IL | IL |
| Departure Country | USA | USA |
| Departure Time | -- | -- |
| Departure Time Zone | EST | EST |
| Destination Same as Local Flt | -- | -- |
| Destination Airport Code | EDDL | KSDF |
| Destination City | Dusseldorf | Louisville |
| Destination State | -- | KY |
| Destination Country | GE | USA |
| Specific Phase of Flight | Takeoff - aborted | Takeoff - aborted |
| Report sent to ICAO? | -- | -- |
| Evacuation occurred | -- | -- |
| Date of most recent change to record | Nov 19 2007 2:03PM | Nov 19 2007 2:03PM |
| User who most recently changed record | ROWS | ROWS |
| Since inspection or accident | -- | -- |
| Event Location Runway Number and Location | rL | 9L |
| Runway Length | 7500 | 7967 |
| Runway Width | 150 | 150 |
| Sight Seeing flight | No | No |
| Air Medical Flight | No | No |
| Medical Flight | -- | -- |