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 -- --