CHI00IA062

NTSB incident investigation · British Aerospace Jetstream 3101 · Milwaukee, WI · January 21, 2000

Incident · No injuriesIncident investigationFinal report
Date
January 21, 2000, 05:58 local (11:58 UTC)
Place
Milwaukee, WI
Injuries
2 uninjured
Damage
No damage
Phase of flight
Taxi
Aircraft
N842JSBritish Aerospace Jetstream 3101
Weather
Visual (VMC) · Dawn
Status
Completed · report July 26, 2001
Report
Approved by Office Director
FAA report
20000121040559I
Case key
48562

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.

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Probable cause

the hold-short clearance not being followed by the flightcrew, which resulted in a near collision with the departing Boeing 727-200.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

Near collision between aircraftTaxi
Atc clearance - not followedFlightcrewCause
Fatigue(lack of sleep)Flightcrew
Weather condition - temperature,low
Window,flight compartment window/windshield - contamination,other than water

Analysis

After receiving a taxi clearance, which included holding short of runway 1L, the crew of Chataqua Flight 4376 proceeded to taxi across runway 1L, without clearance, resulting in a near collision with a departing Sun Country Boeing 727-200. The First Officer of Chataqua Flight 4376 reported that he was handling radio communications and had received the taxi clearance, which included the hold-short limitation, and read-back the clearance to ground control. According to the captain, contributing factors to the incident were crew fatigue, the cold temperature of the cockpit, and the windows being obscured with de-icing fluid.

Factual narrative

On January 21, 2000, at 0558 central standard time, there was a near collision between a taxing British Aerospace Jetstream 3101 and a departing Boeing 727-200 from runway 1L at the General Mitchell International Airport, Milwaukee, Wisconsin. The British Aerospace Jetstream 3101, N842JS, was operating under the provisions of 14 CFR Part 121 as Chataqua Flight 4376. The Boeing 727-200, N283SC, was operating under the provisions of 14 CFR Part 121 as Sun Country Flight 603. Visual meteorological conditions prevailed during this incident. There were no revenue passengers aboard either airplane and the respective crews did not report any injuries.

According to Federal Aviation Administration (FAA) records, Chataqua Flight 4376 was issued a clearance to taxi to runway 25L via taxiways bravo and mike and to hold short of runway 1L. Chataqua Flight 4376 read back the taxi-clearance, including the hold-short clearance. Sun Country Flight 603 was issued a clearance to takeoff from runway 1L and fly the runway heading. Full transcripts of Air Traffic Control (ATC) voice transmissions are attached to this factual report.

According to a written statement, provided by the captain of Sun Country Flight 603, just prior to rotation the crew noticed a Jetstream taxing onto runway 1L at the mike taxiway/runway intersection. The Boeing 727-200 captain reported that that his aircraft was able to clear the taxing airplane without taking any "extraordinary" actions. The captain stated that their aircraft cleared the Jetstream by approximately 50-feet and the position of the taxing aircraft was approximately 30-feet left of the runway 1L centerline. The captain stated that his inboard landing lights, runway turnoff lights, and strobe lighting systems were on at the time of the incident.

According to a written statement, provided by the captain of Chataqua Flight 4376, he was taxing the aircraft and the first officer was handling the radio communications. The captain reported that prior to crossing runway 1L, he and the first officer visually checked to see if the runway was clear. The captain stated that visibility was restricted from de-icing fluid on the side windows. The captain reported that the runway was clear of traffic, and he continued to taxi across runway 1L. The captain stated that after crossing runway 1L the crew was informed that a departing Boeing 727-200 had just cleared them. The captain stated that he did not hear the hold-short clearance given by ground control.

According to a written statement, provided by the first officer of Chataqua Flight 4376, the crew was issued instructions to taxi to runway 25L via taxiways bravo and mike and to hold short of runway 1L. The first officer stated that he acknowledged the clearance by reading-back the taxi instructions to ground control.

Airport operations inspected the taxiway/runway intersection and found the wigwag lighting system operating normally, and the doublewide hold short lines visible at the center of the taxiway, with snowdrifts obscuring the taxiway edges.

According to the captain's written statement, "Contributing Factors:

(1) The crew was on a CDO (Continuous Duty Over-Night) and the incident in question occurred some 12+ hrs into the duty period. While at the hotel the crew had only 4 hours sleep.

(2) The aircraft was parked outside in sub-zero degree-Fahrenheit temperatures for approximately 5 hrs. Temperatures in the cockpit at the time of taxi was approx. 10 degrees-Fahrenheit.

(3) Due to heavy frost on the aircraft, de-icing was required. With Glycol on the aircraft windows there was reduced visibility to the sides of the aircraft."

Aircraft

Registration
N842JS
Reported as
British Aerospace Jetstream 3101 (JETSTREAM)
Category
Airplane
Serial number
753
Airframe hours
24,587
Engine
Garrett TPE331-10-UGR, 1,000 horsepower, turbo prop
Damage
No damage
Flight
Part 121
Operator
Chataqua Airlines, Inc., doing business as US Airways Express
Registered owner
First Union National Bank
Airworthiness certificate
Standard, Normal
Last inspection
AAIP · December 28, 1999
Departed
MKE
Destination
IND · Indianapolis, IN
Flight plan
IFR
Airport
MKE · General Mitchell Internat, runway 1L, 9,690 × 200 ft

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
34
Certificate
Airline transport
Airplane ratings
Multi-engine land, Single-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
2,636 total · 150 in this make and model · 2,500 as pilot in command · 130 in the last 90 days · 50 in the last 30 days

Weather

Conditions
Visual (VMC) · Dawn
Wind
300° at 8 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
32 °F
Altimeter
30.00 inHg
Observed at
MKE

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.