DCA23LA125

NTSB incident investigation · Boeing 737-900ER · Queens, NY · January 14, 2023

Incident · No injuriesClass 1 · LimitedFinal report
Date
January 13, 2023, 20:44 local (Jan 14, 2023, 01:44 UTC)
Place
Queens, NY · KJFK
Injuries
308 uninjured
Phase of flight
Takeoff
Aircraft
N914DUBoeing 737-900ERN754ANBoeing 777-223
Weather
Visual (VMC) · Night
Status
Completed · report May 29, 2024
Report
Board-adopted by Notation
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
Boeing, Allied Pilots Association, National Air Traffic Controllers Association, Delta Air Lines, American Airlines, FAA
Safety recommendations
Yes
Case key
106577

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

On this page

Probable cause

The American Airlines flight 106 (AAL106) crew’s surface navigation error due to distractions caused by their performance of concurrent operational tasks during taxi, which resulted in a loss of situational awareness. Contributing to the incident was the air traffic control tower team’s nondetection of the AAL106 crew’s deviation from taxi instructions while performing concurrent operational tasks; the timing of the runway status light system, which activated too late to prevent the AAL106 crew from crossing the runway hold short line; and American Airlines’ lack of adequate risk controls to prevent concurrent flight crew tasks from leading to distraction, loss of situational awareness, and deviation from an authorized taxi clearance. Reducing the severity of the incident, and likely preventing an accident, was the activation of the ASDE-X warning in the air traffic control tower and the local controller’s prompt cancellation of DAL1943’s takeoff clearance.

Findings · 12

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings. Under each, the cases with the same finding.

N914DU · Boeing 737-900ER

Attention/monitoring: task monitoring/vigilancePersonnel issues › Psychological · Pilot of other aircraftBoeing 737-900ER: 1 caseAll aircraft: 330 casesProbable cause
Action: incorrect action performancePersonnel issues › Action/decision · Pilot of other aircraftBoeing 737-900ER: 1 caseAll aircraft: 1,386 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · ATC personnelBoeing 737-900ER: 1 caseAll aircraft: 792 casesProbable cause
Airport facilities/design: runway lightingEnvironmental issues › Operating environment · Timing of related infoBoeing 737-900ER: 1 caseAll aircraft: 18 casesProbable cause
Safety programs: adequacy of safety programOrganizational issues › Support/oversight/monitoring · OperatorBoeing 737-900ER: 1 caseAll aircraft: 24 casesProbable cause

N754AN · Boeing 777-223

Action: incorrect action performancePersonnel issues › Action/decision · Flight crewBoeing 777-223: 2 casesAll aircraft: 1,386 casesProbable cause
Attention/monitoring: task monitoring/vigilancePersonnel issues › Psychological · Flight crewBoeing 777-223: 1 caseAll aircraft: 330 casesProbable cause
Action: lack of actionPersonnel issues › Action/decision · ATC personnelBoeing 777-223: 1 caseAll aircraft: 792 casesProbable cause
Airport facilities/design: runway lightingEnvironmental issues › Operating environment · Timing of related infoBoeing 777-223: 1 caseAll aircraft: 18 casesProbable cause
Safety programs: adequacy of safety programOrganizational issues › Support/oversight/monitoring · OperatorBoeing 777-223: 1 caseAll aircraft: 24 casesProbable cause

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident. Under each, the cases with the same event anywhere in their sequence.

Analysis

On January 13, 2023, about 2044 eastern standard time, the flight crew of American Airlines (AAL) flight 106, a Boeing 777-200, N754AN, crossed runway 4L on taxiway J without air traffic control (ATC) clearance at John F. Kennedy International Airport (JFK), Queens, New York, causing the flight crew of Delta Air Lines (DAL) flight 1943, a Boeing 737-900, N914DU, to abort their takeoff roll on runway 4L. None of the 6 crew and 153 passengers on DAL1943, nor the 12 crew and 137 passengers on AAL106, were injured, and there was no damage to either airplane. AAL106 operated as a Title 14 Code of Federal Regulations (CFR) Part 121 scheduled international passenger flight from JFK to London Heathrow International Airport (LHR), London, United Kingdom. DAL1943 was a CFR Part 121 scheduled international passenger flight from JFK to Santo Domingo (SDQ), Dominican Republic. Night visual meteorological conditions prevailed at the airport at the time of the incident.

Aircraft · 2

Registration
N914DU
Reported as
Boeing 737-900ER
Category
Airplane
Serial number
62782
Built
2019
Engines
CFM Intl CFM56-7B27E/B, 27,300 lbs thrust, turbo fanCFM Intl CFM56-7B27E/B, 27,300 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
Delta Air Lines
Registered owner
Delta Air Lines
Airworthiness certificate
Standard, Transport
Destination
SDQ · Santo Domingo, OF
Airport
KJFK · John F. Kennedy International Airport, runway 4L, 12,079 × 200 ft, asphalt

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Registration
N754AN
Reported as
Boeing 777-223
Category
Airplane
Serial number
30262
Built
2001
Airframe hours
80,362
Engines
Rolls-Royc TRENT 892-17 W/QEC, 90,000 lbs thrust, turbo fanRolls-Royc TRENT 892-17 W/QEC, 90,000 lbs thrust, turbo fan
Damage
No damage
Flight
Part 121
Operator
American Airlines
Registered owner
American Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · January 13, 2023
Destination
LHR · London, OF
Equipment
ADS-B, Stall warning system, Onboard weather, Heads up display, Electronic primary flight display, Electronic multifunction display, Electronic flight bag or handheld device, Data recorder, Auto-pilot, Angle of attack indicator

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Weather

Conditions
Visual (VMC) · Night
Wind
320° at 17 knots, gusting 25
Lowest ceiling
3,000 ft overcast
Temperature
4 °F, dew point -4 °F
Altimeter
29.70 inHg
Observed at
JFK

Docket · 33

The files NTSB released with the investigation on January 29, 2024, on NTSB’s docket system: statements, records, photos and specialists’ reports. 739 MB in all.

Pilot/operator aircraft accident report, NTSB form 6120.1 (American airlines)Item 1 · PDF · 12 pages · 5.5 MBPilot/operator aircraft accident report, NTSB form 6120.1 (delta air lines)Item 2 · PDF · 11 pages · 4.8 MBFlight data recorder - specialist's factual reportItem 3 · PDF · 13 pages · 4 photos · 1.3 MBFlight data recorder - attachment 1 (compressed csv data for delta airplane)Item 4 · ZIP · 529 KBFlight data recorder - attachment 2 (compressed csv data for American airplane)Item 5 · ZIP · 70 KBOperations & human performance factual reportItem 6 · PDF · 41 pages · 765 KBOperational factors attachment 1 aal pilot interview transcriptsItem 7 · PDF · 195 pages · 675 KBOperational factors attachment 2 delta air lines pilots' statementsItem 8 · PDF · 3 pages · 125 KBOperational factors attachment 3 aal pilots' statementsItem 9 · PDF · 4 pages · 103 KBOperational factors attachment 4 aal pilots statements refusing to be recordedItem 10 · PDF · 4 pages · 2.5 MBOperational factors attachment 5 American airlines notoc AA106 January 13, 2023Item 11 · PDF · 5 pages · 370 KBOperational factors attachment 6 American airlines fleet harmonization quick reference pageItem 12 · PDF · 3 pages · 448 KBOperational factors attachment 7 aal 106 load closeoutItem 13 · PDF · 2 pages · 1.0 MBOperational factors attachment 8 American airlines flight operations manual [excerpts]Item 14 · PDF · 19 pages · 897 KBOperational factors attachment 9 party formsItem 15 · PDF · 4 pages · 1.7 MBOperational factors attachment 10 captains written response to follow -up questionsItem 16 · PDF · 3 pages · 88 KBOperational factors attachment 11 aa 106 13 jan acars prior to takeoffItem 17 · PDF · 23 pages · 2.7 MBOperational factors attachment 12 taxi procedures to eliminate potential runway and taxiway incursionsItem 18 · PDF · 2 pages · 294 KBAirports specialist's factual reportItem 19 · PDF · 19 pages · 2.8 MBAirports specialist's factual report - attachment 1Item 20 · PDF · 3 pages · 200 KBAircraft performance studyItem 21 · PDF · 18 pages · 2.5 MBADS-B data N754ANItem 22 · CSV · 7.8 MBADS-B data N914DUItem 23 · CSV · 787 KBAir traffic control factual reportItem 24 · PDF · 20 pages · 2.4 MBAir traffic control attachment 1 - ATC interview transcriptsItem 25 · PDF · 204 pages · 2.7 MBAir traffic control attachment 2 - ATC local control audioItem 26 · WAV · 131 MBAir traffic control attachment 3 - ATC ground control audioItem 27 · WAV · 168 MBAir traffic control attachment 4 - ATC operations supervisor position audioItem 28 · WAV · 134 MBAir traffic control attachment 5 - ATC traffic management coordinator position audioItem 29 · WAV · 170 MBAir traffic control attachment 6 - ATIS recording audioItem 30 · WAV · 80.0 MBAir traffic control attachment 8 - ADS-B dataItem 31 · ZIP · 1.0 MBAir traffic control attachment 9 - ATC facility administrative documentsItem 32 · PDF · 32 pages · 5.2 MBAir traffic control attachment 7 - ATC recorded telephone line audioItem 33 · WAV · 7.1 MB