# NTSB DCA23LA125: Boeing 737-900ER, N914DU, Queens, NY, January 14, 2023

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Class 1 · Limited · Final report
- Date: January 13, 2023, 20:44 local (Jan 14, 2023, 01:44 UTC)
- Place: Queens, NY · KJFK
- Coordinates: 40.6413, -73.7781
- Nearby events: https://openairdocs.org/map.md?lat=40.6413&lon=-73.7781&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining events: [Takeoff: Runway incursion veh/AC/person](https://openairdocs.org/ntsb-events/320); [Taxi: Runway incursion veh/AC/person](https://openairdocs.org/ntsb-events/320)
- Highest injury: No injuries
- Injuries: 308 uninjured
- 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
- NTSB case key (mKey): 106577
- NTSB case page: https://www.ntsb.gov/investigations/Pages/DCA23LA125.aspx
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106577/pdf
- Board report AIR2401 (PDF): https://www.ntsb.gov/investigations/AccidentReports/Reports/AIR2401.pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=106577
- Page: https://openairdocs.org/ntsb/DCA23LA125

## Probable cause (aircraft 1)

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

NTSB's coded findings; those marked are part of the probable cause.

- [Attention/monitoring: task monitoring/vigilance](https://openairdocs.org/ntsb-findings/02021520): Personnel issues › Psychological · Pilot of other aircraft (probable cause), aircraft 1; cases with it: [Boeing 737-900ER, 1 case](https://openairdocs.org/ntsb-findings/02021520/cases.md?model=138488H), [All aircraft, 330 cases](https://openairdocs.org/ntsb-findings/02021520/cases.md)
- [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Pilot of other aircraft (probable cause), aircraft 1; cases with it: [Boeing 737-900ER, 1 case](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=138488H), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 1; cases with it: [Boeing 737-900ER, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=138488H), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Airport facilities/design: runway lighting](https://openairdocs.org/ntsb-findings/03017015): Environmental issues › Operating environment · Timing of related info (probable cause), aircraft 1; cases with it: [Boeing 737-900ER, 1 case](https://openairdocs.org/ntsb-findings/03017015/cases.md?model=138488H), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/03017015/cases.md)
- [Safety programs: adequacy of safety program](https://openairdocs.org/ntsb-findings/04035015): Organizational issues › Support/oversight/monitoring · Operator (probable cause), aircraft 1; cases with it: [Boeing 737-900ER, 1 case](https://openairdocs.org/ntsb-findings/04035015/cases.md?model=138488H), [All aircraft, 24 cases](https://openairdocs.org/ntsb-findings/04035015/cases.md)
- [Indicating/recording systems: data recorders (flight/maint)](https://openairdocs.org/ntsb-findings/01023130): Aircraft › Aircraft systems · Design, aircraft 1; cases with it: [Boeing 737-900ER, 1 case](https://openairdocs.org/ntsb-findings/01023130/cases.md?model=138488H), [All aircraft, 17 cases](https://openairdocs.org/ntsb-findings/01023130/cases.md)
- [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · Flight crew (probable cause), aircraft 2; cases with it: [Boeing 777-223, 2 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md?model=1385213), [All aircraft, 1,386 cases](https://openairdocs.org/ntsb-findings/02041015/cases.md)
- [Attention/monitoring: task monitoring/vigilance](https://openairdocs.org/ntsb-findings/02021520): Personnel issues › Psychological · Flight crew (probable cause), aircraft 2; cases with it: [Boeing 777-223, 1 case](https://openairdocs.org/ntsb-findings/02021520/cases.md?model=1385213), [All aircraft, 330 cases](https://openairdocs.org/ntsb-findings/02021520/cases.md)
- [Action: lack of action](https://openairdocs.org/ntsb-findings/02041030): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 2; cases with it: [Boeing 777-223, 1 case](https://openairdocs.org/ntsb-findings/02041030/cases.md?model=1385213), [All aircraft, 792 cases](https://openairdocs.org/ntsb-findings/02041030/cases.md)
- [Airport facilities/design: runway lighting](https://openairdocs.org/ntsb-findings/03017015): Environmental issues › Operating environment · Timing of related info (probable cause), aircraft 2; cases with it: [Boeing 777-223, 1 case](https://openairdocs.org/ntsb-findings/03017015/cases.md?model=1385213), [All aircraft, 18 cases](https://openairdocs.org/ntsb-findings/03017015/cases.md)
- [Safety programs: adequacy of safety program](https://openairdocs.org/ntsb-findings/04035015): Organizational issues › Support/oversight/monitoring · Operator (probable cause), aircraft 2; cases with it: [Boeing 777-223, 1 case](https://openairdocs.org/ntsb-findings/04035015/cases.md?model=1385213), [All aircraft, 24 cases](https://openairdocs.org/ntsb-findings/04035015/cases.md)
- [Indicating/recording systems: data recorders (flight/maint)](https://openairdocs.org/ntsb-findings/01023130): Aircraft › Aircraft systems · Design, aircraft 2; cases with it: [Boeing 777-223, 1 case](https://openairdocs.org/ntsb-findings/01023130/cases.md?model=1385213), [All aircraft, 17 cases](https://openairdocs.org/ntsb-findings/01023130/cases.md)

## Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event best describes what happened.

- [Takeoff: Runway incursion veh/AC/person](https://openairdocs.org/ntsb-events/320) (defining event), aircraft 1; cases with it: [Boeing 737-900ER, 1 case](https://openairdocs.org/ntsb-events/320/sequence.md?model=138488H), [All aircraft, 104 cases](https://openairdocs.org/ntsb-events/320/sequence.md)
- [Takeoff-rejected takeoff: Runway incursion veh/AC/person](https://openairdocs.org/ntsb-events/320), aircraft 1; cases with it: [Boeing 737-900ER, 1 case](https://openairdocs.org/ntsb-events/320/sequence.md?model=138488H), [All aircraft, 104 cases](https://openairdocs.org/ntsb-events/320/sequence.md)
- [Taxi: Runway incursion veh/AC/person](https://openairdocs.org/ntsb-events/320) (defining event), aircraft 2; cases with it: [Boeing 777-223, 1 case](https://openairdocs.org/ntsb-events/320/sequence.md?model=1385213), [All aircraft, 104 cases](https://openairdocs.org/ntsb-events/320/sequence.md)

## Analysis (aircraft 1)

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 1

- Registration: [N914DU](https://openairdocs.org/aircraft/N914DU), registered now, S/N 62782, built 2019 (OpenAirDocs)
- Reported make and model: BOEING 737-900ER
- Registry model: [Boeing 737-900ER](https://openairdocs.org/model/boeing-737-900er) (registry code 138488H) (OpenAirDocs)
- Registry engine: [CFM International CFM56-7B27E/B series](https://openairdocs.org/engine/cfm-international-cfm56-7b27e-b-series) (registry code 13800, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 62782
- Year built: 2019
- Engines: CFM INTL CFM56-7B27E/B 27300 lbs thrust turbo fan; CFM INTL CFM56-7B27E/B 27300 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

## Aircraft 2

- Registration: [N754AN](https://openairdocs.org/aircraft/N754AN), registered now, S/N 30262, built 2001 (OpenAirDocs)
- Reported make and model: BOEING 777-223
- Registry model: [Boeing 777-223](https://openairdocs.org/model/boeing-777-223) (registry code 1385213) (OpenAirDocs)
- Registry engine: [Rolls-Royce RB-211 series](https://openairdocs.org/engine/rolls-royce-rb-211-series) (registry code 54555, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 30262
- Year built: 2001
- Airframe hours: 80362
- Engines: ROLLS-ROYC TRENT 892-17 W/QEC 90000 lbs thrust turbo fan; ROLLS-ROYC TRENT 892-17 W/QEC 90000 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

## 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 files)

The files NTSB released with the investigation on January 29, 2024, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=106577. 739 MB in all.

- Pilot/operator aircraft accident report, NTSB form 6120.1 (American airlines) (item 1, PDF, 12 pages, 5.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16369913&FileExtension=pdf&FileName=AA_6120_complete_Redacted-Rel.pdf
- Pilot/operator aircraft accident report, NTSB form 6120.1 (delta air lines) (item 2, PDF, 11 pages, 4.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16369923&FileExtension=pdf&FileName=Delta_6120_Redacted-Rel.pdf
- Flight data recorder - specialist's factual report (item 3, PDF, 13 pages, 4 photos, 1.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15779360&FileExtension=pdf&FileName=DCA23LA125%20-%20FDR%20-%20FINAL%20-%20DOCKET-Rel.pdf
- Flight data recorder - attachment 1 (compressed csv data for delta airplane) (item 4, ZIP, 529 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15779821&FileExtension=zip&FileName=Attachment1_DCA23LA125_DAL_CSV-Rel.zip
- Flight data recorder - attachment 2 (compressed csv data for American airplane) (item 5, ZIP, 70 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=15779163&FileExtension=zip&FileName=Attachment2_DCA23LA125_AAL_CSV-Rel.zip
- Operations & human performance factual report (item 6, PDF, 41 pages, 765 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16236659&FileExtension=pdf&FileName=DCA23LA125%20OPS-HP%20Factual%20Post%20Tech%20Review-Rel.pdf
- Operational factors attachment 1 aal pilot interview transcripts (item 7, PDF, 195 pages, 675 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16236304&FileExtension=pdf&FileName=OPS-HP%20Factual%20-%20Attachment%201%20-%20AAL%20pilots%27%20interview%20transcripts_Redacted-Rel.pdf
- Operational factors attachment 2 delta air lines pilots' statements (item 8, PDF, 3 pages, 125 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16235830&FileExtension=pdf&FileName=OPS-HP%20Factual%20-%20Attachment%202%20-%20DAL%20pilots%27%20statements_Redacted-Rel.pdf
- Operational factors attachment 3 aal pilots' statements (item 9, PDF, 4 pages, 103 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16236472&FileExtension=pdf&FileName=OPS-HP%20Factual%20-%20Attachment%203%20-%20AAL%20pilots%27%20statements-Rel.pdf
- Operational factors attachment 4 aal pilots statements refusing to be recorded (item 10, PDF, 4 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16236482&FileExtension=pdf&FileName=OPS-HP%20Factual%20-%20Attachment%204%20-%20AAL%20pilots%27%20statements%20refusing%20to%20be%20recorded_Redacted-Rel.pdf
- Operational factors attachment 5 American airlines notoc AA106 January 13, 2023 (item 11, PDF, 5 pages, 370 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16236585&FileExtension=pdf&FileName=OPS-HP%20Factual%20-%20Attachment%205%20-%20American%20Airlines%20NOTOC%20-%20AA106%20January%2013,%202023_Redacted-Rel.pdf
- Operational factors attachment 6 American airlines fleet harmonization quick reference page (item 12, PDF, 3 pages, 448 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16236314&FileExtension=pdf&FileName=OPS-HP%20Factual%20-%20Attachment%206%20-%20American%20Airlines%20Fleet%20Harmonization%20Quick%20Reference%20Page-Rel.pdf
- Operational factors attachment 7 aal 106 load closeout (item 13, PDF, 2 pages, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16235840&FileExtension=pdf&FileName=OPS-HP%20Factual%20-%20Attachment%207%20-%20AAL106%20Load%20Closeout_Redacted-Rel.pdf
- Operational factors attachment 8 American airlines flight operations manual [excerpts] (item 14, PDF, 19 pages, 897 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16236492&FileExtension=pdf&FileName=OPS-HP%20Factual%20-%20Attachment%208%20-%20American%20Airlines%20Flight%20Operations%20Manual%20%5Bexcerpts%5D-Rel.pdf
- Operational factors attachment 9 party forms (item 15, PDF, 4 pages, 1.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16236595&FileExtension=pdf&FileName=OPS-HP%20Factual%20-%20Attachment%209%20-%20Party%20Forms_Redacted-Rel.pdf
- Operational factors attachment 10 captains written response to follow -up questions (item 16, PDF, 3 pages, 88 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16236125&FileExtension=pdf&FileName=OPS-HP%20Factual%20-%20Attachment%2010%20-%20Captains%20Written%20responses%20to%20Follow-Up%20Questions-Rel.pdf
- Operational factors attachment 11 aa 106 13 jan acars prior to takeoff (item 17, PDF, 23 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16236324&FileExtension=pdf&FileName=OPS-HP%20Factual%20-%20Attachment%2011,%20AA%20106%2013%20JAN%20ACARS%20Prior%20to%20Takeoff_Redacted-Rel.pdf
- Operational factors attachment 12 taxi procedures to eliminate potential runway and taxiway incursions (item 18, PDF, 2 pages, 294 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16236423&FileExtension=pdf&FileName=Ops-HP%20Factual%20-%20Attachment%2012%20Taxi%20Procedures%20to%20Eliminate%20Potential%20Runway%20and%20Taxiway%20Incursions-Rel.pdf
- Airports specialist's factual report (item 19, PDF, 19 pages, 2.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16579162&FileExtension=pdf&FileName=DCA23LA125%20Airports%20Factual%20FINALv2.0-Rel.pdf
- Airports specialist's factual report - attachment 1 (item 20, PDF, 3 pages, 200 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16577610&FileExtension=pdf&FileName=Attachment%201%20-%20FAA%20Response%20To%20NTSB%20Questions-Rel.pdf
- Aircraft performance study (item 21, PDF, 18 pages, 2.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16602125&FileExtension=pdf&FileName=DCA23LA125_PerformanceStudy-Rel.pdf
- ADS-B data N754AN (item 22, CSV, 7.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16602192&FileExtension=csv&FileName=20230114_AA28F2_505284381_ADSB-Rel.csv
- ADS-B data N914DU (item 23, CSV, 787 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16602482&FileExtension=csv&FileName=20230114_ACA5E5_505284003_ADSB-Rel.csv
- Air traffic control factual report (item 24, PDF, 20 pages, 2.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16431711&FileExtension=pdf&FileName=ATC%20Group%20Chair%20Factual%20Report%20JFK%20DCA23LA125-docket-Rel.pdf
- Air traffic control attachment 1 - ATC interview transcripts (item 25, PDF, 204 pages, 2.7 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16624457&FileExtension=pdf&FileName=Attachment%201%20ATC%20Interview%20Transcripts_Redacted-Rel.pdf
- Air traffic control attachment 2 - ATC local control audio (item 26, WAV, 131 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16624293&FileExtension=wav&FileName=Attachment%202%20ATC%20Local%20Control%20Audio-Rel.wav
- Air traffic control attachment 3 - ATC ground control audio (item 27, WAV, 168 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16624303&FileExtension=wav&FileName=Attachment%203%20ATC%20Ground%20Control%20Audio-Rel.wav
- Air traffic control attachment 4 - ATC operations supervisor position audio (item 28, WAV, 134 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16623846&FileExtension=wav&FileName=Attachment%204%20ATC%20Operations%20Supervisor%20Position%20Audio-Rel.wav
- Air traffic control attachment 5 - ATC traffic management coordinator position audio (item 29, WAV, 170 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16624625&FileExtension=wav&FileName=Attachment%205%20ATC%20Traffic%20Management%20Coordinator%20Position%20Audio-Rel.wav
- Air traffic control attachment 6 - ATIS recording audio (item 30, WAV, 80.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16624313&FileExtension=wav&FileName=Attachment%206%20ATIS%20Recording%20Audio-Rel.wav
- Air traffic control attachment 8 - ADS-B data (item 31, ZIP, 1.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16623792&FileExtension=zip&FileName=Attachment%208%20ADS-B%20Data-Rel.zip
- Air traffic control attachment 9 - ATC facility administrative documents (item 32, PDF, 32 pages, 5.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16624587&FileExtension=pdf&FileName=Attachment%209%20%20ATC%20Faciliy%20Administrative%20Documents_Redacted-Rel.pdf
- Air traffic control attachment 7 - ATC recorded telephone line audio (item 33, WAV, 7.1 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=16663501&FileExtension=wav&FileName=Attachment%207%20ATC%20Recorded%20Phone%20Line%20Audio-Rel.wav

From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model.

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