- Date
- December 2, 2007, 19:22 local (Dec 3, 2007, 00:22 UTC)
- Place
- Baltimore, MD
- Injuries
- 184 uninjured
- Phase of flight
- Takeoff
- Weather
- Visual (VMC) · Night
- Status
- Completed · report March 31, 2008
- Report
- Approved by Office Director
- NTSB office
- Operational Factors Division
- Case key
- 67195
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 NTSB’s determination of the probable cause, and any contributing factors.
The probable cause of this incident is local controller's failure of maintaining awareness of the situation and failing to provide the appropriate separation between the two aircraft operating on intersecting runways. Providing separation between aircraft is a first duty priority, in accordance with FAA Order 7110.65.
The probable cause of this incident is local controller's failure of maintaining awareness of the situation and failing to provide the appropriate separation between the two aircraft operating on intersecting runways. Providing separation between aircraft is a first duty priority, in accordance with FAA Order 7110.65.
Analysis
On December 2, 2007, at approximately 7:21 pm Eastern Standard time, Comair flight 5412 (COM5412), a Bombardier Regional Jet (CRJ), departed runway 15R and over flew America West (AWE) flight 83, an Airbus A320, that had landed on runway 10 at Baltimore/Washington International Thurgood Marshall Airport (BWI), Baltimore, Maryland during night visual meteorological conditions.
Weather conditions were: wind calm, visibility 5 statute miles, light rain and mist, ceiling 1,000 feet broken and 3,000 feet overcast.
The tower controller had cleared AWE83 to land on runway 10 and AWE83 was approximately 6 mile on final approach when the ATC local controller cleared COM5412 for takeoff on runway 15R. COM5412 was on taxiway A about 500 feet short of runway 15R when the takeoff clearance was issued. AMASS alerted. COM5412 rotated at taxiway F and over flew AWE83, at the intersection of runways 10 and 15R. The initial report from the Federal Aviation Administration stated that COM5421 over flew AWE83 by 300 feet. AWE83 exited runway 10 at runway 22.
On December 2, 2007, at approximately 7:21 pm Eastern Standard time, Comair flight 5412 (COM5412), a Bombardier Regional Jet (CRJ), departed runway 15R and over flew America West (AWE) flight 83, an Airbus A320, that had landed on runway 10 at Baltimore/Washington International Thurgood Marshall Airport (BWI), Baltimore, Maryland during night visual meteorological conditions.
Weather conditions were: wind calm, visibility 5 statute miles, light rain and mist, ceiling 1,000 feet broken and 3,000 feet overcast.
The tower controller had cleared AWE83 to land on runway 10 and AWE83 was approximately 6 mile on final approach when the ATC local controller cleared COM5412 for takeoff on runway 15R. COM5412 was on taxiway A about 500 feet short of runway 15R when the takeoff clearance was issued. AMASS alerted. COM5412 rotated at taxiway F and over flew AWE83, at the intersection of runways 10 and 15R. The initial report from the Federal Aviation Administration stated that COM5421 over flew AWE83 by 300 feet. AWE83 exited runway 10 at runway 22.
Factual narrative
The factual narrative720 words
On December 2, 2007, at approximately 1922 Eastern Standard time (EST), Comair, Inc., flight 5412 (COM5412), N781CA, a Bombardier Canadair Regional Jet, departed runway 15R and over flew America West Airlines flight 83 (AWE 83), N659AW, an Airbus Industrie A-320, that had landed on runway 10, at Baltimore/Washington International Thurgood Marshall Airport (BWI), Baltimore, Maryland. Both aircraft were operating as a 14 Code of Federal Regulations Part 121 flight and both crews had filed instrument flight rules flight plans. There were no injuries to the occupants of either aircraft and neither aircraft was damaged. The incident occurred during night visual flight rules conditions.
About 1919:07, when AWE 83 was approximately six mile final for landing on runway 10, the BWI local controller cleared AWE 83 to land. The pilot of AWE 83 acknowledged the landing clearance.
About 1920:33, as evidenced by BWI radar data and Airport Movement Area Safety System (AMASS) data, AWE 83 was two and one half mile final to runway 10 when the local controller cleared COM5412 for takeoff on runway 15R. At the time of the takeoff clearance, COM5412 was situated on taxiway A about 500 feet south of the departure end of runway 15R. The pilot of COM5412 acknowledged the takeoff clearance.
About 1921:29, the ASDE (airport surface detection equipment) tower display showed the runway 10 red hold bars illuminated for AWE 83 on final approach to runway 10.
About 1921:38, the ASDE tower display showed the runway 15R red hold bars illuminated for COM5412 departing on runway 15R.
About 1921:47, the ASDE tower display alerted with both visual and aural alarms. According to the local controller, trom the back of the tower cab, an aural alert announced, "WARNING: AWE83, runways 10, 15R, converging." The AMASS also displayed numerous visual alarms such as a textual warning box, red hold bars for both runways indicating restricted runway/taxi crossing points, and purple circles around each aircraft as they approached the intersection of runways 10 and 15R. According to the local controller, he had turned his back from the runway operations to ask another controller to adjust the volume on the Domestic Events Network (DEN) line when he heard the AMASS alert. As the local controller turned back towards the local control position, he looked at the ASDE display and saw the circles around the two targets. After recognizing the situation, the local controller said, "Comair, Comair, cancel, cancel or" According to the COM5412 pilot's statement, they were at V1/Vr speed passing taxiway F on runway 15R, when the local controller attempted to instruct the crew to cancel takeoff clearance; however, it was too late to abort the takeoff. COM5412 crossed in front of AWE83, as AWE 83 proceeded through the intersection of runways 10 and 15R. According to the FAA Runway Safety office, COM5412 missed AWE 83 by 400 feet laterally and 400 feet vertically. The FAA Runway Safety Office classified the incident as category "B" event.
About 1922:17, the local controller instructed AWE83 to turn left on runway 4/22, and advised the crew to contact ground control. The pilot of AWE 83 acknowledged.
Personnel information
The BWI ATCT local controller was appropriately certified and qualified to perform his assigned duties. He received his control tower operator's certificate in 1981 and had been working at as an air traffic controller for 26 years. Certification and experience for the captains and first officers of both aircraft was not requested.
Meteorological information
The BWI special weather observation for 1917EST was: Wind calm, visibility 5 statute miles, light rain and mist, sky conditions ceiling broken at 1,000 feet, overcast 3,000 feet, temperature 39, dew point 39 and altimeter 30.02 inches.
Wreckage and impact information
There was no damage reported for either aircraft.
Additional information
Airport Information
BWI serves airline, air taxi, military, and general aviation aircraft. The annual air activity averages 307,000 flight operations per year. BWI had four runways, 10/28, 15L/33R, 15R/33L and 4/22. Runway 10/28 was 10,502 feet long and 200 feet wide with high intensity runway lights (HIRLS). The runway surface consisted of an asphalt/grooved surface in fair condition. Runway 15R/33L was 9,501 feet long and 150 feet wide with HIRLS. Runway 15R/33L surface consisted of an asphalt/grooved surface in fair condition. The airport field elevation was 146 feet msl. The tower was equipped with an AMASS.
The factual narrative720 words
On December 2, 2007, at approximately 1922 Eastern Standard time (EST), Comair, Inc., flight 5412 (COM5412), N781CA, a Bombardier Canadair Regional Jet, departed runway 15R and over flew America West Airlines flight 83 (AWE 83), N659AW, an Airbus Industrie A-320, that had landed on runway 10, at Baltimore/Washington International Thurgood Marshall Airport (BWI), Baltimore, Maryland. Both aircraft were operating as a 14 Code of Federal Regulations Part 121 flight and both crews had filed instrument flight rules flight plans. There were no injuries to the occupants of either aircraft and neither aircraft was damaged. The incident occurred during night visual flight rules conditions.
About 1919:07, when AWE 83 was approximately six mile final for landing on runway 10, the BWI local controller cleared AWE 83 to land. The pilot of AWE 83 acknowledged the landing clearance.
About 1920:33, as evidenced by BWI radar data and Airport Movement Area Safety System (AMASS) data, AWE 83 was two and one half mile final to runway 10 when the local controller cleared COM5412 for takeoff on runway 15R. At the time of the takeoff clearance, COM5412 was situated on taxiway A about 500 feet south of the departure end of runway 15R. The pilot of COM5412 acknowledged the takeoff clearance.
About 1921:29, the ASDE (airport surface detection equipment) tower display showed the runway 10 red hold bars illuminated for AWE 83 on final approach to runway 10.
About 1921:38, the ASDE tower display showed the runway 15R red hold bars illuminated for COM5412 departing on runway 15R.
About 1921:47, the ASDE tower display alerted with both visual and aural alarms. According to the local controller, trom the back of the tower cab, an aural alert announced, "WARNING: AWE83, runways 10, 15R, converging." The AMASS also displayed numerous visual alarms such as a textual warning box, red hold bars for both runways indicating restricted runway/taxi crossing points, and purple circles around each aircraft as they approached the intersection of runways 10 and 15R. According to the local controller, he had turned his back from the runway operations to ask another controller to adjust the volume on the Domestic Events Network (DEN) line when he heard the AMASS alert. As the local controller turned back towards the local control position, he looked at the ASDE display and saw the circles around the two targets. After recognizing the situation, the local controller said, "Comair, Comair, cancel, cancel or" According to the COM5412 pilot's statement, they were at V1/Vr speed passing taxiway F on runway 15R, when the local controller attempted to instruct the crew to cancel takeoff clearance; however, it was too late to abort the takeoff. COM5412 crossed in front of AWE83, as AWE 83 proceeded through the intersection of runways 10 and 15R. According to the FAA Runway Safety office, COM5412 missed AWE 83 by 400 feet laterally and 400 feet vertically. The FAA Runway Safety Office classified the incident as category "B" event.
About 1922:17, the local controller instructed AWE83 to turn left on runway 4/22, and advised the crew to contact ground control. The pilot of AWE 83 acknowledged.
Personnel information
The BWI ATCT local controller was appropriately certified and qualified to perform his assigned duties. He received his control tower operator's certificate in 1981 and had been working at as an air traffic controller for 26 years. Certification and experience for the captains and first officers of both aircraft was not requested.
Meteorological information
The BWI special weather observation for 1917EST was: Wind calm, visibility 5 statute miles, light rain and mist, sky conditions ceiling broken at 1,000 feet, overcast 3,000 feet, temperature 39, dew point 39 and altimeter 30.02 inches.
Wreckage and impact information
There was no damage reported for either aircraft.
Additional information
Airport Information
BWI serves airline, air taxi, military, and general aviation aircraft. The annual air activity averages 307,000 flight operations per year. BWI had four runways, 10/28, 15L/33R, 15R/33L and 4/22. Runway 10/28 was 10,502 feet long and 200 feet wide with high intensity runway lights (HIRLS). The runway surface consisted of an asphalt/grooved surface in fair condition. Runway 15R/33L was 9,501 feet long and 150 feet wide with HIRLS. Runway 15R/33L surface consisted of an asphalt/grooved surface in fair condition. The airport field elevation was 146 feet msl. The tower was equipped with an AMASS.
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.
Aircraft · 2
- Registration
- N781CA
- Reported as
- Bombardier CRJ1
- Category
- Airplane
- Damage
- No damage
- Flight
- Part 121
- Operator
- Comair Inc, doing business as Wholly Owned subsidary of Delta Airlines, Inc.
- Departed
- BWI · Baltimore, MD
- Destination
- BOS · MA
- Flight plan
- IFR
- Airport
- BWI · Baltimore-Washington Intl, runway 15R, 9,501 × 150 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
- N659AW
- Reported as
- Airbus Industrie A320
- Category
- Airplane
- Damage
- No damage
- Flight
- Part 121
- Operator
- America West Airlines Inc, doing business as US Airways
- Departed
- PHX · Phoenix, AZ
- Destination
- BWI · Baltimore, MD
- Flight plan
- IFR
- Airport
- BWI · Baltimore-Washington Intl, runway 10, 10,502 × 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.
Flight crew · 2
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot, aircraft N781CA
- Injuries
- None
- Role
- Co-pilot, aircraft N781CA
- Injuries
- None
Weather
- Conditions
- Visual (VMC) · Night
- Wind
- Calm
- Visibility
- 5 statute miles
- Lowest ceiling
- 10 ft broken
- Temperature
- 39 °F, dew point 39 °F
- Altimeter
- 30.02 inHg
- Observed at
- BWI