# NTSB OPS09IA009: Bombardier DHC-8-202, N375PH, Cleveland, OH, June 26, 2009 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: June 26, 2009, 08:56 local (12:56 UTC) - Place: Cleveland, OH - Coordinates: 41.490013, -81.66954 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=41.4900&lon=-81.6695&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-into takeoff position: Runway incursion veh/AC/person](https://openairdocs.org/ntsb-events/320) - Highest injury: No injuries - Injuries: 66 uninjured - Status: Completed, report May 6, 2010 - Report: Approved by Office Director - NTSB office: Operational Factors Division - Parties: FAA - NTSB case key (mKey): 74462 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=OPS09IA009 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/74462/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=74462 - Page: https://openairdocs.org/ntsb/OPS09IA009 ## Probable cause (aircraft 1) The local controller did not visually scan the runways and ensure that the E145 had crossed runway 24L prior to issuing a takeoff clearance to the DH8, did not ensure separation between the two airplanes, and did not cancel takeoff clearance for the DH8 in a timely manner. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action sequence](https://openairdocs.org/ntsb-findings/02041020): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 1 - [Training: type/qual of instruct/training](https://openairdocs.org/ntsb-findings/02031535): Personnel issues › Experience/knowledge · ATC personnel (probable cause), aircraft 1 - [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 2 - [Training: type/qual of instruct/training](https://openairdocs.org/ntsb-findings/02031535): Personnel issues › Experience/knowledge · ATC personnel (probable cause), aircraft 2 ## Analysis (aircraft 1) On Friday, June 26, 2009, a runway incursion occurred at Cleveland /Hopkins International Airport (CLE), Cleveland, Ohio involving Continental Express (BTA) flight 2426, call sign BTA2426, an Embraer 145 and Commutair (UCA) flight 8717, a De Havilland Canada Dash 8-200 (DH8). The incident occurred during daylight visual conditions. At the time of the incident there was a developmental controller being monitored by a certified controller at the local control position. Continental Express (BTA) flight 2426, call sign BTA2426, an Embraer 145, aircraft number N24103 was on a scheduled part 121 flight from CLE to Kansas City International Airport (MCI), Kansas City, Missouri. BTA2426 had a crew of 3, which included the pilot, first officer, a flight attendant, and 40 passengers plus 1 lap child on board. Commutair (UCA) flight 8717, a De Havilland Canada Dash 8-200 (DH8), aircraft number N375PH was on a scheduled part 121 flight from CLE to Port Columbus International Airport (CMH) Columbus, Ohio. UCA8717 had a crew of 3 which included the pilot, first officer, a flight attendant and 19 passengers on board. At 0856, the developmental controller directed UCA8717 to taxi into position and hold on the approach end of runway 24L at CLE. BTA2426, taxied from spot 5 to runway 24R via taxiways J and S and was directed to hold short of runway 24L by the ground controller before being directed to monitor the tower local controller on frequency 120.9. Nineteen seconds after directing UCA8717 to taxi into position and hold, the developmental trainee directed BTA2426 to cross runway 24L and advised BTA2426 that UCA8717 was in position for departure. Twenty seconds after directing BTA2426 to cross runway 24L, the local control developmental trainee directed UCA8717 to fly runway heading and issued a takeoff clearance. BTA2426 had not yet crossed runway 24L. UCA8717 acknowledged the takeoff clearance followed by the controller directing another aircraft to taxi into position and hold runway 24L. BTA2426 immediately called the tower with “BTA2426 we’re holding short of 24L you gave a clearance to cross though”. The local control developmental trainee did not respond. There were no other transmissions on the local control frequency until BTA2426 transmitted 10 seconds later “you copy for BTA2426”. The local control developmental trainee responded with “BTA2426 just hold there please”. According to the pilots of UCA8717, the tower controller instructed them to taxi into position and hold on runway 24L. As the pilot was positioning his aircraft, he noticed that a Jetlink (BTA2426) aircraft was approaching the intersection of taxiway S and runway 24L when the pilot heard the tower direct BTA2426 to cross runway 24L. Shortly thereafter, the tower issued UCA8717 a takeoff clearance. Noticing that BTA2426 had not crossed the runway but was still able to do so, the pilot of UCA8717 planned to ask the local controller about BTA2426 when BTA2426 asked the tower, “I thought Iwas cleared to cross”. After a few seconds of silence, the pilot of UCA8717 heard BTA2426 state that he would hold short of the runway. After observing BTA2426 hold his position, the pilot of UCA8717 commenced his takeoff roll, after which BTA2426 crossed runway 24L at taxiway S. Eighteen seconds later, BTA2426 was directed to taxi across runway 24L and advised that traffic was holding in position. BTA2426 crossed runway 24L without incident. CLE was on a south flow configuration landing 24L departing runway 24L/R. Reported weather at CLE at 0851 EDT/1251 UTC was wind 270 degrees at 8 knots, visibility 10 statute miles, scattered clouds at 1,200 feet. The temperature was 24 degrees Celsius, dew point 21 degrees Celsius. The altimeter was 2980. ATCT staffing included 4 air traffic control specialist (ATCS); a controller-in-charge (CIC) combined at the flight data/clearance delivery position (FD/CD), 1 ground controller (GC), and a local controller (LC) combined on local control 1 and 2 positions as an on the job training instructor (OJTI) monitoring a LC developmental trainee. ## Factual narrative (aircraft 1) On Friday, June 26, 2009, a runway incursion occurred at Cleveland /Hopkins International Airport (CLE), Cleveland, Ohio involving Continental Express (BTA) flight 2426, call sign BTA2426, an Embraer 145 and Commutair (UCA) flight 8717, a De Havilland Canada Dash 8-200 (DH8). The incident occurred during daylight visual conditions. At the time of the incident there was a developmental controller being monitored by a certified controller at the local control position. Continental Express (BTA) flight 2426, call sign BTA2426, an Embraer 145, aircraft number N24103 was on a scheduled part 121 flight from CLE to Kansas City International Airport (MCI), Kansas City, Missouri. BTA2426 had a crew of 3, which included the pilot, first officer, a flight attendant, and 40 passengers plus 1 lap child on board. Commutair (UCA) flight 8717, a De Havilland Canada Dash 8-200 (DH8), aircraft number N375PH was on a scheduled part 121 flight from CLE to Port Columbus International Airport (CMH) Columbus, Ohio. UCA8717 had a crew of 3 which included the pilot, first officer, a flight attendant and 19 passengers on board. At 0856, the developmental controller directed UCA8717 to taxi into position and hold on the approach end of runway 24L at CLE. BTA2426, taxied from spot 5 to runway 24R via taxiways J and S and was directed to hold short of runway 24L by the ground controller before being directed to monitor the tower local controller on frequency 120.9. Nineteen seconds after directing UCA8717 to taxi into position and hold, the developmental trainee directed BTA2426 to cross runway 24L and advised BTA2426 that UCA8717 was in position for departure. Twenty seconds after directing BTA2426 to cross runway 24L, the local control developmental trainee directed UCA8717 to fly runway heading and issued a takeoff clearance. BTA2426 had not yet crossed runway 24L. UCA8717 acknowledged the takeoff clearance followed by the controller directing another aircraft to taxi into position and hold runway 24L. BTA2426 immediately called the tower with “BTA2426 we’re holding short of 24L you gave a clearance to cross though”. The local control developmental trainee did not respond. There were no other transmissions on the local control frequency until BTA2426 transmitted 10 seconds later “you copy for BTA2426”. The local control developmental trainee responded with “BTA2426 just hold there please”. According to the pilots of UCA8717, the tower controller instructed them to taxi into position and hold on runway 24L. As the pilot was positioning his aircraft, he noticed that a Jetlink (BTA2426) aircraft was approaching the intersection of taxiway S and runway 24L when the pilot heard the tower direct BTA2426 to cross runway 24L. Shortly thereafter, the tower issued UCA8717 a takeoff clearance. Noticing that BTA2426 had not crossed the runway but was still able to do so, the pilot of UCA8717 planned to ask the local controller about BTA2426 when BTA2426 asked the tower, “I thought Iwas cleared to cross”. After a few seconds of silence, the pilot of UCA8717 heard BTA2426 state that he would hold short of the runway. After observing BTA2426 hold his position, the pilot of UCA8717 commenced his takeoff roll, after which BTA2426 crossed runway 24L at taxiway S. Eighteen seconds later, BTA2426 was directed to taxi across runway 24L and advised that traffic was holding in position. BTA2426 crossed runway 24L without incident. ## 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 - [Taxi-into takeoff position: Runway incursion veh/AC/person](https://openairdocs.org/ntsb-events/320) (defining event), aircraft 2 ## Aircraft 1 - Registration: N375PH (not matched to a registry record) - Reported make and model: BOMBARDIER INC DHC-8-202 - Category: Airplane - Serial number: 529 - Engines: P&W CANADA PW123 2142 horsepower turbo prop; P&W CANADA PW123 2142 horsepower turbo prop - Damage: No damage - Flight: Part 121 - Operator: Continental Airlines Inc - Registered owner: Wells Fargo Bank Northwest Na Trustee - Departed: CLE, Cleveland, OH - Destination: CMH, Columbus, OH - Flight plan: IFR - Airport: CLE, Cleveland/Hopkins Int'l Airpor, runway 24L, 9,995 × 150 ft ## Aircraft 2 - Registration: [N24103](https://openairdocs.org/aircraft/N24103), registered now, S/N 145645, built 2002 (OpenAirDocs) - Reported make and model: EMBRAER EMB-145XR - Registry model: [Embraer EMB-145XR](https://openairdocs.org/model/embraer-emb-145xr) (registry code 3260214) (OpenAirDocs) - Registry engine: [Rolls-Royce AE3007 series](https://openairdocs.org/engine/rolls-royce-ae3007-series) (registry code 54582, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 145645 - Engines: ROLLS-ROYC AE3007 SER 7200 horsepower turbo fan; ROLLS-ROYC AE3007 SER 7200 horsepower turbo fan - Damage: No damage - Flight: Part 121 - Operator: Continental Airlines Inc - Registered owner: Wells Fargo Bank Northwest Na Trustee - Departed: CLE, Cleveland, OH - Destination: MCI, Kansas City, MO - Flight plan: IFR - Airport: CLE, Cleveland/Hopkins Int'l Airpor, runway 24L, 9,955 × 150 ft, concrete ## Weather - Conditions: Visual (VMC), Day - Wind: 270° at 8 knots - Visibility: 10 statute miles - Temperature: 75 °F, dew point 70 °F - Observed at: CLE ## Docket (5 files) The files NTSB released with the investigation on March 8, 2010, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=74462. 7.0 MB in all. - ATC 3 - Attachment 1 - ATQA (item 1, .PDF, 122 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326278&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%201%20-%20ATQA-Master.PDF - ATC 3 - Attachment 2 - Controller Statements (item 2, .PDF, 241 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326279&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%202%20-%20Controller%20Statements-Redacted.PDF - ATC 3 - Attachment 3 - CLE ATC SOP (item 3, .PDF, 6.4 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326280&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%203%20-%20CLE%20ATC%20SOP-Master.PDF - ATC 3 - Attachment 4 - ATC Facility Log (item 4, .PDF, 46 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326281&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%204%20-%20ATC%20Facility%20Log-Redacted.PDF - ATC 3 - Factual Report of Group Chairman (item 5, .PDF, 189 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40326282&FileExtension=.PDF&FileName=ATC%203%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.