OPS11IA173

NTSB incident investigation · Boeing 737-832 · Covington, KY · December 9, 2010

Incident · No injuriesIncident investigationFinal report
Date
December 9, 2010, 11:25 local (16:25 UTC)
Place
Covington, KY
Injuries
92 uninjured
Phase of flight
Taxi
Aircraft
N3731TBoeing 737-832N840HKEmbraer EMB-145LR
Defining events
Taxi-into takeoff position: Air traffic eventApproach-IFR final approach: Air traffic event
Weather
Visual (VMC) · Day
Status
Completed · report October 3, 2011
Report
Approved by Office Director
NTSB office
Operational Factors Division
Case key
77974

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 local controller's distraction with a helicopter south of the field.

Findings · 2

NTSB’s coded findings. Those marked are part of the probable cause; the rest are factors or other findings.

Analysis

A Boeing B737 was instructed to line up and wait on the runway while a helicopter crossed the proposed departure path at a low level four miles south of the airport. After the helicopter conflict was resolved, the B737 was issued takeoff clearance, but contrary to Federal Aviation Administration requirements, the B737 was not advised of the E-145 on approach to the same runway. Less than ½ nautical mile on short final, the E-145 queried the tower local controller if they should go around. About the same time, the Airport Movement Area Safety System alerted. Prior to the E-145 crossing the landing threshold, and as the B737 began its takeoff roll, the tower local controller instructed the E-145 to go around. The E-145 did not overfly the B737 and there was no loss of separation.

Factual narrative

The factual narrative408 words

The local control center (LCC) controller in the Cincinnati/Northern Kentucky International Airport (CVG) air traffic control tower (ATCT) cleared Trans State Airlines (LOF) Flight 8069, call-sign Water-Ski, an E-145 to land on runway 18C. Delta Air Lines (DAL) Flight 2809, a B738, had been instructed to line up and wait (LUAW) on runway 18C. The LCC withheld the takeoff clearance for the B738 until a helicopter had crossed the departure path at low level, four miles south of the airport. The LCC momentarily lost sight of the helicopter and could not locate the helicopter on the tower radar presentation. After re-acquiring the helicopter and determining that no conflict existed for the departing B738, the LCC issued the B738 a takeoff clearance. Contrary to FAA orders, the takeoff clearance did not include traffic information that another aircraft, the E-145, was on approach to the same runway. On short final for runway 18C, the E-145 queried the local controller if they should go around, as they were inside of 1/2 nautical mile final to runway 18C and the B738 was in position on the approach end of runway 18C. At approximately the same time, the tower Airport Movement Area Safety System (AMASS) alerted to the developing conflict between the B738 and the E-145. Prior to the E-145 crossing the landing threshold, the LCC instructed the E-145 to go around; fly runway heading and climb and maintain 4,000 feet. The E-145 passed to the right side of the runway 18C landing threshold and did not overfly the B737. The FAA identified this event as a significant operational error; "SIGNIFICANT OPERATIONAL ERROR/1125E/OPERATIONAL ERROR REPORTED WHEN TRANS WORLD EXPRESS 8069, EMBRAER E145, WAS CLEARED TO LAND RWY 18C WITH DELTA 2809, B738, CLEARED TO DEPART SAME RUNWAY. TRANS WORLD EXPRESS 8069 WAS THEN ISSUED GO AROUND AND OVERFLEW DELTA 2809 DURING TAKEOFF ROLL. CLOSEST PROXIMITY 300 FEET VERTICAL." An on-site investigation and analysis of ATC data by NTSB and FAA investigators revealed that an operational error did not occur. The E-145 offset its flight path during the go-around and passed to the right side of the landing threshold and the departing B738. While it was determined that the local controllers performance was not in compliance with local operating procedures or FAA Order 7110.65 and the missed approach instructions could have been more definitive, a loss of separation did not occur and assured separation was established prior to the E-145 crossing the landing threshold.

Sequence of events

The events NTSB coded, in order, by phase of flight. The defining event is the one that best describes the accident.

Aircraft · 2

Registration
N3731T
Reported as
Boeing 737-832
Category
Airplane
Serial number
30775
Engines
CFM Intl. CFM56 SERIES, 2,200 horsepower, turbo jetCFM Intl. CFM56 SERIES, 2,200 horsepower, turbo jet
Damage
No damage
Flight
Part 121
Operator
Delta Airlines Inc
Registered owner
Delta Air Lines Inc
Departed
CVG · Covington, KY
Destination
KFLL · Fort Lauderdale, FL
Flight plan
IFR
Airport
CVG · Cincinnati/Northern Kentucky I, runway 18C, 11,000 × 150 ft

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
N840HK
Reported as
Embraer EMB-145LR
Category
Airplane
Serial number
145341
Engines
Rolls-Royc AE3007 SER, 7,200 horsepower, turbo fanRolls-Royc AE3007 SER, 7,200 horsepower, turbo fan
Damage
No damage
Flight
Part 121
Operator
Trans States Airlines Inc
Registered owner
Afs Investments Xiv LLC
Airworthiness certificate
Unknown
Departed
ORD · Chicago, IL
Destination
CVG · Covington, KY
Flight plan
IFR
Airport
CVG · Cincinnati/Northern Kentucky I, runway 18C, 11,000 × 150 ft

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) · Day
Wind
140° at 5 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
23 °F, dew point 9 °F
Altimeter
30.30 inHg
Observed at
KCVG

Docket · 2

The files NTSB released with the investigation on August 19, 2011, on NTSB’s docket system: statements, records, photos and specialists’ reports. 258 KB in all.

Other investigations on N3731T · 1

Matched to the same aircraft by N-number and date.