# NTSB OPS11IA173: Boeing 737-832, N3731T, Covington, KY, December 9, 2010

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: December 9, 2010, 11:25 local (16:25 UTC)
- Place: Covington, KY
- Coordinates: 39.042499, -84.667778 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=39.0425&lon=-84.6678&mi=10
- Phase of flight: [Taxi](https://openairdocs.org/ntsb-phases/250) (OpenAirDocs' grouping)
- Defining events: [Taxi-into takeoff position: Air traffic event](https://openairdocs.org/ntsb-events/100); [Approach-IFR final approach: Air traffic event](https://openairdocs.org/ntsb-events/100)
- Highest injury: No injuries
- Injuries: 92 uninjured
- Status: Completed, report October 3, 2011
- Report: Approved by Office Director
- NTSB office: Operational Factors Division
- NTSB case key (mKey): 77974
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=OPS11IA173
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/77974/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=77974
- Page: https://openairdocs.org/ntsb/OPS11IA173

## Probable cause (aircraft 2)

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

## Findings

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

- [Action: forgotten action/omission](https://openairdocs.org/ntsb-findings/02041035): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 1
- [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 2

## Analysis (aircraft 2)

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 (aircraft 2)

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 best describes what happened.

- [Taxi-into takeoff position: Air traffic event](https://openairdocs.org/ntsb-events/100) (defining event), aircraft 1
- [Approach-IFR final approach: Air traffic event](https://openairdocs.org/ntsb-events/100) (defining event), aircraft 2

## Aircraft 1

- Registration: [N3731T](https://openairdocs.org/aircraft/N3731T), registered now, S/N 30775, built 2000 (OpenAirDocs)
- Reported make and model: BOEING 737-832
- Registry model: [Boeing 737-832](https://openairdocs.org/model/boeing-737-832) (registry code 13844CF) (OpenAirDocs)
- Registry engine: [CFM International CFM56 series](https://openairdocs.org/engine/cfm-international-cfm56-series) (registry code 13802, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 30775
- Engines: CFM INTL. CFM56 SERIES 2200 horsepower turbo jet; CFM INTL. CFM56 SERIES 2200 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

## Aircraft 2

- Registration: [N840HK](https://openairdocs.org/deregistered/N840HK-2011-12-15), registration cancelled 2011-12-15, S/N 145341, built 2001 (OpenAirDocs)
- Reported make and model: EMBRAER EMB-145LR
- Registry model: [Embraer EMB-145LR](https://openairdocs.org/model/embraer-emb-145lr) (registry code 3260212) (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: 145341
- Engines: ROLLS-ROYC AE3007 SER 7200 horsepower turbo fan; ROLLS-ROYC AE3007 SER 7200 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

## 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

## Other investigations on N3731T (1)

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.

- [NTSB NYC01LA094](https://openairdocs.org/ntsb/NYC01LA094), Apr 9, 2001: Boeing 737-832 (N3731T), Boston, MA, substantial damage. Probable cause: The Boeing 767 captain's misjudgment of the distance between his airplane and the stationary Boeing 737, which resulted in a ground collision. A factor was sunglare.

## Docket (2 files)

The files NTSB released with the investigation on August 19, 2011, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=77974. 258 KB in all.

- ATC 3 - Attachment 1 - CVG Airport Diagram (item 1, .PDF, 56 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344704&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%201%20-%20CVG%20Airport%20Diagram-Master.PDF
- ATC 3 - Attachment 2 - Preliminary Operational Error Report CVG-T-10-E-004 (item 2, .PDF, 203 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40344705&FileExtension=.PDF&FileName=ATC%203%20-%20Attachment%202%20-%20Preliminary%20Operational%20Error%20Report%20CVG-T-10-E-004-Master.PDF

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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