# NTSB OPS11IA552: Embraer EMB-145LR, Chicago, IL, May 16, 2011 - Type: NTSB incident investigation - Date: May 16, 2011, 14:34 UTC, 09:34 local - Place: Chicago, IL - Location: 41.9769° N, 87.9081° W: Placed by OpenAirDocs at CHICAGO O'HARE INTL (ORD), within about a mile (OpenAirDocs) - Highest injury: No injuries - Injuries: 63 uninjured - Status: Completed - Report: Approved by Office Director, November 7, 2012 - NTSB office: Operational Factors Division - Parties: National Air Traffic Controllers Association, National Transportation Safety Board, Federal Aviation Administration - NTSB case key (mKey): 79125 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=OPS11IA552 - NTSB report (PDF): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/79125/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=79125 - Page: https://openairdocs.org/ntsb/OPS11IA552 ## Probable cause (aircraft 2) The air traffic controller’s failure to adhere to runway separation requirements and his issuance of an improper takeoff clearance. Contributing to the incident was the controller's failure to recall that there was an arrival inbound to a crossing runway. ## Findings - Personnel issues-Action/decision-Action-Incorrect action selection-ATC personnel - C (probable cause), aircraft 1 - Personnel issues-Action/decision-Action-Forgotten action/omission-ATC personnel - C (probable cause), aircraft 1 - Personnel issues-Action/decision-Action-Incorrect action selection-ATC personnel - C (probable cause), aircraft 2 - Personnel issues-Action/decision-Action-Forgotten action/omission-ATC personnel - C (probable cause), aircraft 2 ## Analysis (aircraft 2) A near-midair collision occurred between a Bombardier CRJ2 landing on runway 9R and an Embraer ERJ-145 regional jet departing from runway 32L. The CRJ2 passed 480 feet behind and 275 feet above the ERJ-145. According to the tower air traffic controller responsible for operations on runway 32L, he scanned the final approach course for runway 9R to look for conflicting traffic and saw the approaching CRJ2. However, he then forgot about the arrival and cleared the ERJ-145 for takeoff. The controller was unable to provide any explanation for the lapse. The airport was not equipped with automated assistance for detecting conflicts between departures and arrivals on crossing runways such as these. ## Factual narrative (aircraft 2) SUMMARY On May 16, 2011, at 0934 central daylight time, a near mid air collision (NMAC) occurred at Chicago O’Hare International Airport (ORD) when SkyWest Airlines flight 6958 (SKW6958), a Bombardier CRJ2 en route from Muskegon County, Michigan to ORD passed in close proximity to ExpressJet Airlines flight 6075 (BTA6075), an Embraer 145 departing from ORD to Buffalo, New York. According to recorded FAA radar data, SKW6958 crossed runway 32L about 275 feet above and 480 feet behind BTA6075. Both aircraft were under control of ORD air traffic control tower (ATCT) at the time of the incident. There was no damage reported to either aircraft, or any injuries to passengers or crew. HISTORY OF FLIGHT SKW6958 was a scheduled 14 Code of Federal Regulations Part 121 (14 CFR part 121) passenger flight operating from Muskegon County, Michigan, to Chicago, Illinois. The flight was on a visual approach to runway 9R at Chicago O’Hare International Airport. The pilot contacted the ORD North Local Controller (NLC) at 0934:36, reporting in at LANCE. The controller transmitted to the pilot, “SKW6958 O’Hare Tower, runway 9 right clear to land, wind 020 at 14 traffic departing prior to your arrival,” and the pilot acknowledged. BTA6075 was a scheduled 14 CFR part 121 passenger flight operating from Chicago O’Hare International Airport to Buffalo, New York. The pilot was instructed to taxi to runway 32L for departure. At 09:34:53, the Third Local Controller (3LC) cleared BTA6075 to line up and wait on runway 32L. At 0935:37, BTA6075 was cleared for takeoff, “...don’t delay roll.” At 09:36:33, the 3LC controller transmitted, “aw [expletive].” At 0936:34 the NLC issued a go around to SKW6958. The NLC controller then continued, “SKW6958 climb and maintain four thousand, helicopter traffic just off the departure end low level.” At 09:36:45 the pilot of BTA6075 transmitted “What the [expletive] was that?” followed by “where do you want 6075 to go now?” The 3LC instructed BTA6075 to turn right heading 020 and to remain this frequency. BTA6075 responded with “what was that?” and the controller responded “sorry about that.” The remainder of the ATC handling was routine. The tower supervisor relieved the 3LC controller from position at 0937:00 and logged the incident in the Daily Record of Facility Operations. RADAR DATA Radar data for this report was obtained from the ORD Airport Surface Detection Equipment-X system. Graphics of the two flights as they approached the intersection and after passing the intersection of runway 32L/9R are contained in the ATC Group factual report and have been added to the docket. For further information, see the Air Traffic Control Group Chairman's Factual Report in the docket for this case. ## Sequence of events - Takeoff: Air traffic event (defining event), aircraft 1 - Approach: Air traffic event (defining event), aircraft 2 ## Aircraft 1 - Registration: N15574 (not matched to a registry record) - Reported make and model: EMBRAER EMB-145LR - Category: Airplane - Serial number: 145639 - Engines: ; - Damage: No damage - Flight: Part 121 - Departed: KORD, CHICAGO, IL - Destination: KBUF, Buffalo, NY - Airport: KORD, Chicago O’Hare International, runway 32L ## Aircraft 2 - Registration: N905SW, a cancelled registration (https://openairdocs.org/deregistered/N905SW-2023-01-17) (OpenAirDocs) - Reported make and model: BOMBARDIER INC CL-600-2B19 - Registry model: Bombardier CL-600-2B19 (registry code 1390008, https://openairdocs.org/model/bombardier-cl-600-2b19) (OpenAirDocs) - Registry engine: GE CF34 series (registry code 30015, https://openairdocs.org/engine/ge-cf34-series) (OpenAirDocs) - Category: Airplane - Serial number: 7437 - Engines: GE CF34 SERIES 9140 lbs thrust; GE CF34 SERIES 9140 lbs thrust - Damage: No damage - Flight: Part 121 - Departed: KMKG, Muskegon County, MI - Destination: KORD, CHICAGO, IL - Airport: KORD, Chicago O’Hare International, runway 09R ## Weather - Conditions: Visual (VMC), Day - Wind: 30° at 12 knots, gusting 21 - Visibility (statute miles): 10 - Temperature (°F): 48.2 ## Docket (7 files) On NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=79125 - ATC 3 - Certification of Party Representation (.PDF, 2 pages, 694 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366680&FileExtension=.PDF&FileName=ATC%203%20-%20Certification%20of%20Party%20Representation-Redacted.PDF - ATC 3 - Daily Record of Facility Operations (.PDF, 2 pages, 117 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366681&FileExtension=.PDF&FileName=ATC%203%20-%20Daily%20Record%20of%20Facility%20Operations-Master.PDF - ATC 3 - Position Log - FAA Form 7230-10 (.PDF, 7 pages, 402 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40366683&FileExtension=.PDF&FileName=ATC%203%20-%20Position%20Log%20-%20FAA%20Form%207230-10-Master.PDF - ATC 3 - Factual Report of Group Chairman (.PDF, 12 pages, 156 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40371257&FileExtension=.PDF&FileName=ATC%203%20-%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - ATC 3 - Crew Statements (.PDF, 3 pages, 36 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40372341&FileExtension=.PDF&FileName=ATC%203%20-%20Crew%20Statements-Master.PDF - ATC 3 - Addendum to Factual Report of Group Chairman (.PDF, 2 pages, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380370&FileExtension=.PDF&FileName=ATC%203%20-%20Addendum%20to%20Factual%20Report%20of%20Group%20Chairman-Master.PDF - ATC 3 - Errata to Factual Report of Group Chairman (.PDF, 2 pages, 35 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40380371&FileExtension=.PDF&FileName=ATC%203%20-%20Errata%20to%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. --- From OpenAirDocs.org, an independent open copy of NTSB and FAA data. The NTSB's own report is the official record of an investigation.