# NTSB OPS14IA005: Embraer EMB 145XR, N11176, Newark, NJ, April 24, 2014 - Type: NTSB incident investigation - Classification: Incident · No injuries · Incident investigation · Final report - Date: April 24, 2014, 15:03 local (19:03 UTC) - Place: Newark, NJ - Coordinates: 40.701389, -74.159164 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=40.7014&lon=-74.1592&mi=10 - Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping) - Defining events: [Takeoff: Air traffic event](https://openairdocs.org/ntsb-events/100); [Approach-IFR missed approach: Near midair/TCAS alert/loss of separation](https://openairdocs.org/ntsb-events/260) - Highest injury: No injuries - Status: Completed, report July 7, 2015 - Report: Approved by Office Director - NTSB office: Operational Factors Division - Parties: Federal Aviation Administration, United Airlines, National Air Traffic Controllers Association, ExpressJet Airlines - NTSB case key (mKey): 89111 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=OPS14IA005 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/89111/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=89111 - Page: https://openairdocs.org/ntsb/OPS14IA005 ## Probable cause (aircraft 1) The local controller’s failure to comply with Federal Aviation Administration separation requirements for aircraft operating on intersecting runways. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 1 - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 1 - [Communication (personnel): issuing instructions](https://openairdocs.org/ntsb-findings/02063538): Personnel issues › Task performance · ATC personnel (probable cause), aircraft 1 - [Info processing/decision: expectation/assumption](https://openairdocs.org/ntsb-findings/02041525): Personnel issues › Action/decision · ATC personnel, aircraft 1 - [Air traffic/operating proc: visual approach procedure](https://openairdocs.org/ntsb-findings/03014060): Environmental issues › Operating environment · Ability to respond/compensate, aircraft 1 - [Info processing/decision: decision making/judgment](https://openairdocs.org/ntsb-findings/02041520): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 2 - [Action: incorrect action performance](https://openairdocs.org/ntsb-findings/02041015): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 2 - [Communication (personnel): issuing instructions](https://openairdocs.org/ntsb-findings/02063538): Personnel issues › Task performance · ATC personnel (probable cause), aircraft 2 ## Analysis (aircraft 1) A near midair collision occurred at Newark Liberty International Airport (EWR), Newark, New Jersey, when an Embraer ERJ145 departing from runway 4R passed in close proximity to a Boeing 737-800 arriving to land on runway 29. Both aircraft were on regularly scheduled Title 14 Code of Federal Regulations Part 121 passenger flights and under control of the EWR airport traffic control tower (ATCT) at the time of the incident. Neither aircraft sustained damage, and no passengers or crewmembers sustained injuries. The Boeing 737 pilot contacted the ATCT while on the visual approach to runway 29. The local controller instructed the pilot to follow a Boeing 717 ahead and then cleared the pilot to land on runway 29. When the Boeing 717 was on short final, the local controller instructed the Embraer pilot to line up and wait on runway 4R. After the Boeing 717 crossed runway 4R, the local controller cleared the Embraer for takeoff. At that time, the Boeing 737 was about 3 miles from the runway 29 threshold; however, the Embraer did not actually begin its takeoff roll until the Boeing 737 was about 1 mile from the runway 29 threshold at 200 ft. The local controller recognized that the spacing between the Boeing 737 and the Embraer was insufficient and instructed the Boeing 737 pilot to go around. The Embraer continued its takeoff. The controller then provided traffic advisories to both the Boeing 737 and Embraer pilots and instructed the Embraer pilot to maintain visual separation from the Boeing 737. The Boeing 737 subsequently overflew the Embraer at the intersection of runways 29 and 4R. According to recorded Federal Aviation Administration radar data, the closest lateral and vertical proximity between the airplanes was about 0.03 mile and 400 ft, respectively, which is less than the minimum separation requirements for aircraft operating on intersecting runways. ## Factual narrative (aircraft 1) On Thursday, April 24, 2014, about 1503 eastern daylight time, a near midair collision occurred at Newark Liberty International Airport (EWR), Newark, New Jersey, when an ExpressJet flight 4100 (ASQ4100), an Embraer ERJ145 departing EWR runway 4R for Memphis, Tennessee, passed in close proximity to United Airlines flight 1243 (UAL1243), a Boeing 737-800 arriving from San Francisco, California and intending to land on runway 29. Both aircraft were on regularly scheduled 14 Code of Federal Regulations Part 121 passenger flights and under control of EWR airport 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. At 1457:15, the pilot of UAL1243 contacted EWR ATCT and reported that he was on the Bridge visual approach to runway 29. The local controller informed the pilot that he was following a B717 (Delta Airlines flight 1942, DAL1942) and cleared the flight to land on runway 29. About 1459, the local controller requested DAL1942 to shorten up his approach to runway 29, and subsequently instructed UAL1243 to fly a normal to slightly wider procedure because he was "starting to bunch up with the 717." Both pilots acknowledged the instructions. According to the local controller, in order to create space for departures off runway 4R, he had to adjust the pattern for each arrival to build a departure gap. He had some of the arrivals make a short approach to runway 29, and some make a wider approach so he could build in an extra mile of spacing. At 1500:22, the local controller instructed ASQ4100 to line up and wait (LUAW) on runway 4R. Twenty seconds later the local controller advised the pilot of UAL1243 that he could turn back toward final. The pilots acknowledged the instructions. At 1501:20, the local controller informed the pilot of ASQ4100 to "be ready in about 20 seconds, up on the power." The pilot acknowledged. According to radar data, DAL1942 was approximately 1.2 miles from the threshold of runway 29, and UAL1243 was approximately 3.5 miles east-southeast of the airport flying a modified Bridge visual approach. At 1501:44, the local controller cleared ASQ4100 for takeoff from runway 4R. According to radar data, DAL1942 was approximately 0.35 mile from the threshold of runway 29, and UAL1243 was approximately 3.1 miles from the runway 29 threshold. At 1502:40, the local controller directed UAL1243 to "go around," and informed the pilot that departing traffic was to his left. The pilot acknowledged and began to execute a missed approach. According to radar data, UAL1243 was approximately .85 mile from the threshold of runway 29 and at 200 feet when the local controller issued the go-around instruction. At 1502:49, the local controller advised the pilot of ASQ4100, "traffic off your right, do you have him in sight, maintain visual." Six seconds later the pilot responded, "yeah, we put the nose down, yeah he was real close." After ASQ4100 had crossedunder UAL1243, the local controller instructed the pilot to resume the standard instrument departure procedure (SID) and contact departure. The pilot responded, "contact departure, yeah, he was real close sir." The local controller issued UAL1243 the missed approach instructions for runway 29 and instructed the pilot to contact departure control . The remainder of the flight was uneventful. UAL1243 landed on EWR runway 29 about 1514. Radar data indicated the closest lateral and vertical proximity was approximately 0.03 mile and 400 feet. For further information, see the air traffic control group chairman's report in the docket for this case. ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Takeoff: Air traffic event](https://openairdocs.org/ntsb-events/100) (defining event), aircraft 1 - [Approach-IFR missed approach: Near midair/TCAS alert/loss of separation](https://openairdocs.org/ntsb-events/260) (defining event), aircraft 2 - [Approach-IFR missed approach: Air traffic event](https://openairdocs.org/ntsb-events/100), aircraft 2 ## Aircraft 1 - Registration: [N11176](https://openairdocs.org/aircraft/N11176), registered now, S/N 14500881, built 2004 (OpenAirDocs) - Reported make and model: EMBRAER EMB 145XR (XR) - 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: 14500881 - Year built: 2004 - Engines: ROLLS-ROYC AE3007 SER; ROLLS-ROYC AE3007 SER - Damage: No damage - Flight: Part 121 - Operator: Not Specified - Registered owner: Not Specified - Airworthiness certificate: Unknown - Departed: EWR, Newark, NJ - Destination: MEM, Memphis, TN - Flight plan: IFR - Airport: EWR, Newark Liberty Intl, runway 04R, 10,000 × 150 ft, asphalt ## Aircraft 2 - Registration: [N77520](https://openairdocs.org/aircraft/N77520), registered now, S/N 31658, built 2010 (OpenAirDocs) - Reported make and model: BOEING 737 824 (824) - Registry model: [Boeing 737-824](https://openairdocs.org/model/boeing-737-824) (registry code 13844BZ) (OpenAirDocs) - Registry engine: [CFM International CFM56-7B26/3 series](https://openairdocs.org/engine/cfm-international-cfm56-7b26-3-series) (registry code 13073, turbo-fan) (OpenAirDocs) - Category: Airplane - Serial number: 31658 - Year built: 2010 - Engines: CFM INTL CFM56-7B26/3; CFM INTL CFM56-7B26/3 - Damage: No damage - Flight: Part 121 - Operator: Not Specified - Registered owner: Not Specified - Airworthiness certificate: Unknown - Departed: SFO, SAN FRANCISCO, CA - Destination: EWR, Newark, NJ - Flight plan: IFR - Airport: EWR, Newark Liberty Intl, runway 29, 6,726 × 150 ft, asphalt ## Weather - Conditions: Visual (VMC), Day - Wind: 320° at 24 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 63 °F, dew point 12 °F - Altimeter: 29.87 inHg - Observed at: KEWR, 1 nm away ## Docket (10 files) The files NTSB released with the investigation on June 1, 2015, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=89111. 12.8 MB in all. - Air Traffic Control Factual Report (item 1, .PDF, 1 photo, 481 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427140&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Factual%20Report-Master.PDF - FAA Forms 7230-10 Position Logs (item 2, .PDF, 2.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427141&FileExtension=.PDF&FileName=FAA%20Forms%207230-10%20Position%20Logs-Master.PDF - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 3, .PDF, 1.2 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427142&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Master.PDF - Controller Statements (item 4, .PDF, 1.8 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427143&FileExtension=.PDF&FileName=Controller%20Statements-Master.PDF - EWR ATCT RWY4R-RWY29 Letter of Authorization (item 5, .PDF, 1.9 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427144&FileExtension=.PDF&FileName=EWR%20ATCT%20RWY4R-RWY29%20Letter%20of%20Authorization-Master.PDF - FAA Form 7230-4 Daily Record of Facility Operation (item 6, .PDF, 3.5 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427148&FileExtension=.PDF&FileName=FAA%20Form%207230-4%20Daily%20Record%20of%20Facility%20Operation-Master.PDF - Pilot Statements UAL1243 (item 7, .PDF, 157 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427149&FileExtension=.PDF&FileName=Pilot%20Statements%20UAL1243-Master.PDF - Mandatory Occurrence Report (item 8, .PDF, 16 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427150&FileExtension=.PDF&FileName=Mandatory%20Occurrence%20Report-Master.PDF - Pilot Statement ASQ4100 (item 9, .PDF, 51 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427151&FileExtension=.PDF&FileName=Pilot%20Statement%20ASQ4100-Master.PDF - Certification of Party Representative (item 10, .PDF, 1.6 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40427152&FileExtension=.PDF&FileName=Certification%20of%20Party%20Representative-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.