# NTSB OPS15IA011: Embraer EMB 145LR, N698CB, Chicago, IL, February 18, 2015

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: February 17, 2015, 21:45 local (Feb 18, 2015, 03:45 UTC)
- Place: Chicago, IL
- Coordinates: 41.971668, -87.901947
- Nearby events: https://openairdocs.org/map.md?lat=41.9717&lon=-87.9019&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-to runway: Runway incursion veh/AC/person](https://openairdocs.org/ntsb-events/320)
- Highest injury: No injuries
- Injuries: 113 uninjured
- Status: Completed, report August 4, 2015
- Report: Approved by Office Director
- NTSB office: Operational Factors Division
- Parties: National Air Traffic Controllers Assoc. (NATCA), FAA Compliances Services Group AJI-131
- NTSB case key (mKey): 90743
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=OPS15IA011
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/90743/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=90743
- Page: https://openairdocs.org/ntsb/OPS15IA011

## Probable cause (aircraft 1)

The flight crew's failure to manage cockpit tasks during taxi resulting in a loss of situation awareness and subsequently taxiing past a required turn point and onto an active runway without clearance. Contributing to the runway incursion was the ground controllers ineffective monitoring to ensure issued taxi instructions were followed.

## Probable cause (aircraft 2)

The flight crew's failure to manage cockpit tasks during taxi resulting in a loss of situation awareness and subsequently taxiing past a required turn point and onto an active runway without clearance. Contributing to the runway incursion was the ground controllers ineffective monitoring to ensure issued taxi instructions were followed.

## Findings

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

- [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 1; cases with it: [Embraer EMB-145LR, 4 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md?model=3260212), [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md)
- [Workload management: task allocation](https://openairdocs.org/ntsb-findings/02064020): Personnel issues › Task performance · Pilot (probable cause), aircraft 2; cases with it: [All aircraft, 12 cases](https://openairdocs.org/ntsb-findings/02064020/cases.md)
- [Info processing/decision: identification/recognition](https://openairdocs.org/ntsb-findings/02041510): Personnel issues › Action/decision · ATC personnel (probable cause), aircraft 2; cases with it: [All aircraft, 559 cases](https://openairdocs.org/ntsb-findings/02041510/cases.md)

## 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; cases with it: [Embraer EMB-145LR, 4 cases](https://openairdocs.org/ntsb-events/320/sequence.md?model=3260212), [All aircraft, 104 cases](https://openairdocs.org/ntsb-events/320/sequence.md)
- [Taxi-to runway: Runway incursion veh/AC/person](https://openairdocs.org/ntsb-events/320) (defining event), aircraft 2; cases with it: [All aircraft, 104 cases](https://openairdocs.org/ntsb-events/320/sequence.md)

## Analysis (aircraft 1)

The flight crew of GJS3710 was heads down during taxi and missed the turn from taxiway F to taxiway N, did not observe the flashing runway guard lights at the edge of runway 28R and taxiway F, and taxied onto runway 28R without clearance, nearly colliding with ENY3084. The closest proximity between center of each airplane was estimated to be about 94 feet, which corresponds to approximately 20 to 30 feet between wingtips. According to interviews with the flight crew of GJS3710, the first officer was head down doing cockpit tasks and coordinating with the flight attendant for pre-takeoff passenger requirements. The captain, operating the aircraft, gave way to an inbound 757 on taxiway A. The captain stated that as he was approaching taxiway F, he looked down to confirm the frequency settings in the cockpit and when he looked up again, he thought he was passing taxiway B on taxiway F, but was actually passing taxiway N on taxiway F. He stated that he did not see the runway guard lights at the intersection of taxiway F and runway 28R. This loss of situation awareness resulted in GJS3710 entering runway 28R without clearance. The ASDE-X was working normally and alarmed, indicating a conflict on runway 28R; however, the air traffic control front-line manager on duty in the tower stated that there was insufficient time to cancel ENY3084's takeoff clearance. ENY3084 maneuvered to the left of runway centerline to avoid GJS3710, and then continued takeoff. Following the event, taxiway F was closed from taxiway N to taxiway P, removing direct access to the runway from the terminal ramp on taxiway F.

## Analysis (aircraft 2)

The flight crew of GJS3710 was heads down during taxi and missed the turn from taxiway F to taxiway N, did not observe the flashing runway guard lights at the edge of runway 28R and taxiway F, and taxied onto runway 28R without clearance, nearly colliding with ENY3084. The closest proximity between center of each airplane was estimated to be about 94 feet, which corresponds to approximately 20 to 30 feet between wingtips. According to interviews with the flight crew of GJS3710, the first officer was head down doing cockpit tasks and coordinating with the flight attendant for pre-takeoff passenger requirements. The captain, operating the aircraft, gave way to an inbound 757 on taxiway A. The captain stated that as he was approaching taxiway F, he looked down to confirm the frequency settings in the cockpit and when he looked up again, he thought he was passing taxiway B on taxiway F, but was actually passing taxiway N on taxiway F. He stated that he did not see the runway guard lights at the intersection of taxiway F and runway 28R. This loss of situation awareness resulted in GJS3710 entering runway 28R without clearance. The ASDE-X was working normally and alarmed, indicating a conflict on runway 28R; however, the air traffic control front-line manager on duty in the tower stated that there was insufficient time to cancel ENY3084's takeoff clearance. ENY3084 maneuvered to the left of runway centerline to avoid GJS3710, and then continued takeoff. Following the event, taxiway F was closed from taxiway N to taxiway P, removing direct access to the runway from the terminal ramp on taxiway F.

## Factual narrative (aircraft 1)

On Tuesday, February 17, 2015, at 2145 central standard time, an Embraer E145, N698CB, operated by American Airlines Group as ENY3084, was on takeoff roll on runway 28R from intersection EE at the Chicago O'Hare International Airport (ORD), Chicago, Illinois. A Canadair Regional Jet CRJ-700, N154GJ, operated by GoJet Airlines as GJS3710 was taxiing to runway 28R via taxiways F and N. GJS3710 did not turn left at taxiway N as instructed and instead entered runway 28R and made a left turn toward the departing ENY3084. According to the pilot of ENY3084, he maneuvered to avoid GJS3710, and continued his departure. ENY3084 was a regularly scheduled flight from ORD to Port Columbus International Airport (CMH), Columbus, Ohio. GJS3710 was a regularly scheduled flight from ORD to the Lester B. Pearson International Airport (YYZ), Toronto, Ontario, Canada. Both flights were operating under the provisions of Title 14 Code of Federal Regulations Part 121. Night visual meteorological conditions prevailed, and ENY3084 was departing ORD from runway 28R at the taxiway EE intersection and had been cleared for takeoff. GJS3710 was on the outbound taxi from taxiway H to U to F to N to taxiway EE. According to recorded Airport Surface Detection Equipment, Model X (ASDE-X) data, ENY3084 began departure roll at 2145:17. GJS3710 was about 265 feet north of the runway 28R edge line, taxiing south on Taxiway F at approximately 11 knots. At 21:45:28, an ASDE-X alert was issued when ENY3084 met the velocity and acceleration parameters that are required by the ASDE-X to be considered a departure. ENY3084 was traveling at approximately 56 knots and was approximately 1041 feet from the runway 28R/taxiway F intersection. GJS3710 was on taxiway F approximately 42 feet from crossing the runway 28R edge line and was traveling at approximately 11 knots. At 21:45:30, ENY3084 was about 831 feet from the runway 28R/taxiway F intersection, traveling about 66 knots. GJS3710 entered runway 28R traveling at about 11 knots and turned east toward ENY3084 before coming to a stop on the north side of Runway 28R at taxiway F. When GJS3710 entered the runway from taxiway F, an aural alert of "Warning Runway Two Eight Right Occupied" was voiced in the tower and the corresponding alert text "RWY 28R|ENY3084, GJS3710|RWY OCCUPIED" was displayed on the ASDE-X displays. According to the flight crew of ENY3084, they were traveling at about 100 knots when they first observed GJS3710 enter the runway and stated they maneuvered the aircraft to the left of centerline to avoid a collision. According to the pilot of GJS3710, after he realized that he had missed the turn to taxiway N and had entered runway 28R, he made an immediate left turn and saw what looked like an Embraer 145 aircraft taking off. He stated he turned his aircraft to face the departing aircraft in order to present the lowest profile. His primary concern was keeping the tail section of his aircraft away from the runway centerline. Herecalled that the centerline of his aircraft was on the north side of the painted runway edge, so only the right half of his aircraft was on the runway proper. He saw the nose gear of the Embraer and recalled seeing the main landing gear of the Embraer come off the ground as the Embraer passed his aircraft. He estimated that the aircraft wingtip to wingtip clearance had been 15-20 feet. At 21:45:36, ENY3084 passed GJS3710 on runway 28R. The ASDE-X could not resolve the minimum separation distance. The positional accuracy of the ASDE-X is +/- 20 feet. GJS3710 then exited runway 28R at taxiway P. The pilot of GJS3710 called his flight dispatcher and then the tower supervisor to discuss the event and then continued the flight to CMH. Airport Surface Detection Equipment Model X The air traffic control front-line manager on duty in the tower stated that the airport surface detection equipment, model X (ASDE-X) alarmed; however, there was insufficient time to cancel ENY3084's takeoff clearance. The distance between taxiways EE and F was approximately 1,900 feet. ASDE-X data for this investigation was obtained from the Federal Aviation Administration. Figure 1 shows the ASDE-X presentation just prior to ENY3084 starting takeoff roll. Figure 2 illustrates the ASDE-X presentation as GJS3710 is approaching runway 28 on taxiway F. Figure 1 – ASDE-X presentation of ENY3084 and GJS3710 at 2145:13. Figure 2 – ASDE-X presentation of ENY3084 and GJS3710 at 2145:27. Weather Information The 2051 Aviation Routine Weather Report (METAR) observation for ORD reported wind 290 degrees true at 12 knots with gusts to 18 knots, visibility 10 statute miles. Few clouds at 3,800 feet above ground level (agl), scattered clouds at 12,000 feet agl, and broken clouds at 15,000 feet agl. Temperature minus 11 degrees Celsius (C), dew point minus 18 degrees C, altimeter 29.88 inches of mercury. Federal Aviation Administration Air Traffic Control Service Duty Priority FAA Joint Order (JO) 7110.65(V), Air Traffic Control, paragraph 2-1-2 addresses an air traffic controller's operational duty priority and stated [in part]: a. Give first priority to separating aircraft and issuing safety alerts as required in this order. Good judgment must be used in prioritizing all other provisions of this order based on the requirements of the situation at hand Team Position Responsibilities FAA Joint Order (JO) 7110.65(V), Air Traffic Control, paragraph 2-10-3 addresses air traffic control tower team position responsibilities and stated [in part]: c. Primary responsibilities of the Tower Team Positions: 1. Tower Position(s) (LC or GC) (a) Ensure separation (b) Initiate control instructions (c) Monitor and operate communications equipment

## Factual narrative (aircraft 2)

On Tuesday, February 17, 2015, at 2145 central standard time, an Embraer E145, N698CB, operated by American Airlines Group as ENY3084, was on takeoff roll on runway 28R from intersection EE at the Chicago O'Hare International Airport (ORD), Chicago, Illinois. A Canadair Regional Jet CRJ-700, N154GJ, operated by GoJet Airlines as GJS3710 was taxiing to runway 28R via taxiways F and N. GJS3710 did not turn left at taxiway N as instructed and instead entered runway 28R and made a left turn toward the departing ENY3084. According to the pilot of ENY3084, he maneuvered to avoid GJS3710, and continued his departure. ENY3084 was a regularly scheduled flight from ORD to Port Columbus International Airport (CMH), Columbus, Ohio. GJS3710 was a regularly scheduled flight from ORD to the Lester B. Pearson International Airport (YYZ), Toronto, Ontario, Canada. Both flights were operating under the provisions of Title 14 Code of Federal Regulations Part 121. Night visual meteorological conditions prevailed, and no injuries were reported on either flight. ENY3084 was departing ORD from runway 28R at the taxiway EE intersection and had been cleared for takeoff. GJS3710 was on the outbound taxi from taxiway H to U to F to N to taxiway EE. According to recorded Airport Surface Detection Equipment, Model X (ASDE-X) data, ENY3084 began departure roll at 2145:17. GJS3710 was about 265 feet north of the runway 28R edge line, taxiing south on Taxiway F at approximately 11 knots. At 21:45:28, an ASDE-X alert was issued when ENY3084 met the velocity and acceleration parameters that are required by the ASDE-X to be considered a departure. ENY3084 was traveling at approximately 56 knots and was approximately 1041 feet from the runway 28R/taxiway F intersection. GJS3710 was on taxiway F approximately 42 feet from crossing the runway 28R edge line and was traveling at approximately 11 knots. At 21:45:30, ENY3084 was about 831 feet from the runway 28R/taxiway F intersection, traveling about 66 knots. GJS3710 entered runway 28R traveling at about 11 knots and turned east toward ENY3084 before coming to a stop on the north side of Runway 28R at taxiway F. When GJS3710 entered the runway from taxiway F, an aural alert of "Warning Runway Two Eight Right Occupied" was voiced in the tower and the corresponding alert text "RWY 28R|ENY3084, GJS3710|RWY OCCUPIED" was displayed on the ASDE-X displays. According to the flight crew of ENY3084, they were traveling at about 100 knots when they first observed GJS3710 enter the runway and stated they maneuvered the aircraft to the left of centerline to avoid a collision. According to the pilot of GJS3710, after he realized that he had missed the turn to taxiway N and had entered runway 28R, he made an immediate left turn and saw what looked like an Embraer 145 aircraft taking off. He stated he turned his aircraft to face the departing aircraft in order to present the lowest profile. His primary concern was keeping the tail section of hisaircraft away from the runway centerline. He recalled that the centerline of his aircraft was on the north side of the painted runway edge, so only the right half of his aircraft was on the runway proper. He saw the nose gear of the Embraer and recalled seeing the main landing gear of the Embraer come off the ground as the Embraer passed his aircraft. He estimated that the aircraft wingtip to wingtip clearance had been 15-20 feet. At 21:45:36, ENY3084 passed GJS3710 on runway 28R. The ASDE-X could not resolve the minimum separation distance. The positional accuracy of the ASDE-X is +/- 20 feet. GJS3710 then exited runway 28R at taxiway P. The pilot of GJS3710 called his flight dispatcher and then the tower supervisor to discuss the event and then continued the flight to CMH. Airport Surface Detection Equipment Model X The air traffic control front-line manager on duty in the tower stated that the airport surface detection equipment, model X (ASDE-X) alarmed; however, there was insufficient time to cancel ENY3084's takeoff clearance. The distance between taxiways EE and F was approximately 1,900 feet. ASDE-X data for this investigation was obtained from the Federal Aviation Administration. Figure 1 shows the ASDE-X presentation just prior to ENY3084 starting takeoff roll. Figure 2 illustrates the ASDE-X presentation as GJS3710 is approaching runway 28 on taxiway F. Figure 1 – ASDE-X presentation of ENY3084 and GJS3710 at 2145:13. Figure 2 – ASDE-X presentation of ENY3084 and GJS3710 at 2145:27. Weather Information The 2051 Aviation Routine Weather Report (METAR) observation for ORD reported wind 290 degrees true at 12 knots with gusts to 18 knots, visibility 10 statute miles. Few clouds at 3,800 feet above ground level (agl), scattered clouds at 12,000 feet agl, and broken clouds at 15,000 feet agl. Temperature minus 11 degrees Celsius (C), dew point minus 18 degrees C, altimeter 29.88 inches of mercury. Federal Aviation Administration Air Traffic Control Service Duty Priority FAA Joint Order (JO) 7110.65(V), Air Traffic Control, paragraph 2-1-2 addresses an air traffic controller's operational duty priority and stated [in part]: a. Give first priority to separating aircraft and issuing safety alerts as required in this order. Good judgment must be used in prioritizing all other provisions of this order based on the requirements of the situation at hand Team Position Responsibilities FAA Joint Order (JO) 7110.65(V), Air Traffic Control, paragraph 2-10-3 addresses air traffic control tower team position responsibilities and stated [in part]: c. Primary responsibilities of the Tower Team Positions: 1. Tower Position(s) (LC or GC) (a) Ensure separation (b) Initiate control instructions (c) Monitor and operate communications equipment

## Aircraft 1

- Registration: [N698CB](https://openairdocs.org/aircraft/N698CB), registered now, S/N 14500877, built 2004 (OpenAirDocs)
- Reported make and model: EMBRAER EMB 145LR (LR)
- 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: 14500877
- Year built: 2004
- Engines: ROLLS-ROYC AE3007 SER turbo fan; ROLLS-ROYC AE3007 SER turbo fan
- Damage: No damage
- Flight: Part 121
- Operator: American Eagle Airlines
- Registered owner: American Airlines Inc
- Airworthiness certificate: Standard, Transport
- Departed: ORD, Chicago, IL
- Destination: CMH, COLUMBUS, OH
- Flight plan: IFR
- Airport: ORD, Chicago O'Hare Intl, runway 28R, 13,000 × 150 ft, concrete

## Aircraft 2

- Registration: N154GJ (not matched to a registry record)
- Reported make and model: BOMBARDIER INC CL 600 2C10 (700C)
- Category: Airplane
- Serial number: 10224
- Year built: 2005
- Engines: GE CF34-8C5B1 turbo fan; GE CF34-8C5B1 turbo fan
- Damage: No damage
- Flight: Part 121
- Operator: GoJet Airlines
- Registered owner: Afs Investments 73 LLC
- Airworthiness certificate: Standard, Transport
- Departed: ORD, Chicago, IL
- Destination: CYYZ, Toronto
- Flight plan: IFR
- Airport: ORD, Chicago O'Hare Intl, runway 28R, 13,000 × 150 ft, concrete

## Flight crew

As NTSB recorded them. NTSB leaves out names.

- Pilot, aircraft N698CB; age 115; injuries: none; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: unknown
- Co-pilot, aircraft N154GJ; age 28; injuries: none; medical: class 1, unknown; seat: right; flight hours: 4,500 total, 1,200 in this make and model
- Pilot, aircraft N154GJ; age 115; injuries: none; airline transport; airplane ratings: multi-engine land; instrument ratings: airplane; medical: class 1; seat: left; flight hours: 6,100 total, 5,400 in this make and model

## Weather

- Conditions: Visual (VMC), Night
- Wind: 290° at 12 knots, gusting 18
- Visibility: 10 statute miles
- Lowest ceiling: 15,000 ft broken
- Temperature: 12 °F, dew point -0 °F
- Altimeter: 29.87 inHg
- Observed at: ORD

## Docket (10 files)

The files NTSB released with the investigation on June 16, 2016, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=90743. 2.1 MB in all.

- Air Traffic Manager Memo to workforce regarding Serious Incident - Runway Incursion 0n 2-17-15 (item 1, .PDF, 81 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441431&FileExtension=.PDF&FileName=Air%20Traffic%20Manager%20Memo%20to%20workforce%20regarding%20Serious%20Incident%20-%20Runway%20Incursion%200n%202-17-15-Master.PDF
- ORD Air Traffic Manager Letter re Actions Taken in response to ruwnay incursion on 2-17-15 (item 2, .PDF, 58 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441432&FileExtension=.PDF&FileName=ORD%20Air%20Traffic%20Manager%20Letter%20re%20Actions%20Taken%20in%20response%20to%20ruwnay%20incursion%20on%202-17-15-Master.PDF
- Certificate of Party Representative - NATCA (item 3, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441433&FileExtension=.PDF&FileName=Certificate%20of%20Party%20Representative%20-%20NATCA-Master.PDF
- Certificate of Party Representative - Envoy Air INC (item 4, .PDF, 86 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441434&FileExtension=.PDF&FileName=Certificate%20of%20Party%20Representative%20-%20Envoy%20Air%20INC-Master.PDF
- Daily Record of Facility Operation - ORD (item 5, .PDF, 266 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441435&FileExtension=.PDF&FileName=Daily%20Record%20of%20Facility%20Operation%20-%20ORD-Master.PDF
- Mandatory Occurrence Report ORD-M-2015/02/17-007 (item 6, .PDF, 50 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441436&FileExtension=.PDF&FileName=Mandatory%20Occurrence%20Report%20ORD-M-2015%2F02%2F17-007-Master.PDF
- Air Traffic Control Factual Report (item 7, .PDF, 624 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441438&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Factual%20Report-Master.PDF
- Air Traffic Control Factual Report Addendum (item 8, .PDF, 87 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40451235&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20Factual%20Report%20Addendum-Master.PDF
- Certificate of Party Representative - Go Jet (item 9, .PDF, 298 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441441&FileExtension=.PDF&FileName=Certificate%20of%20Party%20Representative%20-%20Go%20Jet-Master.PDF
- Operations Go Jet General Operations Manual Excerpt (item 10, .PDF, 416 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40441445&FileExtension=.PDF&FileName=Operations%20Go%20Jet%20General%20Operations%20Manual%20Excerpt-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.

---
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.