# NTSB OPS16IA002: Bombardier CL600 2D24, N316PQ, Detroit, MI, January 27, 2016

- Type: NTSB incident investigation
- Classification: Incident · No injuries · Incident investigation · Final report
- Date: January 27, 2016, 08:04 local (13:04 UTC)
- Place: Detroit, MI
- Coordinates: 42.221942, -83.356391 (estimated)
- Nearby events: https://openairdocs.org/map.md?lat=42.2219&lon=-83.3564&mi=10
- Phase of flight: [Takeoff](https://openairdocs.org/ntsb-phases/300) (OpenAirDocs' grouping)
- Defining event: [Takeoff: Runway incursion veh/AC/person](https://openairdocs.org/ntsb-events/320)
- Highest injury: No injuries
- Status: Completed, report April 14, 2020
- Report: Approved by Office Director
- NTSB office: Operational Factors Division
- Parties: National Air Traffic Controllers Assoc, Federal Aviation Administration
- NTSB case key (mKey): 92646
- NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=OPS16IA002
- NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/92646/pdf
- NTSB docket: https://data.ntsb.gov/Docket?ProjectID=92646
- Page: https://openairdocs.org/ntsb/OPS16IA002

## Probable cause

The local controller's failure to visually scan and ensure that the runway surface was not occupied by a vehicle or other aircraft before issuing a takeoff clearance to the pilot. Contributing to this incident was the relieved controller's failure to monitor and review the position, after completing the relief briefing, to ensure that nothing had been overlooked.

## Findings

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

- [Communication (personnel): crew/duty change-over](https://openairdocs.org/ntsb-findings/02063545): Personnel issues › Task performance · ATC personnel (probable cause)
- [Use of equip/info: use of policy/procedure](https://openairdocs.org/ntsb-findings/02063032): Personnel issues › Task performance · ATC personnel (probable cause)

## Analysis

The Local Northwest (LNW) controller cleared Ops 373 (O373), an airport ops vehicle, to drive on runway 22L to conduct a routine inspection. About 90 seconds prior to the incident, and while O373 was operating on the runway, the LNW and Local Northeast (LNE) positions were combined and the LNE controller assumed all LNE and LNW duties. The LNW and LNE controllers conducted a required position relief briefing but did not conduct the briefing at the relieved position in accordance with standard operating procedures. During the position relief briefing, the LNW controller informed the LNE controller that O373 was driving on runway 22L and at about the same time, Endeavor Air (FLG3860), a CRJ 900, transmitted on the frequency they were ready for departure on runway 22L. About four seconds after completion of the position relief briefing, at 0802:44, the LNE controller instructed FLG3860 to line up and wait on runway 22L and at 0803:46 cleared FLG3860 for takeoff. About 20 seconds later the Airport Surface Detection System – Model X (ASDE-X) alerted indicating the runway was occupied by both FLG3860 and O373. The LNE controller instructed FLG3860 to "…abort takeoff" and instructed O373 to exit the runway. Both complied with the instruction. ASDE-X data indicated the closest proximity between FLG3860 and O373 was about 211 feet. The relieved LNW controller did not conduct a required two-minute overlap upon completion of the position relief briefing in order to monitor and review the position to ensure that nothing had been overlooked or incorrectly displayed. At the time of the incident, the tower was staffed with four personnel; one combined LNE/LNW controller, one combined ground northeast/ground northwest controller, one flight data/clearance delivery controller, and one controller in charge.

## Factual narrative

HISTORY OF FLIGHT On Wednesday, January 27, 2016, about 0804 eastern standard time (EST), a runway incursion occurred at Detroit Metropolitan Wayne County Airport (DTW), Detroit, Michigan when an airport operations vehicle (OPS), O373, was provided a clearance to operate on runway 22L, and Endeavor Air (Flagship) flight 3860 (FLG3860), a CRJ9, was cleared for takeoff on runway 22L. FLG3860 was operating under the provisions of 14 Code of Federal Regulations Part 121 as a regularly scheduled passenger flight to Norfolk International Airport (ORF), Norfolk, Virginia, and O373 was conducting a routine runway inspection on runway 22L. There was no damage to the aircraft or vehicle, and no reported injuries. Visual meteorological conditions prevailed at the time of the incident. About five minutes prior to the incident, the driver of O373 completed a runway inspection for runway 22R, and informed the local northwest (LNW) controller that he was proceeding to the departure end of runway 22L and would hold short; where he would wait until permission was granted for him to him to drive on runway 22L. The LNW controller responded to the driver by reiterating instructions to hold short of runway 22L at taxiway R. The driver acknowledged and complied. At 0801:37, the LNW controller instructed O373 to, "…turn right and drive on runway two two left…" The driver responded, "…cleared to drive on runway two two left..." The driver proceeded southbound (toward the departure end of runway 22L), made a 180 degree turn on the runway 4R numbers, then proceeded northbound (toward the approach end of runway 22L). About 0802 the local control positions in the tower , LNW and local northeast (LNE), were combined. The LNE controller received a position relief briefing from the LNW controller, and assumed all LNE and LNW duties from the LNE workstation. According to audio data, the local control position relief briefing began at 0802:25 and ended at 0802:40. During the briefing, at 0802:31, the LNW controller informed the LNE controller that, "…Ops 373 is driving runway two two left, ah, he is just turning northbound on it now…." At the same time, the pilot of FLG3860 transmitted on the frequency, "Flagship thirty-eight sixty ready two two left." At 0802:44, the combined local controller (LNE/LNW) instructed FLG3860 to line up and wait on runway 22L. At 0803:46, the local controller cleared FLG3860 for take-off on runway 22L. The pilot acknowledged the take off clearance. About 20 seconds later the airport surface detection system - model X (ASDE-X) alerted, indicating that the runway was occupied by FLG3860 and O373. At 0804:10, the local controller transmitted, "Flagship thirty-eight sixty abort takeoff, Flagship thirty-eight sixty abort takeoff," and then instructed O373 to exit the runway to the right. The pilot and vehicle driver both acknowledged and complied with the instructions. According to ASDE-X data, the closest proximity between the aircraft and the vehiclewas about 211 feet laterally. About 0804, the local controller transmitted, "…that was my fault, you can exit the runway to the left and do whatever you want to do right now, just advise ground on point 8 [reference to ground control frequency 121.8] when you are all collected." The driver of O373 exited and reported off the runway, then returned to his base operations location. About 0805, the pilot of FLG3860 exited the runway, switched to ground control frequency, and requested taxi instructions to the runway. The pilot advised the ground controller that he needed about 15 minutes before he would be ready to depart. The ground controller taxied FLG3860 to runway 22L, and advised the pilot to, "let me know when you are ready to go." About 21 minutes later, the pilot informed the ground controller that he needed to go back to the gate. RADAR DATA Radar data for this report was obtained from the ASR-9 sensor located at DTW. METEOROLOGICAL INFORMATION The DTW weather for January 27, 2016 was obtained from the KDTW automatic surface observing system (ASOS). The current weather at the time of the incident was: METAR KDTW 271253Z 25009KT 10SM -SN SCT025 BKN040 OVC170 M02/M04 A3020 RMK AO2 SLP232 P0000 T10171044= Weather for KDTW at 0753 EST, wind from 250 degrees at 9 knots, 10 miles visibility, light snow, scattered clouds at 2,500 feet above ground level (agl), broken ceiling at 4,000 feet agl, overcast skies at 17,000 feet agl, temperature -2 degrees Celsius (C), dew point temperature -4 degrees C, altimeter 30.20 in Hg. Remarks: station with a precipitation discriminator, sea level pressure 1023.2 hPa, one-hourly precipitation of a trace, temperature -1.7 degrees C, dew point temperature -4.4 degrees C.

## 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

- Registration: [N316PQ](https://openairdocs.org/aircraft/N316PQ), registered now, S/N 15316, built 2014 (OpenAirDocs)
- Reported make and model: BOMBARDIER INC CL600 2D24 (900)
- Registry model: [Bombardier CL-600-2D24](https://openairdocs.org/model/bombardier-cl-600-2d24) (registry code 1390016) (OpenAirDocs)
- Registry engine: [GE CF34-8C5](https://openairdocs.org/engine/ge-cf34-8c5) (registry code 30050, turbo-fan) (OpenAirDocs)
- Category: Airplane
- Serial number: 15316
- Year built: 2014
- Damage: No damage
- Flight: Part 121
- Operator: Endeavor Air
- Registered owner: Wells Fargo Bank Northwest Na Trustee
- Airworthiness certificate: Unknown
- Departed: DTW, Detroit, MI
- Destination: ORF, NORFOLK, VA
- Flight plan: IFR
- Airport: DTW, Detroit Metropolitan Wayne Cou, runway 22L, 12,003 × 200 ft, concrete
- Equipment: Unknown

## Weather

- Conditions: Visual (VMC), Day
- Wind: 250° at 9 knots
- Visibility: 10 statute miles
- Lowest ceiling: 4,000 ft broken
- Temperature: 28 °F, dew point 25 °F
- Altimeter: 30.20 inHg
- Icing: Unknown
- Observed at: KDTW, 1 nm away

## Docket (7 files)

The files NTSB released with the investigation on April 14, 2020, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=92646. 4.2 MB in all.

- Air Traffic Control (item 1, .PDF, 422 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482338&FileExtension=.PDF&FileName=Air%20Traffic%20Control-Master.PDF
- Air Traffic Control -Attachment 1 (item 2, .PDF, 490 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482339&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20-Attachment%201-Master.PDF
- Air Traffic Control-Attachment 2 (item 3, .PDF, 542 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482340&FileExtension=.PDF&FileName=Air%20Traffic%20Control-Attachment%202-Master.PDF
- Air Traffic Control -DTW Airport Diagram (item 4, .PDF, 286 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482341&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20-DTW%20Airport%20Diagram-Master.PDF
- Air Traffic Control - DTW Tower Cab Layout (item 5, .PDF, 200 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482342&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20-%20DTW%20Tower%20Cab%20Layout-Master.PDF
- Air Traffic Control - Daily Record of Facility Operation (item 6, .PDF, 13 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482343&FileExtension=.PDF&FileName=Air%20Traffic%20Control%20-%20Daily%20Record%20of%20Facility%20Operation-Master.PDF
- Air Traffic Control-Position Logs (item 7, .PDF, 2.3 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40482344&FileExtension=.PDF&FileName=Air%20Traffic%20Control-Position%20Logs-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.

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From OpenAirDocs.org, an independent open copy of NTSB and FAA data. The NTSB's own report is the official record of an investigation.