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B733 / B744, Chicago IL USA, 2006

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Summary
On 23 July 2006, a Boeing B737-300 operated by United Airlines executed an early rotation during a night take off when a Boeing 747 operated by Atlas Air was observed on a landing roll on an intersecting runway at Chicago O’Hare Airport. The occurrence is attributed to ATC error.
Event Details
When July 2006
Actual or Potential
Event Type
Human Factors, Runway Incursion
Day/Night Night
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BOEING 737-300
Operator United Airlines
Domicile United States
Type of Flight Public Transport (Passenger)
Origin Chicago/O'Hare International Airport
Intended Destination Denver International Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Take Off
TOF
Flight Details
Aircraft BOEING 747-400 (international, winglets)
Operator Atlas Air
Domicile United States
Type of Flight Public Transport (Cargo)
Origin Frankfurt am Main Airport
Intended Destination Chicago/O'Hare International Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Landing
LDG
Location - Airport
Airport Chicago/O'Hare International Airport
General
Tag(s) Aircraft-aircraft near miss
HF
Tag(s) ATC clearance error,
Ineffective Monitoring,
Procedural non compliance
RI
Tag(s) ATC error,
Incursion pre Take off,
Incursion after Landing,
Intersecting Runways,
Near Miss
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Air Traffic Management
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Description

On 23 July 2006, a Boeing B737-300 operated by United Airlines executed an early rotation during a night take off when a Boeing 747 operated by Atlas Air was observed on a landing roll on an intersecting runway at Chicago O’Hare Airport. The occurrence is attributed to ATC error.

KORD Runways
Chicago O’Hare intersecting runways

Synopsis

The National Transportation Safety Board (USA) (NTSB) Report on the Serious Incident provides the following description of the event:

"At the time of the incident, the north local control (NLC) position was closed and the responsibilities were combined with south local control (SLC), located at the LC5 position in the ORD tower cab. The SLC was responsible for aircraft landing and departing runway 14R and departing runway 27L and used frequencies 120.75 and 126.9. Because of this configuration the ORD Standard Operating Procedures Order, ORD 7110.65E , required that either the Electronic Flight Strip Transfer System (EFSTS) position or Local Monitor (LMN) position be staffed to assist the SLC. The third local controller (LC3) was responsible for aircraft departing runway 22L and used frequency 132.7. SLC had several flight crews who had requested to depart from runway 14R for operational purposes. Because aircraft departing from runway 14R entered LC3's airspace, SLC was required to coordinate with LC3 for the release of those flights. SLC verbally coordinated the release of two departure aircraft, United Airlines (UAL) flight 938 and Air India (AI) flight 124, that he intended to depart before GTI6972 (Atlas Air) landed.

At 0257:00, the SLC controller instructed UAL938 to taxi into position to hold on runway 14R. The crew acknowledged.

At 0257:28, the flight crew of GTI6972 made initial contact with the ORD SLC and said, "hello tower, Giant 6972 heavy 9 D-M-E I-L-S one four right. The tower controller replied, "…O'Hare tower, runway 14 right cleared to land. [Wind] one six zero at eight, traffic will depart ahead of your arrival." The flight crew read back the landing clearance.

At 0257:50, the SLC cleared UAL938 for takeoff. At 0258:10, the SLC instructed UAL1015, "Traffic lands, departs, crossing, runway 27 left position and hold. The crew replied, "need about two minutes, UAL1015 if you could delay us in position that's fine." The SLC said, "UAL1015, let me know when you're ready, hold in position runway 27L." The crew acknowledged.

According to the SLC's interview, he stated that at this time he determined there was not enough spacing to permit AI124 to depart from runway 14R prior to GTI6972's arrival. He walked to the LC3 controller and advised that he would not be departing the second airplane and would re-coordinate a release at a later time.

At 0259:19, the SLC instructed UAL938 to contact departure control, which the crew acknowledged.

At 0300:20, the crew of UAL1015 advised, "tower, United 1015, we're ready 27L." In his interview, the SLC said, "As this was happening, I looked to see what was on the third local controller's board to effectively coordinate the remaining departures from runway 14R.

GTI6972 was the last arrival that was on the D-BRITE display so it allowed for a great deal of flexibility. Because of this flexibility, rather than cut off the [runway] 22L departures, I looked at his board to see what the best time to release his flights would be. I then saw an American B777 moving up as the third departure aircraft [from runway 14R]. As I was determining the traffic flow, UAL1015 called 'ready'. I checked the [runway] 14R final out the window and there was nothing there. I scanned [runway] 27L from the departure end to the aircraft and there was nothing there. I checked the D-BRITE. I was checking the range on UAL938 to be sure he was far enough out on [runway] 14R to ensure I had the necessary wake turbulence separation for a [runway] 27L departure, and there was. Based on recall and hindsight, all this happened in about 3 or 4 seconds." At 0300:22, the SLC said, "United 1015, thank you, fly runway heading runway 27 left cleared for takeoff, wind one five zero at seven." The crew responded, "runway heading, cleared for takeoff United 1015.

During the EFSTS' interview, he said he looked up and saw GTI6972 on landing roll on runway 14R at slow speed approaching taxiway T10. Although he was required to monitor the SLC frequencies, he did not and did not hear any communications between the SLC and any flight crews. He said he assumed GTI6972 was turning off at taxiway T10, because "it is very common". He looked left and saw out of the corner of his eye UAL1015 departing runway 27L. He looked back to GTI6972 and thought he might turn off on the next taxiway, M, to go to the NE cargo area then decided he was not. He then alerted the SLC."

At 0301:12, the SLC said, "stop, stop, stop.

According to the Captain of the B733 statement:

"At that point, I did not feel that we would be able to abort and stop prior to those intersections (around 110-120 knots), so I decided to continue accelerating towards [GTI6972] and if needed, attempt to rotate over him. The other option was an abort and a right steer behind [GTI6972] to the north of runway 27L. Knowing there are substantial obstacles right of [runway] 27L, I felt that option would guarantee significant airframe damage and probably passenger injury. [GTI6972] continued encroaching on our runway, and it became clear that I would have to rotate early to clear it. By the time I rotated, [GTI6972] was fully on our runway. Vr at our weight was 143 kts264.836 km/h
73.502 m/s
, and I estimate I began the rotation 10 kts18.52 km/h
5.14 m/s
prior to Vr. The First Officer called V1 shortly after I started rotating. I flew a smooth rotation until we were airborne for fear of dragging the tail and delaying further rotation."

Probable Cause(s)

The NTSB determines the probable cause(s) of this incident as follows:

  • The failure of the ORD tower south local controller to monitor Atlas Air flight 6972, B747, on arrival to runway 14R and subsequently clearing United Airlines flight 1015, B737, for takeoff on intersecting runway 27L causing a loss of separation between the two aircraft.

No safety recommendations were made in the Report.

Related Articles

Further Reading

The NTSB Report (OPS06IA008) on the Serious Incident.