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B742 / B744, Chicago O'Hare IL USA, 1999

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Summary
On 1 April 1999, an Air China Boeing 747-200F which had just landed on and cleared runway 14R at Chicago O’Hare failed to follow its correctly read back taxi-in clearance and crossed the landing runway at night ahead of a Boeing 747 taking off. The latter rotated abruptly and banked away from the taxiing 747, missing it by an estimated 75 feet. It was found that the Air China aircraft had realised it was going the wrong way but had slowed rather than stopped taxiing with the nose of the aircraft past the runway centreline as it was overflown.
Event Details
When April 1999
Actual or Potential
Event Type
Human Factors, Runway Incursion
Day/Night Night
Flight Conditions On Ground - Normal Visibility
Flight Details
Aircraft BOEING 747-400 (international, winglets)
Operator Korean Air
Domicile South Korea
Type of Flight Public Transport (Passenger)
Origin Chicago/O'Hare International Airport
Actual Destination Incheon International Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Take Off
TOF
Flight Details
Aircraft BOEING 747-200
Operator Air China
Domicile China
Type of Flight Public Transport (Cargo)
Origin Beijing Capital International Airport
Intended Destination Chicago/O'Hare International Airport
Actual Destination Chicago/O'Hare International Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Taxi
TXI
Location - Airport
Airport Chicago/O'Hare International Airport
General
Tag(s) Aircraft-aircraft near miss,
Extra flight crew (no training),
Inadequate Aircraft Operator Procedures,
Airport Layout
HF
Tag(s) Ineffective Monitoring,
Procedural non compliance
RI
Tag(s) Accepted ATC Clearance not followed,
Incursion after Landing,
Near Miss,
Intentional Premature Rotation
Outcome
Damage or injury No
Causal Factor Group(s)
Group(s) Aircraft Operation
Safety Recommendation(s)
Group(s) None Made
Investigation Type
Type Independent

Description

On 1 April 1999, a Boeing 747-200F being operated by Air China on a scheduled cargo flight into Chicago cleared runway 14R after a night landing but, in normal ground visibility, then re-entered the same runway as a Boeing 747-400 being operated by Korean Airlines on a scheduled passenger flight from Chicago to Seoul was taking off on the same runway. The departing aircraft rotated early and immediately deviated from the runway centreline so as to avoid hitting the other aircraft.

Investigation

Although the NTSB investigated this complex and serious incident, for reasons that have not been established, no formal official report of the Investigation was ever published. However, all the pertinent factual information was officially released during a subsequent overall review by the Board of runway incursions in which this event was one of four examples of serious runway incursions which occurred in 1999 and were detailed at a Public Hearing dedicated to the subject on 13 June 2000.

It was established than the 747-200 had landed on runway 14R and was instructed by the TWR controller to exit the runway via a right turn onto taxiway T10, then a left turn on taxiway K, crossing runway 27L to the south cargo ramp. This instruction was correctly acknowledged. The same controller then cleared the 747-400 for take off on runway 14R. The 747-200 aircraft commander acting as PM and receiving ATC instructions with the assistance of an interpreter subsequently advised the Investigation he had placed his finger on taxiway K on the chart he was using but whilst manipulating the checklist, his finger had unintentionally moved to taxiway M and he had instructed the First Officer to taxi accordingly. The aircraft made a second left turn onto taxiway M, which would take the aircraft across runway 14R at about three quarters along its total available length of 3962 metres.

As the aircraft approached the runway, the commander reported that he had realised that they were not going the right way to the cargo terminal but had only told the PF to slow down not stop and so the aircraft entered the runway at an obtuse angle in front of the departing 747-400. The pilot of that aircraft reported that by the time he had realised what was happening, the nose of the slow crossing aircraft had passed the runway centreline. He had reacted with a more abrupt pitch up than normal at around the calculated Rotation Speed (Vr) and, once airborne, had banked to the left to ensure clearance over the top of the other aircraft.

Subsequent Flight Data Recorder (FDR) download had found that the left bank made had been to 9° and the other aircraft cleared by about 75 feet within 3 seconds of becoming airborne. At the time of the occurrence, there was no controller runway incursion alerting system installed on runway 14R but the NTSB calculated that the system available at the time, Airport Movement Area Safety System (AMASS), would have provided an alert only 6 seconds ahead of a collision when the departing aircraft was already accelerating through 172 KCAS which would have been of no use. The primary concern of the Board was this ineffectiveness of alerting systems.

The Runway/Taxiway Layout at the time of the Incident (reproduced from the NTSB Safety Recommendations Letter dated 6 Jul 2000 re A-00 66-71 and © 2000 Jeppesen Sanderson Inc and reproduced by the NTSB with permission)

Because of a number of other equally serious runway incursion events had also occurred in 1999, following the 13 June 2000 Public Hearing, the NTSB issued a total of six Safety Recommendations to the FAA aimed at collectively addressing the demonstrated runway incursion risk. These covered:

  • the requirement for a runway collision alerting system providing a direct and timely alert to pilots.
  • more rigorous ATC procedures for the issue of runway crossing clearances and clearances for departing aircraft to line up and wait.
  • adoption of ICAO PANS-ATM phraseology by ATC for runway and ground movement operations excluding “conditional phraseology.”
  • the need for controllers to “speak at reasonable rates when communicating with flight crews, especially those whose primary language is not English.”

The exact text of these Recommendations is available on SKYbrary: NTSB Runway Incursion Safety Recommendations A-00-66 to A-00-71

Since the Investigation, the configuration of runways and taxiways in the area where the conflict occurred has been changed. Runway 14R/32L now terminates before intersecting runway 27L/09R, now re-designated 10/28.

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