Pilot Debrief

BOEING 737-900ER near Queens, NY — 2023-01-14

Final reportDCA23LA125
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Date
2023-01-14
Location
Queens, NY, USA
Airport
KJFK
Aircraft
BOEING 737-900ER
Registration
N914DU
Category
Airplane
Highest injury
None
Fatalities
0

Probable cause

The American Airlines flight 106 (AAL106) crew’s surface navigation error due to distractions caused by their performance of concurrent operational tasks during taxi, which resulted in a loss of situational awareness. Contributing to the incident was the air traffic control tower team’s nondetection of the AAL106 crew’s deviation from taxi instructions while performing concurrent operational tasks; the timing of the runway status light system, which activated too late to prevent the AAL106 crew from crossing the runway hold short line; and American Airlines’ lack of adequate risk controls to prevent concurrent flight crew tasks from leading to distraction, loss of situational awareness, and deviation from an authorized taxi clearance. Reducing the severity of the incident, and likely preventing an accident, was the activation of the ASDE-X warning in the air traffic control tower and the local controller’s prompt cancellation of DAL1943’s takeoff clearance.

Contributing factors

Contributing to the incident was the air traffic control tower team’s nondetection of the AAL106 crew’s deviation from taxi instructions while performing concurrent operational tasks; the timing of the runway status light system, which activated too late to prevent the AAL106 crew from crossing the runway hold short line; and American Airlines’ lack of adequate risk controls to prevent concurrent flight crew tasks from leading to distraction, loss of situational awareness, and deviation from an authorized taxi clearance.

NTSB narrative

On January 13, 2023, about 2044 eastern standard time, the flight crew of American Airlines (AAL) flight 106, a Boeing 777-200, N754AN, crossed runway 4L on taxiway J without air traffic control (ATC) clearance at John F. Kennedy International Airport (JFK), Queens, New York, causing the flight crew of Delta Air Lines (DAL) flight 1943, a Boeing 737-900, N914DU, to abort their takeoff roll on runway 4L. None of the 6 crew and 153 passengers on DAL1943, nor the 12 crew and 137 passengers on AAL106, were injured, and there was no damage to either airplane. AAL106 operated as a Title 14 Code of Federal Regulations (CFR) Part 121 scheduled international passenger flight from JFK to London Heathrow International Airport (LHR), London, United Kingdom. DAL1943 was a CFR Part 121 scheduled international passenger flight from JFK to Santo Domingo (SDQ), Dominican Republic. Night visual meteorological conditions prevailed at the airport at the time of the incident.

NTSB coding

Evidence available

  • ATC audio
  • FDR / data
  • ADS-B / radar
  • 33 docket documents
View NTSB final reportView NTSB docket

Docket documents33

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