Pilot Debrief

EMBRAER EMB 145LR near Chicago, IL — 2015-02-18

Final reportOPS15IA011
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Date
2015-02-18
Location
Chicago, IL, USA
Airport
ORD
Aircraft
EMBRAER EMB 145LR
Registration
N698CB
Category
Airplane
Highest injury
None
Fatalities
0

Probable cause

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.

NTSB narrative

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.

NTSB coding

  • Runway incursion veh/AC/person · Taxi-to runway
  • Runway incursion veh/AC/person · Takeoff
View NTSB final report

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