CHICAGO, IL, USA
GOITG
Boeing 767-300ER-33A
The captain was flying the localizer approach for runway 9R into O'Hare airport, and the first officer was handling radio communications with Chicago Approach Control. The captain said that the frequency was extremely busy, and at no time during the approach did they receive another frequency change. The controller at O'Hare Tower controlling arrivals on runway 9R saw the airplane and inquired on his frequency, 'Alitalia 638 heavy are you with me, sir?' There was no response. The controller repeated the transmission and then broadcasted, 'Alitalia 638 heavy, are you with me, sir, execute a missed approach.' The first officer made a call to what he thought was O'Hare tower that they were on short final. The controller at Chicago Approach Control transmitted, 'short final, go over to tower one two one seven five.' The controller transmitted the instruction two more times. The captain checked the runways, saw no conflicting traffic, and landed the airplane without clearance. Investigation of the Terminal Radar Air Traffic Control facility, Elgin, Illinois, revealed that the controller did not issue the instruction to the airplane to switch over to O'Hare tower's radio frequency.
HISTORY OF FLIGHT On November 19, 1996, at 1924 central standard time (cst), a Boeing 767-300ER-33A, GOITG, operated as Alitalia flight 638, landed on runway 09R at O'Hare International Airport, Chicago, Illinois, without landing clearance from O'Hare Air Traffic Control Tower (ATCT). The airplane touched down approximately 7,000 feet behind a Boeing 747, operated as Japan Air Lines (JAL) flight 038, which was on landing rollout. Visual meteorological conditions prevailed at the time of the incident. The flight was being conducted as regular scheduled foreign international air carrier service under 14 CFR Part 129. An IFR flight plan was on file. There were no reported injuries to the 11 crew and 129 passengers who deplaned normally at the gate. The flight originated at Rome, Italy, at 0900 cst. The captain, a British national, stated that he was flying the approach into O'Hare International Airport, and that radio communications were being handled by the first officer, an Italian national. The captain said that a supervisory first officer was also on board and was monitoring communications. While on downwind leg for the localizer approach to runway 09R, the captain received a frequency change to Chicago Approach Control. The crew was advised that their landing runway would be 09R and that speed control was in effect. The captain said that the frequency was extremely busy. The captain received instructions to turn onto base leg and then was advised to intercept the localizer. The instruction was late, causing the airplane to overshoot the localizer course and to intercept the course from the other side. The first officer reported to Chicago Approach Control that they were established on the localizer. The captain said that at that time, he believed that they were on tower frequency. The captain said, at no time during the approach did they receive another frequency change. The first officer informed the captain that pre-landing checks were completed and stated, "landing clearance yet to come." The local controller at O'Hare ATCT controlling arrivals on runway 09R made a radio transmission to Alitalia flight 638 at 1920:34 est, "Alitalia 638 heavy are you with me, sir?" The local controller repeated the transmission at 1920:46 est. At 1920:54, the local controller made the radio transmission, "Alitalia 638 heavy, are you with me, sir, execute a missed approach." On short final for the approach, the captain told the first officer to make a call advising what he thought was O'Hare ATCT that they were on short final. At 1920:55, the first officer transmitted over Chicago approach control frequency, "Alitalia 638, short final." The east arrival controller at Chicago Terminal Radar Air Traffic Control (TRACON) transmitted, "short final, go over to tower one two one seven five." The east arrival controller transmitted the frequency change two more times. The captain said that the first officer was "unable to break in as the periods between transmissions was practically nil." The captain made two attempts to advise the controlling agency that they were on short final for the approach. In both attempts, he did not receive replies. The captain checked the runway and noted a Boeing 747 crossing the landing runway towards the far end. The captain said, "I was sure that it (the B-747) would be clear of the runway before I touched down, which in fact it was. I also checked the intersecting runways and saw no conflicting traffic." The captain elected to treat the situation as a communications failure and landed the airplane without landing clearance. The local controller at O'Hare ATCT made a radio transmission to Alitalia flight 638 at 19:21:41, "Alitalia 638 heavy, are you with me yet, sir?" This transmission was repeated by the local controller at 19:22:25. After landing, the captain instructed the first officer to contact O'Hare ground control. O'Hare ground control advised the crew to "taxi to the gate." The first officer responded, "Taxi to the gate, Alitalia 635." The captain was then able to check the frequency selected against the approach plate. He found that the tower frequency was not selected. O'Hare ground control then inquired, "Alitalia 638 heavy, did you ever talk to the tower on 121.75?" The captain responded, "Negative." PERSONNEL INFORMATION The captain and supervisory first officer were British nationals employed by Monarch Airlines, Limited, Luton Beds, United Kingdom. They were on loan to Alitalia Airlines for the purpose of operating airplanes on Alitalia's international routes. They were additionally tasked with training Alitalia pilots on the Boeing 767-300ER equipment and on procedures for operating on international routes into the United States. The captain had 580 hours in the Boeing 767 airplane, and 219 hours within the 90 days prior to the incident. The captain had successfully passed a company proficiency flight check on September 25, 1996. The first officer was an Italian national employed by Alitalia Airlines. According to the captain, the first officer was being trained. The first officer "was new to the American environment. This was his first flight to Chicago." The captain also said that English was not the first officer's first language, but it was satisfactory. The first officer had successfully passed a company proficiency flight check on September 11, 1996. AIRCRAFT INFORMATION The Boeing 767-300ER-33A airplane was owned by Ansett Worldwide Airlines, Melbourne, Australia. It was on "wet lease" to Monarch Airlines, Limited, Luton Beds, United Kingdom, which managed and operated the airplane for Alitalia Airlines, Rome, Italy, under the rules of the British Civil Aviation Authority. The airplane was being maintained by Monarch Airlines Engineering, Limited, Luton, United Kingdom. The airplane had undergone a "Type A-6" continuous maintenance inspection at Rome, Italy, on November 19, 1996, prior to the incident flight. TESTS AND RESEARCH A review of the operations, procedures and equipment of the Air Traffic Control Tower at O'Hare International Airport, Chicago, Illinois, was conducted on December 3, 1996, at 1000 est. It was found that O'Hare ATCT controllers can establish a direct communication link with the arrival controller at the Terminal Radar Air Traffic Control (TRACON) Facility at Elgin, Illinois through a communications system known as Remote Digital Voice Switches (RDVS). This system allows the ATCT local controller by depressing and holding a button on the RDVS panel, to communicate directly with the TRACON arrival controller through both controller's headsets. The ATCT local controller on duty at the time of the incident did not exercise this option in attempting to communicate with Alitalia flight 638. The Air Traffic Control Tower is also equipped with several laser-sight light guns, which are used to send visual signals to airplanes on the ground or in flight. The ATCT local controller on duty at the time of the incident did not attempt to use one of the light guns to send a visual signal to Alitalia flight 638. A review of the operations, procedures and equipment of the Terminal Radar Air Traffic Control facility, Elgin, Illinois, was conducted on December 10, 1996, at 0900 est. It was found that controller's procedures for issuing instructions and clearances to foreign air carriers differed from their procedures used to issue instructions and clearances to U. S. air carriers. Local controllers would give multiple instructions and clearances to U. S. air carrier pilots in order to minimize the number of radio calls to the airplanes; hence, managing the large volume of airplanes coming into the class "B" airspace around O'Hare International Airport. With the foreign air carriers, local controllers, considering possible comprehension delays due to language differences, would issue single-event instructions. This required area controllers to make more radio calls to each foreign air carrier airplane. FAA Order 7110.65, "Air Traffic Control," paragraph 2-1-15, "Control Transfer," stated: a. Transfer control of an aircraft in accordance with the following conditions: 1. At a prescribed or coordinated location, time, fix or altitude; or, 2. At the time a radar handoff and frequency change to the receiving controller have been completed, when authorized by facility directives or Letter of Agreement which specifies the type and extent of control that is transferred. A facility directive entitled ORD 7110.65A, paragraph 4-2, "General Arrival Procedures," stated: a. Unless coordinated, arrival aircraft shall be transferred to the appropriate Local Control frequency no later than the Outer Marker of the ILS final approach course or the Final Approach Fix (FAF) on a non-precision approach. The east arrival controller on duty at the time of the incident did not issue the instruction to Alitalia flight 638 to switch over from his radio frequency to O'Hare ATCT's radio frequency. ADDITIONAL INFORMATION Parties to the investigation were the Federal Aviation Administration Flight Standards District Office, Schiller Park, Illinois, the National Air Traffic Controllers Association, Naperville, Illinois, and Alitalia Airlines, Rome, Italy.
the approach controller's failure to issue the frequency change to the flightcrew, and the pilot landing without clearance. A factor relating to this incident is the pilot's decision to land without clearance.
Source: NTSB Aviation Accident Database
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