Chicago, IL, USA
N315UA
Boeing 737-322
N418MC
Boeing 747
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 flightcrews 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 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 United 1015 Captain's written statement, "The takeoff was completely normal until approximately 110 knots, when I noticed [GTI6972] approaching our runway on what appeared to be [runway] 14R or taxiway T. I commented that it didn't look like he was going to stop. I would estimate [GTI6972] was traveling 15-20 knots. 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 knots, and I estimate I began the rotation 10 knots 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." Airport Movement Area Safety System (AMASS) did not activate. (See section 2.) Data recorded by the AMASS indicates that UAL1015 flew over GTI6972.
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 flightcrews 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 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 United 1015 Captain's written statement, "The takeoff was completely normal until approximately 110 knots, when I noticed [GTI6972] approaching our runway on what appeared to be [runway] 14R or taxiway T. I commented that it didn't look like he was going to stop. I would estimate [GTI6972] was traveling 15-20 knots. 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 knots, and I estimate I began the rotation 10 knots 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." 2. Weather At the time of the incident, the ATIS information "U" broadcasted the 0253 UTC weather. The information was: wind calm, visibility 10 statute miles, few clouds at 25,000 feet. Temperature 20 degrees Celsius, dew point 15. Altimeter 29.95. 3. ORD Standard Operating Procedures (SOP), (Order ORD 7110.65E) The purpose of this document is to prescribe standard operating procedures for providing air traffic control services by O'Hare Airport Traffic Control Tower (ATCT). ORD ATCT controllers are required to be familiar with and apply the procedures contained within this Order. On February 15, 2004, the ORD Air Traffic Manager signed the document. 4. Facility Waivers a. Taxi in Position and Hold (TIPH) FAA Order 7110.65, Air Traffic Control, paragraph 3-9-4, "Taxi into Position and Hold (TIPH)" states in part: The intent of TIPH is to position aircraft for an imminent departure. Authorize an aircraft to taxi into position and hold, except as restricted in subpara f, when takeoff clearance cannot be issued because of traffic. Issue traffic information to any aircraft so authorized. Traffic information may be omitted when the traffic is another aircraft which has landed on or is taking off the same runway and is clearly visible to the holding aircraft. Do not use conditional phrases such as "behind landing traffic" or "after the departing aircraft." Paragraph 3-9-4f, states: Do not authorize an aircraft to taxi into position and hold at an intersection between sunset and sunrise or at anytime when the intersection is not visible from the tower. The Acting Director, Terminal Safety and Operations Support signed Waiver 98-T-53F on December 12, 2005 authorizing ORD ATCT to taxi aircraft into position and hold from the following intersections between sunset and sunrise or when the intersections are not visible from the tower: Runway 27L and taxiway M6 Runway 14L and taxiway U Runway 32L and taxiways T10 and M Runway 32R and taxiway V Runway 14L and taxiway V According to the waiver, procedures were required to be appropriately addressed in the facility's SOP. Procedures in the SOP require that the ground controller ensure the accuracy of the departure sequence prior to switching the aircraft to LC; GC/LC correlate the aircraft's position using the Airport Surface Detection Equipment (ASDE); on initial contact LC shall state the aircraft call sign and the runway/intersection when issuing a taxi into position and hold clearance and request a pilot read back, and LC restate the aircraft call sign and runway/intersection when issuing a departure clearance. While exercising the provisions of the waiver, the listed runways/intersections must be "departure only" runways. Only one aircraft is permitted to taxi into position and hold on each respective runway and intersection listed. The waiver was effective December 12, 2005 and valid for 2 years. On April 14, 2006, the ORD Acting Manager requested a waiver for FAA Order 7110.65, paragraph 3-9-4g and FAA Order 7210.3, paragraph 10-3-8b6. FAA Order 7110.65, paragraph 3-9-4g states: Do not authorize aircraft to taxi into takeoff position to hold simultaneously on intersecting runways. A review of FAA Order 7210.3, indicated that paragraph 10-3-8b6 does not exist. General Notice (GENOT) 6/13 eliminated TIPH procedures on intersecting runways. On March 17, 2006, the Director, Terminal Safety and Operations Support, signed Waiver number 06-T-C-ORD-01 that provided that facility a waiver to GENOT 13. GENOT 6/15 mandated a variety of requirements to be met to continue TIPH operations on all runways, in addition to GENOT 6/13. On March 20, 2006, the Director, Terminal Safety and Operations Support, signed Waiver number 06-T-C-ORD-02 that provided a waiver to GENOT 15, N7210.622, Amendment to TIPH Operations. Both waivers authorize the ATCT personnel to conduct TIPH. To maintain the conditional approves, facilities must submit the risk mitigation strategy for any requirements they are unable to meet. Submissions must be made within 30 days from the date of the temporary waiver. Although official documentation was not provided, Safety Board staff was advised that these were the planned Mitigating Strategies: During operations that use multiple runways with aircraft in position and hold, as many as 3 controllers are plugged in, and listening to the frequency. For example, on Plan X, aircraft typically depart runways 9L, 4L, and 32R. During those operations, a LMN is actively watching the LC position with the shared responsibility of the intersecting runways. By definition, the LMN can have no other duties. In addition to the LMN, an EFSTS position is open, listening to the operation through a headset. These positions are open regardless of the weather conditions. ORD also has 2 Operational Supervisors on duty each day and evening shift. These requirements include that the Operations Supervisor (OS) position not be combined with another position, local control positions not be combined with any other positions, and AMASS be in the "full core" alert mode. If AMASS is not in "full core" alert status, ORD has a current waiver that permits TIPH at intersections after dark, and when the intersections are not visible from the tower. To mitigate risk during TIPH operations, the following apply: 1. Require the 2 OS positions be staffed (Watch Supervisor and Support Supervisor) when conducting runway TIPH. 2. Amend ORD 7110.65, 4-3-2a, Support Supervisor, to include a section requiring the Support Supervisor to eliminate/minimize distractions surrounding the LC position and the LMN position. 3. ORD 7110.65, 4-3-2a, Support Supervisor, assigns responsibilities to the Support Supervisor to, "provide general supervision to the LC and LMN positions." 4. Air Traffic Manager will provide a face-to-face briefing to all Operations Supervisors covering items 1-3. 5. Provide a face-to-face briefing to all personnel concerning duties of control positions and hazards of distractions. 6. Ground Control (GC) shall ensure the accuracy of the departure sequence prior to switching the aircraft to LC. 7. GC/LC shall correlate the aircraft's position using the Airport Surface Detection Equipment (ASDE) in accordance with FAA Order 7110.65, Section 6, Airport Surface Detection Procedures. 8. LC on initial contact shall state the aircraft call sign and the runway/intersection when issuing a taxi into position and hold clearance. 9. LC shall request a pilot read back for accuracy when issuing taxi into position and hold clearance. 10. LC shall restate the aircraft call sign and runway/intersection when issuing a departure clearance. b. Waiver to FAA Order 7110.65, paragraph 3-10-4a1, "Intersecting Runway Separation" FAA Order 7110.65, paragraph 3-10-4 states in part: a. Separate an arriving aircraft using one runway from another aircraft using an intersecting runway or a nonintersecting runway when the flight paths intersect by ensuring that the arriving aircraft does not cross the landing threshold or flight path of the other aircraft until one of the following conditions exists: 1. The preceding aircraft has departed and passed the intersection/flight path or is airborne and turning to avert any conflict. On May 6, 2006, the Director, Terminal Safety and Operations Support signed Waiver 04-T-10A authorizing ORD personnel to conduct intersecting runway operations to runway 27L and runway 14R whereby an aircraft departing runway 27L shall be through the intersection of runway 14R prior to the arriving aircraft on runway 14R reaching a point no closer than 5,000 feet from the intersection of both runways. Special provision: LC must issue traffic information to both aircraft; procedures broadcast on the ATIS; special procedures be advertised in a Letter to Airmen, Notice to Airmen Publication, and the Airport Facility Directory. The waiver is issued on the basis that the procedure continues to provide an equivalent level of safety and ensures the safe and efficient control of aircraft. The waiver became effective on May 6, 2006, and valid until May 5, 2008. 5. Changes to ORD 7110.65E On July 24, 2006, the ORD Acting ATM, as a result of the operational error, directed these changes to be made immediately: When landing 14R and departing 27L or landing 27R departing 32R, the option of staffing either the LMN or the EFSTS position is removed. The LMN shall be staffed when landing runway 14R departing 9R/27L and also when landing runway 27R departing 32R. All other pertinent requirements of the LMN position remain in effect. The Watch Supervisor position shall be open 24 hours per day, and staffed by an Operations Supervisor or CIC. The net effect of this change is requiring 3 positions to be open during the midnight shift operation. The Watch Supervisor position shall not be combined with any other operating position other than those listed in the Notice. On July 24, 2006, the Acting ATM made the following change to ORD 7110.65E, paragraph 4-3-1p: The Watch Supervisor shall be staffed 24 hours per day. This position shall not be combined with any other positions except the Operations Manager, Support Supervisor, Secondary Support Supervisor, or Traffic Management Coordinator position. 6. South Local Control (SLC) Controller Interview Summary Prior to the configuration change, he was working runway 32L/T10 departures. After the configuration change, he became responsible for arrivals on runway 14R and departures on runways 14R and 27L. SLC Plan X became LC3 Plan 14s. The transition between configurations was "very smooth." He did not recall any equipment problems before the incident. AMASS was in "limited" mode. He understood that to mean it would alert if an airplane started to take off or land on a closed runway, and that the ASDE display would show a data block including a call sign for an arrival aircraft. Asked whether he used the ASDE display when the AMASS was in "limited" mode, he said he would use it if working IGC, or if working NLC on Plan Weird with a triple arrival runway, or SLC on Plan X because the data blocks were useful. Asked whether that was the only time he would use it, he said, "given clear weather, yes." He was asked to describe the incident as it developed. He stated that he had three departure aircraft holding short of runway 14R. They were "heavy" aircraft bound overseas. The first was UAL938. The next was Air India 124 (AI124). It was followed by a UAL going to South America. The outbound fixes for these aircraft
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.
Source: NTSB Aviation Accident Database
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