Charlotte, NC, USA
N257PS
BOMBARDIER INC CL-600-2B1
N409DR
PILATUS PC12
The controller cleared PSA Airlines (JIA) flight 390, a CRJ-200, for takeoff on runway 18L. N409DR, Pilatus PC-12, was waiting to depart Runway 18L at intersection A. As required, the ground controller had written on the flight progress strip and verbally coordinated with the local controller that N409DR was requesting an intersection departure off Runway 18L at taxiway A; however; the local controller forgot about the intersection and instructed N409DR to taxi into position and hold on Runway 18L. JIA390 had already begun departure roll and had rolled approximately 1,600 feet as N409DR taxied onto the runway. The ASDE-X alerted, and as JIA390 began to slow the controller canceled the takeoff clearance. N409DR had pulled to the side of the runway when the pilot recognized what was happening. According to the Federal Aviation Administration, JIA390 stopped approximately 10 feet from N409DR. At the time of the incident the weather was visual flight rules with 9 miles visibility.
On May 29, 2009 about 1017 EDT a runway incursion occurred involving PSA Airlines (JIA) flight 390, (call sign "Bluestreak 390"), a Canadair Regional Jet CRJ-200, and N409DR, a Pilatus PC-12 at the Charlotte/Douglas International Airport (CLT), Charlotte, North Carolina. JIA390 was on a scheduled 14 Code of Federal Regulations Part 121 flight from CLT to the New Bern Craven County Airport (EWN), New Bern, North Carolina. JIA390 had a crew of 3 and 43 passengers. N409DR, with a crew of two and one passenger, was a 14 CFR Part 91 flight departing CLT on an instrument flight rules (IFR) flight plan to Asheville Regional Airport (AVL), Asheville, North Carolina. At the time of the incident, the tower local control (LC) east controller was on position for 29 minutes working 9 aircraft. At 1011, ground control (GC) east directed JIA390 to taxi to runway 18L from spot 12. Three minutes later, JIA390 taxied to the approach end of runway 18L. At 1012:10, N409DR called GC east for taxi from the general aviation ramp and advised GC east that they wanted to “waive the wake” indicating that the pilot was requesting to waive any wake turbulence criteria that may be applied on departure. GC east directed N409DR to taxi to runway 18L, hold short of taxiway D, and to expect an intersection departure at taxiway A. At 1013:26, GC east directed N409DR to cross taxiway D and taxi to the intersection of taxiway A and runway 18L. Taxiway A intersected runway 18L approximately 2,500 feet from the approach end. The CLT ATCT standard operating procedure (SOP), CLT7110.65J, change 4 dated February 5, 2009, described the coordination process for intersection departures. The GC was required to verbally notify the LC anytime an aircraft is taxied for a departure to a location other than the approach end of the runway. Additionally the flight progress strip for the aircraft departing from the intersection must be annotated with the intersection taxiway identifier in block 12 and circled in red. In this incident, the GC east completed the required coordination and the flight progress strip was correctly annotated. At 1015:11, LC east directed JIA390 to taxi into position and hold at the approach end of runway 18L and advised that there was traffic landing on runway 23, which intersected runway 18L. LC east cleared JIA390 for takeoff from runway 18L at 1016:40 after landing traffic had passed through the intersection. JIA390 acknowledged the takeoff clearance and began takeoff roll. Three seconds later, at 1016:47, LC east directed N409DR to taxi into position and hold on runway 18L which were acknowledged by the pilot. N409DR had been holding short of runway 18L on the east side of the runway at taxiway A and had not advised the LC that he was ready for departure. The LC east controller stated in his interview that he did not visually correlate N409DR as the next aircraft for departure and did not scan the flight progress strip that was annotated as an intersection departure at taxiway A. Additionally, the LC east controller stated that he did not recall looking for N409DR on the ASDE system display nor did the controller scan the runway to ensure the runway was clear. The CLT ATCT was equipped with airport surface detection equipment (ASDE). As the Pilatus entered the runway, the ASDE system activated with an aural alert: “Warning, Runway 18L occupied”. As the ASDE-X alarmed, the tower controllers immediately began scanning all runways trying to identify the conflict before the ASDE-X aural alarm identified the conflict on runway 18L. At 1017:10, LC east canceled the takeoff clearance for JIA390 by transmitting “uhm cancel takeoff clearance uhm bluestreak”. At 1017:22, JIA390 transmitted that they were “rejecting 18L”. LC east directed JIA390 to hold its position on the runway. N409DR advised the tower that they were exiting runway 18L at taxiway D6. JIA390 requested and was authorized to exit runway 18L at taxiway C9. N409DR queried JIA390 on the LC frequency “bluestreak was there any contact? This is nine delta romeo”. The crew of JIA390 did not respond. According to the pilots of JIA390, as they started the takeoff roll both the pilot and first officer saw N409DR approaching runway 18L from the left side. As JIA390 continued to accelerate to approximately 85 knots, the pilots noticed that N409DR did not appear to be slowing down to hold short of runway 18L. When it became apparent that N409DR was not going to stop and hold short of the runway, the pilot of JIA390 initiated a rejected takeoff. N409DR entered runway 18L from taxiway A. The first officer made the required rejected takeoff callouts and the pilot started braking the aircraft. At 1017:22, JIA390 transmitted that they were “rejecting 18L”. According to the pilot in command, JIA390 came to a complete stop on the centerline of runway 18L approximately 2-3 feet from N409DR. The pilots of JIA390 stated that N409DR stayed to the left of the centerline which prevented JIA390 from colliding with N409DR. After JIA390 was brought to a complete stop, the pilot set the parking brake and made a public announcement to the passengers to remain seated. N409DR exited the runway at taxiway D6 while JIA390 exited the runway at taxiway C9. After exiting runway 18L, the pilots of JIA390 stopped the aircraft again and completed the quick reference handbook rejected takeoff checklist and communicated with the flight attendant, passengers, CLT ATC, PSA maintenance and dispatch. The flight crew waited the required brake cooling time and then taxied to the approach end of runway 18L and completed the flight to EWN without further incident. CLT was in a south flow configuration departing runways 18L and 18C. Arrivals were utilizing runways 18C and 23. Air traffic control tower staffing included 7 controllers: a front line manager (FLM) who was on position, a east local control (LC) controller on position, a west LC controller on position with a developmental controller in training, an east ground control (GC) controller on position, a west GC controller on position, a cab coordinator (CC) on position, and a flight data/clearance delivery (FD/CD) controller on position.
The Charlotte local control east controller's failure to ensure that the runway was clear prior to authorizing N409DR to enter the runway.
Source: NTSB Aviation Accident Database
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