E145 / DH8B, Cleveland USA, 2009

Summary: 

On 26 June 2009 a Bombardier DHC8-200 being operated by Commutair on a scheduled Continental Express passenger flight from Cleveland to Port Columbus was cleared for take off when an Embraer 145 being operated by Jetlink on another scheduled Continental Express passenger flight from Cleveland to Kansas City was about to cross the same runway in accordance with its ATC clearance in normal daylight visibility. The conflicting clearances were resolved by flight crew awareness and action rather than ATC intervention and once satisfied that the 145 was holding position clear of the runway, the DHC8 took off as already cleared.

Event Details
When: 
26/06/2009
Event Type: 
Day/Night: 
Day
Flight Conditions: 
On Ground - Normal Visibility

19068

Flight Details
Operator: 
Type of Flight: 
Public Transport (Cargo)
Flight Origin: 
Intended Destination: 
Phase of Flight: 
Take Off

19069

Flight Details
Aircraft: 
Operator: 
Type of Flight: 
Public Transport (Passenger)
Flight Origin: 
Intended Destination: 
Phase of Flight: 
Taxi
Location
Location - Airport
Airport: 
General
Tag(s): 
Aircraft-aircraft near miss, ATC Training
HF
Tag(s): 
Ineffective Monitoring, Procedural non compliance
RI
Tag(s): 
ATC error, Incursion pre Take off, Runway Crossing, Near Miss
Outcome
Damage or injury: 
Yes
Aircraft damage: 
None
Non-aircraft damage: 
Yes
Non-occupant Casualties: 
No
Occupant Injuries: 
None
Occupant Fatalities: 
None
Off Airport Landing: 
Yes
Ditching: 
Yes
Causal Factor Group(s)
Group(s): 
Air Traffic Management
Safety Recommendation(s)
Group(s): 
None Made
Investigation Type
Type: 
Independent

Description

On 26 June 2009 a Bombardier DHC8-200 being operated by Commutair on a scheduled Continental Express passenger flight from Cleveland to Port Columbus was cleared for take off when an Embraer 145 being operated by ExpressJet on another scheduled Continental Express passenger flight from Cleveland to Kansas City was about to cross the same runway in accordance with its ATC clearance in normal daylight visibility. The conflicting clearances were resolved by flight crew awareness and action rather than ATC intervention and once satisfied that the E145 was holding position clear of the runway, the DHC8 took off as already cleared.

Investigation

An Investigation was carried out by the National Transportation Safety Board (USA) (NTSB). It was established that On the Job Training (OJT) was taking place in respect of the TWR controller position involved - the “Local Controller”. The Airport was using 24L and 24R for take off and 24L for landings. The trainee instructed the DHC8 to taxi into position and hold on the approach end of runway 24L. The Embraer 145, which had been cleared to taxi towards runway 24R via taxiways J and S was directed to hold short of runway 24L by the GND controller and instructed to change to and monitor the TWR frequency which the departing DHC8 was working. Shortly after instructing the DHC8 to taxi into position and hold, the TWR trainee cleared the E145 to cross runway 24L, advising that the DHC8 was awaiting clearance for a full length departure. After a similar short interval, the trainee cleared the DHC8 for take off and the clearance was acknowledged. The 145 crew immediately called saying “we’re holding short of 24L you gave a clearance to cross though”. There was no response from the trainee and no other transmissions on the frequency until the 145 queried for a response 10 seconds later and was then told by the trainee to “just hold there please”. The DHC8 then took off.

KCLE Airport Diagram

Probable Cause was determined as “the local controller did not visually scan the runways and ensure that the E145 had crossed runway 24L prior to issuing a takeoff clearance to the DH8, did not ensure separation between the two airplanes, and did not cancel takeoff clearance for the DH8 in a timely manner”.

The Final Reports were adopted on 6 May 2010 and may be seen in full at SKYbrary bookshelf: NTSB OPS09IA009A and NTSB OPS09IA009B

No Safety Recommendations were made.

Further Reading

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