N71Beech 300 · 1988

On April 21, 2010, at 2153 central daylight time, an operational error occurred at the Chicago O’Hare International Airport (ORD) Air Traffic Control Tower involving American Eagle flight 3962 (EGF3962), an EMB-135, and Flight Check 71 (FLC71), a KingAir 300. EGF3962 had just departed from runway 9R at ORD and was instructed to turn right to heading 140. FLC71 was operating under visual flight rules and inspecting the runway 32R instrument landing system. At the time of the incident, FLC71 was tracking the runway 32R localizer inbound to the airport at 2,200 feet. EGF3962 was operating under instrument flight rules on a scheduled 14 Code of Federal Regulations part 121 passenger flight to Little Rock, Arkansas. There was no damage reported to either aircraft, and no injuries to passengers or crew.

EGF3962 was instructed to taxi into position and hold on runway 9R at 2151:02, and was cleared for takeoff at 2151:26. The pilot was instructed to fly heading 140 after departure. At 2152:51, there was a coordination call from Chicago TRACON to the North Local Controller position confirming that the North Local controllers were aware that FLC71 was inbound on the runway 32R final approach course. At 2153:14, the North Local controller transmitted a traffic advisory to EGF 3962, stating "Eagle 3962 traffic ahead and to the right is a King Air on a final for runway 32R he’s at 2200.” There was no response from the crew. At 2153:27, the North Local controller transmitted, “Eagle 3962?”, and the crew of EGF 3962 replied, "Yeah traffic’s in sight." At 2153:39, the North Local controller instructed EGF 3962 to turn right heading 180 and the crew acknowledged, stating “All right sir turn right to heading 180 Eagle 3962 we had a [traffic collision avoidance system -TCAS] resolution advisory.” The controller replied, “Thank you - that was a VFR King Air, Eagle 3962.” The crew responded,”…3962 we had him we were following an RA on the TCAS.” At 2154:02, the controller transmitted, "Eagle 3962 come back to heading of 140" and the crew acknowledged. At 2154:35, EGF3962 was instructed to contact departure.

There was training in progress on the North Local position at the time of the incident.

Radar Data

Review of radar data showed that at closest point of approach, the two aircraft were 0.41nm apart laterally and 300 feet vertically. Following the incident, FLC71 continued inspection of the airport navigational aids and EGF3962 continued to Little Rock.

Personnel Interviews

North Local Trainee

The controller being trained on the North Local position entered on duty with the FAA in September 2006 at Las Vegas, Nevada, was fully certified at Las Vegas, and transferred to O'Hare in February 2009. He was certified on the clearance delivery, flight data, ground metering, and inbound and outbound ground control positions. He stated that operations at the North Local position were normal, and he was having no trouble seeing aircraft from the control position.

The trainee knew that FLC71 was going to be conducting operations on or near various runways around the airport, and that he was to protect for the operation. The instructions were to have aircraft departing runway 9R continue on a 090 heading when it was necessary to do so to avoid the flight check aircraft.

An American Airlines flight departed runway 9R, and the trainee controller recalled that someone, probably his instructor, had told him that the American aircraft should be the last flight issued a 140 heading off the ground. EGF3962 was the next departure from runway 9R, and the trainee mistakenly also issued the pilot a 140 heading. The instructor was sitting next to him at the time, but apparently did not hear the incorrect heading being issued. The trainee stated that he was sure the instructor did not hear the clearance, because if he had he would have corrected it. The trainee could not specifically recall what the instructor was doing at the time, but said that the instructor may have been talking with another controller about FLC71.

After EGF3962 took off, the aircraft turned to a 140 heading. The instructor noticed the turn, and asked the trainee where the aircraft was going. He then instructed the trainee to issue traffic advisories to the pilots. Their biggest concern at that point was for the two pilots to be aware of each other because of the impending conflict.

The trainee stated that when issuing a takeoff clearance he normally scans the runway, then the ASDE-X display, and then the tower radar display. He did so when he issued departure clearance to EGF3962, but he overlooked FLC71 on the runway 32R final approach course even though there was a data tag on the aircraft's target. He said he checked the runway for traffic and checked the other "normal" conflict areas, but missed the traffic inbound to runway 32R, possibly because it was a "weird operation."

The trainee stated that he first realized there was a problem when he saw EGF3962 off the departure end of the runway and beginning to turn. He stated that he and the instructor were "shaken up" after the event. The trainee did recognize that there had been a loss of separation and that the incident may have been an operational error. He left any discussions about the incident and the possible loss of separation up to his instructor.

The trainee stated that he did not file an Air Traffic Safety Action Program (ATSAP) report because he did not believe it was necessary. However, he noted that if yet been certified on the position and it had been “...his ticket," he would have done so for protection. The trainee was uncertain whether there was a local requirement for controllers to report resolution advisories when they occur, but he believed that the management was required to report resolution advisories when they become aware of them.

North Local Instructor

The instructor entered on duty with the FAA in May 1989. He worked at St. Louis (STL) Flight Service, STL TRACON, Columbia tower, Meigs tower, and Midway tower before coming to ORD in 2000. He became fully certified in the tower in 2002.

The instructor stated that the only unusual operational condition was the presence of the flight check aircraft around the airport. The supervisor on duty briefed the controllers that FLC71 would be following the localizer inbound to runway 32R, then breaking the approach off and heading east. The South Local controller and the East Arrival controller at the TRACON also passed along information about what FLC71 was planning to do. The instructor stated that the phone calls only verified what he had already been told by the supervisor. He was aware of FLC71’s position and what the general plan was.

The instructor stated that he had instructed the trainee to discontinue the use of the 140 departure heading after the American Airlines flight took off. The trainee seemed to understand, and the instructor thought they had a common understanding of the traffic situation. The instructor then became occupied with coordination (possibly a phone call from the South Local controller relaying information from the approach control about FLC71) and did not hear the incorrect heading assignment.

The instructor recalled that when EGF3962 lifted off, the aircraft turned right and ended up nose to nose with FLC71 inbound on the runway 32R localizer. The instructor told the trainee to issue traffic advisories to the pilots, and as the aircraft passed each other the instructor amended the 140 heading to heading 180 in order to increase the spacing between them. They had to issue the traffic advisories twice because the pilot of EGF3962 did not acknowledge the first call. The instructor stated that he saw the conflict out the window and noted that, "...it didn’t look as bad as it did on the radar."

The instructor stated that when he detected the conflict, his intention was to try to establish visual separation between the two aircraft. However, the event happened so fast that he and the trainee were unable to complete the steps before the conflict occurred. Asked if he thought the incident was an operational error, the instructor responded that he had “messed up” and that the outcome was not as planned. He did not hear the incorrect 140 heading, and then had to backtrack to try to establish some form of legal separation.

The instructor stated that he did not file an ATSAP [Air Traffic Safety Action Program] report at the time of the incident because he did not believe that he “needed to”, that is, he did not think he needed any protection at that point. He did file a report later when the operational error came to light, and now understands that there was a loss of separation between the two aircraft.

After the incident, the instructor did talk to the supervisor about what happened, explaining that EGF3962 had been given an erroneous heading, a resolution advisory had occurred with FLC71, and that he had both aircraft in sight when the conflict occurred. He was unsure what, if any, followup actions she took. His remarks were based on concern about what had occurred, and he did not intend to imply that separation existed throughout the event.

East Arrival Controller

The East Arrival controller entered on duty with the FAA in September 1990, after seven years as an Air Force tower and radar controller. He was initially assigned to Moline, Illinois, and Cedar Rapids, Iowa, before transferring to to Chicago TRACON in April 2006.

On the night of the incident, he was assigned to the East Arrival position to monitor the operations of FLC71. He had no other traffic. FLC71 had been operating around the airport for approximately 30 minutes, including operations to runway 10, flight checking an arc around the airport, and then beginning operations along the localizer for runway 32R. Most of the arrival operations on the airport were using runway 4L, while departures were using runway 9R. FLC71 was checking the localizer and glideslope for runway 32R, and was making multiple passes inbound on the localizer.

The group's review of the ARTS Retrack replay showed that the East Arrival controller was quick-looking (visually monitoring) the data blocks for aircraft on approach to runway 4R, but was not quick-looking the departure traffic off runway 9R. Asked why the difference, the East Arrival controller stated that he was aware of the departure traffic and was monitoring the limited data blocks. When the American Airlines aircraft that departed before EGF3962 took off, he had brought up a data block for the flight and made a traffic call. Asked why he did not handle EGF3962 the same way, he said that he saw the EGF aircraft but did not force up a data block because FLC71 was in the turn and the tower was supposed to resolve the conflict.

When the conflict alert activated, the East Arrival controller believed that the conflict was being resolved because FLC71 was turning away from EGF3962. He did not call to ask what the tower was doing. The East Arrival controller stated that he did not issue a traffic advisory because FLC71 was in the turn and anything he would have said to the aircraft would not have been useful. The flight check pilot could not see through the belly of the plane. Asked if he saw the conflict coming, the controller stated that not all of the departures were cleared to fly 140 headings, and there was not an automatic assumption that the traffic was going to turn southeast. The tower was supposed to miss the inbound traffic, and the East Arrival controller stated that if he had taken any action it could have aggravated the situation. He also restated his belief that a traffic call would not have accomplished anything.

Asked if he considered telling FLC71 to continue inbound instead of turning outbound, he stated that the aircraft was already in the turn and having him turn back would have made it worse. In retrospect, if faced with the same situation he might handle it differently.

Coordination for the flight check operation was initially handled between the tower and TRACON supervisors. The additional coordination between himself and the tower controller that occurred just before the incident was a reminder call about what had already been agreed to by the supervisors.

Asked what separation was being applied during the event, the East Arrival controller stated, “Obviously none – but once the FLC aircraft turned the aircraft were diverging.” He was unsure whether the tower was applying separation from their end. He said that when the event occurred, everyone in the room “yelled” – they seemed to be aware of it. He does not recall any specific conversation with the TRACON supervisor about the event. She was busy with a variety of tasks and may not have been aware of what had occurred.

Tower Supervisor

The tower supervisor entered on duty with the FAA in November 1982. Before coming to O'Hare, the supervisor worked at control towers at Philadelphia, Teterboro, and LaGuardia. She came to O'Hare in May 1990.

When notified about the planned flight check operations, the tower supervisor contacted the approach control supervisor to develop a plan for how to handle the aircraft. The conversation did not result in a clear answer, so the tower supervisor decided that it would be best for the tower controllers to maintain awareness of the flight check aircraft's position and work around it as necessary. She briefed the controllers about the flight check operation.

The normal practice at ORD was to go to a single runway operation late in the evening as traffic demand fell. There was some discussion about discontinuing the use of runway 9R, but there were more aircraft waiting to depart so the tower continued to use 9R along with runway 32L in order to minimize delays. EGF3962 was the last departure from runway 9R.

The supervisor first became aware that there had been a problem when she heard the South Local controller loudly say that something, “…didn't look very good.” She overheard the controllers at the North Local position issuing traffic but she did not directly observe the conflict either on the radar or through the window. A few minutes after the incident occurred, the instructor described it to her, noting that the North Local controllers had both aircraft in sight during the conflict and had pointed out the traffic. He also stated that it was "not a good operation" and that he was sorry it happened. She does not remember if he mentioned a resolution advisory having occurred during that discussion, nor does she remember whether the controllers said that they had applied visual separation during the incident or simply said they had the aircraft in sight.

She did not look into the incident any further, log it for a quality assurance review, or discuss it with anyone else that evening. The incident occurred because the controllers turned EGF3962 prematurely. At the time she thought that separation existed because the traffic was a VFR King Air and the controllers had applied visual separation. The supervisor could not explain her decision not to log the incident, except to say that it seemed to have been resolved.

She next heard about the incident on approximately May 6 when she came to work. A manager asked to review the incident with her and showed her a replay of it. After watching the replay, her assessment was that it "wasn’t a great operation," but she knew that before she saw the replay.

Asked if she believed that the incident constituted an operational error, the tower supervisor said that she did not pass judgment on whether it was or not. Since the incident occurred the facility has reported it as an operational error. Asked if she agreed with that, the supervisor responded, "...I can’t say that I have a real good handle on what they call operational errors and what they don’t.” There are many different considerations that determine whether a particular incident is reported as an operational error. She said that she recognized that this was a bad operation, and she also recognized what would have made it a good operation. They had a plan for how to handle FLC71, and she was uncertain what happened to interrupt the plan. Communications appeared to have broken down.

Asked if she would handle the incident the same way now, the supervisor stated that she would ensure that all coordination between the tower and approach control goes through the supervisors, and she would likely want the flight check aircraft to be on the tower frequency while operating in the tower's airspace. Because she was the only supervisor on duty at the time, she was required to move all around the tower cab to monitor the operation and had to spend some time in the center of the cab at the supervisor’s desk taking phone calls. This kept her away from the operational positions and reduced her ability to monitor what was going on.

TRACON Supervisor

The TRACON supervisor entered on duty with the FAA in 1987, subsequently working at Boston Center, Worcester Tower, and Manchester Tower. She transferred to Chicago TRACON in October 1995, and became a supervisor in May 2009. At the time of the incident involving FLC71, she was the only supervisor on duty in the TRACON.

The TRACON supervisor coordinated FLC71’s approaches to runway 32R with the ORD supervisor, and also coordinated handling of departures from runway 4L. There was no specific coordination about the handling of flights departing runway 9R. She did not talk directly to the local controllers at ORD.

The TRACON supervisor assigned a controller to work the East Arrival position and handle FLC71. There was no other traffic for East Arrival – all he was expected to do was monitor FLC71 and provide assistance as necessary; vectoring, directing the flight, issuing traffic advisories, and coordinating when needed. The expectation was that ORD would be providing separation between departing flights and FLC71 as coordinated. There should have not been any conflicts that the East Arrival controller would need to work out. In the event of a conflict, the supervisor's expectation was that the East Arrival controller would act as necessary to resolve it by issuing traffic and doing what was needed to avoid a bad situation.

The TRACON supervisor stated that her first knowledge of the incident involving FLC71 came about a week after it occurred. Asked about the East Arrival controller's statement to the effect that “everyone yelled” when the conflict occurred, the supervisor said that she was heavily occupied with various tasks and did not realize what had taken place. If she had known, she would have addressed it and/or logged it for quality assurance review. She did not remember anything unusual being called out, nor did any of the controllers bring the event directly to her attention. Someone should have advised her of the incident. It would be unlike the East Arrival controller to not notify the supervisor of a serious incident. He might have said something over his shoulder about what had happened without specifically addressing her, but if he did, she missed it. There were no subsequent contacts from ORD regarding the incident.

The TRACON supervisor stated that she conducted crew briefings every week. She noted that incident reporting requirements have come up several times over the past year, and controllers should have high awareness of those requirements. Since the incident, reporting requirements have again been provided to controllers in the local equivalent of the read and initial binder.

When interviewed, the TRACON supervisor had not yet discussed the incident with the East Arrival controller, although she was his supervisor. Her evaluation of the event was that it was “…an ugly situation,” but she thinks the only thing the East Arrival controller did wrong was not issue a traffic advisory. She will stress to him that there needs to be a traffic advisory given in such situations.