Serious incident Bombardier CRJ-900LR N316PQ, Wednesday 27 January 2016
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Date:Wednesday 27 January 2016
Time:08:04 LT
Type:Silhouette image of generic CRJ9 model; specific model in this crash may look slightly different    
Bombardier CRJ-900LR
Owner/operator:Endeavor Air, opf Delta Connection
Registration: N316PQ
MSN: 15316
Year of manufacture:2014
Fatalities:Fatalities: 0 / Occupants:
Other fatalities:0
Aircraft damage: None
Category:Serious incident
Location:Detroit-Metropolitan Wayne County Airport, MI (DTW/KDTW) -   United States of America
Phase: Take off
Nature:Passenger - Scheduled
Departure airport:Detroit-Metropolitan Wayne County Airport, MI (DTW/KDTW)
Destination airport:Norfolk International Airport, VA (ORF/KORF)
Investigating agency: NTSB
Confidence Rating: Accident investigation report completed and information captured
Narrative:
Delta flight 3860, a CRJ-900 operated by Endeavor Air, was involved in a Cat B runway incursion at Detroit-Metropolitan Wayne County Airport, MI (DTW).

The Local Northwest (LNW) controller cleared Ops 373 (O373), an airport ops vehicle, to drive on runway 22L to conduct a routine inspection. About 90 seconds prior to the incident, and while O373 was operating on the runway, the LNW and Local Northeast (LNE) positions were combined and the LNE controller assumed all LNE and LNW duties. The LNW and LNE controllers conducted a required position relief briefing but did not conduct the briefing at the relieved position in accordance with standard operating procedures.

During the position relief briefing, the LNW controller informed the LNE controller that O373 was driving on runway 22L and at about the same time, Endeavor Air (FLG3860), a CRJ 900, transmitted on the frequency they were ready for departure on runway 22L.

About four seconds after completion of the position relief briefing, at 0802:44, the LNE controller instructed FLG3860 to line up and wait on runway 22L and at 0803:46 cleared FLG3860 for takeoff. About 20 seconds later the Airport Surface Detection System – Model X (ASDE-X) alerted indicating the runway was occupied by both FLG3860 and O373. The LNE controller instructed FLG3860 to "…abort takeoff" and instructed O373 to exit the runway. Both complied with the instruction. ASDE-X data indicated the closest proximity between FLG3860 and O373 was about 211 feet.

The relieved LNW controller did not conduct a required two-minute overlap upon completion of the position relief briefing in order to monitor and review the position to ensure that nothing had been overlooked or incorrectly displayed.

At the time of the incident, the tower was staffed with four personnel; one combined LNE/LNW controller, one combined ground northeast/ground northwest controller, one flight data/clearance delivery controller, and one controller in charge.

Probable Cause:
The local controller's failure to visually scan and ensure that the runway surface was not occupied by a vehicle or other aircraft before issuing a takeoff clearance to the pilot. Contributing to this incident was the relieved controller's failure to monitor and review the position, after completing the relief briefing, to ensure that nothing had been overlooked.

Accident investigation:
cover
  
Investigating agency: NTSB
Report number: OPS16IA002
Status: Investigation completed
Duration: 4 years and 2 months
Download report: Final report

Sources:

NTSB OPS16IA002

Location

Revision history:

Date/timeContributorUpdates
01-Apr-2023 13:36 ASN Update Bot Added

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