BOEING 737-900ERDelta Air Lines
Queens, NY, USA · 2023-01-14·N914DU
What happened
NTSB summary, verbatimOn January 13, 2023, about 2044 eastern standard time, the flight crew of American Airlines (AAL) flight 106, a Boeing 777-200, N754AN, crossed runway 4L on taxiway J without air traffic control (ATC) clearance at John F. Kennedy International Airport (JFK), Queens, New York, causing the flight crew of Delta Air Lines (DAL) flight 1943, a Boeing 737-900, N914DU, to abort their takeoff roll on runway 4L. None of the 6 crew and 153 passengers on DAL1943, nor the 12 crew and 137 passengers on AAL106, were injured, and there was no damage to either airplane. AAL106 operated as a Title 14 Code of Federal Regulations (CFR) Part 121 scheduled international passenger flight from JFK to London Heathrow International Airport (LHR), London, United Kingdom. DAL1943 was a CFR Part 121 scheduled international passenger flight from JFK to Santo Domingo (SDQ), Dominican Republic. Night visual meteorological conditions prevailed at the airport at the time of the incident.
Photographs
1the aircraft, and what the investigators foundProbable cause
the Board's determinationThe American Airlines flight 106 (AAL106) crew’s surface navigation error due to distractions caused by their performance of concurrent operational tasks during taxi, which resulted in a loss of situational awareness. Contributing to the incident was the air traffic control tower team’s nondetection of the AAL106 crew’s deviation from taxi instructions while performing concurrent operational tasks; the timing of the runway status light system, which activated too late to prevent the AAL106 crew from crossing the runway hold short line; and American Airlines’ lack of adequate risk controls to prevent concurrent flight crew tasks from leading to distraction, loss of situational awareness, and deviation from an authorized taxi clearance. Reducing the severity of the incident, and likely preventing an accident, was the activation of the ASDE-X warning in the air traffic control tower and the local controller’s prompt cancellation of DAL1943’s takeoff clearance.
Occurrence sequence
3 stepsNTSB coding · CICTT taxonomy- 1 · TakeoffRunway incursion veh/AC/persondefining event
- 2 · Takeoff-rejected takeoffRunway incursion veh/AC/person
- 1 · TaxiRunway incursion veh/AC/persondefining event
Findings
10 causal · 2 contributing- CAUSEPersonnel issues › Action/decision › Action › Incorrect action performance — Flight crew
- CAUSEPersonnel issues › Psychological › Attention/monitoring › Task monitoring/vigilance — Pilot of other aircraft
- CAUSEPersonnel issues › Psychological › Attention/monitoring › Task monitoring/vigilance — Flight crew
- CAUSEPersonnel issues › Action/decision › Action › Incorrect action performance — Pilot of other aircraft
- CAUSEPersonnel issues › Action/decision › Action › Lack of action — ATC personnel
- CAUSEPersonnel issues › Action/decision › Action › Lack of action — ATC personnel
- CAUSEEnvironmental issues › Operating environment › Airport facilities/design › Runway lighting — Timing of related info
- CAUSEEnvironmental issues › Operating environment › Airport facilities/design › Runway lighting — Timing of related info
- CAUSEOrganizational issues › Support/oversight/monitoring › Safety programs › Adequacy of safety program — Operator
- CAUSEOrganizational issues › Support/oversight/monitoring › Safety programs › Adequacy of safety program — Operator
- FACTORAircraft › Aircraft systems › Indicating/recording systems › Data recorders (flight/maint) — Design
- FACTORAircraft › Aircraft systems › Indicating/recording systems › Data recorders (flight/maint) — Design
Safety recommendations
8 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Encourage Title 14 Code of Federal Regulations Part 91K, 135, and 121 operators to incorporate into their standard operating procedures a procedural crosscheck that requires flight crews to verbalize the number of a runway they are about to cross, as indicated by runway signs, unless an installed automated system already provides an aural advisory.
TO THE FEDERAL AVIATION ADMINISTRATION: Encourage Title 14 Code of Federal Regulations Part 121 operators to use their safety management system to identify flight crew surface navigation errors resulting from the performance of concurrent tasks during taxi and develop and implement effective risk mitigation strategies considering human factors principles.
TO THE FEDERAL AVIATION ADMINISTRATION: Collaborate with aircraft and avionics manufacturers and software designers to develop the technology for a flight deck system that would provide visual and aural alerts to flight crews of traffic on a runway or taxiway and traffic on approach to land. (Supersedes A-00-66)
TO THE FEDERAL AVIATION ADMINISTRATION: Require that the technology developed in response to Safety Recommendation A-24-4 be installed in all newly certificated transport-category airplanes. (Supersedes A-00-66)
TO THE FEDERAL AVIATION ADMINISTRATION: Require that existing transport-category airplanes be retrofitted with the technology developed in response to Safety Recommendation A-24-4. (Supersedes A-00-66)
TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate the effectiveness of the activation logic for the runway status light system considering the circumstances of this incident.
TO THE FEDERAL AVIATION ADMINISTRATION: Using the findings of the evaluation conducted in response to Safety Recommendation A-24-7, update the runway status light system activation logic as necessary to improve system effectiveness.
TO THE FEDERAL AVIATION ADMINISTRATION: Require retrofit of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last 25 hours of audio. (Supersedes A-18-31)
Sequence of events
5 timed eventsfrom the FDR factual report · claude-sonnet-5- 20:44:15 ESTTakeoff sequencep.6Start of FDR data window recorded during the incident
- Between 20:44:15 and 20:45:15 ESTTakeoffp.6Delta airplane pressed the TOGA switch
- Between 20:44:15 and 20:45:15 ESTTakeoff rollp.7Delta airplane reached a maximum computed airspeed of about 105 knots
- Between 20:44:15 and 20:45:15 ESTTakeoff abortp.6Delta airplane aborted the takeoff sequence
- 20:45:15 ESTPost-abortp.6End of FDR data window recorded during the incident
NTSB analysis
from the final reportOn January 13, 2023, about 2044 eastern standard time, the flight crew of American Airlines (AAL) flight 106, a Boeing 777-200, N754AN, crossed runway 4L on taxiway J without air traffic control (ATC) clearance at John F. Kennedy International Airport (JFK), Queens, New York, causing the flight crew of Delta Air Lines (DAL) flight 1943, a Boeing 737-900, N914DU, to abort their takeoff roll on runway 4L. None of the 6 crew and 153 passengers on DAL1943, nor the 12 crew and 137 passengers on AAL106, were injured, and there was no damage to either airplane. AAL106 operated as a Title 14 Code of Federal Regulations (CFR) Part 121 scheduled international passenger flight from JFK to London Heathrow International Airport (LHR), London, United Kingdom. DAL1943 was a CFR Part 121 scheduled international passenger flight from JFK to Santo Domingo (SDQ), Dominican Republic. Night visual meteorological conditions prevailed at the airport at the time of the incident.