NTSB Factual Report

On June 9, 2005, about 1940 eastern daylight time, an Airbus A330-301, Irish registration EI-ORD, operated by Aer Lingus as flight 132 (EIN132), and a Boeing 737-3B7, N394US, operated by US Airways as flight 1170 (USA1170) were involved in a runway incursion at General Edward Lawrence Logan International Airport (BOS), Boston, Massachusetts. There were no injures to the 12 crew members, and 328 passengers on the Airbus, or the 5 crew members, and 103 passengers on the Boeing. Neither airplane was damaged. Visual meteorological conditions prevailed and an instrument flight rules flight plan had been filed for both flights. Aer Lingus flight 132 was conducted under the provisions of 14 CFR Part 129, and was destined for Shannon, Ireland. US Airways flight 1170 was conducted under the provisions of 14 CFR Part 121, and was destined for Philadelphia, Pennsylvania.

According to information obtained from the Federal Aviation Administration (FAA), both airplanes were under control of the BOS Air Traffic Control Tower. At the time of the incident, aircraft operating at BOS were landing on runways 4R and 4L, and departing from runways 15R and 9. The BOS Local East Controller (LCE) was responsible for aircraft operating on runways 4R and 9, and the BOS Local West Controller (LCW) was responsible for aircraft operating on runways 15R and 4L. Runway 15R intersected 3 active runways: 4L, 4R, and 9. Because runways 4R and 9 were under the control of the LCE, the LCW was required to obtain a release from the LCE before authorizing departures from runway 15R.

The LCW was responsible for EIN132 and the LCE was responsible for USA1170. Both controllers were utilizing different frequencies. At 1927:51, EIN132 was instructed to taxi into position and hold on runway 15R, a 10,083 foot-long, 150 foot-wide, asphalt runway. At 1938:24, the LCE contacted the LCW and said, "observed and released fifteen right [EIN132]..." At 1939:10, the LCW cleared EIN132 for takeoff from runway 15R. Five seconds later, the LCE cleared USA1170 for departure from runway 9, a 7,000 foot-long, 150 foot-wide, asphalt runway.

The co-pilot of US Airways flight 1170 reported that he had called "V1," and then noticed the Aer Lingus A330 rotating just prior to the intersection of runways 15R and 9. He told the captain to "keep it down," and pushed the control column forward. He further stated:

"The Airbus passed overhead our aircraft with very little separation, and once clear of the intersection, the captain rotated, and we lifted off towards the end of the runway. I reported to departure control that we had a near miss at which time Aer Lingus reported 'we concur.'"

Both airplanes proceeded to their respective destinations without further incident.

Both airplanes were equipped with flight data recorders, which were removed and forwarded to the Safety Board's Vehicle Recorders Division, Washington, D.C. (Information pertaining to the flight data recorder from each airplane, can be found in the associated Flight Data Recorder Specialist's Factual Report, located in the public docket.)

During an interview with a Safety Board air traffic control specialist, the LCE stated he was very busy coordinating with airplanes and other controllers at the time of the incident. After releasing EIN132, he noticed the airplane begin the takeoff roll about 1 minute later. At that same time, he received a release for a Delta Shuttle airplane; however, USA1170 was in front of the Delta airplane, and needed to depart first in order for the Delta flight to get on the runway. He further stated that he cleared USA1170 for takeoff to get the Delta airplane in position for departure, and forgot that he had given the LCW the release for EIN132. (For further information pertaining to Air Traffic Control, please see the Air Traffic Control Group Factual Report, located in the public docket.)

The FAA Runway Safety Office categorized the incursion as a "Category A," which was defined as "Separation decreases to the point that participants take extreme action to narrowly avoid a collision, or the event results in a collision."

Boston Air Traffic Control Tower Standard Operating Procedures (SOPs), required the LCW to utilize the interphone to coordinate the release with the LCE. The SOPs indicated that the LCW will say: "Request release runway 15R, (CALL SIGN)." The LCE should respond: "(CALL SIGN) observed and released runway 15R." Once the aircraft departed 15R, the LCE could resume normal operations without further coordination.

Federal Aviation Administration Order 7110.65, Air Traffic Control, paragraph 3-9-8, Intersecting Runway Separation, stated in part:

"Separate departing aircraft from an aircraft using an intersecting runway, or nonintersecting runways when the flight paths intersect, by ensuring that the departure does not begin takeoff roll until one of the following exists:

a. The preceding aircraft has departed and passed the intersection, has crossed the departure runway, or is turning to avert any conflict.

b. A preceding arriving aircraft is clear of the landing runway, completed the landing roll and will hold short of the intersection, passed the intersection, or has crossed over the departure runway.

c. Separate IFR/VFR aircraft taking off behind a heavy jet/B757 departure by 2 minutes when departing:

NOTE- Takeoff clearance to the following aircraft should not be issued until 2 minutes after the heavy jet/B757 begins takeoff roll.

1. Crossing runways if projected flight paths will cross...."

POST INCIDENT ACTIONS

On June 29, 2005, Boston Tower implemented Notice 7110.6, "Aircraft Releases on Non-Standard Runways." The notice:

A. Reiterated timely release coordination for non-standard runway departures and prohibited the use of any other intersecting runway until the departure from the non-standard runway was no longer a factor.

B. Required that once a release had been authorized, the departure strip(s) of the number one/first aircraft to depart on any intersection runway shall be flipped over and placed upside down in the strip bay until the departure from the non-standard runway is no longer a factor.

C. Required a recorded "Rolling Report" on the aircraft departing the non-standard runway.

On July 19, 2006, Boston Tower Notice 7110.6, was superceded by Boston Tower Notice N7110.17, which stated in part:

"7. Procedures.

a. Only Local Control West (LCW) may initiate a release request for a runway 15R departure.

b. The runway 15R departure must be cleared for takeoff within 5 seconds of release or the release is void.

c. Local Control East (LCE) must not have an aircraft holding in position on Runway 9 when a release is given to LCW.

d. LCW must advise LCE when the Runway 15R departure has passed Runway 9. For example: 'Runway 15R Operation Complete.'...

In addition, BOS airport management established a facility workgroup to explore potential changes to control position jurisdiction to minimize/eliminate distractions caused by multiple aircraft on the movement areas waiting for release times.

NTSB Probable Cause

The local east controller's failure to follow FAA Order 7110.65, para 3-9-8 and Boston Tower Order 7110.11, Standard Operating Procedures, which resulted in a runway incursion during takeoff involving two transport category airplanes.