NTSB Identification: NYC89IA028A.
The docket is stored on NTSB microfiche number 39509.
Scheduled 14 CFR (D.B.A. PAN AM SHUTTLE, INC. )
Incident occurred Sunday, November 13, 1988 in BOSTON, MA
Probable Cause Approval Date: 10/20/1992
Aircraft: BOEING 727-227, registration: N555PE
Injuries: 144 Uninjured.

NTSB investigators used data provided by various sources and may not have traveled in support of this investigation to prepare this aircraft incident report.

THE TOWER CONTROLLER CLEARED PAN AM FLT 543 (BOEING 727, N555PE) INTO POSITION & HOLD ON RWY 22R, THEN HE CLEARED THE 727 FOR TAKEOFF. THE CONTROLLER THEN CLEARED PRECISION FLT 649 (DORNIER DO-228, N238RP) INTO POSITION & HOLD ON RUNWAY 22R. THE CONTROLLER DID NOT REALIZE THE DORNIER WAS AT AN INTERSECTION, 4200 FT DOWN THE RUNWAY, RATHER THAN AT THE APPROACH END. HE HAD FAILED TO NOTICE THAT THE TAKEOFF STRIP WAS MARKED WITH A RED 'T' INDICATING AN INTERSECTION TAKEOFF. ALSO, THE GROUND CONTROLLER DID NOT ADEQUATELY COORDINATE WITH THE LOCAL CONTROLLER, WHEN HE CLEARED THE DORNIER TO TAXI TO THE INTERSECTION FOR AN INTERSECTION DEPARTURE. THE 727 FLIGHT CREW SAW THE DORNIER ON THE RUNWAY & MADE AN EARLY ROTATION, MISSING THE DORNIER. THERE WAS NO CONTACT BETWEEN AIRCRAFT OR INJURIES. THE 727 FLT CREW RETURNED FOR A LANDING TO CHECK THE ENGINES, WHICH HAD BEEN OVERBOOSTED AFTER MAXIMUM POWER WAS APPLIED TO CLEAR THE DORNIER. THE DORNIER WAS TAXIED CLEAR OF THE RUNWAY & BACK TO THE RAMP TO ASSURE THERE WAS NO DAMAGE.

The National Transportation Safety Board determines the probable cause(s) of this incident to be:

FAILURE OF THE LOCAL CONTROLLER TO DETECT THE RED T ON THE DEPARTURE STRIP ON PRE659 WHEN HE CLEARED HIM INTO POSITION AND HOLD. FACTORS RELATED TO THE ACCIDENT WERE: DARKNESS AND THE LACK OF POSITIVE COORDINATION BETWEEN THE GROUND CONTROLLER AND LOCAL CONTROLLER.

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