NTSB Identification: OPS09IA001A
Incident occurred Monday, September 22, 2008 in Peoria, IL
Probable Cause Approval Date: 02/19/2009
Aircraft: , registration:
NTSB investigators used data provided by various sources and may not have traveled in support of this investigation to prepare this aircraft incident report.
On Monday, September 22, 2008 at 1750 central daylight time, Skywest (SKW) flight 5961, a Canadair Regional Jet (CRJ-200), and American Eagle (EGF) flight 4075, an Embraer ERJ-145 (E145) were cleared to land simultaneously on intersecting runways at the Greater Peoria Regional Airport (PIA) in Peoria, Illinois. The air traffic control tower operator that cleared the two aircraft to land was a position certified developmental controller working local control (LC). EGF4075, number 1 in the landing sequence, on a visual approach to runway 22, rejected the landing clearance stating he was too high and requested a 360 degree turn on final. The LC disapproved the request due to aircraft that were following and directed EGF4075 to enter a right downwind for runway 13. At 1747:45, LC cleared SKW5961, on a visual approach, to land on runway 22 when the flight was four miles from the landing threshold. At 1748:09, LC cleared EGF4075 to land on runway 13 and advised that a regional jet was on a three mile final for runway 22.
At 1749:45, SKW5961 was on landing rollout and LC asked if they could hold short of runway 13. The crew advised they could. The LC directed SKW5961 to hold short of runway 13 for landing traffic. SKW5961 did not acknowledge the hold short instructions. Five seconds later SKW5961 transmitted "Well almost, uh, but uh, we're here what do you want us to do". The LC directed SKW5961 to hold short of runway 13, because of landing traffic. SKW 5961 responded; "We're kind of technically on the runway [runway 22] but there's plenty of room for a small plane". SKW5961 had stopped short of runway 22 on runway 13 just past old land and hold short (LAHSO) markings on runway 13.
The pilot of SKW5961 assumed the LASHO markings on runway 13 was the hold short point for the intersection of runways 13 and 22. LAHSO is an acronym for "Land and Hold Short Operation." These operations include landing and holding short of an intersecting runway, a taxiway, a predetermined point, or an approach/departure flightpath. A LAHSO hold short point is a point on the runway beyond which a landing aircraft with a LAHSO clearance is not authorized to proceed. This point may be located prior to an intersecting runway, taxiway, predetermined point, or approach/departure flight path. The LAHSO markings on runway 13 are 235 feet from the edge of runway 22. PIA is not a LASHO airport even though LASHO markings are maintained by the airport authority. The PIA air traffic manager, at PIA for approximately one year, was not ware of when PIA ceased LAHSO operations. According to the PIA ATCT Order 7110.1B, Peoria Air Traffic Control (ATC) Facility Standard Operating Procedures (SOP), reference to LAHSO were removed in November 2001.
After SKW5961 reported they were technically on runway 22, the LC directed the pilot to hold his position. At 1750:42 LC instructed EGF4075 to exit runway 13 at taxiway M, 1900 feet from the intersection of runway 13 and runway 22, followed shortly thereafter with instructions to SKW5961 to turn right onto runway 31 and turn right onto taxiway M.
The LC, stated that he believed that SKW5961 would exit runway 22 at taxiway E and that EGF4075 would fly a longer downwind leg of the traffic pattern. This belief resulted in the LC clearing EGF4075 to land on runway 13 prior to having assured separation between aircraft landing on intersecting runways. When the LC realized that separation would be close, he observed SKW5961 stopped on runway 22 short of runway 13 and believed separation was assured. When SKW5961 advised they were technically on runway 13, the LC considered it safer to allow EGF4075 to land rather direct a go around considering the critical phase of flight EGF4075 was in at the time. The controller-in-charge (CIC) was working combined positions that included ground control, flight data, and clearance delivery and stated that he did not perceive a situation developing that would have resulted in a loss of separation.
Per FAA Order 7110.65, Air Traffic Control, Paragraph 3-10-4, Intersecting Runway Separation: "Issue traffic information to each aircraft operating on intersecting runways. a. Separate an arriving aircraft using one runway from another aircraft using an intersecting runway or a nonintersecting runway when the flight paths intersect by ensuring that the arriving aircraft does not cross the landing threshold or flight path of the other aircraft until one of the following conditions exists:
1. The preceding aircraft has departed and passed the intersection/flight path or is airborne and turning to avert any conflict.
2. A preceding arriving aircraft is clear of the landing runway, completed landing roll and will hold short of the intersection/flight path, or has passed the intersection/flight path."
Tower staffing included four controllers: LC, and another controller working ground control, flight data, clearance delivery, and controller-in-charge (CIC) positions combined. Two controllers were on break.
The weather at PIA at 1754 was wind 130 at 04 knots, visibility 10 statute miles, few clouds at 6500 feet, broken clouds at 10,000 feet, temperature 27 degrees Celsius, dew point 16 degrees Celsius, altimeter 30.26 inches of mercury. Sunset occurred at 1807. The runways were dry.
The National Transportation Safety Board determines the probable cause(s) of this incident to be: The tower local controller's failure to provide adequate separation between EGF4075 and SKW5961 that landed on intersecting runways. Full narrative available
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