Investigation Summary
The incident occurred during a period of complex operations where the airport used two separate local controllers, East (LCE) and West (LCW), managing different intersecting runways. The LCW, responsible for Runway 15R, followed proper protocol by requesting a release for the Aer Lingus A330 from the LCE, who controlled the intersecting Runway 9. Although the LCE granted this release at 19:38:24, he subsequently cleared US Airways 1170 for takeoff on Runway 9 only 46 seconds later. The LCE later admitted to investigators that he was busy coordinating multiple aircraft and forgot about the release he had granted to the LCW. The US Airways crew saved the lives of all 448 people on board both aircraft when the First Officer noticed the A330 rotating ahead of them. By pushing the control column forward and delaying their own rotation, they ensured the A330 passed over them with minimal vertical separation before they performed their own takeoff from the remaining runway.
Final Conclusions
The National Transportation Safety Board determined the probable cause was the local east controller's failure to follow FAA Order 7110.65, para 3-9-8 and Boston Tower Order 7110.11J, Standard Operating Procedures. This failure resulted in the simultaneous clearance of two transport category aircraft on intersecting runways. The FAA categorized the event as a Category A runway incursion, the most serious level short of a collision.
Video Analysis
How One Mans Quick Thinking Saved 381 Lives — A detailed breakdown of the 2005 Logan Airport runway incursion, featuring the quick actions of the US Airways crew that prevented a disaster.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
US Airways USA1170 — Boeing 737-3B7 · N394US
Aer Lingus EIN132 — Airbus A330-301 · EI-ORD
Crew Experience
Captain
US Airways pilot, age 49, Male. Last FAA medical Dec 1, 2004.
First Officer
US Airways pilot who recognized the conflict, age 34, Male. Last FAA medical Oct 1, 2004.
Systems & Failure Modes
Intersecting Runway Separation
Procedures requiring controllers to ensure a departing aircraft has passed the intersection or crossed the departure runway before another aircraft begins its takeoff roll on an intersecting path.
Flight Data Recorder (FDR)
Both aircraft had their FDRs removed and analyzed by the NTSB to determine the exact timing and proximity of the two jets during the incursion.
Interesting Facts
- 01The FAA categorized the incident as a Category A runway incursion, indicating a narrow avoidance of collision.
- 02The US Airways co-pilot pushed the control column forward to prevent premature rotation while traveling at approximately V1 speed.
- 03The two aircraft were operating on different radio frequencies, preventing the crews from hearing each other's takeoff clearances.
- 04The Local East Controller was distracted by the need to sequence a Delta Shuttle flight behind the US Airways aircraft.
Safety Actions & Advisories
Boston Tower Notice 7110.6
Implemented June 29, 2005, requiring controllers to flip departure strips upside down once a release is authorized to provide a visual reminder of the pending operation.
Boston Tower Notice N7110.17
Mandated that Runway 15R departures must be cleared within 5 seconds of release or the release becomes void, and required 'Rolling Reports' to confirm aircraft movement.