NTSB Final Report: “Plan Continuation Bias” Led to Envoy Airlines Wrong Runway Landing at O’Hare

The National Transportation Safety Board (NTSB) has published its final report regarding a serious incident involving an Envoy Airlines passenger jet at Chicago O’Hare International Airport (ORD). The investigation concludes that a combination of pilot error, technical mismanagement, and air traffic control (ATC) deficiencies led an Embraer 170 to land on the wrong runway on September 25, 2024.

According to the report, released on February 25, 2026, Envoy Airlines flight 3936 (ENY3936) landed safely on Runway 10L despite being cleared for and assigned to Runway 10C. While no injuries or damage occurred to the aircraft (registration N772MR), the NTSB highlights the event as a significant example of “wrong-surface landing” risks, a top safety priority for federal regulators.

The investigation identifies “plan continuation bias” and “expectation bias” as primary psychological factors that caused the flight crew to continue an unstable approach despite lacking critical instrument guidance.

Sequence of Events: Changing Plans and Cognitive Load

The NTSB investigation details a complex arrival phase where the flight crew faced a rapid series of runway assignment changes. These changes likely contributed to a high cognitive workload and “expectation bias” as the crew prepared for landing.

According to the final report, the crew prepared for four different runways in succession due to shifting weather conditions and airport operations:

• Initial Plan: Runway 27R
• First Update: Runway 9L
• Second Update: Runway 10R
• Final Assignment: Runway 10C

The NTSB noted that this sequence of changes forced the crew to repeatedly reprogram the Flight Management System (FMS) and briefing protocols, setting the stage for the errors that followed.

Technical Mismanagement in the Cockpit

Once cleared for a visual approach to Runway 10C, the crew attempted to back up their visual flight path with an Instrument Landing System (ILS) approach to ensure precision. However, the aircraft’s systems failed to “autotune” the correct ILS frequency for Runway 10C.

In an effort to correct the automation failure manually, the captain tuned the navigation radios himself. The investigation revealed a critical error in this process:

“The flight crew’s decision to continue the approach without the correct ILS frequency in the FMS [Flight Management System].”

The report states that the captain manually tuned 108.4 MHz, which was an incorrect frequency, instead of the required 108.95 MHz for Runway 10C. Furthermore, the second radio was tuned to 113.0 MHz, a VOR frequency that provided no vertical or lateral guidance for the landing. Deprived of valid instrument data to verify their alignment, the crew relied entirely on visual cues and inadvertently lined up with Runway 10L, which runs parallel to their assigned runway.

Air Traffic Control Deficiencies

While the primary error originated in the cockpit, the NTSB assigned significant weight to the failure of Air Traffic Control to intervene. The approach controller observed that Envoy flight 3936 was aligned with Runway 10L rather than the assigned 10C.

Under Federal Aviation Administration (FAA) directives, controllers are required to notify pilots immediately if they observe an aircraft aligning with a wrong surface. However, in this instance, the controller did not issue a safety alert or order a go-around. Instead, the approach controller coordinated with the tower controller responsible for Runway 10L to ensure the strip was clear, effectively allowing the error to proceed to a landing.

The NTSB described this decision as “deficient,” noting that it bypassed critical Safety layers designed to prevent collisions.

“Air traffic control’s failure to notify the flight crew that they were lined up with the incorrect runway contrary to FAA directives.”

Probable Cause and Safety Findings

The Board’s final report formally identifies the probable cause of the incident as the crew’s failure to identify the correct runway, driven by psychological biases.

“The flight crew’s misidentification of the intended landing runway, which resulted in an approach to and landing on the wrong runway due to their planned continuation bias.”

The report emphasizes “plan continuation bias”, a phenomenon where pilots continue with an original plan (landing) despite emerging cues that suggest the plan is no longer safe or valid (such as the failure to receive positive ILS guidance). The NTSB also reiterated that wrong-surface landings remain a “top 5” safety focus for the FAA, noting that while this specific incident ended without damage, similar errors have historically led to near-misses and catastrophic collisions.

AirPro News Analysis

This incident serves as a textbook example of how “Swiss Cheese” failure models manifest in modern Aviation. While the pilots made the initial errors, mis-tuning a radio and visually misidentifying a runway, the safety net that is supposed to catch these errors also failed. The ATC decision to silently accommodate the wrong runway landing rather than correct it suggests a potential normalization of deviance in busy terminal environments.

Furthermore, the “expectation bias” noted by the NTSB highlights the vulnerability of human performance during high-workload phases of flight. When runway assignments change four times in a short window, the mental model of the arrival becomes fragmented. For operators, this underscores the importance of “stopping the line”, or initiating a go-around, when automation (like the ILS autotune) behaves unexpectedly, rather than attempting manual workarounds at low altitudes.

Sources

Sources: NTSB Final Report (ID 195210)

This article summarizes reporting by Fox News and official filings from Southwark Crown Court.

AOG Technics Director Sentenced to Prison for Massive Fake Parts Scheme

A former techno DJ turned aviation parts supplier has been sentenced to four years and eight months in prison for orchestrating a fraudulent scheme that infiltrated the global aviation supply chain with thousands of unverified components. According to reporting by Fox News and court records released this week, Jose Alejandro Zamora Yrala, the founder of AOG Technics, pleaded guilty to fraudulent trading after admitting to selling over 60,000 Commercial-Aircraft parts backed by forged safety documents.

The sentencing at Southwark Crown Court in London marks the conclusion of a scandal that grounded aircraft worldwide and cost the aviation industry an estimated £39.3 million ($53 million). The fraud specifically targeted the CFM56 engine, the most widely used commercial jet engine in the world, raising urgent questions about the vulnerability of regulatory frameworks that rely heavily on paper documentation.

The “Garage” Operation That Fooled the World

Prosecutors revealed that between January 2019 and July 2023, Zamora Yrala operated AOG Technics from his home in Virginia Water, Surrey. Despite presenting the company as a legitimate global supplier, the operation was run almost entirely by Zamora Yrala using a laptop and graphic design software.

According to court findings, the defendant forged Authorised Release Certificates (ARCs), which are critical documents guaranteeing a part’s airworthiness and origin. He utilized two primary methods to deceive buyers:

• Alteration: Modifying genuine certificates from other suppliers to match his inventory.
• Fabrication: Creating entirely fake documents using software to mimic official regulatory forms.

To maintain the illusion of a large-scale enterprise, Zamora Yrala invented fictitious employees, including non-existent sales and quality managers, to sign emails and documents. Prosecutors noted that approximately 90% of the business conducted by AOG Technics was fraudulent, generating £6.9 million ($9 million) in revenue for the firm.

Global Fallout and Safety Risks

The fraudulent parts were primarily small components such as bolts, washers, and seals. While these are not major rotating parts like turbine blades, aviation experts warn that their failure could still lead to significant safety hazards, including oil leaks or engine shutdowns.

The scheme unraveled in 2023 due to the diligence of an engineer at TAP Air Portugal. Suspicious of a part’s documentation, the engineer contacted the manufacturer, Safran, for verification. Safran confirmed the certificate was a forgery, triggering a chain reaction across the industry.

Following the discovery, major regulators including the UK Civil Aviation Authority (CAA), the US Federal Aviation Administration (FAA), and the European Union Aviation Safety Agency (EASA) issued urgent safety alerts. This forced airlines to ground fleets and inspect engines for the suspect parts.

Financial and Operational Impact

The cost of the fraud extended far beyond the purchase price of the fake parts. Airlines including American Airlines, Delta Air Lines, Ryanair, and Ethiopian Airlines were forced to remove aircraft from service to replace components. The total financial damage, covering grounded flights, replacement hardware, and engineering labor, is estimated at £39.3 million.

Judge Simon Picken remarked that the defendant’s actions represented a “more or less complete undermining” of the regulatory framework designed to protect passenger safety.

Defense and Sentencing

During the proceedings, Zamora Yrala’s defense attorney argued that the former DJ did not fully appreciate the catastrophic potential of his actions, suggesting he merely “cut corners.” However, the prosecution emphasized the sophistication of the forgeries and the deliberate nature of the deception over a four-year period.

Ultimately, the court handed down a sentence of four years and eight months. The case has served as a wake-up call for the industry, highlighting how easily a single individual could bypass safety checks that rely on trust and static documentation.

AirPro News Analysis

The Vulnerability of “Paper Trust”

While the sentencing of Zamora Yrala closes the chapter on AOG Technics, it opens a wider debate about the antiquated nature of aviation supply chain verification. The fact that a “garage operation” could introduce 60,000 parts into the global fleet using Photoshop highlights a critical weakness: the industry still relies heavily on PDF and paper-based Authorised Release Certificates (ARCs) that are easily forged.

We anticipate this case will accelerate the push toward digital immutability in aviation maintenance. Technologies such as blockchain-verified ledgers or centralized digital databases for ARCs, where a certificate cannot be “photoshopped” because its validity is checked against a live manufacturer database, are likely to move from experimental pilots to industry requirements. Trust can no longer be assumed; it must be digitally verified.

Frequently Asked Questions

Which aircraft engines were affected by the fake parts?
The fraud specifically targeted the CFM56 engine, a joint venture between GE Aerospace and Safran. This engine powers the Boeing 737 and Airbus A320 families.

Were any accidents caused by these parts?
There have been no reports of accidents or injuries directly attributed to the parts sold by AOG Technics. The parts were identified and removed following regulatory alerts.

How was the fraud discovered?
The scheme was exposed in 2023 when an engineer at TAP Air Portugal noticed irregularities in documentation and contacted the manufacturer, Safran, who confirmed the forgery.

Sources

Fox News, Southwark Crown Court Filings, UK Serious Fraud Office.

This article summarizes reporting by the Associated Press and journalist Josh Funk.

House Rejects ROTOR Act: Mandate for Anti-Collision Tech Stalls Amid Pentagon Opposition

Legislation designed to mandate advanced aircraft locator systems near busy airports failed to pass the U.S. House of Representatives on Tuesday, dealing a blow to safety advocates who have championed the technology for nearly two decades. The bill, known as the Rotorcraft Operations Transparency and Oversight Reform (ROTOR) Act (S. 2503), was introduced in direct response to a fatal midair collision near Washington Reagan National Airport (DCA) in January 2025.

According to reporting by the Associated Press, the measure failed to win necessary approval despite the backing of the National Transportation Safety Board (NTSB). NTSB Chair Jennifer Homendy has long argued that the technology, which her agency first recommended in 2008, is essential for preventing tragedies like the one that claimed 67 lives last year.

While the bill received a majority of votes (264–133), it was brought to the floor under a suspension of the rules, a procedural move that requires a two-thirds supermajority for passage. The failure highlights a deepening rift between safety regulators, the military, and general aviation groups over how best to modernize airspace surveillance.

The ROTOR Act and the Push for ADS-B In

The ROTOR Act sought to close a critical technological gap in safety by mandating the installation of Automatic Dependent Surveillance-Broadcast (ADS-B) “In” technology. While most aircraft in controlled airspace are already required to have ADS-B “Out” (which broadcasts their location to ground controllers), ADS-B “In” allows pilots to see the precise location of other aircraft directly on their cockpit displays.

The legislation aimed to require this receiving technology for all aircraft operating in complex airspace by December 31, 2031. Additionally, it sought to repeal Section 373(a) of the National Defense Authorization Act (NDAA), a provision that currently permits military aircraft to disable their location broadcasters during sensitive missions.

The “Blood on Hands” Argument

The NTSB has been vocal about the necessity of this technology. Following the failure of the vote, proponents of the bill pointed to the agency’s longstanding frustration with regulatory delays. According to the Associated Press, the NTSB head noted that the system has been a standing recommendation for 18 years.

In testimony regarding the legislation, Chair Homendy emphasized the human cost of inaction:

“The question is: How many more people need to die before we act?”

— Jennifer Homendy, NTSB Chair (via legislative records)

Why the Bill Failed: Security and Bureaucracy

Despite passing the Senate unanimously, the ROTOR Act faced a coalition of opposition in the House that ultimately prevented it from reaching the two-thirds threshold.

Pentagon Opposition

A primary factor in the bill’s defeat was late-breaking opposition from the Department of Defense. The Pentagon withdrew its support due to concerns regarding the repeal of NDAA Section 373(a). Defense officials argued that strict requirements for military aircraft to broadcast their location at all times could compromise operational security, particularly during classified or sensitive training missions.

Competing Legislation: The ALERT Act

The ROTOR Act also faced resistance from general aviation groups and House leadership who favor a competing bill, the Airspace Location and Enhanced Risk Transparency (ALERT) Act of 2026 (H.R. 7613). Supported by the Aircraft Owners and Pilots Association (AOPA) and the National Business Aviation Association (NBAA), the ALERT Act proposes a regulatory rulemaking process rather than a legislative mandate.

Supporters of the ALERT Act argue that a rulemaking process allows for necessary industry input and cost-benefit analyses, ensuring that mandates do not place an undue financial burden on small aircraft owners. However, critics, including the Air Line Pilots Association (ALPA), contend that this approach merely delays life-saving implementation through bureaucracy.

Context: The 2025 DCA Tragedy

The urgency behind these legislative efforts stems from the catastrophic midair collision on January 29, 2025, near Washington Reagan National Airport. The crash involved an American Airlines regional jet (operated by PSA Airlines) and a U.S. Army UH-60 Black Hawk helicopter, resulting in the deaths of all 67 people aboard both aircraft.

Investigations revealed a fatal blind spot in the current system:

• The Black Hawk was on a training mission and was not broadcasting its location via ADS-B Out.
• The regional jet lacked ADS-B In, leaving the pilots without a digital display of surrounding traffic.

NTSB analysis determined that if the regional jet had been equipped with ADS-B In, the pilots would have had approximately one minute of warning, enough time to alter course. Instead, they had only 19 seconds of visual warning, which proved insufficient to avoid the collision.

AirPro News Analysis

The failure of the ROTOR Act illustrates the complex tension between civil aviation safety and national security interests. While the NTSB’s mandate is singular, preventing accidents, the legislative branch must weigh these recommendations against the Department of Defense’s operational requirements.

We observe that the “suspension of the rules” procedure was a calculated risk by the bill’s sponsors that ultimately backfired. By bypassing the standard amendment process to expedite the vote, proponents required a higher threshold for passage that they could not meet once the Pentagon signaled its disapproval. The focus now shifts to the ALERT Act, where the battle will likely move from the House floor to the slow-moving corridors of FAA rulemaking. For passengers, this likely means that the “technological safety net” envisioned by the NTSB remains years away from universal implementation.

Sources

Associated Press / WRAL. (link)