CITY OF CHICAGO DEPARTMENT OF AVIATION (PLEASE PRINT) ACCIDENT/ANCIDENT REPORT SUBMIT COPY WITHIN 24 HOURS TO (Keep originals) DOA Satety Oftce (OHare International Aiport Chicago, i 60866 ION OR EMPLOYEES & EQUIPMENT A Boal injuries ic I Passenger injuryitiness C1 city Emptoyee injuritiness IC Visitor injury/itiness: 5 Tenant injury! Employes IC weather incident terminal incident iSecurty Incident Fire Ciaz-Aat incidant Ploisabied aircraft Elrunway incurston {]Damage to City Vohiclo [Cloamage to Non-cityVehic, ILOcATION 1 anc = Parking Garagest.ot Airside [Airside Service Road IC] Public Road C]kennedy Exprwy ats Efterminat + 1) cargo Tunts, C)Terminal 2 I) Runway — Li terminal 3 ID taxiway — Oitorminat s BODILY INJURYILLNESS (Individuals Parties Injured) Rane DAO, DAVID [aaaress (Number Steot Gy Stato and Zp Code) Tolep (773) 886-7233, Fax: (773) 894-6475, ce: Employee's Deputy Commissioner PLEASE CHECK APPROPRIATE BOX (s)_ 7) ED TO 1 moway Clmotor vehicio |ACTION and/or Notified oD Ineurer Citrades LlPhotographs Taken D Received inury Report D other expan D Aireraft Stand-by O Towing Damage to city Property Ovandatism Oats incident Delevator incident DEscalator incident O construction O Contractorvendor OO wip arcivateparture iwitatite incident CO other (exptain) 1 DOA commissioners D1 D0 satety ID aor IE) Grounds Transportation 1 Suiting Commissioner C1 irerart ovement Restrictions D Vehicle Movement Restrictions Gj Emergency Services provided I Documented Refusal (medica) ‘Omidway Terminal ass Qk euitaing other (explain) [Adaross (umber Sveet Ohy Siale and Zip Coda) DNA Fretephone( DNA TTelophone(BODILY INJURY/LLNESS (dvicuats/Paries- inured) Cont DESCRIE NATURE OF INJURY/LLNESS: “MOUTH INDURY PROPERTY DAMAGE fiybe OF PROPERTY F] ty Owned Property Damage jescribe Property Damage (Bip, & blag # Avcrof, Ala, Taw, ote) ID_Non - City Owned Property Damage MOTOR VEHICLE INCIDENT OF. Besoribe Vehicle Incident (Type, Model, ear, Ete) Na FT automate C1 Other expla) Please Indicate: POLICE REPORT # JA218865 Nano [Address (Streat, Cy, State 8 Zp Code) JAddress (sieet city, state & 2p Code) [retephone{ —) DNA INDIVIDUAL COMPLETING REPORT. arson Was An Eyewitness Yes__UNo hone (773) 686-2685 [Stanatar 09 MAR 2017 STATEMENT t [EVENT 6170402577 IN SUMMARY, 10 RODRIGUEZ HEAT NUMBER 3009 RESPONDED TO GATE C3 FOR 2 INDIVIDUALS REFUSING TO [DEBOARD UA FLIGT2411 UPON ARRIVAL ROCAME INTOCONTACY WITHA UNITED ARLES suPER SCR ss [EXPLAINED THAT THERE WAS | NDIVIDUAL, aR. DAVID DAO WHO WAS YELLING ABOUT LEAVING THE AIRCRAFT.0 WAS ESCORTED BY 1S BMBF Fo wizre un. ono WAS str7NG. v0 MADE CONTACT WITH THE SUBJECT AND TRIED TO FERSUADEMR, DAO TOLEAVE INA ‘CALM MANNER Mt DAO STATED, “PM NOT LEAVING THIS FLIGHT THAT 1 PAID MONEY FOR. [DONT CARE (F |GET ARRESTED AFTER ‘SEVERAL MINUTES OF TRYING TO PERSUADE MR, DAO TO LEAVE THE FLIGHT, OFC. SMITH BEAT NUMBER 3012 ARRIVED ON SCENE [AND ADVISED Mit, DAO TO LEAVE TUE FLIGHT, OUT THE SUBJECT REFUSED TO GET OFF HIS SEAT. AFTER SEVERAL ATTEMPTS FROM B/O RODRIGUEZ AND OFC SMITH, OFC. LONG BEAT NUMBER 3022 CAME ON SCENE AND IDENTIFIED HIMSELF AS AN OFFICER AND REPEATEDLY [ASKED THE SUBJECT TO REMOVE HIMSELF FROM THE AIRCRAFT. SEE ADDITIONAL PG 2BODILY INJURYALLNESS (retvicualoParies-inuroc) Cont PROPERTY DAMAGE jescribe Property Damage (Glig, & Biss ¥ Arerak, Afela, Tai ele) [Yee OF VEHICLE [Describe Vehicle Incident (tyoo, Mosel Your Ela) IC) Automobite OF Other (explain Please Indicate: POLICE REPORT # Name JAddress (Street, iy, State & Zp Code) STATEMENT AS TO CAUSE OF ACCIDENT/INCIDENT (CONT... THE SUBJECT RESPONDED REPEATEDLY IN AN AGGRESIVE MANNER, “TM NOT GETTING OFF", OFC. LONG ATTEMPTED ‘TO ASSIST THE SUBJECT OFF HIS SEAT WITH TWO HANDS, BUT THE SUBJECT STARTED SWINGING HIS ARMS UP AND DOWN FAST AND \IOLENTLY: OFC. LONG WAS ADLE TO GRAB HOLD OF THE SUBJECT AND PULL HIM FROM TH SEAT TOWARDS THE AISLE. THE SUEVECT THEN STARTED FLAILING HIS ARMS AND STARTED TO FIGHT WITH OFC. LONG. DUB TO THIS INCIDENT, THE SUBIECT WAS ABLE TO KNOCK OFC LONG'S RIGHT HAND OFF THE SUBJECTS ARM CAUSING OFC. LONG TO LOSE CONTROL. OF MR, AO, CONSEQUENTIALLY, THE SUBJECT FELL AND ATT HIS MOUTH OW THE ARMILEST ACROSS FROM MIM WHICH CAUSED AN IWJURY TO IS MOUTH. ORC. LONG REGAINED CONTROL. OF "HE SUBJECT AND HE WAS REMOVED FROMTHE AIRCRAFT AND BROUGHT TO THE JETARIDGE. THE SUSIECT LAYED DOWN OW THE DECK AND ‘CLAIMED TO BE A DIABETIC. SUBJECT WAS CONSCIOUS AND BREATHING. CPD 7212 AND 7210 ARRIVED ON SCENE AND WER BRIEFED OF ‘THE INCIDENT. 3005 ARRIVED ON SCENE REQUESTING EMS. SEE ADDITIONAL P63BODILY INJURYALLNESS (inviuate/Partcs - inured) Cont. DESCRIBE NATURE OF INJURVILLNESS: PROPERTY DAMAGE Describe Property Damage (Glss, & be # Avcrat, Aifel,Tal#, ols). Porson Was An yeulnoss DNo. STATEMENT AS TO CAUSE OF ACCIDENT/INCIDENT. ‘CONT, THE SUBJECT THEN GOT UP AND RAN PAST 7212 BACK ONTO THE AIRCRAFT INTO THE GALLEY OF THE PLANE, UNTS 7212 [AND 03 PURSUED THE SUBJECT AND UPON CONTACT. THE SUBJECT WAS HANGING ONTO A POLE IN-THE AIRCRAFT. SUBJECT STATED, "M [NOT GETTING OFF THE PLANE JUST KILL ME. { WANT TO GO HOME” CFD AMBULANCE I6 CAME ON SCENE AND PERSUADED THE SUBJECT TO BETREATED. AT WHICH POINT, HE WILLINGLY SAT ON THE STRETCHER AND WAS PLACED INTO AMBULANCE 1610 BE TRANSPORTED TO LUTHERAN GENERAL HOSPITAL.TO: Watch Commander FROM: Steven Smith #668 supsect Event # 170402677 Disturbance ‘ica oepanrt OF ATATION POLCE pate: __9-Apr-17 TIME: 1808 120801 W, HIGGINS RD L0G meso ‘CHICAGO, 60665 PHONE: (773 685-2605, This statement is not being given voluntary, but under duress. | am only giving this stament at this time because | know that | could lose my job if | refuse the direct order being giving to me. This " TO/FROM " report should not be considered a verbatim statement but only a summary of requested information. In summary : on April 9th 2017 R.O. Smith 3012 was dispatched to disturbance on aircraft in terminal one C-3. Upon arriving on the scene R.O. Smith saw P.O. Rodriguez ask the passenger to leave the plane, but the passenger refused to leave. R.O. Smith also began to ask the passenger to leave as well but he continued to refuse, At this time P.O. Long arrived on the scene and asked the passenger several times to leave but he refused, During this time P.O. Long removed the passenger out of the seat, then P.O. Rodriguez and R.O. Smith assited P.O. Long as he removed the passenger off the aircraft . At this time CPD and CFD arrived on the scene then moments later the passenger ran back onto the aircraft. During this time R.O. Smith conducted crowd control. No further information to report. ‘CONTINUED REVERSE SIDE arr PRINT RANE START. SqFTURE STEVEN SOON sen b ae Oth Co ‘SUPERVISOR: PRINT NAME Approved [~] denied [—] Received [_] (supervisor Check One Box if Applicable)anonorr OficerTo-From Blank (Mauricio, Resriguer J) x TO: WATCH COMMANDER From: RODRIGUEZ JR, MAURICIO #665 SUBJECT EVENT # 170402677 440 DEEATMENT OF ATION POUCE pate:__9-Apr-17__ TIME:__ 1808 ‘ose oars ma 0 —<—e nee cago tee one: 7736862605 THIS STATEMENT IS NOT BEING GIVEN VOLUNTARILY, BUT UNDER DURESS. | AM. ONLY GIVING THIS STATEMENT AT THIS TIME BECAUSE | KNOW THAT | COULD LOSE MY JOB IF | REFUSE THE DIRECT ORDER BEING GIVEN TO ME. THIS "TO/FROM" REPORT SHOULD NOT BE CONSIDERED A VERBATIM STATEMENT, BUT ONLY A SUMMARY OF REQUESTED INFORMATION. IN SUMMARY, ON APRIL STH 2017 R/O RODRIGUEZ BEAT # 3003 RESPONDED TO A DISTURBANCE AT C3 ON UNITED AIRLINE FLIGHT 3411. UPON ARRIVAL R/O WAS ADVISED BY THE SUPERVISING AGENT OF UNITED AIRLINES THAT THERE WAS A GUEST WHO REFUSED TO LEAVE HIS SEAT. UPON CONTACT WITH THE SUBJECT R/O ADVISED AND TRIED TO PERSUE THE SUBJECT TO LEAVE HIS SEAT, THE SUBJECT REFUSED. OFC. SMITH BEAT #3012 ARRIVED AND ALSO TRIED TO PERSUE AND ADVISE THE SUBJECT TO LEAVE HIS SEAT. OFC. LONG BEAT # 3022 CAME ON SEEN AND ALSO ADVISED THE SUBJECT TO LEAVE. AFTER SEVERAL FAILED ATTEMPTS ON TRYING TO REMOVE THE SUBJECT, OFC. LONG ASSISTED THE SUBJECT BY USING MINIMAL BUT NECCESARY FORCE TO REMOVE THE SUBJECT, SEE ACCIDENT INCIDENT REPORT # 170402677 Utw Mone _€S ‘SUPERVISOR: PRINT NAME ‘STAR NO. DATE:_O% AP. ZOV7 Time:_20 70 ‘tpg -eKcegov.rlire.of0265.vax_Jaycuthxprntview aspx 7NoAulh= 1Bsesslonld=12 ad807ESD6SSI1.D377. E72 MIpMAAYZF%AFGerCPASFIC%IDH.. 13TO: SGT MOORE FROM: OFFICER LONG SUBJECT INCIDENT AT C3 caso DEPARTMENT OF AVIATION POMCE DATE: _9-Apr-17 TIME: 2340 20801 W. HIGGINS RD BLDG #850 AGO, 160655, PHONE: (773 606-2685, OFC LONG, 3022 RESPONDED AS BACKUP TO 3003 REGARDING A 2 PERSON DISTURBANCE FOR A REFUSAL TO LEAVE THE AIRCRAFT. AFTER GETTING ON THE SCENE, RO LONG SAW 3003 AND 3012 TALKING TO THE SUBJECT. OFC LONG THEN ANNOUNCED THAT HE IS AN OFFICER AND JOINED IN TRYING TO GET THE SUBJECT TO EXIT THE AIRCRAFT. THE SUBJECT CONTINUED TO REFUSED TO LEAVE AND SAID, I'M NOT LEAVING AND FOLDED HIS ARMS TIGHTLY. OFC LONG ASKED THE OTHER OFFICERS TO ASSIST IN REMOVING THE SUBJECT. WHEN OFC LONG TRIED TO REACH OUT TO HOLD THE SUBJECT, THE SUBJECT STARTED SWINGING HIS ARMS UP AND. DOWN WITH A CLOSED FIST. OFC LONG WAS ABLE TO GRAB THE SUBJECT AND PULL HIM AWAY FROM THE WINDOWN SEAT TOWARDS THE AISLE. BUT SUDDENLY, THE SUBJECT STARTED FLAILING AND FIGHTING. CONSEQUENTLY, THE SUBJECT WAS ABLE TO KNOCKED THE RIGHT HAND OF OFC LONG OFF OF HIS ARM AND SHOULDER AREA, WHICH CAUSED THE SUBJECT TO FALL, HIT, AND INJURED HIS MOUTH ON THE ARMREST ON THE OTHER SIDE OF THE AISLE. AT THIS TIME, OFC LONG WAS ABLE TO REGAIN CONTROL OF THE SUBJECT AND WAS ABLE TO REMOVE THE SUBJECT FROM THE AIRCRAFT WITH THE HELP OF 3003. THE SUBJECT WAS BROUGHT OUT TO THE JETBRIDGE AREA. HE WAS LIMP SO THE SUBJECT WAS LAID ON THE FLOOR. HE BEGAN TALKING ABOUT A MINUTE LATER. A FEW MINUTES LATER 7211 CAME ON THE SCENE AND HE WAS BRIEFED BY 3022. THE SUBJECT MENTIONED THAT HE WAS A DIABECTIC. THE EMS WAS CALLED. ABOUT A FEW MINUTES LATER, 7012 CAME ON THE SCENE. THE SUBJECT WAS ASKED IF HE WANTED WATER BY A MALE WORKER FOR THE AIRLINE HE SAID YES AND GOT UP AND RAN PASSED 7012 BACK ONTO THE AIRCRAFT. 7012 AND 3003 PERSUED HIM. THE SUBJECT SAID THEY'LL HAVE TO KILL HIM. CCONTINIJED REVERSE SIDE SS Ow SiN ‘OFFICER: PRINT NAME ‘STAR NO. ‘SIGNATURE SOK PRINT NAME ‘STAR NO. or GAAP (LE me OBO Approved [] denied [7] receves [FJ (Supervisor Check One Box f Applicable) ‘SUPERVISOR:To: LT. Schmidt FROM: Sgt. Moore SUBJECT Disturbance-C3 DATE: _9-Apr-17 TIME: 2200 PHONE: (773 686-2635 In summary, Reporting Sergeant responded toa disturbance Gate C3 on the aircraft. While en route, R/Sgt heard EMT requested to scene. R/Sgt arrived alongside Ambulance 16. APD units 3002, 3003, 3005, 3012 and 3022 on scene, CPD units 7212 and 7217 on scene. R/Sgt proceeded to aircraft where 3003 was interviewing flight crew members. Passengers in back of aircraft were deplaning and subject causing disturbance was in the galley of the plane. R/Sgt waited for EMT to assess subject and R/Sgt checked on well being of officers at the scene. Subject transported to Lutheran General by CFD Ambulance 16. 3012, 3003, and 3022 ordered to write To/From reports of incident and 3003 ordered to write Accident/Incident report of event. 3099 also at scene and updated of all events. Aircraft was deplaned and cleaned of fluids from the scene. Plane reboarded shortly and took off without further incident. Nothing further at time of this report. ‘SUPERVISOR: PRINT NAME 'STARNO- ‘SIGNATURE DATE: TIME: Approved [—] denied [—] Received [—] (Supervisor Check One Box if Applicable)Apr 09 2017 1817 OHare Command Center 7738943091 page 1 Display Event Event Date Event Time Cailtaker Caltaker Term 04/00/2017 18:08:23 472481 cadordapd’ Agency P Ara Group Event # Type ‘Sub-Type ssD 2 OHARE ORD $170402877 MDISTAC default Location: —1.C3, Apt:, Mun: C3 Area: , Cnty: , State: , Bidg: x IL SPC E(1,099,232.29, 1,934,413.47) Loe Comments: @c3: Caller Name: ‘scoTT Caller Addr: Caller Phone: Caller Source: Remarks: cs ‘TWO PAX REFUSING TO GET OFF AC DEPARTING FLIGHT WAS OVERBOOKED ‘SPECIAL ADDRESS COMMENT: United Airines ** LOI search completed at 04/0017 18:08:25 3012, 3003, 002 EN ROUTE 3003 - SLOW IT DOWN TO C3 ‘3003 -PAX STILL REFUSING TO GET OFF ‘3005 - REQ EMS 40 M DIA+ C/B RAMP LVL “Event Type changed from MDIST to FAMBU(DIA) at: 04/08/17 18:21:66 ** Event Type changed from MDIST to FAMBU(DIA) at: 04/09/17 18:21:66 ** CFD event F170400245 created * >>>> by: DORAE. CORNELIO on terminal: cadordapd1 ** Event Location changed from “1 W C3 ST ORD: @C3: ON THE AC" to “1 W C3 ST ORD: @C3: RAMP" at: 04/00/17 18:21:56 “>>> by: DORA E, CORNELIO on terminal: cadordapd1 ** Event Type changed from FAMBU(DIA) to MDISTAC at: 04/09/17 18:22:46 ** Event Type changed from FAMBU(DIA) to MDISTAC at; 04/09/17 18:22:46 ** >>>> by: DORIS RHINE on terminal: cadordead1 * >>>> by: DORIS RHINE on terminal: cadordeadt 3030 - EN ROUTE CFD#170901838 *" Event Location changed from "1 W C3 ST ORD: @C3: RAMP" to "1 W C3 ST ORD: @C3" at: 04/00/17 18:24:08 ** >>> by: DORIS RHINE on terminal: cadordcpd1 3005 - CORRECTION ON LOCATION, PATIENT ON JETBRIDGE 1829 HRS, DELAYED ACCESS TO PATIENT AMB 16 ‘4/9/2017 7:08:34 PM Page 1 of 2Agr 09 2017 1816 CHare Command Center 7738943091 Display Event 7830 HRS PATIENT CONTAGT AMB 16 REQ A CO FOR MANPOWER ENG 10 ENRT 3090 -EN ROUTE AMB 16 REQUESTING 453 FOR AN EXPOSURE 3004 - O/S 3002 - TAIL #NE32RW UAL 3411 - LOUISVILLE, KY 3099 O/S AMB 16 TO LGH ALS1/1 ENG 10 AND 453 WILL MEET AT LGH ‘Times: Add Dispatch Arrive ‘Close Closing (1D Cl. Terminal 18:08:23 18:08:52 18:11:12 Dispo: ‘Units Assioned: Unit 4/9/2017 Page 2 of 2Gy) AVS Quality Management System apm # ORD.W-FORMSO4t Revision 4 Date: 03/19/2010 Paga 1 off Title: InefdentPassenger(s) Complaint US DerantuenT ‘Chicaga Fight Standards Det Ole Of TRawsPoRTaTON, 2800 &. Devan Avenue, Sure 251 FEDERAL AVATION AowmistRarion Owe Ages 4 SOVT Flight No. : 34 {{ Drivers License No.: Name: Last Joo. cl 967314 Poe: 8472040992 name Unted ooparture city: ORD) Passport No: other 10: First Qowwrd Midetotnital rs SD oo es ‘Bae Nose overlies Saenaieel 8 Olftbar Name: Saeet ~ stato: oy Sox tame: Last dress: jeat Balt" issue? a. Was the “Seat Belt* sign on? b, Was tha Passenger briefed? iy-aiAlconol iste? ° | is Was tho passengar Intoxicated at the time of boarding?, b, Was the passenger served alcohol during the fllght? ©, Old the passenger drink from his/her own bottle? Is this a smoking issue? a. Ware the “No Smoking" signs on? , Wers all requosted FAA placards stating, “No smoking’ Installed? ©. Were the "Placards" prohibiting smoking In lavatory Installed? 4. Woro the required FAA briefings about “No Smoking", and “Tampering or Disabling af the Smoke Oatactor" made? Was tho FAA Brlafing on “Use of Portable Electronic Oavice: ar -Was this usage oF disttranteédevice during fightlsaue?*~ 1h. Mas this non storage of ofectronic dloviee issue? Oia po diy dtsilad stato Nok Creo member 1 Plot fon First 2p code ide tial once io: E i : (lead Flight Ataadant ication First widate tnt Viotation(s) 8y Passonger(s) ", "No Smoking in the Lavatory" mado?Desarige The Event in Osta: lane: over Oder’ so CoM cok Re 2 id See uonined vackliy elane, OPhcer aan Xpa Greece Ne wasld oor A nen dds ext She oa by at We oes Token a-er by (medese ee Taal pei isi Ean Crown agab a Na casey nen POSTUON, CARTS ND ( Crowipambor slam: position: ® Eek tended’