A CIDEN HN CIDEN REPOR Date of ReportTime: 20: I4 DEPARTMENT OF A VIA TION Date of (PLEASE PRINT) Occurrence: 09 APR 20? Time: [8:08 SUBMIT copy WITHIN 24 HOURS T0 (keep originals) DOA Safety Office O'Hare International Airport Chicago, iL 60666 Teiep (773) 686?7233 Fax: (773) cc: Employee's Deputy Commissioner I: MIDWAY PLEASE CHECK APPROPRIATE BOX (3) AIRPORT LOCATION OR EMPLOYEES EQUIPMENT ASSIGNED TO TYPE OF INCIDENT Bodily El Property Damage I: Motor Vehicle [3 Aircraft [:IOther INCIDENT ACTION and/or Notified Passenger injuryllilness Aircraft Standby Chicago Fire Dept. Insurer El City Employee injuryiiliness Towing Chicago Police Dept. Trades Visitor El Damage to City Property DOA Police El Photographs Taken El Tenant injury! Employee Weather incident Terminal Incident Security Incident Vandalism ATS Incident El Elevator Incident El Escalator incident BOA Commissioners DOA Safety El AOR El Grounds Transportation Received injury Report Other (explain) CI Fire Construction [3 Building Commissioner Haz~Mat incident ContractorNendor El Aircraft Movement Restrictions Disabled Aircraft VIP ArrivaiiDeparture El Vehicle Movement Restrictions DRunway lncursion El Wildlife incident Emergency Services provided [:IDamage to City Vehicle Other (explain) Documented Refusal (medical) Cl Damage to Non-City Vehici. LOCATION WEATHER SURFACE ?33.53. UNUSUAL AMC Parking GarageiLol: [3 Midway Terminal Clear El Wet Daylight Airside DAirside Service Road Dans El Over Cast El Cracked Dawn Wind Public Road Kennedy i-i-R Building Rain Even El Dusk Glare El ATS 'Terminal 1 Other (explain) [3 Snow Uneven El Darkness El Odor El Cargo Tunis. DTenninaiz Fog ice El Artificial Other Runway DTerminai 3 Sleet Snow Taxiway UTerminal 5 Temp-__ Dry INJURWILLNESS (individuals fParties - injured) Name Name Date of Birth DAO, DAVID Address (Number,Streel,City.State and Zip Code) DNA Address (Number. Street.City, State and Zip Code) Telephone DNA Telephone BODILY INJUR SS (Individuals/Parties - Injured) Cont. MOUTH INJURY DESCRIBE NATURE OF PROPER TY DAMA GE TYPE OF PROPERTY City Owned PrOperty Damage Non - City Owned Property Damage Describe Property Damage (Bldg. 8. Bldg. Aircraft. Air?eld. Tail ate): DNA MOTOR VEHICLE INCIDENT TYPE OF VEHICLE El Automobile Other (explain) Truck Bus Describe Vehicle Incident (Type. Model, Year, Etc.) DNA Please Indicate: POLICE REPORT JA218865 WITNESS (ES) Address (Street. City. State Zip Code) DNA Name Address (Street. City. State Zip Code) TElephone DNA Te'ephm? INDIVIDUAL COMPLETING REPORT A It Name Yeerzon EN: yew ness Department . $3?me (773)686-2685 SignaWAgL 5% 09 MAR 2017 STATEMENTZS TO CA USE OF EVENT I 70402;? IN SUMMARY. RIO RODRIGUEZ BEAT NUMBER 3003 RESPONDED TO GATE C3 FOR 2 INDIVIDUALS REFUSING To DEBOARD UA FLIGHT 341 I. UPON ARRIVAL RIO CAME INTO CONTACT WITH A UNITED AIRLINES SUPERVISOR MS.- EXPLAINED THAT THERE WAS I INDIVIDUAL. MR. DAVID DAO WHO WAS VELLING ABOUT LEAVING THE AIRCRAFT. RIO WAS ESCORTED BV MS. .TO WHERE MR. DAO WAS SITTING. RIO MADE CONTACT WITH THE SUBJECT AND TRIED TO PERSUADE MR. DAO To LEAVE IN A CALM MANNER. MR DAO STATED. NOT LEAVING THIS FLIGHT THAT I PAID MONEY FOR. I CARE IF I GET AFTER SEVERAL MINUTES OF TRYING TO PERSUADE MR. DAO TO LEAVE THE FLIGHT, OFC. SMITH BEAT NUMBER 3012 ARRIVED ON SCENE AND ADVISED MR. DAG To LEAVE THE FLIGHT. BUT THE SUBJECT REFUSED TO GET OFF HIS SEAT. AFTER SEVERAL ATTEMRTS FROM RIO 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 INJUR (Individuals/Parties - Injured) Cont. DESCRIBE NATURE OF PROPER TY DAMA GE TYPE OF PROPERTY City Owned Property Damage Non - City Owned Property Damage Describe Property Damage (Bldg. 8. Bldg. Aircraft, Air?eld. Tail etc.): MOTOR VEHICLE INCIDENT TYPE OF VEHICLE Automobile El Truck [3 Bus Other (explain) Describe Vehicle incident (Type. Model, Year. Etc.) Please Indicate: POLICE REPORT WITNESS (ES) Name Name Address (Street. City. State Zip Code) Address (Street. City. State 8t Zip Code) Telephone I Tetephone INDIVIDUAL COMPLETING REPORT [Name Person Was An Eyewitness Yes DNO Department Telephone I Signature Date STA TEMEN AS TO CA USE OF ACCIDEN THE SUBJECT RESPONDED REPEATEDLY IN AN AGGRESIVE MANNER, NOT GETTING 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 VIOLENTLY. OFC. LONG WAS ABLE TO GRAB HOLD OF THE SUBJECT AND PULL HIM FROM THE SEAT TOWARDS THE AISLE. THE SUBJECT THEN STARTED FLAILING HIS ARMS AND STARTED TO FIGHT WITH OFC. LONG. DUE TO THIS INCIDENT, THE SUBJECT WAS ABLE TO KNOCK OFC. RIGHT HAND OFF THE ARM CAUSING OFC. LONG TO LOSE CONTROL OF MR. DAO. CONSEQUENTIALLY, THE SUBJECT FELL AND HIT HIS MOUTH ON THE ARMREST ACROSS FROM HIM WHICH CAUSED AN INJURY TO HIS MOUTH. OFC. LONG REGAINED CONTROL OF THE INCIDENT. 3005 ARRIVED ON SCENE REQUESTING EMS. THE SUBJECT AND HE WAS REMOVED FROM THE AIRCRAFT AND BROUGHT TO THE JETBRIDGE. THE SUBJECT LAYED DOWN ON THE DECK AND CLAIMED TO BE A DIABETIC. SUBJECT WAS CONSCIOUS AND BREATHING. CPD 7212 AND 7210 ARRIVED ON SCENE AND WERE BRIEFED OF SEE ADDITIONAL PG 3 BODIL INJUR {IndividuaIs/Par?es - Injured) Cont. DESCRIBE NATURE OF INJURYIILLNESS: PROPER TY DAMA GE TYPE OF PROPERTY City Owned Property Damage El Non City Owned Property Damage Describe ?roperty Damage (Bldg. Bldg. Aircraft, Air?eld. Tail eta): TOR VEHICLE INCIDENT TYPE OF VEHICLE Automobiie Other (explain) El Truck Bus Describe Vehicle Incident (Type, Modei, Year, Etc.) Piease Indicate: POLICE REPORT WITNESS (ES) Name Name Address (Street. City. State Zip Code) Address (Street. City. State Zip Code) Telephone Telephone INDIVIDUAL COMPLETING REPORT Person Was An Eyewitness Name CI Yes Department Telephone Signature Date STATEMENT AS TO CAUSE THE SUBJECT THEN GOT UP AND RAN PAST T212 BACK ONTO THE AIRCRAFT INTO THE GALLEY OF THE. PLANE. UNITS 72 [2 AND 3003 PURSUED THE SUBJECT AND UPON CONTACT, THE SUBJECT WAS HANGING ONTO A POLE IN THE AIRCRAFT. SUBJECT STATED, . NOT GETTING OFF THE PLANE. JUST KILL ME. I WANT TO GO CFD AMBULANCE l6 CAME ON SCENE AND PERSUADED THE SUBJECT TO BE TREATED. AT WHICH HE WILLINGLY SAT ON THE STRETCHER AND WAS PLACED INTO AMBULANCE 16 TO BE TRANSPORTED TO LUTHERAN GENERAL HOSPITAL. To: Watch Commander FROM: Steven Smith #668 sumecr Event 170402677 Disturbance CHICAGO POLICE DATE1808 10601 W. HIGGINS RD BLDG #850 CHICAGO, lL 60666 PHONE: {773} 686-2685 This statement is not being given voluntary, but under duress. lam only giving this stament at this time because I know that could lose my job if I refuse the direct order being giving to me. This report should not be considered a verbatim statement but only a summary of requested information. In summary on April 9th 2017 RD. 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 I I OFFICER: PRINT NAME STAR Rog - -g?fmm jog/v 7747,0726 K668 SUPERVISOR: PRINTNAME STAR no& if OKPWRE (0 610 0 DATE: TIME: ?4:89? Approved Denied Received (Supervisor Check One Box if Applicable) 4? 0.12017 Of? cer To- FromwBIank (Mauricio, Rodriguez Jr.).xlsx TO: WATCH COMMANDER mom: RODRIGUEZ JR, MAURICIO #665 SUBJECT 170402677 DATE: 9-Apr-17 TIM E: 1808 10601 W. HIGGINS RD BLDG #350 CHICAGO, IL 60666 PHONE: [773} 636-2685 THIS STATEMENT IS NOT BEING GIVEN VOLUNTARILY, BUT UNDER DURESS. I AM ONLY GIVING THIS STATEMENT AT THIS TIME BECAUSE I KNOW THAT I COULD LOSE MY JOB IF I REFUSE THE DIRECT ORDER BEING GIVEN TO ME. THIS REPORT SHOULD NOT BE CONSIDERED A VERBATIM STATEMENT, BUT ONLY A SUMMARY OF REQUESTED INFORMATION. IN SUMMARY, ON APRIL 9TH 2017 RODRIGUEZ 3003 RESPONDED TO A DISTURBANCE AT C3 0N UNITED AIRLINE FLIGHT 3411. UPON ARRIVAL 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 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 ?an/1675225? meuo COMEM OFFICER: PRINT NAME STAR NO. (MW ?8 SUPERVISOR: PRINT NAME STAR N0. SIGNATU DATE: 051 Mm ?20 V7 TIME: 20. 3?0 :?gc 1 -excel .gov.onI i ne.of? . 113 TO: . SGT MOORE FROM: OFFICER LONG SUBJECT INCIDENT AT 3 CHICAGO POLICE DATE: 9-Apr-17 TI IVI E: 2340 10501 W. HIGGINS RD BLDG #850 CHICAGO, II. 60666 PHONE: (773} 586-2685 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, NOT LEAVING AND FOLDED HIS ARMS OFC LONG ASKED THE OTHER OFFICERS TO ASSIST IN REMOVING THE SUBJECT. WHEN OFC LONG TRIED TO REACH I 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 ANDWAS 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 HAVE TO KILL HIM. CONTIN ED REVERSE (p I) MU EEeyxaM OFFICER: .. PRINT NAME NO. ISIGNATURE (Do Not Write Below This Line, For Supervisor Use Only. -- jbna7yt?pmwi?u SUPERVISOR: PRINT NAME STAR NO. SIG A RE 0.900 Approved Denied Received [Supervisor Check One Box if Applicable) To: LT. Schmidt FROM: Sgt. Moore SUBJECT Disturbance-C3 CHICAGO Depga?mm'g??mmu POLICE DATE 10601 W. HIGGINS RD 5106 #850 CHICAGO, IL 60666 PHONE: {773} 686-2585 In summary, Reporting Sergeant responded to a 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. I - /,commueo SE IDE I 1F d/owx/ Mao/t5" 8/ 5 (Do Not Write Below This Line For Supervisor Use On PRINT NAME STAR NO. NATURE 5%6701/7 SUPERVISOR: PRINT NAME STAR NO. SIGNATURE DATE: TIME: Approved Denied Received (Supervisor Check One Box if Applicable) Apr 09 2017 18:17 O?Hare Command Center 7738943091 page 1 Display Event Event Date Event Time Callie ker Quaker Term 04/09/2017 18:08:23 472481 oadordapdl Agency Area Group Event Type Sub?Type SSD 2 OHARE 0RD 3170402677 MDISTAC default mm 1 C3, Apt, Mun: C3 Area: Cnty: . State: Bldg: IL SPC 1,934,413.47) Loc Comments: Caller Name: SCOTT Caller Addr: Caller Phone: Caller Source: RemarksDEPARTING FLIGHT WAS OVERBOOKED SPECIAL ADDRESS COMMENT: United Airlines LOI search completed at 04/09/17 18:08:25 3012.3003,3002 EN ROUTE 3003 - SLOW IT DOWN T0 03 3008 -PAX STILL REFUSING TO GET OFF 3005 - REQ EMS 40 RAMP LVL Event Type changed from MOIST to at: 04709117 18:21 :56 Event Type changed from MOIST to at: 04109717 18:21 :56 CFD event F170400245 created by: DORA E. CORNELIO on terminal: cadordapd1 Event Location changed from "1 C33 ST ORD: @03ORD: @03: at: 04709117 18:21 :56 by: DORA E. CORNELIO on terminal: oadordapd1 Event Type changed from to MDISTAC at: 04/0971? 18:22:46 Event Type changed from to MDISTAC at: 04/0971? 18:22:46 by: DORIS RHINE on terminal: by: RHINE on terminal: 3030 - EN ROUTE Event Location changed from "1 03 ST ORD: @03: to ?1 (33 ST 0RD: at: 04/0911? 18:24:06 me? by: DORIS RHINE on terminal: 3005 - CORRECTION ON LOCATION. PATIENT ON JETBRIDGE 1829 HRS, DELAYED ACCESS TO PATIENT AMB 16 419/201 7 7:08:34 PM Page 1 of 2 Apr 09 2017 18:16 O'Hara Command Center 7738943091 Display Event page 1 1830 HRS PATIENT CONTACT AME 16 REQ A CO FOR MANPOWER ENG 1O ENRT 3099 EN ROUTE 16 REQUESTING 453 FOR AN EXPOSURE 3004 - 0/5 3002 - TAIL UAL 3411 - LOUISVILLE, KY 3099 0AND 453 WILL MEET AT LGH Add Dispatch Arrive Close 18:08:23 18:08:52 18:11:12 Dis 0: Units Assigned: Unit Cl. Terminal 49/2017 7:03:34 PM Page 2 of 2 QP AVS Quality Management System 4 Incident/Passengerfs) Complaint Date: 03/19/3070 Page 10" 1 UIS I - Chicago Flight ISIIanIda'rds orneeII Oi TRANSPORTATION - 2300 E. AQENIIE. SUITE 261 Des Fumes, IL 60.018 . . 847-29449? FEDERAL FAX: 347.294.7902 ADMINISTRATION -I I gage. 5? Carrier: Uni+?A Flightl?toa 5/4? . Drivers License No.: Name: La-s't? ?36)th Departure City: 0 RD Passport No: other' ID: First dmuxckI . Middle initial ID Veri?ed . '6 Cfftetr Meme: - .II(also: 3??:qu .. . 11' . . IPllot-ln- I II onI .I - Name: Last FirstWI - Middle lnitiai- - Certificate No Address . . . W-I I . Lead identification tame: past. First_ Middle initial - Violatlon?ls) 8y Passengeris) I. . is this a use of "Seat Belt? issue? Was the "Seat Belt" Sign on? in. Was the Passenger briefed? I- is this atr??IAicehoi? issue? ELI Was the passenger intoxicated at the time of boarding? b. Was the passenger served alcohol during the flight? 0, Did the passenger drink from his/her own bottle? . is this a Smoking issue? 3. Were the ?No Smoking" signs on? Were all requested F-AA placards stating, ?No smoking" installed? c. Were the "Placards" prohibiting smoking in lavatory installed? i It. More the required FAA briefings about "No Smoking", ?No Smoking in the Lavatory" i and' Tampering or Disabling of the Smoke Detector? made? I Was the FAA Briefing on ?Use of Portable Electronic Devices? made? - . I usage of?electrenicdevice during filght?lssue? 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