NTSB cites ATC error as probable cause of near mid-air collision over Gulfport-Biloxi International Airport

January 21, 2012

The NTSB cited an operational error by a tower air traffic controller as the probable cause of a near mid-air collision involving a commercial jetliner and a small private plane over the Gulfport-Biloxi Airport.

On Sunday, June 19, 2011, at 12:35 p.m. CDT at Gulfport-Biloxi International Airport, a Cessna 172 was cleared for takeoff on runway 18 by the tower air traffic controller. Sixteen seconds later, the same air traffic controller cleared an Embraer 145, a commercial passenger flight, for takeoff on runway 14, the flight path of which intersects the flight path of runway 18.

While both airplanes were about 300 feet above the airfield, the Embraer passed in front of the Cessna. The closest proximity between the two planes was estimated to be 0 feet vertically and 300 feet laterally.

The Embraer 145, N13929, operated as ExpressJet flight 2555 (dba Continental/United Express) was carrying 50 passengers and 3 crewmembers, and was bound for Houston Bush Intercontinental Airport (IAH) where it landed uneventfully.

The Cessna 172P Skyhawk, N54120, operated on a local  instructional flight carrying an instructor and a student.

No one in either airplane was injured in the incident.

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NTSB investigates ATC incident at Chicago-O’Hare

May 20, 2011

The National Transportation Safety Board (NTSB) is investigating an air traffic control incident involving two regional jets that occurred on Monday, May 16, 2011 at Chicago O’Hare International Airport.

At approximately 09:35, ExpressJet Airlines flight 6075, an Embraer ERJ-145, was cleared for takeoff on runway 32L at Chicago-O’Hare (ORD), en route to Buffalo, NY (BUF).  SkyWest Airlines flight 6958, a Canadair CRJ-200 (N905SW), arriving at O’Hare from Muskegon, MI (MKG), was cleared to land on runway 9R.   Aircraft approaching runway 9R cross runway 32L at low altitude before landing. Because of the timing of the two operations, the SkyWest flight nearly overflew the departing ExpressJet flight.

A supervisor on duty in the tower noticed the traffic on the runway and the traffic on the approach and instructed the controller handling the SkyWest flight to direct the pilot to go around.  The SkyWest pilot discontinued the initial approach as instructed.  The ExpressJet flight continued takeoff  roll and departed without further incident.  The SkyWest flight returned a few minutes later and landed.  There were no injuries or damage to either aircraft.

Safety Board investigators are reviewing radar data, air traffic control audio recordings, and statements provide by the pilots of the aircraft involved. Preliminary radar information provided to the Safety Board by the Federal Aviation Administration indicates that the SkyWest aircraft crossed runway 32L approximately 225 feet above the ExpressJet aircraft when the two aircraft were laterally less than 480 feet apart.

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Audits initiated of FAA’s process for reporting operational ATC errors

May 14, 2011

The U.S. DoT’s Office of Inspector General plans to review the Federal Aviation Administration’s (FAA) process for reporting and mitigating the risk of operational errors by air traffic controllers. 

The review is conducted at the request of the Chairmen and Ranking Members of the Senate Committee on Commerce, Science, and Transportation and its Subcommittee on Aviation Operations, Safety, and Security as well as the Ranking Member of the House Transportation and Infrastructure Subcommittee on Aviation.

FAA statistics show that the number of operational errors—when a controller fails to maintain a safe separation distance between aircraft—increased by more than 50 percent in fiscal year 2010.

According to FAA, this increase is mostly due to the introduction of voluntary, non-punitive safety reporting, such as through the Air Traffic Safety Action Program (ATSAP).  FAA also recently implemented the System Loss of Standard Separation (LoSS) Index, which aims to capture incidents where there is a loss of separation between aircraft.

Two audits will be initiated to review these programs in relation to the recent rise of operational errors.  The first will evaluate the policies and process by which FAA is using the LoSS index to (1) collect, measure, evaluate, and report separation losses and (2) mitigate those risks.  The second audit will evaluate FAA’s implementation and oversight of ATSAP.

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NTSB investigating incident involving ATC request for a commercial plane to fly near non-responsive airplane

March 30, 2011

The National Transportation Safety Board is investigating an incident involving a Southwest Airlines airplane that was requested to veer off course by Air Traffic Control to view into the cockpit of a general aviation airplane that had been out of radio communication.

On Sunday, March 27, 2011, Southwest Airlines flight 821 – a Boeing 737 – was requested by Central Florida Terminal Radar Approach Control (TRACON) to check on a Cirrus SR22 that had been out of radio contact for an hour. The TRACON vectored the Southwest Airlines commercial flight until visual contact was obtained with the Cirrus. The Southwest pilots reported seeing two people in the cockpit.  The Southwest flight turned away and the air traffic controller then vectored the aircraft for its arrival at Orlando International Airport.  Approximately thirty seconds later the Cirrus contacted Jacksonville Center who gave them the current frequency. Both aircraft landed safely at their destinations.

In a statement, the FAA reported that preliminary information indicated that there was a loss of required separation between the two aircraft. The FAA has suspended the air traffic controller, who is a supervisor.

“By placing this passenger aircraft in close proximity to another plane, the air traffic controller compromised the safety of everyone involved. This incident was totally inappropriate,” said FAA Administrator Randy Babbitt.  “We are reviewing the air traffic procedures used here and making sure everyone understands the protocols for contacting unresponsive aircraft.”

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Report: Learjet near-accident due to “inappropriate prioritisation and allocation of pilot´s workload”

November 15, 2010

The Swedish Accident Investigation Board (SHK) released their final investigation report into a an incident involving a Learjet near Stockholm. The aircraft  deviated from the cleared altitude and descended below the minimum obstacle clearance altitude.

An Austrian Learjet 40 corporate jet was involved in an incident in November 2008 during a positioning flight from Paris-Le Bourget (LBG) to Stockholm-Bromma Airport.

The flight was radar vectored at the incident; the co-pilot was PF and was operating the aeroplane on autopilot according to instructions from the ATC about heading, altitude and speed. The minutes preceding the incident there was one instruction about heading change and four instructions to reduce the speed. When the new heading, left 330 degrees, was confirmed, the PF selected the new heading on the autopilot panel. The flight was at the same time cleared for ILS-approach, and the APPR-mode was selected on the autopilot panel. The aeroplane was apparently not commencing the turn to the new heading, but continued straight ahead. The pilots were at this moment also busy with checklist reading and other preparations for the imminent landing.

When the pilots realised that they were going through the approach track, the PNF disconnected the autopilot and made a steep left turn to join the inbound track. This action was aimed at helping the PF to quickly point the aeroplane into the approach direction. The PNFs take-over of the controls was not made by the use of standard phraseology. During the left turn towards the approach track, the aeroplane started an unintentional descent. There was no formally correct transfer of controls back to the PF.

The ATC gave warnings and instructions to immediately turn to a heading of 270 degrees and commence a climb, which were confirmed by the pilots.

Somewhat later the GPWS-warning was triggered and the PNF regained the control of the aeroplane by the phrase “I have it”, and commenced a go-around and a left turn. The PNF claims that he had visual contact with the ground at this moment, but not with the runway, and that he was aware of obstacles in the area, i.e. the radio/TV-broadcasting antennas. After climbing to 2500 feet, the ATC issued new headings and the approach to runway 30 at Stockholm-Bromma was carried out with no further deviations.

The height of the antennas are about 1370 feet (about 418 m) above sea level and the lowest altitude of the aeroplane was about 650 feet (about 200 m).

The incident was caused by inappropriate prioritisation and allocation of the pilot´s workload.


FAA: Pilots and air traffic controllers share safety data

September 22, 2010

FAA logoThe U.S. Federal Aviation Administration (FAA) announced a safety program that for the first time will integrate voluntary safety information self-reported by pilots and air traffic controllers. This data-sharing program will give the FAA a more complete picture of the national airspace system by collecting, assessing and reviewing safety events from the perspective of both pilots and air traffic controllers.

United Airlines and its pilots have the first agreement in place to participate in a demonstration program. The FAA expects to sign similar agreements with other carriers in the future.

For the first time, information from the Aviation Safety Action Program (ASAP) and the Air Traffic Safety Action Program (ATSAP) will be merged, so input from both pilots and controllers can help guide safety decisions. The program will develop processes and policies to share and analyze relevant safety information in a non-punitive way, consistent with the basic principles of Safety Management Systems. These systems are widely used within the FAA and the aviation industry.

ASAP encourages aviation employees to voluntarily report safety information that may help identify potential precursors to accidents. The ASAP process resolves safety issues through corrective action rather than through punishment or discipline. Each program is based on a safety partnership that includes the FAA and the aviation operator, and usually includes a third party, such as the reporting employee’s labor organization. In today’s agreement, the airline’s labor organization is the United chapter of the Air Line Pilots Association (ALPA). Today, 73 air carriers have 169 ASAP programs for pilots, mechanics, flight attendants, and dispatchers.

ATSAP is an agreement between the FAA and the National Air Traffic Controllers Association (NATCA) that is designed to foster a voluntary, cooperative, non-punitive environment for FAA air traffic employees to openly report safety concerns  As a result of ATSAP, all parties have access to valuable safety information that otherwise might never have been discovered or reported. The FAA analyzes the information to develop skill enhancements or system corrective actions that will help solve safety problems.


FAA error-reporting program: 14,000 reports so far

April 5, 2010

A report by USA Today’s Alan Levin showed that 14,000 reports have been made in the FAA’s Air Traffic Safety Action Program (ATSAP).  ATSAP is modeled after the airlines ASAP (Aviation Safety Action Program). The program is non-punitive. The intent is to identify and report all events that may or did lead to a breakdown in safety, or increase risk to air traffic control operation. To mitigate all safety risks, thousands of unreported events need to be identified and studied. This may reveal the one critical safety event that could result in disaster.

In the year and a half since the program started more than 14,000 reports have been filed, USA Today reports.

The reports have allowed the FAA to make numerous fixes to festering problems, such as improving signage at critical runway intersections, the agency says.


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