@ Willow Run6-3 , quote :
SLF/attorney intruding, apologies in advance.
I don't see it as "luck" - the non-occurence of a mid-air. It was the result not of random chance, but instead the reserves of safety-system building blocks
Apologies accepted. nobody is perfect
You see there are no "reserves" as you put it in Safety management , just layers and back ups. Fedex did not save the day, he improvised a self made solution ouriside the box, "SW abort" which had no effect , The "Luck" I was talking about is the luck they did in not hitting each other during the go around manouvre , because in this geometry , none of the 3 participants had a clear SA and could see the other one, The Fedex was above the SW and could not see it, the Fedex could not be seen by the SW because it was behind , and the controller could not see both because of the Low vsibility. The correct procedures were not followed : i.e. wrong landing clearance by ATC, wrong line up clearance by ATC , no reaction by SW to an immediate take off instruction wrongly issued by the controller , no monitoring of the actual departure by the controller, no go-around ordered by the controller, no traffic info given by the controller after the go around , no apparent side step made by the Fedex, etc.. and on top of that wrong non-standard phraseology used .all around.
Yes the fact they missed by 100ft above the runway was caused by pure luck, or fate as we call it, but definitively not by "reserves" in the safety system .
@ MPN 11 quote :
Sorry, but as a former ATCO at very busy Mil airfields, I blame ATC 100%. The rest is semi-aligned cheese-hole
I do not like to apportion blame, and certainly not before a proper investigation report is available. FR24 and ATCLive radio are great tools but we know it is not 100% reality , especially regading the exact timing of things .But so far, yes it looks like poor ATC.
W
But what I see here is a system that has deteriorated over time . It not so much to blame the individual controller here, but rather ra system that allows this mess to sound like "normal" . But who trained the guy to do this , who supervises him and finds it OK ? This is more the issue for me.