Runway incursion at Burbank

[fdr]

Originally Posted by DIBO

Maybe, just maybe, the "Swiss cheeseholes..." started here, taking TWR's attention away from SKW5326 -not visible on FR24- still in position rwy33 (and ASH5826 closing in rapidly):

N1547C was landing on 26, thus preventing SKW5326 from taking off on 33, so TWR G/A'd it with an interesting left crosswind turn in an almost reciprocal course towards ASH5826 (and ~2000ft lateral), which probably (and understandingly) drew TWR's attention to these two aircraft, unfortunately a bit too long....


...thereby losing track of SKW5326 not yet having been cleared for T/O.

Given the urgency, this T/O clearance was given by stepping over another aircraft's transmission (which most likely was well received by TWR).
But, especially with hindsight, a G/A for ASH5826 was the only good option (and keeping SKW5326 in position on the threshold).

And from there on, compared to the KAUS incident, it will be hard to blame any pilot for any contributing factor:
* even a 'third party' (was it N1547C?) with better SA stepped in with "is he off the runway yet"
* ASH5826 G/A'd and was subsequently instructed by TWR to climb on RWY heading (with SKW taking off!!), so no blaming here that the pilot did not side-step
* then TWR "ASH5826 turn right two-seventy" ... "left two-seventy"
* soon after "SKW5326 continue on the SID" which is in fact also a left turn towards ~270° !!!!
* TWR "ASH5826 do you have the Embraer in sight" - ASH "Negative we got an RA complying with it" (maintaining a super relaxed voice given the circumstances )
* TWR "ASH5826 roger, turn right thirty degrees..left thirty degrees' (second time in a few minutes that L & R are mixed up )

stuff happens, and the traffic conditions in this case certainly added to a couple of oddities. '47C GA and vectors were directly towards the landing aircraft on 33, setting up a potential RA, or worse, as the landing CRJ900 would have been near the inhibit point for RA's. The right no, left turns in the middle of an RA advisory from the CRJ is problematic, it contradicts the primacy of the TCAS RA at that point, and the crew would have had an interesting moment to think that situation through as far as training and policy went, and the ingrained response to ATC clearances. The ATC officer was dealing with a lousy setup, where was the supervisory oversight looking at the flow control and the potential for this to get entertaining? There were a number of crew there that had a good SA of what what happening, it still ended up with an RA which could have been avoided by a cancelled TO clearance for the E-175. The 5826 and 5326 C/S's are close enough to add additional confusion which would have been even more uncomfortable.