NTSB to probe Fedex/Southwest close encounter at Austin

[DaveReidUK]

Originally Posted by ATC Watcher

On the other hand there will always be someone (a Capt Hindsight) that will say that If the Fedex had landed " normally" and decelerated behind the accelerating 737 possibly the separation would have been greater and consequently the risk of collision would have been smaller.

I doubt that anyone who has looked at the traces would think that.

A rather more sobering "what-if" is to consider what the outcome would have been had the 737 paused for as little as 10 seconds longer during its run-up checks before rolling. That scenario doesn't bear thinking about.

[Errwolf]

I'm not an ATC guy nor familiar with the setup at KAUS, but I can find some areas where ATC separation standards were not met and procedures were not followed, all citations from FAA JO Order 7110.65W and emphasis mine.

Any ATC pros/part 121 types please let me know if I am on target with the ATC duties, or even in the ballpark.

3−10−3. SAME RUNWAY SEPARATION

a. Separate an arriving aircraft from another aircraft using the same runway by ensuring that the arriving aircraft does not cross the landing threshold until one of the following conditions exists or unless authorized in para 3−10−10, Altitude Restricted Low Approach.

1. The other aircraft has landed and is clear of the runway. Between sunrise and sunset, if you can determine distances by reference to suitable landmarks and the other aircraft has landed, it need not be clear of the runway if the following minimum distance from the landing threshold exists: (a) When a Category I aircraft is landing behind a Category I or II− 3,000 feet. (b) When a Category II aircraft is landing behind a Category I or II− 4,500 feet.

2. The other aircraft has departed and crossed the runway end. If you can determine distances by reference to suitable landmarks and the other aircraft is airborne, it need not have crossed the runway end if the following minimum distance from the landing threshold exists: (a) Category I aircraft landing behind Category I or II− 3,000 feet. (b) Category II aircraft landing behind Category I or II− 4,500 feet. (c) When either is a category III aircraft− 6,000 feet.

3−10−5. LANDING CLEARANCE

b. Procedures.

1. Facilities without a safety logic system or facilities with the safety logic system inoperative or in the limited configuration must not clear an aircraft for a full−stop, touch−and−go, stop−and−go, option, or unrestricted low approach when a departing aircraft has been instructed to line up and wait or is holding in position on the same runway. The landing clearance may be issued once the aircraft in position has started takeoff roll.

3−10−6. ANTICIPATING SEPARATION a. Landing clearance to succeeding aircraft in a landing sequence need not be withheld if you observe the positions of the aircraft and determine that prescribed runway separation will exist when the aircraft crosses the landing threshold. Issue traffic information to the succeeding aircraft if a preceding arrival has not been previously reported and when traffic will be departing prior to their arrival.

3−10−7. LANDING CLEARANCE WITHOUT VISUAL OBSERVATION When an arriving aircraft reports at a position where he/she should be seen but has not been visually observed, advise the aircraft as a part of the landing and separation clearance that it is not in sight and restate the landing runway. PHRASEOLOGY− NOT IN SIGHT, RUNWAY (number) CLEARED TO LAND. NOTE− Aircraft observance on the CTRD satisfies the visually observed requirement.
der 7110.65W, Air Traffic Control

[WillowRun 6-3]

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 (for want of a better more precise term) which kept the Swiss nonaligned. The FedEx crew had enough reserves of SA and its correlate - readiness to take immediate action - to see the problem before it was too late. I regret risking semantics here.... but: was it "luck" that prompted the UA pilot in SFO in 2017 to say, "where's this guy going? He's lined up on the taxiway." My set of older UA FCOMs (obtained legit, I swear) probably don't have an operational guidance instructing pilots what to say when they see this exact situation as on the 28 taxiway. It was that individual pilot's reserves of the fundamental "factor inputs" which, ka-thunka ka-thunka, yield the aviation safety system.

So I don't think it's indulging in ascribing heroism to PIC of the FedEx aircraft for intercepting the situation. Okay yes it points once again to the "cowboys and bad guys" mentality of lots of my Yankee compatriots when it comes to R/T, but that issue is entirely a different problem-solution cause-and-effect chain.

As for seeing NTSB honcho say CVRs were overwritten, Expletive. House T&I Reauthoirization hearings have begun. Better get this done, methink(s).

Apologies for SLF/att'y incursion amongst aviators.

[MPN11]

So, Members if the Jury, who is to blame for this near catastrophic mid-air over the airport?

SW for taking too long to get moving?
FedX for trundling down the glideslope when cleared to land?
Or ATC for lacking SA in foggy conditions and issuing unsafe clearances to BOTH aircraft?

Sorry, but as a former ATCO at very busy Mil airfields, I blame ATC 100%. The rest is semi-aligned cheese-holes.

[SINGAPURCANAC]

I would like to ask USA colleagues what is exact benefit of doing land/take off c1earances your way?
e.g. you have one a/c 4Nm final RYR11 at 00
you have one a/c at holding point DLH 22 at 00

Option 1. Ryr 11 continiue app, landing clearance will be given shortly ( traffic info)at 00
DLH 22 clear for immediate take off ,...( traffic info) at 00
DlH 22 departs at 01 or so
Ryr 11 clear to land at 01 or so
ryr 11 on ground at 02

Option 2. RYR 11 clear to land...(traffic info) at 00
DLH 22 clear for immediate take off ....( traffic info) at 00

DLH 22 departs at 01 or so
RYR 11 on ground at 02

??
Thanks for clarification.

[hans brinker]

Originally Posted by dr dre

And there are plenty of non US backgrounded pilots flying for US airlines as well.

While not related to this incident here's a glaring example of very poor phraseology by US ATC (in addition to unnecessary aggression) that caused confusion and frustration and could've led to a safety incursion:

https://www.youtube.com/watch?v=ZWOOKQlEe5s

But it's not just the lax phraseology, there's also the lax procedures and the laisse faire culture, things like clearing an aircraft to land off a CAT III approach while a preceding departing aircraft hasn't even entered the runway yet. You don't really see this in any developed aviation environment outside the US.

Dissenting opinion. Not talking about operating procedures. I’ve flown all over the EU and a bit of Northern Africa for about 7 years, for the last 18 years North and Central America. Speak multiple languages, did ATC in Spanish and French when I worked there. English is not my first language. There’s no excuse for the absolutely appalling language skills many foreign carriers pilots have that fly international. That definitely includes the carriers from Southern Europe, and definitely Asia. There is no way some of those pilots in the video should be considered English proficient level 4, and as such, they should not be allowed to fly international.

[BFSGrad]

Originally Posted by SINGAPURCANAC

I would like to ask USA colleagues what is exact benefit of doing land/take off c1earances your way?

Pointless to discuss benefits of “our way” as either methodology of granting a landing clearance requires ATC to maintain situation awareness, which was clearly lost and causal to this incident.

[ATC Watcher]

@ 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.

[dr dre]

Originally Posted by SINGAPURCANAC

I would like to ask USA colleagues what is exact benefit of doing land/take off c1earances your way?

One could say if the international standard method of clearances was being observed at Austin then the controller would’ve been aware of the position and movement of SWA entering the runway and then rolling to a safe separation distance before issuing the landing clearance to FedEx. Instead they just issued two clearances under the assumption that their would be no conflict, and maybe diverted their attention to something else rather than the unfolding conflict.

A lax safety culture and short cuts. If the International standard of issuing take off and landing clearances had been followed this incident would not have occurred.

[WillowRun 6-3]

ATC Watcher, thank you for the explanation and additional discussion.

[pattern_is_full]

Originally Posted by MPN11

So, Members if the Jury, who is to blame for this near catastrophic mid-air over the airport?

SW for taking too long to get moving?
FedX for trundling down the glideslope when cleared to land?
Or ATC for lacking SA in foggy conditions and issuing unsafe clearances to BOTH aircraft?

Sorry, but as a former ATCO at very busy Mil airfields, I blame ATC 100%. The rest is semi-aligned cheese-holes.

SA is everyone's job - however I agree that SA is the one and only job for ATC, and that was clearly a fail... call it 95%+. Overall SA, and forgetting the word "immediate!" in the TO clearance.

I'd ding SW a little bit for counting too much on ATC's TO clearance when they knew (or should have absorbed from the tower comms) that the situation was tightening (spacing, weather, darkness) and not a good time and place for a 20-second delay after lineup (if accurate). I always try to save a little brain-juice for "the big picture" even if ATC gives a clearance - if only to check final and the runway myself when possible.

(As I said long ago on these forums, the goal of SOPs is not to tick boxes, but to avoid an accident - if you tick all the boxes and still have an accident, you're just as potentially dead.)

I'd ding Fedex, less, for trying to play ATCO (which muddied the waters - who was saying "Abort" and what did it mean? And took up a little time - again if accurate). And also perhaps assuming too much that the clearances would actually work.

But I wasn't there, cockpits are demanding places for either TO or landing (esp. CAT III), and with the weather/time, everyone was flying blind (literally).

[ATC Watcher]

Something I forgot to mention yesterday , and which has not been mentioned so far, is the apparaent unawareness of the seriousness of what happened and the self congrartulations in the end to reinforce them in their convinctions that they did themselves everything rght and it was all the fault of the SW...: The controller telling the Fedex " we appreciate your professionalism " and Fedex replying " Thank you " in a happy voice. This trends to prove to me that the deviances from normality we saw are deeply embedded in the system, at least in Austin.

[22/04]

I think we are discussing cultural differences and the exchange between the Southwest pilot and the Virgin one where the former mentions "a little freedom" points to this. In the U.K. it isn't only the job of ATC to have SA, but at a controlled airport it is to control. Pilots by and large do what he says. I remember a controller once said of an airfield "all this is mine and nothing moves without my say so." The U.S. seems to leave a little more to pilots.

I am pretty sure that here after both this and the JFK incident the controllers would have been relived of duty afterwards and not sure if this happened. Such a culture is widespread her for a variety of non-accusatory reasons - for example if a train driver passes a red signal even by a little bit the train can't proceed and a new driver must be found.

I fin the concept of an uncontrolled ramp a little extraordinary too. Presume the call "push back and start approved" is rarely heard in the U.S. Could lead to an expensive argument in court I would have thought.

Oh and the use of the word clear for anything other than take off or landing clearance still seems to happen - I must listen for the use of vacate in U.S ATC.

Tin hat on against incoming from the U.S.

[172_driver]

The controller telling the Fedex " we appreciate your professionalism " and Fedex replying " Thank you " in a happy voice. This trends to prove to me that the deviances from normality we saw are deeply embedded in the system, at least in Austin.

To med that sounds like a controller who knows he f*cked up and probably wanted to admit that, to relieve his chest. What should he reply?

[ATC Watcher]

Originally Posted by 172_driver

To med that sounds like a controller who knows he f*cked up and probably wanted to admit that, to relieve his chest.

Possibly .Only the controller himself can tell you exactly what he meant, but I am not that convinced that he realises that he is also a fault here, since a few minutes later he does exactly the same : i.e. clearing the American 808Q , also on a declared CAT III approach to land while the runway is still occupied ( by the Fedex) so either the guy does not know what a CATIII aproach requires, or it is an accepted normal deviation of the LVP procedures.

[waito]

I can't see any major issue in what FedEx Crew performed. Only thing is, they should've called out "going around" first, then maybe suggest Southwest to react like stop. Why FedEx went around so late? Well, we can't judge. This is very dynamic, they might have thought it works out at first. Even after the assumed major delay due to SW runup test.

I can imagine a sort of "non-constructive" role of the SW crew in happily accept the jump in front of the arriving traffic and doing whatever served themselves. Hope they learn from it, if that's the case. Hope it's not systemic to get advantage at sb elses' expense.

I can see a major screw from ATC, and to be honest, the conditional landing clearance was not the major issue. FedEx would have continued the approach almost as long waiting for the clearance. The major screwup is to let come a/c as close each other in poor vis conditions. And risking ILS signal quality by interference. I guess also a systemic one if executed by the same controller.

BTW, how often is low vis in Austin?

[DaveReidUK]

Originally Posted by waito

Why FedEx went around so late? Well, we can't judge.

Out if interest, is there a verified, time-stamped version of the ATC audio that can be overlaid on the vertical profile ?

That said, using either the track or the audio to try to establish definitively the point that the GA was initiated would need to take account of (a) the delay while the CF6s spooled up and (b) the likelihood that Aviating took priority over Communicating.

[BFSGrad]

Originally Posted by ATC Watcher

Something I forgot to mention yesterday , and which has not been mentioned so far, is the apparaent unawareness of the seriousness of what happened and the self congrartulations in the end to reinforce them in their convinctions that they did themselves everything rght and it was all the fault of the SW...: The controller telling the Fedex " we appreciate your professionalism " and Fedex replying " Thank you " in a happy voice. This trends to prove to me that the deviances from normality we saw are deeply embedded in the system, at least in Austin.

It was mentioned back in my post #13 responding to your post #11. I interpreted the local controller’s apology as 100% ATC mea culpa. I think by the point when the apology was issued, the local controller realized how badly he FU’d. He may have also realized that Fedex tried to bail him out when asking the 2nd time for a landing clearance. In effect Fedex was saying, “I don’t like the way this situation is developing, but I’ll stick with it a bit longer to allow YOU to do your job.” Ultimately, Fedex had to call the go around when it should have been called by ATC. Again, Fedex covering for ATC.

[waito]

Originally Posted by DaveReidUK

... using either the track or the audio to try to establish definitively the point that the GA was initiated would need to take account

Well, I didn't even bother to look at the timestamp. According to Avherald, GA was initiated at 150' AGL, 1000FT from threshold. Whatever the fidelity of that info is.

I call the GA potentially late because FedEx could have chosen to go around when they detected the SW 737 on the rwy possibly messing up ILS.

On the other hand, what did the FedEx Crew really see, detect., and when?
Does HUD Guidance with RNAV work without ILS signals these days?
​​​​​​

[WideScreen]

Originally Posted by ATC Watcher

Something I forgot to mention yesterday , and which has not been mentioned so far, is the apparaent unawareness of the seriousness of what happened and the self congrartulations in the end to reinforce them in their convinctions that they did themselves everything rght and it was all the fault of the SW...: The controller telling the Fedex " we appreciate your professionalism " and Fedex replying " Thank you " in a happy voice. This trends to prove to me that the deviances from normality we saw are deeply embedded in the system, at least in Austin.

I agree with you on this "conclusion", the undesirable waved off with a BBQ level amicably "thanks".

Not to say, Blancolirio his pay-off in this subjects' video also warns for another Tenerife in the making, an A380 on top of a 777-300ER ????