Runway incursion at Burbank

[DaveReidUK]

Per CNN, the NTSB announced today that it is investigating a Wednesday evening (22 Feb) runway incursion at Bob Hope Burbank Airport in California, involving a landing Mesa CRJ9 and a departing Skywest E175.

https://edition.cnn.com/travel/artic...all/index.html

[BFSGrad]

Rough ADS-B eyeball on both aircraft at 02:57:00Z looks like both at same altitude and 0.25 to 0.5 nm lateral separation, with the ERJ being at about 2 o’clock from the CRJ. Comms were a mess.

[Capn Bloggs]

Webtrak:

https://webtrak.emsbk.com/bur1

Set the time to 0655 PM, 02/22/2023.

[DaveReidUK]

Thanks, I'd forgotten that Burbank has WebTrak:



Departing E75L in blue, inbound CRJ9 in green.

[Carbon Bootprint]

A bit more from today's WSJ. Skywest was operating as UA Express to SFO.

Close Call at Airport Near Los Angeles Under Investigation

[Zeffy]

FR24 Blog:
​​​​​​https://www.flightradar24.com/blog/n...on-in-burbank/

[ATC Watcher]

Can someone finfs the R/T audio and post it here ? thanks

[DIBO]

R/T Audio clip here: https://forums.liveatc.net/atcaviati...5707/#msg75707

[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 )

[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.

[BFSGrad]

Originally Posted by fdr

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?

The lousy setup was partially due to the local controller’s (LC) decision to grant 47C’s request to land 26 instead of 33. When 47C initially checked in, the LC advised 47C he would be in sequence behind a SWA 737. 47C requested a change to 26. The original plan would have had 47C land after the SWA737 but before the CRJ. The LC then would have had no choice but to hold the ERJ short of 33, delaying its takeoff until after the CRJ landed. Other distractions were the police helo, initially request to “work to the east,” but then changing that plan to requesting to land BUR (sequenced behind 47C), and a DA42 requesting a BUR transition to VNY.

Regarding the “is he off the runway yet” transmission, I think that was from the CRJ. To me it sounded like someone in the CRJ inadvertently keyed the mic transmitting the dialogue between the CRJ PF/PM; i.e., “is he off the runway yet, no, we’re going around.”

One other observation. When the LC issued the go-around to 47C, she called the CRJ at 2 miles. Another 30 seconds elapsed before she issued the takeoff clearance for the ERJ immediately followed by the landing clearance to the CRJ. That means the CRJ was well inside of 1 mile when she issued those clearances.

Within 2 minutes after this incident, there was a change in LCs.

[JanetFlight]

Wow...such a confusing mess in all those comms...

[ATC Watcher]

Indeed , lousy set up and "inventive and flexible " way of working to optimize and expedite traffic while pleasing everyone. . Listening to the audio, any experienced cotroller would detect that she's up the limit ,:i.e. the speed of talking , contradicting clearances ,non-standard phraseology . the tone of the "Stand-by " given to the transit request, etc... Not sure if this is "standard Burbank day " or an exception though..
. The heli crossing at the threshold did not help ( standard procedure in burbank,?) ,, The " Fly runway cetreline on the go around was unfortunate , etc.. and ,just like the Austin case on the other thread, procedures on go around above or just behing a take off needs to be revisisted. . And this is not a US problem , happens everywhere.

[punkalouver]

Originally Posted by ATC Watcher

Indeed , lousy set up and "inventive and flexible " way of working to optimize and expedite traffic while pleasing everyone. . Listening to the audio, any experienced cotroller would detect that she's up the limit ,:i.e. the speed of talking , contradicting clearances ,non-standard phraseology . the tone of the "Stand-by " given to the transit request, etc... Not sure if this is "standard Burbank day " or an exception though..
. The heli crossing at the threshold did not help ( standard procedure in burbank,?) ,, The " Fly runway cetreline on the go around was unfortunate , etc.. and ,just like the Austin case on the other thread, procedures on go around above or just behing a take off needs to be revisisted. . And this is not a US problem , happens everywhere.

Yes, interesting audio.

[Chiefttp]

That area of Southern California (LA Basin) is very challenging airspace. Both large, and very large airports, and numerous small airports as well as military. Compounding this congested airspace is a large amount of general aviation aircraft, as witnessed by the audio tape. The weather is usually very nice, which generates all the aerial activity. It is the only airspace that I fly in, where I’ll put the autopilot on ASAP because it’s vital to have eyes and ears open. I will always brief my F/O to keep any extraneous chatter to a minimum and make short, crisp, transmissions on the radio.

[DIBO]

Originally Posted by Chiefttp

as witnessed by the audio tape

Not doubting for one second your firsthand insights in the matter, this particular half-hour recording had 9 minutes of actual transmissions out of 32 minutes of recording. Compared to the traffic load on the airport at that specific time (two times two aircraft), operating intersecting runways is far more of a challenge, especially with these 4 movements so tightly intermeshed.


On another matter, I hesitated and refrained from posting, but now I'm at it, I might as well post it as a matter of discussion. Similar to the sterile flight deck concept:

Distractions occur frequently in operation rooms or at the controllers working positions (CWPs). Air Traffic Control Officers (ATCOs) are facing these distractions day to day apart from performing their duties. The detrimental effect of distractions poses considerable threats to the safe operation of the air traffic management (ATM) system which may cause significant safety issues.

While listening to the ATC recording leading up to the incident, I made a few notes that would be quite meaningless, if no incident had taken place:
* on several TWR transmissions, voices in the background can be heard (which of course is not uncommon)
* at least on two transmissions, one could draw the (premature) conclusion that one was suppressing some form of laughter while speaking. One transmission was preceded with a few short unmodulated transmissions, possibly indicating hesitation or inability to state what needed to be stated.
* on one exchange the callsign of the carrier was incorrect, the flightnumber was correct (can happen to the best)
* on one ATC handover, an incorrect and totally different frequency was given, and upon the aircrew's acknowledgement which was 1 digit off, TWR gave the completely different, but correct frequency (can also happen to the best)

All small, almost meaningless events, that leading up to the incident, makes one wonder how sterile the working environment was...

Originally Posted by BFSGrad

Regarding the “is he off the runway yet” transmission, I think that was from the CRJ. To me it sounded like someone in the CRJ inadvertently keyed the mic transmitting the dialogue between the CRJ PF/PM; i.e., “is he off the runway yet, no, we’re going around.”

Not that it matters in the analysis of the incident (only to compliment the SA of the unknown party), but when looking at the waveform of the transmissions, the CRJ had a specific pattern (from the -not uncommon to jets- whistling noise in the background) which made it stand out from rest on the freq. at that moment. The “is he off the runway yet” transmission was ended with a click (release of the PTT button) more like the Cirrus's transmissions. It were also 3 distinct transmission, one of unknown source and two from the CRJ. So it was either another aircraft, another pilot stepping in only for this transmission (which I'm inclined to believe), or it indeed came from the CRJ, with the first transmission (inadvertently) by the other CRJ crewmember, using a sound-technically different headset/mic.

[JanetFlight]

A new more "detailed" clip »»»

BTW, is it only me having a great difficulty understanding such rapid english non-standard comms or the ATC lady gave the SKW clr for TO run even before the light N47C crossed their path from right to left, in front of them on the GA procedure!!???

Tks

You Tube

[BFSGrad]

Originally Posted by JanetFlight

BTW, is it only me having a great difficulty understanding such rapid english non-standard comms or the ATC lady gave the SKW clr for TO run even before the light N47C crossed their path from right to left, in front of them on the GA procedure!!???

Keep in mind that these video recreations are merging ADS-B data with LiveATC audio. As far as I know, there is no way to time synchronize the two sources. Therefore, what you see and hear on these videos may not be accurate and is just a best guess by the video creator. The ADS-B data shows that 47C passes in front of the ERJ before the ERJ starts moving.

In contrast, the official FAA ATC tapes are time stamped and can be synchronized with ADS-B data allowing for an accurate video/audio recreation, but are available only to FAA and NTSB investigators. Most of these video creators will include such a disclaimer regarding aircraft positions and will also caption when audio is edited (or not edited).

[DIBO]

Originally Posted by JanetFlight

BTW, is it only me having a great difficulty understanding such rapid english non-standard comms

wasn't all that bad, if you ask me. I don't think any of the parties concerned had a problem with this. Only the more than usual number of comm's being stepped-over, complicated things, but not to the point that it was a contributing factor in the unfolding of the events. And a caveat when listening to third-party recordings of ATC comms, this recording does not necessarily reproduce what the parties concerned were receiving. The SKW T/O clearance is a good example of something hardly readable on LiveATC, but would most likely have been perfectly readable by the SKW crew.

Originally Posted by JanetFlight

or the ATC lady gave the SKW clr for TO run even before the light N47C crossed their path from right to left, in front of them on the GA procedure!!??

But the necessary vertical separation was already in place (some 700+ft AGL when N1547C crossed rwy 33), so I think that is about the only element in this event, that had sufficient safety margin. However, the "N47C go around and turn base rwy 33" would have certainly confused me for a moment. "Turn crosswind" or "Turn downwind rwy 33" would have been clear right away...

[JanetFlight]

Many tks for your wise and important Inputs and feedbacks, dear Dibo & BFS.