Close Call at Boston Logan

[konradeck]

Originally Posted by JanetFlight

Welll...with this recent amount of "Near" & "Close" last times, i really pray one of these next days we won't see such words changing to something worst...

Isn't it a case of "informational bias"? Having one incident of a type raises sensivity on similar cases around...
Just like the epidemy of lost navigation cases recently.

[22/04]

Just wondering whether you have the Mandatory Occurrence Report system in the U.S. which will occur here whenever thee is loss of separation unauthorized entry into controlled airspace etc. here in the U.K.

at least this one appears simple and not a system failure - an error.

[ATC Watcher]

Originally Posted by 22/04

at least this one appears simple and not a system failure - an error.

Does someone knows if in the US a CVR is mandatory for a business jet in these types of ops ? if it is . and not erased , it would probably give us a very interesting clue as to what the dymanic was. If it was the same as Tenefrife, taking off without being cleared , but believing you are and when told by the other crew member , we are not , replying emphatically : "yes we are" .and because of the cockpit authority gradient it is not challenged. We changed totally the phraseology and developped CRM after that and thought naively that we had solved the problem. But maybe there is another resaon for the error, pity we miss some of the R/T.

@ DIBO : thank you for your "cleaner"version of the R/T , ( also to BFSGrad for his transcript ) but would have liked to hear the Lear jet confirmation of the line up and wait and traffic info instructions.

[BFSGrad]

Originally Posted by ATC Watcher

Does someone knows if in the US a CVR is mandatory for a business jet in these types of ops ? if it is . and not erased , it would probably give us a very interesting clue as to what the dymanic was.

Yes, CVR required for 135 ops but as with other recent incidents, 2-hr CVR spec coupled with subsequent flight after incident (nearly 3 hrs for N280LJ), makes the installation of a CVR useless for incident investigation.

[DIBO]

Originally Posted by ATC Watcher

but would have liked to hear the Lear jet confirmation of the line up and wait and traffic info instructions.

I went back to the original audio track, just in case I would have filtered/trimmed out too much.
On TWR West 128.8, HPJ's replies were barely readable and incomplete, it's last instruction by TWR West ("monitor TWR 132.22") was without any recorded reply (only 8.5 seconds of silence, before TWR West's subsequent transmission - which strongly suggests that TWR West indeed received the reply).
A bit later on TWR East 132.225, for the partially (=callsign missing) recorded instruction "...line up and wait...", no HPJ reply was recorded (only 11.5 seconds of silence, before a transmission from the other TWR (West) was recorded).

So as stated before, this LiveATC audio is a dead end, all the missing transmissions are almost certainly due to the shortcomings of this LiveATC contributor, its location, its receiving/recording equipment, combined frequency recording, etc.

[Equivocal]

Originally Posted by 22/04

at least this one appears simple and not a system failure - an error.

I find it disappointing that we might draw this conclusion and believe that an investigation is complete. There may well be more behind the incident - asking 'how was this allowed to happen', or maybe 'how did the system allow this to happen', may elicit a variety of contributing factors which could be improved. For example, was there something in the phraseology used by ATC or the pilot which was ambiguous, is this an isolated incident or have there been similar occurrences in the past at this airport, were there any pressures on the crew of the HPJ which might have encouraged them into a 'go' mindset, have any HPJ flights generated any similar incidents in the (recent) past. Any of these - which are all elements of the 'system' - could be a latent weakness (hole in the Swiss cheese) which could be addressed.

Of course, it could just be an error - one of those unexplainable things or decisions that we all do from time to time - and completely out of character for the individuals involved. But without a proper investigation, no-one will ever know.