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Close Call at Boston Logan

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Close Call at Boston Logan

Old 2nd Mar 2023, 08:01
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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.
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Old 2nd Mar 2023, 08:59
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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.
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Old 2nd Mar 2023, 09:27
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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.

Last edited by ATC Watcher; 2nd Mar 2023 at 09:35. Reason: typo
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Old 2nd Mar 2023, 14:34
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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.
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Old 2nd Mar 2023, 19:52
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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.

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Old 3rd Mar 2023, 10:56
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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.
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Old 4th Aug 2023, 03:17
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NTSB Report with Photo

https://www.cbsnews.com/boston/news/...the%20incident.

https://www.reuters.com/business/aer...sb-2023-08-03/



Last edited by Lake1952; 4th Aug 2023 at 11:18.
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Old 4th Aug 2023, 07:14
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According to the ATC recording the JetBlue queried the reason for the go around, so presumably they didn't see what that video image captured.
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Old 4th Aug 2023, 11:19
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The NTSB Report on Boston Logan Incident

Sorry, bad link...
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Old 4th Aug 2023, 11:47
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Originally Posted by Lake1952
Sorry, bad link...
The 'NTSB Final Report' link on the CBS report which you referenced leads to a Twitter post which includes a link to the NTSB Report (which look genuine to me).

...according to which the Jet Blue pilot reported that they did see the aircraft on the runway ahead. I guess the questioning of ATC was to see if they would get any more information.
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Old 4th Aug 2023, 14:33
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Originally Posted by Ivor_Bigunn
Errr, the NTSB Report states that the pilot of Jet Blue did see HPJ280, as follows:
Yes, that's what I said.

I was just surprised that, having seen the plane crossing ahead of them, the pilot still asked ATC the reason for the go-around. Maybe they really didn't register how close it was?
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Old 4th Aug 2023, 15:06
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Disappointed to see that this scant report is what the NTSB produces 6 months after a serious incident.

From the docket statements, the Learjet SIC was in the left seat as PF for the no-pax flight back to FXE. The SIC heard the LUAW instruction (and was therefore monitoring ATC comms) but then claimed he didn’t “hear” the imaginary CFTO instruction because he was concentrating on taxiing onto the departure runway. He therefore relied solely on the Captain’s (PM) confirmation of CFTO. That seems like some dubious CRM.

Last edited by BFSGrad; 4th Aug 2023 at 15:53.
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Old 5th Aug 2023, 00:56
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Originally Posted by netstruggler
I was just surprised that, having seen the plane crossing ahead of them, the pilot still asked ATC the reason for the go-around. Maybe they really didn't register how close it was?
No, it was ATC (Boston Depature) asking Jetblue the reason for the go-around. "Tower instructed, Jetblue 206" was the pilot's reply.
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Old 5th Aug 2023, 02:47
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Very surprised to hear the Learjet pilot state he was not feeling well (unfit to fly…) which in the land of litigation is quite an admission of guilt!
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Old 5th Aug 2023, 06:06
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Originally Posted by DIBO
No, it was ATC (Boston Depature) asking Jetblue the reason for the go-around. "Tower instructed, Jetblue 206" was the pilot's reply.
Ah, thanks.
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Old 5th Aug 2023, 12:48
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This "incident" was less than 4 seconds away from a potential disaster. What is the scariest element for me is the lack of a real solution to the insidious effects of confirmation bias... the Lear pilot just kind of "dreamed" he was cleared for takeoff at a busy international airport where landings were on a crossing runway. So many similarities to the JFK incident where the AA crew simply believed they were assigned 31L for takeoff despite the tapes. What's the solution for confirmation bias? Do instructions and clearances need to be visual as well as aural with some type of text system? If so, it had better work better than my talk to text apps!
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Old 5th Aug 2023, 14:01
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Originally Posted by Lake1952
So many similarities to the JFK incident where the AA crew simply believed they were assigned 31L for takeoff despite the tapes. What's the solution for confirmation bias? Do instructions and clearances need to be visual as well as aural with some type of text system?
As in the JFK incident, the BOS incident occurred in an environment with a Runway Status Light System. According to the FAA website, runway 9 (Learjet departure runway) at BOS has Takeoff Hold Lights (assuming also installed at the time of the incident). How did these factor into the incident? As a reminder, in the JFK incident the AA crew crossed an active runway with Runway Entrance Lights that were verified to be operating properly.
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Old 5th Aug 2023, 21:19
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Originally Posted by BFSGrad
As in the JFK incident, the BOS incident occurred in an environment with a Runway Status Light System. According to the FAA website, runway 9 (Learjet departure runway) at BOS has Takeoff Hold Lights (assuming also installed at the time of the incident). How did these factor into the incident? As a reminder, in the JFK incident the AA crew crossed an active runway with Runway Entrance Lights that were verified to be operating properly.
Well, assuming the system was active and operational, this places further emphasis on the power of confirmation bias! The firm belief that what the pilot thinks is true will often trump each piece of evidence that it is not true. And in retrospect, it is often astounding at the contrary clues ignored by not just one pilot, but two pilots. Look at the Comair CRJ crew at KLEX making a pre-dawn takeoff on a 3000 foot UNLIT runway, almost certainly the first time in their careers that they made a night takeoff in a commercial jet on an unlit runway, crossing the lit intended runway on their roll.
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Old 6th Aug 2023, 03:49
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Originally Posted by Lake1952
…in retrospect, it is often astounding at the contrary clues ignored by not just one pilot, but two pilots. Look at the Comair CRJ crew at KLEX making a pre-dawn takeoff on a 3000 foot UNLIT runway, almost certainly the first time in their careers that they made a night takeoff in a commercial jet on an unlit runway, crossing the lit intended runway on their roll.
Fatigue .
i’ve done enough Night shifts in my life to know you do not think the same way at 3 AM than at 3 PM .
Almost all recent large catastrophic accidents , ( e.g. 3 Miles Island,Chernobyl , Bophal , Exon Valdez, etc..) were the result of human error in the middle of the night.
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