Heathrow Near Miss Report

[twistedenginestarter]

From the BBC:
were very disappointed this occurred because we have one of the best safety records in the world

Keith Williams
Nats
A 28-year-old female air traffic control trainee was controlling take-offs on the runway at the time, under the supervision of a mentor, the report said.

The British Midland plane was still on the runway for take-off when the British Airways plane was instructed to go round it at a late stage.

During this procedure, the BA plane performing the "go-around" was estimated to have come within 112ft of the British Midland plane.

Mentor and trainee

The crew in the British Midland plane saw the British Airways aircraft fly over and told the air traffic controller they would be submitting a report.

The mentor and trainee were relieved from duty five minutes after the incident.

The report said no criticism could be made of the trainee's performance during the near miss.

But it said her mentor, a 35-year-old man, had allowed the situation to develop to the point where the BA plane could not be "safely integrated" with the departure of the British Midland plane.

Earlier incident

When the situation became apparent, his initial actions, on taking control of the radio communications, were inappropriate, the report found.

The mentor had been selected as an on-the-job training instructor in 1999 but had said he did not particularly enjoy his job.

It was considered to have been so close to being an accident that the Air Accident Investigation Branch said we had better treat it as if it were an accident

David Learmount
Flight International magazine
He had been involved in an incident in April 1999, in which he cleared a Boeing 757 to cross the runway in front of a Boeing 747.

The situation was resolved after the pilot of the departing aircraft queried his clearance.

It is understood he has now been "demoted" to a less busy airport.

Strobe lights

The system for selecting on-the-job training instructors at Heathrow was flawed at the time of the incident but has subsequently been revised, the report suggested.

The company procedure on the use of strobe lights further meant that the British Midland plane was not as visible as it could be on the runway, the report also found.

It recommended that the Civil Aviation Authority (CAA) should issue instructions requiring UK registered aircraft to use strobe lights, if fitted, when on an active runway in the UK.

Keith Williams, of National Air Traffic Services (Nats), told BBC Radio 4's Today programme: "Last year there were 460,000 aircraft movements at Heathrow and this was the only serious safety-related incident, but it is one too many.

Full investigation

"Nats were very disappointed this occurred because we have one of the best safety records in the world."

David Learmount, operations and safety editor at Flight International magazine, said: "This is a full investigation by the Air Accident Investigation Branch.

"Normally near misses are investigated - even if they are pretty serious - by the independent body known as the joint air proximity working group.

"It was considered to have been so close to being an accident that the Air Accident Investigation Branch said we had better treat it as if it were an accident."

As I heard it the 747 also turned into the path of the A321 to make matters worse.

[information_alpha]

is the report posted on the internet anywhere?

[Whipping Boy's SATCO]

Yes,

http://www.aaib.detr.gov.uk/formal/gbnly/gbnly.htm

[tailscrape]

Standby for more sensationalism in tomorrow's press then........

[CHUUK]

"... During this procedure, the BA plane performing the "go-around" was estimated to have come within 112ft of the British Midland plane... "

Was the journo out there with a yard stick or what?

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Preez mind dah pratform gahp.

[Ranger One]

CHUUK,

From the AAIB report (URL above):

'With one aircraft ('Midland One November Zulu') still on the runway for take off, 'Speedbird Six' was instructed to go-around at a late stage of its approach. During this procedure, the aircraft performing the go-around descended to 118 feet radio height above the runway; the aircraft on the runway for departure had a tail fin height of 38 feet 7 inches.'

Now that particular statement doesn't clarify the precise relative positions of the aircraft involved, but it was undoubtedly bloody close and bloody scary - so I would suggest that, for once, the press comment you mention is not particularly out of order.

One of the nastiest AAIB reports I've read in some time.

R1

[pied piper]

I may be mistaken, but the report said the A/C initiated the GA did it not?

>> However, even after realising that the situation was becoming more critical, the controller did not intervene but allowed the continued approach of the B747 which, at the time the 'One Eleven' began its take off roll, was only 0.5 nm from the runway threshold until any decision was effectively taken out of his hands by the B747 pilot's decision to go-around.

As the B747 reached the runway threshold markings the commander initiated a go-around from approximately 50 feet agl transmitting ‘ON A GO-AROUND … AND WE'LL START A RIGHT TURN TO MISS THE TRAFFIC’.<<

[ATCO Two]

Hi PP,

Er sorry - different incident!

[Airbanda]

No need for tailscrape to wait until tommorrow for press coverage, usual job in today's London Standard. I only paraphrse slightly what was in on display WH Smugs at lunchtime.

"The flight from Japan had called Heathrow ATC for permission to land on the right hand side of Runway number nine"

Airbanda-Proud to be an Anorak

[HotDog]

What was the viz at the time? I think BA should have initiated the go around a lot earlier, unless he wasn't visual?

[stickyb]

CHUUK

Or, in a different section

"Using the recorded altitude and glideslope data, a time history of aircraft height (agl) against distance from Runway 09R threshold was calculated. However, the exact position of 'Midland One November Zulu' was not known and small errors had been introduced into the recorded glideslope data as a consequence of aircraft legitimately entering the ILS sterile area. Nevertheless, from the available information, including the brief variation in recorded radio altitude (see Appendix C), it was calculated that 'Speedbird Six' was at 150 feet (+/- 20 feet) agl when it was overhead 'Midland One November Zulu'."


By my reading the journo could have made it more senaational by taking liberties with the +/- 20ft.

Which bit of the Speedbird was at 150 feet? Although we have it pointed out about the fin height of Midland One, what about the protruding gear of Speedbird? Could that make it even closer in terms of real separation?

[This message has been edited by stickyb (edited 13 June 2001).]

[This message has been edited by stickyb (edited 13 June 2001).]

[PaperTiger]

BA6 did not see BD in position. He thought his departing traffic was LH which had just rotated. Viz was 6km IIRC.
All in the report.

[flaps]

It's possible that the Midland Airbus did not have it's strobes on at the time. The Beacon would be on though. Not trying to suggest anything.

At that time at BA the policy was to use the Auto setting for the strobes which started them as soon as the aircraft left the ground. This was ammended last summer to use the ON setting on entering the runway to ensure the strobes were on when stationary.

[Curious Pax]

The Midland didn't have his strobes on at the time according to the report - it is one of the recommendations that strobes should be on all the time an aircraft is on the runway. He wasn't doing anything wrong however - just following company procedure. If I remember rightly BA are unusual in the time they put their strobes on - I think there was a thread discussing the merits of this ages ago on Pprune (some people objected as it dazzled other pilots at night).

[Captain Airclues]

Todays Daily Mail says that "with the 747 two minutes out, there were still three aircraft on the runway with conditional approval for take-off."
Don't you think that this is taking runway utilisation a bit too far?

Airclues

[anengineer]

I wish to point out that I am NOT a Sun reader, :) but spotted the story on today's front page in a newsagent's.
..and this drivel is from their website :-

TWO airliners carrying 499 people came within 112ft of a catastrophic collision over Heathrow in Britain's worst near-miss yet, it was revealed yesterday.

The huge planes were a split second from disaster when the pilot of the Boeing 747 was alerted.

An air traffic controller - blamed in a damning report for allowing the potentially tragic situation to develop - shouted the frantic radio message: "Go round! Go round!"

At the same time, the British Midland captain was ordered: "Abort takeoff!" The BA pilot just managed to pull his aircraft up and bank away to the left as the Airbus braked to a halt on the tarmac.

The horrifying incident happened while the 35-year-old controller - who has not been named - was supervising a woman trainee.

...I'll spare you all the rest, but you ought to see the 'illustration' of the ATCOs

http://www.thesun.co.uk/storypics/13773479

Whaddaya think ? - Caption competition anyone ?? :)


- edited to remove the [img] commands as they didn't work - sorry, you'll have to click on the link instead -

[This message has been edited by anengineer (edited 13 June 2001).]

[bow5]

Ah, the good old Sun. Never let utter rubbish get in the way of a true story.

I would like to see the Mirror's take on events, something along the lines of -

'HEATHROW IN TURMOIL SHOCKER. PLANES COLLIDE OVER BUCKINGHAM PALACE. BLAIR TO TAKE PERSONAL CHARGE!' :rolleyes:

As for the caption:

Woman: 'What does this do then?'

Man: 'Look at me, i've got some kind of Ricky Martin thing going on here.'

[This message has been edited by bow5 (edited 13 June 2001).]

[pied piper]

atco 2

Thanks for pointing out that erm minor discrepancy? ;-)

[FL390]

Haha! I loved te BBC's impression of what the BM A321 looked like! Unless I'm seeing double, it had four engines!

[JPJ]

I have made this point before, but it bears repetition.

The Press are there, they have a job to do, and they will do it. They work to very tight schedules, and sometimes the boy or girl writing about you, professional pilot, has only a few minutes to get a grip on the story, write and file.

Instead of carping (and yes, it is a pain to see elementary cock-ups) why doesn't the profession organise a programme to inform he journos? Brief them. Invite them to the sim, or the Jumpseat. Fix them a tech tour of your base. Have a regular programme of ATC visits.

That way, the industry has a chance of creating a core of knowledge that will help the journo to write the story, and help the industry to have its case put accurately.

It is better to have them inside the tent...
I think you know the rest.

[anengineer]

Well. S'cuse me if I sound a bit cynical here, but I wonder how long that arrangement would last, if all the above were provided for journos. ...probably until the first time some tabloid hack witnesses a relatively minor incident and the next day's headlines read "PLANE IN NEAR DISASTER".

But of course, that would never happen would it ?

[Wedge]

True that you can't expect journos to get it right all the time - and let's be honest we don't really want them to know all the jargon and be able to report aviation incidents from an aviators point of view. They write article for Joe Public to be able to understand.

However "An air traffic controller - blamed in a damning report for allowing the potentially tragic situation to develop". I am sure we are all very impressed by the ability of the greaseball hacks at The Sun to aportion blame - but I would like to see one of them trying to do the job of a Heathrow tower controller.

[cossack]

Its not just the quality of reporting, using paraphrasing and losing the meaning entirely that leaves a lot to be desired, but the graphics as well.
I saw several of yesterday's papers efforts and none were great, but The Mirror managed to have the two aircraft concerned pointing at each other!
What else do they get so very, very wrong?

[The Growler]

the crew of 'Midland One November Zulu' saw an aircraft indicating on TCAS at about two miles range from their position; they did not have visual contact with the aircraft

Would you have accepted the line up instruction with another aircraft less than 30 seconds from touchdown ?

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"How can we soar like eagles when we're surrounded by turkeys"

[caulfield]

"the pilot wasnt doing anything wrong..he was just following company procedure"
This is a classic case of good airmanship playing second fiddle to piddling company SOP's.I hope the AAIB take BM to town on this oversight.You take an active runway,you put your strobe light on.
Suppose the BM had lined up without clearance and visibility had been even worse than 6k..now only the BA pilots can retrieve the situation..and without the strobe light,the catastrophe would have been inevitable.

[newswatcher]

Wedge,

I think you give Sun reporters too much credibility, in suggesting that they have the intelligence to "apportion blame".

I think you will find that this was actually done by the AAIB report - see 3(b) - Causes.

The "best" headline I saw was something like - "Pax in runway terror". Now correct me if I am wrong, but would any of the pax in either aircraft have known exactly what was happening "at the time of the incident", to put them in a state of "terror"?

[This message has been edited by newswatcher (edited 14 June 2001).]

[fragul]

Tch Tch, gutter press eh !

The TImes - (weds 14th June) has an illustration showing the BM 321 commencing its T/O roll on 09R at the intersection with 23 - didn't know they were STOL ......No wonder the BAW6 didn't see him !

[Airbanda]

Did any paper get the graphic right, the express showed it at the 27 end of the southern runway.

[basil fawlty]

I'd like to agree with/ expand on Hotdogs comments earlier.
Isn't there something in the UK ANO (or whatever has replaced it these days!) regarding the fact that the PIC of an aircraft can disobey/overule an ATC instruction if there is a risk of injury or death?? In this case, as the viz was quite good why did the BA pilot not initiate a go-around earlier, as soon as it became obvious that runway seperation was going to be comprimised? Perhaps he was apprehensive at having to try and justify his actions to management after spending a few quid on a go-around?? Or on the other hand did he just not make the right decision? I wonder if he would have still landed if the controller had not told him to go around? If he had landed and the BM a/c had aborted its T/O, would the 747 have piled into the back of it?? Not just the controller who needs a bit of "retraining"!!!

[PaperTiger]

For the second time, he did not see the British Midland waiting in position. If he had then the go-around would have been commenced earlier. And yes, a pilot can disobey any ATC instruction which is in his opinion unsafe.

[basil fawlty]

If the viz was 6k WHY DID THE BA PILOT NOT SEE THE BM AIRCRAFT then??? Too busy scanning his pay statement?

[Thomas Doubting]

The report makes good reading, much better than the Sun or the Mirror, and addresses just about all the questions asked here.

The report refers to comments on the RT from the BM Captain just after Nigel roared over his head dangling the Dunlop's.

What could possibly be judged "inappropriate" in the circumstances? The mind boggles, a lovely bit of British stiff upper lip understatement.

Has this incident had any effect on Nigel requesting or getting 09R's since?

[fireflybob]

The AIB report does not seem to make any comment with repect to the conspicuity of the Midland aircraft on the runway other than the fact that strobes were not switched on.

I wonder whether a different colour scheme would have made the aircraft more conspicuous?

Having read the report I think it is quite understandable that the BA crew were under the impression that the other departing LH traffic was the traffic that was relevant to them. We should also remember that BA crews fly worldwide to other destinations which are just as busy as LHR, etc.



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[HotDog]

Often the eye sees what the brain dictates, even with a 6K viz!

[This message has been edited by HotDog (edited 15 June 2001).]

[Whipping Boy's SATCO]

Why did the BD line-up when there was a rather large aircraft on short finals?

Airmanship??