Close Call at Boston Logan [Archive]

DIBO

28th Feb 2023, 19:04

FR24 datarecords captured at exactly the same moment (2023-02-27T23:54:57Z):
(JetBlue 206 going around 4R / Hop-A-Jet 280 taking-off rwy 9)

https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/941x702/kbos_d365d6e71f1706243a845c57d8e832a37f38c131.jpg

JanetFlight

28th Feb 2023, 19:08

Wow... Here we go again 👌

DaveReidUK

28th Feb 2023, 22:08

FR24 datarecords captured at exactly the same moment (2023-02-27T23:54:57Z):
(JetBlue 206 going around 4R / Hop-A-Jet 280 taking-off rwy 9)

Yes, the JBU Embraer appears to have crossed the 04R/09 intersection about 4 seconds after the Learjet had crossed it.

BFSGrad

28th Feb 2023, 22:19

Tough to armchair this incident due to limitations of LiveATC. Available audio feed is both KBOS tower frequencies combined in a single audio file. Not all transmissions are heard. When LC instructs Learjet to cross 4L at E and turn right on M, only a partial read back is heard. When LC instructs Learjet to monitor 132.22, no read back is heard. No read back is heard from LC instruction to Learjet to LUAW on 9, with that transmission excluding the Learjet identifier from LC.

Listening to the extended audio file, radio comms/discipline was very good with both pilots and ATC identifying and correcting occasional errors from the other. Given that exhibited discipline, I suspect the Learjet responded to all LC instructions with the appropriate read back, but not captured on audio file due to limitations of LiveATC monitor. Once off the ground, Learjet comms are loud and clear.

VASAviation creator noted in comments of his video that he followed the Learjet for several frequency changes after departure and never heard ATC issue a possible pilot deviation.

One other observation: after JBU gets handed off from tower, TRACON asks for reason for go-around, and pilot responds "tower instructed" (rather than pilot-initiated).

Lake1952

28th Feb 2023, 23:18

The area of KBOS where this took place was once emphasized on KBOS charts as a critical hot spot as I recall from years ago, but I am not seeing that on current charts.

https://images.app.goo.gl/c6gb3WzBHsDmSheY8

chuboy

28th Feb 2023, 23:38

Tough to armchair this incident due to limitations of LiveATC.
Thank goodness for that

Lake1952

1st Mar 2023, 00:31

Lowest recorded altitude was 75 feet. There are reports that the wheels touched the runway.

https://flightaware.com/live/flight/JBU206/history/20230227/2140Z/KBNA/KBOS/tracklog

fdr

1st Mar 2023, 01:50

Yes, the JBU Embraer appears to have crossed the 04R/09 intersection about 4 seconds after the Learjet had crossed it.

4 seconds... 240mtrs approx for the lear from the nose of the E-Jet... close enough to read the rego. 4 seconds later, the Lear is about... 120m to the right of the E-Jets path... The E-Jets captains comment about the G/A due ATC is rather understated... The Lear has some explaining to do at some point to his local FSDO, about rolling without a clearance, and not reading back an apparently non-existent clearance...

Eyes n' ears open, seems to be a busy season for oddities.

ATC Watcher

1st Mar 2023, 07:35

@ DIBO : could you again put the audio link ? Thanks . This one sounds a bit like Teneriffe,i.e. minset to go before actual take off clearance was issued. We all thought the " lineup and wait " phraseology introduced after that would eliminate this, proved wrong again apparently.

DaveReidUK

1st Mar 2023, 08:13

Lowest recorded altitude was 75 feet. There are reports that the wheels touched the runway.

FR24 has one 0 ft plot point (+/- 12.5'), so quite likely that the wheels touched.

Seat4A

1st Mar 2023, 15:55

GarageYears

1st Mar 2023, 16:05

Can someone explain to me why nothing was said to HPJ280?

BFSGrad

1st Mar 2023, 16:54

Can someone explain to me why nothing was said to HPJ280?Assume you’re referring to a possible pilot deviation notification by ATC? While the VASAviation video guy stated he never heard such an ATC notification, another comment in his video stated that HPJ280 was notified about 35 minutes after departure. 7110.65 states that possible pilot deviation notifications are made “workload permitting.” Doesn’t really matter as the FAA has stated via media that HPJ280 departed with no takeoff clearance. I have no doubt that upon arrival at FXE, the pilots were well aware of their regulatory peril.

punkalouver

1st Mar 2023, 17:20

Can someone explain to me why nothing was said to HPJ280?
Probably better to do so in cruise when things are more relaxed. Or after landing and taxi in.

ATC Watcher

1st Mar 2023, 17:29

@Seat4A : Thanks for the audio, Looks like it is partial, the intial call on TWR freq and the readback of the Learjet are missing for instance.
Can someone explain to me why nothing was said to HPJ280?
Most probably because the TWR sup wanted to listen to the recording to make sure what was said before making a decision . Quite normal and professional There was no real hurry to do anything right after the. incident .

GarageYears

1st Mar 2023, 17:32

Assume you’re referring to a possible pilot deviation notification by ATC? While the VASAviation video guy stated he never heard such an ATC notification, another comment in his video stated that HPJ280 was notified about 35 minutes after departure. 7110.65 states that possible pilot deviation notifications are made “workload permitting.” Doesn’t really matter as the FAA has stated via media that HPJ280 departed with no takeoff clearance. I have no doubt that upon arrival at FXE, the pilots were well aware of their regulatory peril.

Thanks for that - I wasn't sure how that was supposed to work.

DIBO

1st Mar 2023, 18:26

... Looks like it is partial, the intial call on TWR freq and the readback of the Learjet are missing for instance.Freq. handover was done twice with "monitor TWR", so both on TWR West and later TWR East the initial call was made by TWR and recorded on the audio. With TWR West the Hop-A-Jet replies were hardly readable, with TWR East no replies were audibly recorded. Post #5 by BFSGrad summarized the audio content perfectly, so I threw away my cleaned up audio. But here it's available (https://forums.liveatc.net/atcaviation-audio-clips/kbos-boston-rwy-4r-jetblue-206-going-around-hop-a-jet-280-taking-off-rwy-9/), not that it has any added value compared to the VASAviation video.

Seat4A

2nd Mar 2023, 01:13

Adding

https://twitter.com/NTSB_Newsroom/status/1631067921924456452?cxt=HHwWiIC8rcPo26ItAAAA

JanetFlight

2nd Mar 2023, 01:32

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...

konradeck

2nd Mar 2023, 08:01

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

2nd Mar 2023, 08:59

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

2nd Mar 2023, 09:27

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

2nd Mar 2023, 14:34

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

2nd Mar 2023, 19:52

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

3rd Mar 2023, 10:56

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.

Lake1952

4th Aug 2023, 03:17

netstruggler

4th Aug 2023, 07:14

https://www.cbsnews.com/boston/news/ntsb-report-jetblue-hop-a-jet-close-call-logan-airport/#:~:text=The%20NTSB%20determined%20the%20probable,was%20hurt %20in%20the%20incident.

https://www.reuters.com/business/aerospace-defense/charter-pilot-cited-boston-near-miss-with-jetblue-plane-ntsb-2023-08-03/

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.

Lake1952

4th Aug 2023, 11:19

Sorry, bad link...

netstruggler

4th Aug 2023, 11:47

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.

netstruggler

4th Aug 2023, 14:33

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?

BFSGrad

4th Aug 2023, 15:06

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.

DIBO

5th Aug 2023, 00:56

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.

bluesideoops

5th Aug 2023, 02:47

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!

netstruggler

5th Aug 2023, 06:06

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.

Lake1952

5th Aug 2023, 12:48

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!

BFSGrad

5th Aug 2023, 14:01

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.

Lake1952

5th Aug 2023, 21:19

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.

ATC Watcher

6th Aug 2023, 03:49

…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.