SFO near ground collision/runway incursion (re-titled from: YIKES)
 

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NTSB ADVISORY
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National Transportation Safety Board
Washington, DC 20594
June 11, 2007
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NTSB INVESTIGATING RUNWAY INCURSION IN SAN FRANCISCO
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The National Transportation Safety Board is
investigating a runway incursion in San Francisco two weeks
ago in which two airliners may have come within 50 feet of
each other on intersecting runways.
At about 1:30 p.m. on May 26, 2007, the tower air
traffic controller cleared SkyWest Airlines flight 5741, an
Embraer 120 arriving from Modesto, California, to land on
runway 28R. Forgetting about the arrival airplane, the same
controller then cleared Republic Airlines flight 4912, an
Embraer 170 departing for Los Angeles, to take off from
runway 1L, which intersects runway 28R.
After the SkyWest airliner touched down, the Airport
Movement Area Safety System (AMASS) alerted and the air
traffic controller transmitted "Hold, Hold, Hold" to the
SkyWest flight crew in an attempt to stop the aircraft short
of runway 1L. The SkyWest crew applied maximum braking that
resulted in the airplane stopping in the middle of runway
1L. As this was occurring, the captain of Republic Airlines
flight 4912 took control of the aircraft from the first
officer, realized the aircraft was traveling too fast to
stop, and initiated an immediate takeoff. According to the
crew of SkyWest 5741, the Republic Airlines aircraft
overflew theirs by 30 to 50 feet. The Federal Aviation
Administration has categorized the incident as an
operational error.
The NTSB sent an investigator to San Francisco, who
collected radar data, recorded air traffic control
communications, and flight crew statements, and interviewed
air traffic control personnel.
A preliminary report on the incident is on the Board's
website at:
http://ntsb.gov/ntsb/brief.asp?ev_id...10X00701&key=1

The ATC guy concerned will have a rather short further career, I suspect.
The FAA is all over runway incursions now.

Years ago, I was waiting to cross 25R at KLAX in the dense fog, and after being cleared to cross, I had a close listening watch on the tower frequency, and heard a DC-8 on the takeoff roll.
I held short...and noticed the DC8 appear out of the fog, thru the intersection, and just begin to lift the nosewheel during rotation, before it disappeared into the mist once again.


Not good...:ooh:

From the NTSB report:

Following the incident, the controller was decertified, required to complete additional training, and recertified by SFO management.

Just a question here, with intersecting runways is it not always possible to ensure just by visual checks whether something is starting a take off roll as you come down - i know nothing, but just like in driving never trust anything so if the person is in the side road assume he will pull out rather than thinking he won't..?

I've only flown Cessna's but during any landing the crew are focused entirely on landing checklists, instruments, and control inputs to plonk the thing down on the centerline and at the start of the runway. Scanning for traffic at a controlled airfield probably introduces more risk than it helps by providing a distraction from the crucial job of flying the approach.
From the NTSB report there was also a slight crosswind, and the winds close to the ground here in SF bay area can be very gusty and change in direction and strength along the approach because of the topography of the mountains on the peninsula.
The best chance for catching the error was probably the departing plane's crew hearing the conflicting clearance. However,they may not have been on tower frequency when the landing clearance was given, and they will also have been very busy doing the pre departure checks.
All in all a very lucky escape. Thank goodness it was not a 757 or something and they managed to get airborne without stalling or hitting the sitting duck.

By coincidence, a bit like 411A, the only runway incursion "near-miss" [near-hit??:*] I've had in 39 years on the job was on the threshold of 28L at SFO. Unconditionally cleared for takeoff, we declined and waited until the B727 on short final had passed. No comment from the controller/s.

Heard a similar "setup" at LAX with a lightie on 25R fairly recently. ATC have their share of blame.

G'day ;)

In incidents like this, why does the ‘regulatory’ system always focus on the individual involved at the sharp end? This is a covert blame culture, which usually reflects very limited thinking by the agency concerned. Blame and train.
It is reported that the controller made a mistake. S/he does not have to be below standard or something, or in need of training, or demoted to improve performance; this person is one of us, a human who suffer error, particularly when given opportunity.
“It’s often the good people who make the worst mistakes.” – James Reason
This appears to be a classic incident of the situation – the opportunity for an error to occur. These situations contain latent failures, which are just waiting for the human frailty of forgetting to combine into an accident.
A major principle of threat and error management (TEM) is the identification of such opportunities and then avoiding them.
So what was the compelling reason for cross-runway operations that judges it an acceptable risk, why allow this operation? No doubt the will be some justification, which will/will not stand up in hindsight.
Is there too much dependence on the Airport Movement Area Safety System (AMASS); is this becoming like MSAW – which together with human weaknesses is not a totally effective system - MSAW.
Why did the controller forget; workload, distraction, fatigue? Again justifiable by regulation; you can’t regulate safety, only participate in it and judge it (usually after the fact).
Thus, another principle of TEM is to actively detect errors. With modern technology there ought to be a means of isolating an active runway, i.e. S-band link from ACAS to ATC such that any aircraft on late final / runway will prevent or warns the controller from issuing a departure clearance on a cross runway. Similarly what external error detection could the flight-crew provide with the use of ACAS.
Flight crews use a human backup – one person decides, the other checks; does this happen with ATC?
I hope that the NTSB can unravel the background factors to this incident (management and equipment) and identify the human issues which contributed to the error.

Not at SFO. Landing 28s, the 1s threshholds are obscured on final. There's usually a queue of planes there anyway - hard to tell who's on the runway and who's hlding short.

Volume and airport configuration. Without intersecting runway use SFO just can't handle the traffic; as witness those days when the WX closes in and they are reduced to single runway ops.

At the risk a flaming :ouch:... I know that the good 'ole US of A has a large proportion of aircraft movements, but it does seem to have an even greater proportion of near miss (sic) events.

I know we've been there before, but it still needs saying. Procedures imho are not always compatible with best practices.

On another point, why are JFK operations so crAp?

[rant] Last night, albeit with SWAP in place (Severe Weather Procedures) in force, and at other times in general. They have 4 runways, why do they only use 2 of them at the same time? Severe weather to the SW/W, so lets block up the P and Q taxiways with aircraft declined departure and stop aircraft departing to the N etc where the wx is clear. And, the aircraft declined departure shut down and not close enough to the a/c ahead so stopping movement in general, requiring some to enter and taxi down the departure runway to vacate and join the back of the queue. Result, 1 aircraft taking off every 5 or 6 minutes on average for a while, and a 1 hour 40 taxi time:=:ugh::mad: At the same time, the 04/22 taxiways were clear!

If you don't use more than 2 runways, at least clear the gates and park up the aircraft whose routes are closed out of the fvcking way. [/rant over]

I always scan for crossing traffic landing at KSFO. Being on final at 200' and having an aircraft cross does make you a bit tense.
Having a European background, flying into the US certainly gives the impression of smaller margins: sudden change of runway late in the approach, a generally stressed atmosphere, sometimes sloppy phraseology. It's not that the individual controller is not professional, it has more to do with the overall culture and too high a workload, me thinks. Also, often things seem to be organized in pecular ways as alluded to above. London Heathrow also moves huge amounts of traffic, but you seldom get the tense feeling of chaos and stress from ATC there.

As an ATC I know these happen but just don't understand why? The movement and placement of strips in a tower environment should be a simple, systematic yet logical way of ensuring these type of incidents don't happen. ie when you clear an aircraft / vehicle / maintenance crew to enter a runway you physically place a strip in the clear to land slot. Then if you clear an aircraft to land you physically have to wonder why you can't fit two strips in the one slot and hopefully bells ring. I might be old fashioned but these old fashioned systems just seem to work.
Regardless of how busy or how quiet you are if you stick to the system so that it becomes automatic ALL THE TIME. then hopefully that system is what keeps it all on the rails.

TopBunk and all,
JFK will hang onto a runway alignment as long as it can because to change it, generally LGA and EWR will have to realign also, essentially bringing all three metro airports to a halt for 20-30 minutes. They will keep going on alignment right up to a 10 knot tailwind, or, in the case of the Canarsie approach, until someone misses or says I’m not going to do it.

In the U.S. landing clearances are usually issued on first contact to tower, when landing is "assured". No matter what number you are on final and how many crossings are there before you are down. In my eyes this is a safety weakpoint.

Alf5071h - Hopefully the final NTSB report will identify any process flaws that helped the holes in the cheese to almost align. If there are flaws, or there is no process in place to guarantee that mistakes like this will be caught, then hopefully the final report will recommend one.
We don't want a repeat of the LAX incident due to a shortcoming in the operational procedures that removed redundancy that should have been in the system:
http://amelia.db.erau.edu/reports/ntsb/aar/AAR91-08.pdf

edit:

The link you posted on the MSAW system makes pretty sobering reading.

http://www.flightglobal.com/articles...ersection.html
:eek::eek::eek:

I heard that the solution to the LAX "problem" [and only a local rule? :rolleyes:] is to only clear a maximum of two [2] aircraft [airplanes] to land on the same runway.

Fascinating logic.

G'day ;)

Now, I'm not blaming the pilots here so there's no need for anyone to get too hysterical even if I'm being a bit cynical, but is it just me or does it appear to everyone else that the chances of being hit by another aircraft when flying with SkyWest seem to be particularly high?

There was the incident a few weeks ago at LAX with a SkyWest turboprop and a Virgin A340-600 and the one, also at LAX where a B737 actually landed on a SkyWest Brasilia which was lined up waiting for take off causing a lot of deaths. There was also an incident back in February 2006, again, at LAX. http://www.pprune.org/forums/showthread.php?t=279604

Not surprising. Skywest is (or was until very recently) the number 1 carrier in terms of movements at LAX.

Although exact pilot readback of "holdshort...", "cleared in position to hold" etc seems not to have been a factor in that near-tragedy, why do only some US airports (i.e. ORD or DFW) put in their ATIS "pilots read back all hold short instructions...".

I realize from reading PPrune for years that US ATC often does not comply with standard ICAO radio phraseology, but do many US airline, corporate (etc) pilots not reply to the tower with their callsign and the proper words?

How about in other countries?

The requirement to include such normal readbacks in the ATIS often puzzles me.
And proper 'hearback' is often clipped, missed or blocked.

CargoBoy: The terrible accident when the 737 landed on the Metroliner was caused by the Controller leaving the Metro in position for an extended period at sunset (for a while, ATC stopped this procedure in the dark). It was not seen by the Boeing on approach. This reminds me-why don't all pilots switch on their floodlights/nacelle lights when crossing any runway or holding in position?
They probably should not be calling for any checklist anyway (heads down..), unless that runway is rarely used. If they don't have such lights, why not at least their taxi lights on bright, if possible?