Event Details


Title:Near-collision on landing involving a Boeing 737 and a Regional Jet at Fort Lauderdale on November 9, 2005
Micro summary:Near-ground collision between a landing 737 and a regional jet holding on the runway.
Event Time:2005-11-09 at 1826 EST
File Name:2005-11-09-US.pdf
Publishing Agency:National Transportation Safety Board (NTSB)
Publishing Country:USA
Report number:OPS06IA001
Pages:8
Site of event:Fort Lauderdale, FL
Departure:Pittsburgh International Airport, Pittsburgh, Pennsylvania, USA
Destination:Fort Lauderdale-Hollywood International Airport, Fort Lauderdale / Hollywood, Florida, USA
Airplane Type(s):Boeing 737-400
Flight Phase:Landing
Registration(s):UNKNOWN
Operator(s):US Airways
Type of flight:Revenue
Occupants:2
Fatalities:
Serious Injuries:
Minor/Non-Injured:2
Other Injuries:0
Executive Summary:

NTSB short summary:

NTSB synopsis:

NTSB factual narrative text:

On November 9, 2005, at 2346 Coordinated Universal Time (UTC), the pilot of Comair flight 5026 (COM26), a Canadair Regional Jet operating as a 14 Code of Federal Regulations (CFR) part 121 scheduled air carrier flight from Fort Lauderdale-Hollywood International airport (FLL), Fort Lauderdale, Florida, to Tallahassee, Florida, reported a near-collision with US Airways flight 1251 (USA1251), a Boeing 737-400 operating under 14 CFR 121 as a scheduled air carrier flight from Pittsburgh, Pennsylvania, to FLL. At the time of the incident, COM26 was holding in takeoff position on runway 9L, and USA1251 was on approach to runway 9L. Neither aircraft was damaged, and there were no reported injuries. Weather conditions at FLL at 2253 UTC were reported as wind 060 at 12 knots, visibility 10 miles, with scattered clouds at 3,500 feet.

USA1251 contacted FLL tower at 2342, and was cleared to land on runway 9L. The local controller advised that there would be several departures before USA1251's arrival, and the pilot acknowledged. At 2342:48, the controller cleared Southwest flight 221 for takeoff and instructed Comair 716 (COM716) to taxi into position and hold, advising the pilot that there was arrival traffic on 9 mile final. At 2343:52, the controller cleared COM716 for takeoff and instructed COM26 to taxi into position and hold on runway 9L, advising the pilot of COM26 that there was arrival traffic on 4 mile final. At 2344:46, COM716 was instructed to contact departure control. At 2344:52, the controller advised an arriving Gulfstream 4 that they were number 2 for the runway, following a 737 on 2 mile final. At 2345:15, the controller began a series of exchanges with a helicopter that was 38 miles from FLL and trying to contact Miami approach control. At 2345:48, USA1251 asked if they were cleared to land, and the controller responded, "USA1251 cleared to land runway 9L." Immediately, an unidentified voice on the frequency stated, "Traffic on 9 left." The controller transmitted, "USAir go around, USAir go around, USAir 1251 go around." USA1251 did go around, and, according to recorded radar data, passed about 100 feet above COM26. USA1251 was issued a 060 heading and given back to Miami approach for resequencing. The flight returned and landed uneventfully at 0003 UTC.

The Local Control North (LCN) controller notified the tower supervisor of the incident as soon as it occurred, and she initiated a quality assurance review (QAR) that was logged in the Daily Record of Facility Operation. According to the QAR summary, the supervisor interviewed both the local and ground controllers and reviewed the tape, concluding that there was no loss of separation between USA1251 and COM26 because USA1251 was instructed to go around when approximately one mile from the runway. The pilot of COM26 filed a near midair collision report with FLL tower on the day after the incident.

At the time of the incident, the LCN controller was responsible for both the LCN and Local Control South (LCS) positions, and was therefore required to monitor operations on all runways. The tower is located between runways 9L and 9R, so the LCN controller was therefore required to divide his attention in opposite directions while handling aircraft on both of those runways. Runway 9L is normally used for jet traffic, and runway 9R is normally used for general aviation traffic. While USA1251 was on approach there were multiple departures and arrivals operating on runway 9L, and a Seneca waiting to depart on runway 9R.

2. Personnel Information
The FLL local controller entered on duty with the FAA on December 19, 1983 at the Lafayette, Louisiana ATCT. He subsequently worked at the Lakefront, Fort Lauderdale Executive, Pompano, Miami, Hollywood and Fort Lauderdale ATCTs. He has also worked at Miami Center and Montgomery radar approach control (RAPCON). His Control Tower Operator certificate was issued on June 20, 1985. He usually had Friday and Saturday off. On the night of the incident, his shift was 1500 to 2300. On Sunday he normally worked either 1600 to 2400 or 1500 to 2300. On Monday he normally worked 1400 to 2200. On Tuesday he normally worked 0800 to 1600 or 1100 to 1900. He normally worked 1400 to 2200 on Wednesday, but had swapped shifts.

The controller said that he had been having a difficult time in his personal life, but that he was "handling it." He had not been having sleeping problems prior to the incident, but had been having some since. He recently fell while coming down the tower stairs, injuring his knee and foot, and has been walking with a cane since then. He has not been taking any medication for pain. In May of this year his mother died, and in June his wife told him she was divorcing him. He inherited his mother's house, but he had been informed that the house does not meet code and there may be fines and penalties that need to be paid due to non-compliance. Both of his homes received hurricane damage. He no longer gets to see his stepdaughter as often as he used to and he misses the contact.

The controller said that operations were normal in the cab during the shift. His first contact with USA1251 was when the pilot checked on frequency about ten miles from the airport. He advised the pilot that there would be several departures prior to his arrival. There was a Southwest Airlines flight and two Comair regional jets waiting to depart from 9L, COM716 and COM26, and Seneca 92C waiting to depart from runway 9R. He cleared the Southwest flight for takeoff, cleared COM716 into position and hold on 9L, and Seneca 92C into position and hold on 9R. As soon as there was enough spacing behind the Southwest departure, the local controller cleared COM716 for takeoff and instructed COM26 to taxi into position and hold. His plan was to launch COM716, then COM26, then the Seneca from runway 9R. After he cleared COM26 into position, a helicopter called, attempting to contact Miami Approach. The local controller stated that he spent some time working with the helicopter pilot, trying to establish his altitude and position in order to give the pilot the correct frequency. At that point, the controller said he mistakenly believed that he had already cleared COM26 for takeoff.

When USA1251 questioned his landing clearance, the controller stated that he scanned the runway and radar display and didn't see anything, so he repeated the landing clearance. He realized that he had lost track of COM26, so he scanned the radar display looking for a "tag up" on COM26 or for a primary return and didn't see either one. He looked at the runway again and saw COM26 still holding in position. He immediately issued go-around instructions, repeating the clearance three times. He said that he did not hear the unidentified "traffic on the runway" transmission at the time, but instead initiated the go-around on his own. He heard the transmission while reviewing the tape in preparation for his interview. By this time the controller had also cleared the Seneca to depart from runway 9R, so he needed to establish separation between USA1251 and Seneca 92C, clear COM26 for takeoff, and separate COM26 from the Seneca as well. He did so through application of both vertical and lateral separation, and then transferred the departures to the radar controller at Miami terminal radar approach control (TRACON).

Asked about taxi into position and hold (TIPH) management, the controller stated that his personal practice used to be to slide the departure strip to the left when clearing an aircraft into position on the runway, and then cock the stripholder to the left when clearing the aircraft for takeoff. Starting in September, the tower adopted a standard procedure requiring that the strip be cocked to the left when an aircraft is cleared into position and hold, and that the paper strip be slid left out of the holder when the takeoff clearance is issued. He had been trying to adapt to the new procedure and believes he was using it at the time of the incident, but it is not second nature to him yet. He is not sure how the new procedure was developed except that it was the result of collaboration between management and the controllers union.

The local controller stated that he should have possibly asked for help in locating COM26 a little sooner, as the extra set of eyes might have resulted in locating the plane faster and prevented the incident.

He also stated that the local assist position is opened as staffing permits. It's not usually necessary to use a local assist in the summer, but the tower gets a lot busier from November through April or May and that's when the position is most needed. Asked about whether a local assist controller would have helped in this scenario, he said that another set of eyes can always help. LCN and LCS are open or closed as traffic dictates, sometimes to relieve frequency congestion caused by traffic on runway 9R, and might or might not be combined in the early evening. Working LCN and LCS combined requires that the LCN controller turn around and stand up (at least partially) in order to scan runway 9R and monitor traffic on the south side of the airport. The local controllers are also responsible for using the tower radar displays, and in this situation the controller stated that he was distracted by locating and communicating with the helicopter. He stated that his workload was moderate at the time of the incident.

Following the go-around, the controller believed that he might have had an operational error. He notified the supervisor, who was sitting on the west side of the tower cab doing some administrative work. She came to the LCN position and began helping with resolving the situation and coordinating with the TRACON about the various departing aircraft. After that, she got him relieved from the position and they went to the supervisor's office to investigate what happened.

The controller stated that he thought USA1251 was issued the go-around at to 1 mile from the runway. The supervisor's report said 1 mile because that was their visual estimate at the time. He was not aware of any other contacts about the incident with either pilot that night.

The controller also mentioned that lights from heavy traffic along I-95 can sometimes interfere with seeing aircraft at the approach end of runway 9L at night.


3. Communications
FLL tower frequencies were 119.3, 257.8, and 120.2


4. Aerodrome Information
FLL had 3 runways: runways 9L/27R, 9R/27L, and 13/31. Runway 9L was 9000 feet long and 150 feet wide. The surface was asphalt/grooved, in good condition. The field elevation of the runway was 5.5 feet.

5. Post-incident Procedural Changes

Because of recent FAA efforts to review and improve TIPH procedures nationally, FLL tower staff and management reviewed local procedures for these operations. On September 19, 2005, the facility manager established standard operating procedures for use of TIPH as follows:

Local Control North/South (LCN/LCS) shall use the following procedures when conducting Taxi Into Position and Hold operations:

1. Use a separate departure strip bay for each runway in use.
2. Place brightly colored strip(s) with letters TIPH in all departure bays.
3. When "Position and Hold" clearance is issued, departure strip holder shall be placed in an angulated position below the strip identifying TIPH.
4. After takeoff clearance is issued, the Local Controller will slide the paper strip to the side (memory jogger / visual aid for the supervisor/CIC [controller-in-charge].)

In addition, FLL controllers have been instructed that TIPH procedures are not authorized when LC and GC positions are combined. (These positions were not combined at the time of this incident.)

When interviewed, the LCN controller stated that he was using these procedures, although he did not recall whether he looked at the strip board at the time of the incident.
Learning Keywords:Operations - Airspace - Air Traffic Control
Operations - Near-Ground Collision

 




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