37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 136741 |
Time | |
Date | 199002 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : jfk |
State Reference | NY |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Transport, High Wing, 2 Turboprop Eng |
Flight Phase | ground other : taxi |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | ground other : taxi |
Person 1 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : non radar |
Experience | controller non radar : 9 |
ASRS Report | 136741 |
Person 2 | |
Affiliation | government : faa |
Function | controller : ground |
Qualification | controller : non radar |
ASRS Report | 136851 |
Events | |
Anomaly | conflict : ground critical non adherence : published procedure non adherence : required legal separation |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : took evasive action |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 50 vertical : 50 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Intra Facility Coordination Failure |
Narrative:
I was working tower (frequency 123.9) departure runway 22R. Local control was split, the other frequency (119.1) working 22L. Standing next to each other. After landing 22L aircraft must hold short of 22R remaining on frequency 119.1. I approve the xings and the other tower controller crosses aircraft and switches them to ground on 121.9. The situation was an air carrier Z in position 22R, an air carrier Y holding short 22R, behind him air carrier X holding short also. I approved local to cross both aircraft. On an indirect access line to the ny TRACON I was calling a taxi line-up. In the interim, at some point I must have cleared air carrier Z for takeoff unaware that air carrier X had not crossed yet. Both lcls, a and B, looked to notice air carrier X not moving. Air carrier X said he held short because air carrier Y was too slow and he noticed an aircraft rolling. He was short of the runway but technically past hold bar lights. Air carrier Z rotated and was switched to departure. After the incident air carrier X called the tower and I spoke to the captain. Callback conversation with reporter revealed the following: reporter experience: 9 yrs non radar at jfk. Reporter admitted the error and said he just forgot he had approved controller B to cross air carrier Y and X. The reporter was the controller in charge and he did not report the incident. Supplemental information from acn 136851: while working ground control, I observed the following: 2 aircraft, air carrier Y and air carrier X, were given instructions to cross runway 22R, which was at the time the departure runway. As I looked at the crossing point to verify the position of the aircraft after transfer of control, air carrier Z company unknown rotated between the 2 aircraft, causing air carrier X to brake suddenly to avoid a conflict. I should also note that air carrier Y had not completed the runway crossing and air carrier X was probably beyond the hold bars. Supplemental information from acn 137166: air carrier X upon arrival jfk runway 22L was instructed by tower on frequency 119.1 to hold short runway 22R and stay with him. We acknowledged hold behind air carrier Y then both air carrier Y and X were instructed to cross runway 22R. As I proceeded past hold short line I noticed an aircraft in position at departure end runway 22R. Then I noticed that the lights were closing. I stopped prior to runway plane and watched as air carrier Z continued his departure roll. As he rotated he barely missed air carrier Y's tail. I queried jfk tower. Silence. Then they proceeded to instruct us to cross 22R. I called jfk tower and requested an explanation whereby I spoke to controller a. He informed me that he owned runway 22R. He was on frequency 123.9 and regulated departures, controller B arrs and runway crossing. He stated he allowed controller B permission to cross air carrier Y and X. Then without checking to see if runway was clear allowed air carrier Z to take off. He admitted his error to myself and to an alpa official. Conclusion: 2 controllers in cabin attendant separate frequencys neither was aware of the other's actions. Result: nearly a disaster avoided only by the quick actions of a dubious commuter pilot. No runway incursion report was requested by air carrier X captain by recommendation of attorney. Supplemental information from acn 137035: air carrier X arrived into jfk. I was the first officer. After being cleared to land on 22L we were instructed to exit on 'J' taxiway and hold short runway 22R and remain on this frequency (119.1) which was tower frequency. As we approached 22R we saw air carrier Y holding short 22R. A few minutes later air carrier Y asked if it was ok to cross 22R. Tower (119.1) replied to hold short. Then after a departure from 22R air carrier Y was cleared to cross. Then 'air carrier X cleared to cross 22R 'J' inner ground .9' at this time air carrier Y was crossing, very slowly, and then we crossed the hold short line of 22R. Before we entered the runway itself the captain immediately stepped on the brakes, and I looked up to see what was going on. We saw bright lights approaching us very quickly. I looked to see if air carrier Y cleared 22R (which he barely did). Air carrier Z rotated off of 22R barely missing air carrier Y. I immediately contacted tower 119.1 and asked, did you clear air carrier X to cross 22R, there was no reply for a few seconds, as though ATC realized something was not right. 30 seconds later we were cleared to cross 22R again.
Original NASA ASRS Text
Title: LESS THAN STANDARD SEPARATION BETWEEN ACR Y AND X CROSSING RWY, AND ACR Z TKOF. SYSTEM ERROR.
Narrative: I WAS WORKING TWR (FREQ 123.9) DEP RWY 22R. LCL CTL WAS SPLIT, THE OTHER FREQ (119.1) WORKING 22L. STANDING NEXT TO EACH OTHER. AFTER LNDG 22L ACFT MUST HOLD SHORT OF 22R REMAINING ON FREQ 119.1. I APPROVE THE XINGS AND THE OTHER TWR CTLR CROSSES ACFT AND SWITCHES THEM TO GND ON 121.9. THE SITUATION WAS AN ACR Z IN POSITION 22R, AN ACR Y HOLDING SHORT 22R, BEHIND HIM ACR X HOLDING SHORT ALSO. I APPROVED LCL TO CROSS BOTH ACFT. ON AN INDIRECT ACCESS LINE TO THE NY TRACON I WAS CALLING A TAXI LINE-UP. IN THE INTERIM, AT SOME POINT I MUST HAVE CLRED ACR Z FOR TKOF UNAWARE THAT ACR X HAD NOT CROSSED YET. BOTH LCLS, A AND B, LOOKED TO NOTICE ACR X NOT MOVING. ACR X SAID HE HELD SHORT BECAUSE ACR Y WAS TOO SLOW AND HE NOTICED AN ACFT ROLLING. HE WAS SHORT OF THE RWY BUT TECHNICALLY PAST HOLD BAR LIGHTS. ACR Z ROTATED AND WAS SWITCHED TO DEP. AFTER THE INCIDENT ACR X CALLED THE TWR AND I SPOKE TO THE CAPT. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: REPORTER EXPERIENCE: 9 YRS NON RADAR AT JFK. REPORTER ADMITTED THE ERROR AND SAID HE JUST FORGOT HE HAD APPROVED CTLR B TO CROSS ACR Y AND X. THE REPORTER WAS THE CTLR IN CHARGE AND HE DID NOT REPORT THE INCIDENT. SUPPLEMENTAL INFORMATION FROM ACN 136851: WHILE WORKING GND CTL, I OBSERVED THE FOLLOWING: 2 ACFT, ACR Y AND ACR X, WERE GIVEN INSTRUCTIONS TO CROSS RWY 22R, WHICH WAS AT THE TIME THE DEP RWY. AS I LOOKED AT THE XING POINT TO VERIFY THE POSITION OF THE ACFT AFTER TRANSFER OF CTL, ACR Z COMPANY UNKNOWN ROTATED BETWEEN THE 2 ACFT, CAUSING ACR X TO BRAKE SUDDENLY TO AVOID A CONFLICT. I SHOULD ALSO NOTE THAT ACR Y HAD NOT COMPLETED THE RWY XING AND ACR X WAS PROBABLY BEYOND THE HOLD BARS. SUPPLEMENTAL INFORMATION FROM ACN 137166: ACR X UPON ARRIVAL JFK RWY 22L WAS INSTRUCTED BY TWR ON FREQ 119.1 TO HOLD SHORT RWY 22R AND STAY WITH HIM. WE ACKNOWLEDGED HOLD BEHIND ACR Y THEN BOTH ACR Y AND X WERE INSTRUCTED TO CROSS RWY 22R. AS I PROCEEDED PAST HOLD SHORT LINE I NOTICED AN ACFT IN POSITION AT DEP END RWY 22R. THEN I NOTICED THAT THE LIGHTS WERE CLOSING. I STOPPED PRIOR TO RWY PLANE AND WATCHED AS ACR Z CONTINUED HIS DEP ROLL. AS HE ROTATED HE BARELY MISSED ACR Y'S TAIL. I QUERIED JFK TWR. SILENCE. THEN THEY PROCEEDED TO INSTRUCT US TO CROSS 22R. I CALLED JFK TWR AND REQUESTED AN EXPLANATION WHEREBY I SPOKE TO CTLR A. HE INFORMED ME THAT HE OWNED RWY 22R. HE WAS ON FREQ 123.9 AND REGULATED DEPS, CTLR B ARRS AND RWY XING. HE STATED HE ALLOWED CTLR B PERMISSION TO CROSS ACR Y AND X. THEN WITHOUT CHECKING TO SEE IF RWY WAS CLEAR ALLOWED ACR Z TO TAKE OFF. HE ADMITTED HIS ERROR TO MYSELF AND TO AN ALPA OFFICIAL. CONCLUSION: 2 CTLRS IN CAB SEPARATE FREQS NEITHER WAS AWARE OF THE OTHER'S ACTIONS. RESULT: NEARLY A DISASTER AVOIDED ONLY BY THE QUICK ACTIONS OF A DUBIOUS COMMUTER PLT. NO RWY INCURSION REPORT WAS REQUESTED BY ACR X CAPT BY RECOMMENDATION OF ATTORNEY. SUPPLEMENTAL INFORMATION FROM ACN 137035: ACR X ARRIVED INTO JFK. I WAS THE F/O. AFTER BEING CLRED TO LAND ON 22L WE WERE INSTRUCTED TO EXIT ON 'J' TXWY AND HOLD SHORT RWY 22R AND REMAIN ON THIS FREQ (119.1) WHICH WAS TWR FREQ. AS WE APCHED 22R WE SAW ACR Y HOLDING SHORT 22R. A FEW MINUTES LATER ACR Y ASKED IF IT WAS OK TO CROSS 22R. TWR (119.1) REPLIED TO HOLD SHORT. THEN AFTER A DEP FROM 22R ACR Y WAS CLRED TO CROSS. THEN 'ACR X CLRED TO CROSS 22R 'J' INNER GND .9' AT THIS TIME ACR Y WAS XING, VERY SLOWLY, AND THEN WE CROSSED THE HOLD SHORT LINE OF 22R. BEFORE WE ENTERED THE RWY ITSELF THE CAPT IMMEDIATELY STEPPED ON THE BRAKES, AND I LOOKED UP TO SEE WHAT WAS GOING ON. WE SAW BRIGHT LIGHTS APCHING US VERY QUICKLY. I LOOKED TO SEE IF ACR Y CLRED 22R (WHICH HE BARELY DID). ACR Z ROTATED OFF OF 22R BARELY MISSING ACR Y. I IMMEDIATELY CONTACTED TWR 119.1 AND ASKED, DID YOU CLEAR ACR X TO CROSS 22R, THERE WAS NO REPLY FOR A FEW SECONDS, AS THOUGH ATC REALIZED SOMETHING WAS NOT RIGHT. 30 SECONDS LATER WE WERE CLRED TO CROSS 22R AGAIN.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.