37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1529860 |
Time | |
Date | 201803 |
Local Time Of Day | 1801-2400 |
Place | |
Locale Reference | BOS.Airport |
State Reference | MA |
Aircraft 1 | |
Make Model Name | B787 Dreamliner Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | Final Approach |
Flight Plan | IFR |
Person 1 | |
Function | Local |
Qualification | Air Traffic Control Fully Certified |
Experience | Air Traffic Control Time Certified In Pos 1 (yrs) 4 |
Events | |
Anomaly | ATC Issue All Types Deviation - Procedural Clearance Deviation - Procedural Published Material / Policy |
Narrative:
I was working local east position. Arrivals landing runway 4R departures off of runwya 9. I lined up [aircraft Z] for departure off runway 4R in front of [aircraft X] on a 7 mile final. I rolled one departure off runway 9 and then had sufficient time to depart [aircraft Y] off runway 9 with [aircraft Z] in position and [aircraft X] on final. [Aircraft X] then checked in; but priority of duties I worked the aircraft on the runways first. I rolled [aircraft Y] off runway 9 on course to provincetown at 1;000 feet. When [aircraft Y] was safely through the runway 4R intersection; I rolled [aircraft Z] 'with no delay on the roll' [aircraft X] was on approximately 2.38 mile final. [Aircraft Z] was a little slow to roll; and the final that night was unusually fast. [Aircraft Y] tagged up off the end of the runway on the wrong departure tag; and as I worked to correct that issue; I neglected to go back to [aircraft X] and clear them to land. At the same time I was watching the spacing between [aircraft Z] and [aircraft X] as this had become closer than I had previously anticipated. [Aircraft X] crossed the threshold with 7;700 feet between them and [aircraft Z]; but due to my haste they did not have a landing clearance and they went around. I called the traffic with the previous departure; and after the 2nd traffic call; [aircraft X] reported they had [aircraft Z] in sight; I then turned [aircraft X] to a 360 heading and instructed them to maintain 3;000 as [aircraft Z] was climbing to 4;000. I waited to turn [aircraft X] because we were running 15R circle to 4L arrivals at the time as well.at this time the supervisor; who was correctly observing the operation intently at the time; left the operation to review the go around. This left the operation short staffed due to the need to now staff a controller in charge on the watch desk. The supervisor called the tower 30 minutes or so early with a message for me to come right to their office when I was relieved from position. Due to staffing the controller in charge desk; we then had to close the GC2 position because of the number of personnel on position during the busiest time of the shift. I was not allowed any time to file a report prior to being summoned to the supervisor's office and reviewing the incident; immediately after I was relieved from position.there were a number of situations; in the 'swiss cheese' model that led to this incident; the improper tag on the [aircraft Y] increased the workload and brought attention away from the arriving/departing aircraft on the runways. The slow roll of the [aircraft Z] also kept attention away from the lack of a landing clearance issued to [aircraft X]. The most safety significant issue I have with this situation is the flm leaving the operation immediately to review the situation in their office. This was the busiest part of the shift; and the requirement to staff controller in charge left the operation short staffed to the point of closing other positions. The flm and operations manager (OM) at boston tower have neglected to protect the operation and flying public consistently lately; by ignoring the operation and what staffing would be required. They are either overworking controllers regularly during slower times of traffic; or leaving the operation during busier times of traffic. The inconsistency and lack of attention to the operation from the OM and flm is severely affecting the safety culture at bos leading into our busier time of year during the summer.by immediately requiring me to discuss this with the flm; I wasn't able to 'self report' and they procedures they are implementing discourage a self reporting safety culture at the airport. This; combined with terrible mismanagement of personnel on a daily basis are creating a serious fatigue issue; and could lead to an extremely unsafe environment in the coming summer months.
Original NASA ASRS Text
Title: BOS Tower Controller reported failing to issue landing clearance to B787 due to distraction; which resulted in a go-around. Controller further stated that tower was short staffed as a result of management's inconsistency and lack of attention.
Narrative: I was working Local East position. Arrivals landing Runway 4R departures off of Runwya 9. I Lined up [Aircraft Z] for departure off Runway 4R in front of [Aircraft X] on a 7 mile final. I rolled one departure off Runway 9 and then had sufficient time to depart [Aircraft Y] off Runway 9 with [Aircraft Z] in position and [Aircraft X] on final. [Aircraft X] then checked in; but priority of duties I worked the aircraft on the runways first. I rolled [Aircraft Y] off Runway 9 on course to Provincetown at 1;000 feet. When [Aircraft Y] was safely through the Runway 4R intersection; I rolled [Aircraft Z] 'with no delay on the roll' [Aircraft X] was on approximately 2.38 mile final. [Aircraft Z] was a little slow to roll; and the final that night was unusually fast. [Aircraft Y] tagged up off the end of the runway on the wrong departure tag; and as I worked to correct that issue; I neglected to go back to [Aircraft X] and clear them to land. At the same time I was watching the spacing between [Aircraft Z] and [Aircraft X] as this had become closer than I had previously anticipated. [Aircraft X] crossed the threshold with 7;700 feet between them and [Aircraft Z]; but due to my haste they did not have a landing clearance and they went around. I called the traffic with the previous departure; and after the 2nd traffic call; [Aircraft X] reported they had [Aircraft Z] in sight; I then turned [Aircraft X] to a 360 heading and instructed them to maintain 3;000 as [Aircraft Z] was climbing to 4;000. I waited to turn [Aircraft X] because we were running 15R circle to 4L arrivals at the time as well.At this time the supervisor; who was correctly observing the operation intently at the time; left the operation to review the go around. This left the operation short staffed due to the need to now staff a CIC on the watch Desk. The supervisor called the tower 30 minutes or so early with a message for me to come right to their office when I was relieved from position. Due to staffing the CIC desk; we then had to close the GC2 position because of the number of personnel on position during the busiest time of the shift. I was not allowed any time to file a report prior to being summoned to the supervisor's office and reviewing the incident; immediately after I was relieved from position.There were a number of situations; in the 'swiss cheese' model that led to this incident; the improper tag on the [Aircraft Y] increased the workload and brought attention away from the arriving/departing aircraft on the runways. The slow roll of the [Aircraft Z] also kept attention away from the lack of a landing clearance issued to [Aircraft X]. The most safety significant issue I have with this situation is the FLM leaving the operation immediately to review the situation in their office. This was the busiest part of the shift; and the requirement to staff CIC left the operation short staffed to the point of closing other positions. The FLM and Operations Manager (OM) at Boston Tower have neglected to protect the operation and flying public consistently lately; by ignoring the operation and what staffing would be required. They are either overworking controllers regularly during slower times of traffic; or leaving the operation during busier times of traffic. The inconsistency and lack of attention to the operation from the OM and FLM is severely affecting the safety culture at BOS leading into our busier time of year during the summer.By immediately requiring me to discuss this with the FLM; I wasn't able to 'self report' and they procedures they are implementing discourage a self reporting safety culture at the airport. This; combined with terrible mismanagement of personnel on a daily basis are creating a serious fatigue issue; and could lead to an extremely unsafe environment in the coming summer months.
Data retrieved from NASA's ASRS site 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.