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|
Attributes | |
ACN | 512129 |
Time | |
Date | 200105 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : dca.airport |
State Reference | DC |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : dca.tower tracon : c90.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | ground : takeoff roll |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : dca.tower |
Operator | general aviation : personal |
Make Model Name | PA-23-250 Aztec |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach landing : roll |
Route In Use | approach : visual |
Person 1 | |
Affiliation | government : faa |
Function | controller : combined local |
Experience | controller military : 3 controller radar : 17 controller time certified in position1 : 17 |
ASRS Report | 512129 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 170 flight time total : 4910 flight time type : 850 |
ASRS Report | 511254 |
Events | |
Anomaly | conflict : ground critical incursion : runway non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : took evasive action |
Consequence | faa : assigned or threatened penalties faa : investigated |
Miss Distance | horizontal : 200 vertical : 0 |
Supplementary | |
Problem Areas | ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
Cleared traffic to land runway 4. Cleared B737 for take off runway 1, forgot about landing aircraft on runway 4, realized this and attempted to send him around without knowing where aircraft was, I then sighted aircraft on runway 4. He had already landed and was taxiing out. I then instructed him to turn short of runway 1. I determined that the departure on runway 1 was not a factor anymore and made no attempt to stop his departure. Factors: radar tag dropped on runway 4 arrival 2 NM from airport. Very busy at the time - 20 aircraft in 10 mins, helicopter position combined with local. Supervisor in back of tower working clearance. Assistant local doing traffic management function at the time of oe. No tmu in tower. Notes: I normally have aircraft report on final for runway because they get below the horizon and are very hard to pick out from ground clutter - I did not do this. My scan failed to pick up this aircraft. Radar tag drop did not help this. When this type of error occurs usually someone in the tower catches it, nobody saw this until after it was over. Callback conversation with reporter revealed the following information: during callback the reporter estimated that the radar tag on the general aviation aircraft dropped out at approximately 2.5 miles which is early. This system is being investigated. Without the tag he forgot the inbound aircraft. The staffing at the tower, according to the reporter, is below what it should be. Each position is doubled up. His assistant was occupied with traffic management and the supervisor was working clearance. The reporter was working local and another frequency, the 'hilo' position which controls traffic rptrs and helicopter traffic. The BRITE radar in the tower cabin attendant is positioned overhead and the reporter finds it difficult to use in this position. The visual scan for traffic is affected by the height of the tower. When you are looking down for traffic on final against the RAIL yards and buildings they are difficult to see. Supplemental information from acn 511254: our flight, aircraft X, was cleared into position and hold on runway 1 at dca. We were then cleared for takeoff. During the takeoff roll, aircraft Y landed on runway 4, an intersecting runway. We heard the tower tell the aircraft Y to go around. Aircraft Y stopped on the runway prior to the intersection. Had the pilot of aircraft Y go around, the point when the tower gave those instructions, it could have caused an near midair collision. I mentioned to the captain that I heard an aircraft had been cleared to land on runway 4 (as we were cleared for takeoff). The captain saw the aircraft as we passed the intersection. Aircraft Y stopped prior to the intersection.
Original NASA ASRS Text
Title: AN ACR IS CLRED FOR TAKE OFF WHEN A GENERAL AVIATION ACFT HAD BEEN CLRED TO LAND ON AN INTERSECTING RWY. THE GENERAL AVIATION ACFT IS ABLE TO STOP SHORT OF THE CROSSING RWY EVEN THOUGH A GAR CLRNC WAS ISSUED TOO LATE TO BE EFFECTIVE.
Narrative: CLEARED TFC TO LAND RWY 4. CLEARED B737 FOR TAKE OFF RWY 1, FORGOT ABOUT LNDG ACFT ON RWY 4, REALIZED THIS AND ATTEMPTED TO SEND HIM AROUND WITHOUT KNOWING WHERE ACFT WAS, I THEN SIGHTED ACFT ON RWY 4. HE HAD ALREADY LANDED AND WAS TAXIING OUT. I THEN INSTRUCTED HIM TO TURN SHORT OF RWY 1. I DETERMINED THAT THE DEP ON RWY 1 WAS NOT A FACTOR ANYMORE AND MADE NO ATTEMPT TO STOP HIS DEP. FACTORS: RADAR TAG DROPPED ON RWY 4 ARR 2 NM FROM ARPT. VERY BUSY AT THE TIME - 20 ACFT IN 10 MINS, HELI POS COMBINED WITH LOCAL. SUPVR IN BACK OF TWR WORKING CLRNC. ASSISTANT LOCAL DOING TFC MGMNT FUNCTION AT THE TIME OF OE. NO TMU IN TWR. NOTES: I NORMALLY HAVE ACFT RPT ON FINAL FOR RWY BECAUSE THEY GET BELOW THE HORIZON AND ARE VERY HARD TO PICK OUT FROM GROUND CLUTTER - I DID NOT DO THIS. MY SCAN FAILED TO PICK UP THIS ACFT. RADAR TAG DROP DID NOT HELP THIS. WHEN THIS TYPE OF ERROR OCCURS USUALLY SOMEONE IN THE TWR CATCHES IT, NOBODY SAW THIS UNTIL AFTER IT WAS OVER. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: DURING CALLBACK THE RPTR ESTIMATED THAT THE RADAR TAG ON THE GENERAL AVIATION ACFT DROPPED OUT AT APPROX 2.5 MILES WHICH IS EARLY. THIS SYSTEM IS BEING INVESTIGATED. WITHOUT THE TAG HE FORGOT THE INBOUND AIRCRAFT. THE STAFFING AT THE TWR, ACCORDING TO THE RPTR, IS BELOW WHAT IT SHOULD BE. EACH POS IS DOUBLED UP. HIS ASSISTANT WAS OCCUPIED WITH TFC MGMNT AND THE SUPVR WAS WORKING CLRNC. THE RPTR WAS WORKING LOCAL AND ANOTHER FREQ, THE 'HILO' POS WHICH CTLS TFC RPTRS AND HELI TFC. THE BRITE RADAR IN THE TWR CAB IS POSITIONED OVERHEAD AND THE RPTR FINDS IT DIFFICULT TO USE IN THIS POS. THE VISUAL SCAN FOR TFC IS AFFECTED BY THE HEIGHT OF THE TWR. WHEN YOU ARE LOOKING DOWN FOR TFC ON FINAL AGAINST THE RAIL YARDS AND BUILDINGS THEY ARE DIFFICULT TO SEE. SUPPLEMENTAL INFO FROM ACN 511254: OUR FLT, ACFT X, WAS CLRED INTO POS AND HOLD ON RWY 1 AT DCA. WE WERE THEN CLRED FOR TKOF. DURING THE TKOF ROLL, ACFT Y LANDED ON RWY 4, AN INTERSECTING RWY. WE HEARD THE TWR TELL THE ACFT Y TO GAR. ACFT Y STOPPED ON THE RWY PRIOR TO THE INTERSECTION. HAD THE PLT OF ACFT Y GAR, THE POINT WHEN THE TWR GAVE THOSE INSTRUCTIONS, IT COULD HAVE CAUSED AN NMAC. I MENTIONED TO THE CAPT THAT I HEARD AN ACFT HAD BEEN CLRED TO LAND ON RWY 4 (AS WE WERE CLRED FOR TKOF). THE CAPT SAW THE ACFT AS WE PASSED THE INTERSECTION. ACFT Y STOPPED PRIOR TO THE INTERSECTION.
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.