Narrative:

The problem arose due to a communication breakdown between widebody transport Y crew and ATC. Widebody transport Y failed to contact tower at the outer marker when inbound for an ILS 25L approach. We, large transport X, were holding in position on runway 25L awaiting takeoff clearance. 2 radio calls from the tower to widebody transport Y had no reply. We were not launched or told to taxi clear from the time we taxied into position on 25L 2 aircraft departed 25R, we thought our departure was imminent. The 1ST radio call on tower frequency from widebody transport Y was after he had passed overhead on missed approach climbing to 2000'. The tower told us nothing, gave no warning or information as to the proximity of widebody transport Y approaching from our 6 O'clock position. Inaction. On our part, we may have been over confident in the tower's control capability and let our guard down. I am normally keenly aware of my environment when flying. This alertness for me is generally increased when I am operating in a new or unfamiliar area or anticipate poor ATC services (e.g., overseas, third world countries). Lax is home base for me and this was just to be another routine departure, almost my last. On hearing tower attempt to contact widebody transport Y, we should have anticipated a possible problem and inquired as to widebody transport Y's distance and the nature of the communication problem. Was widebody transport Y still on approach frequency or not talking to anyone (radio failure)? I should have been more aware that we were sitting on the landing runway and not the 'usual' parallel departure runway. I could have turned on our aircraft strobe lights. The tail strobe fires aft from the top of our T tail. My standard practice is to turn on strobes when cleared for takeoff so they were off. Perceptions. All the ingredients were present for an accident. Widebody transport Y didn't initiate his go around until he was very low. Whether he was directed by radio contact to go around or just saw us at the last min, we don't know yet. Widebody transport Y crew was undoubtedly fatigued, having just completed a long range flight. Lax TRACON is not fully staffed and has many controllers that are not full performance level. As an example, here are some events that happened prior to and after our departure. Our clrncwas via the loop 5 departure to climb and maintain 5000'. This seemed a little unusual since we normally get a clearance to 2000', but I didn't question it at the time since I assumed the VFR corridor was closed with the morning cloud cover. On tower frequency, I heard another aircraft who was about to be cleared for takeoff ask the tower to confirm that his cleared altitude was 5000'. I could not believe the tower's reply. It went like this, 'I don't know what clearance gave you.' that was it! Tower just dropped it. This is a serious flaw in the system if tower can't access that information and confirm the clearance to the pilot. Our takeoff clearance included 'caution wake turbulence widebody transport on missed approach.' contacting departure control, we were told to turn left heading 160 degree for vectors to the flipper departure, climb and maintain 4000'. When we advised departure we were a loop departure, his joking reply was, 'we were just testing you.' he gave us another heading and clearance to 13000' for the loop departure. The final event was as we crossed the lax VOR at just over 10000'. We were told to resume 'normal speed,' yet we never had been issued any speed restriction. It really makes you wonder just how efficiently or inefficiently clearance information is recorded and transferred at this TRACON. Widebody transport Y was never cleared to land but continued approach to near minimums. Approach did not direct widebody transport Y to contact tower and widebody transport Y did not self initiate tower contact. Tower failed to take timely action to reduce the possibility of collision, i.e., taxi us off runway or get on land line sooner to approach control. Tower claims approach control got through to widebody transport Y and directed them to initiate a missed approach. I seriously doubt widebody transport Y crew ever saw us holding in position. I believe a major air disaster could easily have occurred if approach control had not been successful in contacting widebody transport Y with instructions to execute a missed approach. It is indeed a sorry state of affairs when we can't trust the tower to keep us safe from traffic closing from our 6 O'clock position. I guess that the moral of this story is an old one. Communication or the lack thereof can indeed kill you. Widebody transport Y crew obviously shares responsibility in this incident in that they intended to land west/O obtaining landing clearance. Oftentimes, this type of error is of minor significance (e.g., good visibility, runway clear), but as is plainly clear, the potential for disaster is very real. Captain of light transport Z witnessed the near collision from intersection 8J holding short of 25R. He told me later that it appeared that widebody transport Y descended to minimums (150' to 200') before initiating the missed approach. He was concerned that the keel of widebody transport Y might hit our tail as he pitched up. Captain of light transport Z estimated that widebody transport Y cleared our tail by 100', directly overhead. Captain of light transport Z confirmed that runway 25R was clear at the time and we suspect the tower's plan was to land widebody transport Y with a side step on 25R. The tower chief confirmed that the tower made a serious error in delaying contact with approach control, via land line, until after the 2ND radio call on tower frequency went unanswered. Also, he admitted we should have been directed to taxi clear of the runway. No one, including other aircraft on the ground said anything to us about our rapidly closing 6 O'clock traffic. The first we knew of it was as our aircraft was buffeted by widebody transport Y's wake.

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Original NASA ASRS Text

Title: ACR WDB SENT AROUND AT THE LAST MOMENT WITH AN ACR LGT IN POSITION ON THE RWY.

Narrative: THE PROB AROSE DUE TO A COM BREAKDOWN BTWN WDB Y CREW AND ATC. WDB Y FAILED TO CONTACT TWR AT THE OUTER MARKER WHEN INBND FOR AN ILS 25L APCH. WE, LGT X, WERE HOLDING IN POS ON RWY 25L AWAITING TKOF CLRNC. 2 RADIO CALLS FROM THE TWR TO WDB Y HAD NO REPLY. WE WERE NOT LAUNCHED OR TOLD TO TAXI CLR FROM THE TIME WE TAXIED INTO POS ON 25L 2 ACFT DEPARTED 25R, WE THOUGHT OUR DEP WAS IMMINENT. THE 1ST RADIO CALL ON TWR FREQ FROM WDB Y WAS AFTER HE HAD PASSED OVERHEAD ON MISSED APCH CLBING TO 2000'. THE TWR TOLD US NOTHING, GAVE NO WARNING OR INFO AS TO THE PROX OF WDB Y APCHING FROM OUR 6 O'CLOCK POS. INACTION. ON OUR PART, WE MAY HAVE BEEN OVER CONFIDENT IN THE TWR'S CTL CAPABILITY AND LET OUR GUARD DOWN. I AM NORMALLY KEENLY AWARE OF MY ENVIRONMENT WHEN FLYING. THIS ALERTNESS FOR ME IS GENERALLY INCREASED WHEN I AM OPERATING IN A NEW OR UNFAMILIAR AREA OR ANTICIPATE POOR ATC SVCS (E.G., OVERSEAS, THIRD WORLD COUNTRIES). LAX IS HOME BASE FOR ME AND THIS WAS JUST TO BE ANOTHER ROUTINE DEP, ALMOST MY LAST. ON HEARING TWR ATTEMPT TO CONTACT WDB Y, WE SHOULD HAVE ANTICIPATED A POSSIBLE PROB AND INQUIRED AS TO WDB Y'S DISTANCE AND THE NATURE OF THE COM PROB. WAS WDB Y STILL ON APCH FREQ OR NOT TALKING TO ANYONE (RADIO FAILURE)? I SHOULD HAVE BEEN MORE AWARE THAT WE WERE SITTING ON THE LNDG RWY AND NOT THE 'USUAL' PARALLEL DEP RWY. I COULD HAVE TURNED ON OUR ACFT STROBE LIGHTS. THE TAIL STROBE FIRES AFT FROM THE TOP OF OUR T TAIL. MY STD PRACTICE IS TO TURN ON STROBES WHEN CLRED FOR TKOF SO THEY WERE OFF. PERCEPTIONS. ALL THE INGREDIENTS WERE PRESENT FOR AN ACCIDENT. WDB Y DIDN'T INITIATE HIS GO AROUND UNTIL HE WAS VERY LOW. WHETHER HE WAS DIRECTED BY RADIO CONTACT TO GO AROUND OR JUST SAW US AT THE LAST MIN, WE DON'T KNOW YET. WDB Y CREW WAS UNDOUBTEDLY FATIGUED, HAVING JUST COMPLETED A LONG RANGE FLT. LAX TRACON IS NOT FULLY STAFFED AND HAS MANY CTLRS THAT ARE NOT FULL PERFORMANCE LEVEL. AS AN EXAMPLE, HERE ARE SOME EVENTS THAT HAPPENED PRIOR TO AND AFTER OUR DEP. OUR CLRNCWAS VIA THE LOOP 5 DEP TO CLB AND MAINTAIN 5000'. THIS SEEMED A LITTLE UNUSUAL SINCE WE NORMALLY GET A CLRNC TO 2000', BUT I DIDN'T QUESTION IT AT THE TIME SINCE I ASSUMED THE VFR CORRIDOR WAS CLOSED WITH THE MORNING CLOUD COVER. ON TWR FREQ, I HEARD ANOTHER ACFT WHO WAS ABOUT TO BE CLRED FOR TKOF ASK THE TWR TO CONFIRM THAT HIS CLRED ALT WAS 5000'. I COULD NOT BELIEVE THE TWR'S REPLY. IT WENT LIKE THIS, 'I DON'T KNOW WHAT CLRNC GAVE YOU.' THAT WAS IT! TWR JUST DROPPED IT. THIS IS A SERIOUS FLAW IN THE SYS IF TWR CAN'T ACCESS THAT INFO AND CONFIRM THE CLRNC TO THE PLT. OUR TKOF CLRNC INCLUDED 'CAUTION WAKE TURB WDB ON MISSED APCH.' CONTACTING DEP CTL, WE WERE TOLD TO TURN LEFT HDG 160 DEG FOR VECTORS TO THE FLIPPER DEP, CLB AND MAINTAIN 4000'. WHEN WE ADVISED DEP WE WERE A LOOP DEP, HIS JOKING REPLY WAS, 'WE WERE JUST TESTING YOU.' HE GAVE US ANOTHER HDG AND CLRNC TO 13000' FOR THE LOOP DEP. THE FINAL EVENT WAS AS WE CROSSED THE LAX VOR AT JUST OVER 10000'. WE WERE TOLD TO RESUME 'NORMAL SPEED,' YET WE NEVER HAD BEEN ISSUED ANY SPEED RESTRICTION. IT REALLY MAKES YOU WONDER JUST HOW EFFICIENTLY OR INEFFICIENTLY CLRNC INFO IS RECORDED AND TRANSFERRED AT THIS TRACON. WDB Y WAS NEVER CLRED TO LAND BUT CONTINUED APCH TO NEAR MINIMUMS. APCH DID NOT DIRECT WDB Y TO CONTACT TWR AND WDB Y DID NOT SELF INITIATE TWR CONTACT. TWR FAILED TO TAKE TIMELY ACTION TO REDUCE THE POSSIBILITY OF COLLISION, I.E., TAXI US OFF RWY OR GET ON LAND LINE SOONER TO APCH CTL. TWR CLAIMS APCH CTL GOT THROUGH TO WDB Y AND DIRECTED THEM TO INITIATE A MISSED APCH. I SERIOUSLY DOUBT WDB Y CREW EVER SAW US HOLDING IN POS. I BELIEVE A MAJOR AIR DISASTER COULD EASILY HAVE OCCURRED IF APCH CTL HAD NOT BEEN SUCCESSFUL IN CONTACTING WDB Y WITH INSTRUCTIONS TO EXECUTE A MISSED APCH. IT IS INDEED A SORRY STATE OF AFFAIRS WHEN WE CAN'T TRUST THE TWR TO KEEP US SAFE FROM TFC CLOSING FROM OUR 6 O'CLOCK POS. I GUESS THAT THE MORAL OF THIS STORY IS AN OLD ONE. COM OR THE LACK THEREOF CAN INDEED KILL YOU. WDB Y CREW OBVIOUSLY SHARES RESPONSIBILITY IN THIS INCIDENT IN THAT THEY INTENDED TO LAND W/O OBTAINING LNDG CLRNC. OFTENTIMES, THIS TYPE OF ERROR IS OF MINOR SIGNIFICANCE (E.G., GOOD VIS, RWY CLR), BUT AS IS PLAINLY CLR, THE POTENTIAL FOR DISASTER IS VERY REAL. CAPT OF LTT Z WITNESSED THE NEAR COLLISION FROM INTXN 8J HOLDING SHORT OF 25R. HE TOLD ME LATER THAT IT APPEARED THAT WDB Y DSNDED TO MINIMUMS (150' TO 200') BEFORE INITIATING THE MISSED APCH. HE WAS CONCERNED THAT THE KEEL OF WDB Y MIGHT HIT OUR TAIL AS HE PITCHED UP. CAPT OF LTT Z ESTIMATED THAT WDB Y CLRED OUR TAIL BY 100', DIRECTLY OVERHEAD. CAPT OF LTT Z CONFIRMED THAT RWY 25R WAS CLR AT THE TIME AND WE SUSPECT THE TWR'S PLAN WAS TO LAND WDB Y WITH A SIDE STEP ON 25R. THE TWR CHIEF CONFIRMED THAT THE TWR MADE A SERIOUS ERROR IN DELAYING CONTACT WITH APCH CTL, VIA LAND LINE, UNTIL AFTER THE 2ND RADIO CALL ON TWR FREQ WENT UNANSWERED. ALSO, HE ADMITTED WE SHOULD HAVE BEEN DIRECTED TO TAXI CLR OF THE RWY. NO ONE, INCLUDING OTHER ACFT ON THE GND SAID ANYTHING TO US ABOUT OUR RAPIDLY CLOSING 6 O'CLOCK TFC. THE FIRST WE KNEW OF IT WAS AS OUR ACFT WAS BUFFETED BY WDB Y'S WAKE.

Data retrieved from NASA's ASRS site as of August 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.