Near Miss at LGA - ATC Coverups Continue

[The following is excerpted from a 10-page investigation report by the NTSB.  To read the full report (Adobe Acrobat .pdf file), click here:  Full Report.  See also, the editorial ATC Coverup.  All emphasis, in this excerpt, supplied by the Editor of AirlineSafety.Com]

By the time the Safety Board initiated the investigation of the April 1998 incident, radar data for the reported January 1998 NMAC between USA1186 and AAL350 were no longer available; therefore, investigators were unable to confirm USA1186's proximity to runway 13 when AAL350 was cleared for takeoff from runway 4. However, the circumstances of both incidents suggest that the spacing being used by LGA tower personnel between arriving and departing aircraft using intersecting runways may not provide an adequate margin for error in controller technique.

According to the FAA, in response to the April 1998 incident, all FAA terminal supervisors and controllers, including those at LGA, received additional training on intersecting runway operations and incident reporting requirements. However, the rules and procedures for application of visual separation remain unchanged, preserving the possibility that aircraft engaged in operations on intersecting runways may come within unsafe proximity. By the time a controller determines that two aircraft operating on intersecting runways will not meet runway separation requirements, it may be too late for an approaching aircraft to execute a go-around maneuver as a safe alternative to landing in violation of runway separation standards. A collision was averted in the April 1998 incident mainly because of last-second maneuvers by the crew of USA920.

Situations in which ATC and flight crews are essentially without safe alternatives cannot be permitted to occur; air traffic procedures must allow sufficient spacing to guarantee adequate separation between converging aircraft. It appears that the 2-mile converging operations spacing standard used at LGA may be inadequate to prevent incidents such as those described in this letter....

Reporting and Investigation of ATC-Related Events

The local controller involved in the April 1998 incident told Safety Board investigators that he informed the tower supervisor about the NMAC, even though the supervisor was standing directly behind him monitoring the operation from the coordinator position. 3

The supervisor told Safety Board investigators that he first saw USA920 near the departure end of runway 22, which was after the aircraft had crossed ACA703's path. Despite the controller's report, the supervisor decided not to conduct any further inquiry. This decision concerns the Safety Board because, even if the supervisor did not actually see the near-collision, other indicators should have alerted him that an unsafe incident had occurred. For example, he received calls expressing concern about the event from USA920's captain, the FAA's eastern regional office, and the chief pilot's office of US Airways. Even after this, he did not investigate further, and the incident was not reported to FAA management.

On the basis of other incidents that have occurred since the NMAC incidents at LGA, the Safety Board remains concerned about the adequacy of the FAA's processes for identifying and categorizing ATC errors. For example, on June 22, 1998, the captain of American Airlines flight 758 (AAL758), a Fokker F-100, filed a formal report with the ATC tower at Tulsa International Airport (TUL), Tulsa, Oklahoma, after experiencing what he believed to be an NMAC. The Safety Board learned that a Cessna 172 had been cleared for takeoff from runway 18R with ATC approval for an eastbound turn on course, crossing the extended centerline of runway 18L. AAL758 was then cleared for takeoff from runway 18L. According to the captain's report, he was retracting the landing gear when the local controller provided a traffic advisory on the Cessna. The captain sighted the Cessna about 500 feet above ground level, just as AAL758's Traffic Alert and Collision Avoidance System issued a resolution advisory alerting the crew to the potential collision threat. AAL758 turned right to avoid the Cessna and continued to climb.

In his NMAC report, the captain estimated that the aircraft were separated by 100 feet vertically and 200 feet laterally. Although this incident clearly compromised safety of flight and was directly related to unacceptable ATC performance, the FAA processed the incident as an NMAC rather than as an operational error 4 because Tulsa tower personnel and the FAA's Air Traffic Division headquarters staff contend that separation standards were met. NMACs not associated with an operational error are investigated by FAA flight standards personnel, who primarily focus on pilot performance rather than possible ATC shortcomings. It appears from the two incidents at LGA and the one at TUL that there is no FAA requirement to investigate and report on the ATC aspects of NMAC incidents that occur while controllers are applying visual separation....

After landing, the captain of USA920 asked ATC to provide a telephone number for the LGA tower and was given a number for an unrecorded line.5  When he called the tower, the captain asked to speak with the tower supervisor to discuss the incident. According to the supervisor's description of the conversation, the captain asked what had happened and why his flight was instructed to execute a go-around. The supervisor said that he told the captain that ACA703 had been slow in departing. The captain then asked if ACA703's crew knew that USA920 was on final approach for runway 22. The supervisor replied that he could not answer the question.6  

According to the supervisor, USA920's captain then asked him to tell the local controller that he had done a good job.  In a subsequent telephone interview with Safety Board investigators, the captain of USA920 refuted the supervisor's account of the conversation. According to the captain, the supervisor told him that the local controller was distracted by a spilled cup of coffee after clearing ACA703 for takeoff. When the local controller looked up, he decided that ACA703 would not pass through the runway intersection before USA920 crossed the threshold of runway 22. The local controller then instructed USA920 to go around. According to the captain's account, the supervisor complimented him on the "outstanding job of missing ACA703" and on the "good job of getting back around to land." 

Because the conversation was not recorded, the discrepancies between the two accounts of the conversation could not be resolved conclusively.  After the initial investigation at LGA, the Safety Board informed the manager of the Air Traffic Services evaluation and investigations staff at FAA headquarters of the discrepancies between the LGA tower supervisor's account of the conversation and the account provided by the captain of USA920. The supervisor was subsequently relieved of his management duties for 10 days during an internal FAA investigation, which found that the incident had not been properly reported or investigated.

3 FAA Order 7210.3, "Facility Operation and Administration," section 5-2-7, states in part, "Any employee who is aware of an occurrence that they believe to be an operational error/deviation shall immediately report that occurrence to the supervisor/manager-in-charge, or in their absence, any available supervisor or controller-in-charge."

4 An operational error is an ATC action that results in loss of required separation between aircraft. An operational deviation occurs when a controller fails to comply with a rule, but the error does not result in a loss of separation between aircraft. Allowing an aircraft to enter restricted airspace without proper coordination is one example of an operational deviation. Either type of incident triggers an internal ATC investigation and may result in retraining or disciplinary action against the responsible controller. The LGA and TUL incidents do not technically qualify as operational errors or deviations because no separation standard or mandatory procedure was violated.

5 FAA Handbook 7210.3, "Facility Operation and Administration," states, "Air traffic facilities shall record operational communications to the maximum extent practicable." Telephone calls on nonoperational lines normally are not recorded.

6 In a subsequent interview with Safety Board investigators, the supervisor denied witnessing the NMAC and stated that he had not discussed the incident with the controller before speaking with the captain; therefore, he was not aware of the details of the incident.