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ATC Error: Runway Incursion @ MDW Near Miss

NTSB REPORT:
Two front line managers (FLM) were in the tower at the time of the runway incursion. One FLM was monitoring air traffic operations as part of his normal duties and the other FLM was plugged into the communications switch at the ground control 2 (GC2) position and was monitoring the local control 1 (LC1) frequency while executing the Very Important Person (VIP) arrival checklist. The FLM had positioned himself behind and to the left of the local assist 1 (LA1) position between LC1 and GC1 and was coordinating with and assisting the ground controller. The VIP arrival would effectively stop traffic at MDW therefore ATC was attempting to get as many arrivals in and departures out before the VIP arrived. The monitoring FLM acknowledged monitoring the local control frequency, but he said he was not really listening to the communications on the frequency. The monitoring FLM stated that he was confident of the local controller’s ability and did not consider it critical to actively monitor the local control frequency prior to the VIP arrival.

The local controller stated that he was busier than normal with a mix of air carrier and business jets arriving and departing. There was also a helicopter operating VFR in the vicinity of the approach corridor to runway 31. The local controller was departing an aircraft from runway 31C, followed by an arrival to runway 31C and sequentially departing aircraft from runway 22L. The three arrivals to runway 31C prior to SWA844 had been directed to turn right, cross runway 31R, contact ground.

The local controller had two business jets awaiting departure for runway 31C, GAJ17 and Options 445. The local assist suggested that the local controller depart the two business jets from runway 31R and the local controller advised GAJ17 and Options 445 that they would be departing from runway 31R and directed the two business jets to taxi across the approach end of runway 31C. At 09:05:30, the local controller cleared SWA844 to land on runway 31C. At 09:05:36, the local controller directed GAJ17 to cross runway 31C and to line up and wait (LUAW) runway 31R. After working several other aircraft and directing the helicopter to depart the area, the local controller directed GAJ17 to fly heading 220 degrees and cleared GAJ17 for takeoff from runway 31R at 09:07:17 followed immediately with directions to SWA844 to turn right, cross runway 31R, contact ground. GAJ17 and SWA844 both acknowledged their respective clearances.

The FLM monitoring the local control frequency noted the conflict between SWA844 and GAJ17 and said he twice asked the local controller if he was holding SWA844 short of runway 31R. The local controller did not respond to the FLM on either occasion nor did he attempt to stop SWA844 from entering the runway or cancel GAJ17’s takeoff clearance. The local controller stated that he was not sure which aircraft the FLM was referring to, because he was seated and a tower cab mullion blocked his view as did other controllers who were standing in the tower cab.

The local assist, whose first priority was to advise the local controller of safety issues related to LUAW, same runway and intersecting runway separation and to actively monitor the local control operation, stated that he had been listening to the FLM discuss the VIP arrival plan and did not recall hearing the local controller issue a takeoff clearance to GAJ17 or issue a crossing instruction to SWA844. However, the local assist did recall observing GAJ17 departing on runway 31R and SWA844 taxiing at a high rate of speed on taxiway B and stated that he asked the local controller twice “is he stopping” referring to SWA844. The local assist did not recall getting a response from the local controller but observed that SWA844 had stopped. The local assist was initially of the opinion that incident had occurred because SWA844 failed to comply with hold short instructions.

The FAA performance data analysis and reporting system (PDARS) playback of the runway incursion indicate closest lateral proximity at the time of GAJ17’s rotation of 1196 feet and closest lateral proximity as GAJ17 passed SWA844 of 287 feet lateral and vertical proximity of 62 feet

At 09:07:59 the pilot of SWA844 called the tower and advised that “we just had a plane take off from 31R and you cleared us to cross.” The local controller responded “SWA844 cross 31R, contact ground.” SWA844 responded with “Ok if you just copied you cleared us to cross a runway where there was a plane taking off.” The local controller continued to work other traffic and at 09:08:52 again called the tower and asked the local controller for a telephone number to call and was directed to contact ground after which the pilot of SWA844 asked the local controller to acknowledge that they had been cleared onto a runway which a plane was taking off. The local controller responded with “contact ground please”.

The FLM monitoring the VIP arrival directed that the local controller be relieved and directed a review of the audio tapes. The local controller was relieved at 09:10 and participated in an audio recording review of the incident.

The local controller stated that he was of the opinion that he had told SWA844 to hold short of runway 31R until he heard the audio playback and realized that he had in fact directed SWA844 to cross runway 31R after clearing GAJ17 for takeoff on the same runway. The local controller could not explain his action.

FAA Order 7110.65, Air Traffic Control, paragraph 3-1-3, use of Active Runways states in part:

The local controller has primary responsibility for operations conducted on the active runway and must control the use of those runways.

FAA Order 7110.65, Air Traffic Control, paragraph 3-1-5, Vehicles/Equipment/Personnel on Runways states is part:

Ensure that the runway to be used is free of all known ground vehicles, equipment, and personnel before a departing aircraft starts takeoff or a landing aircraft crosses the runway threshold.

FAA Order 7110.65, Air Traffic Control, paragraph 3-10-9, Runway Exiting states in part:

Instruct aircraft where to turn-off the runway after landing, when appropriate, and advise the aircraft to hold short of a runway or taxiway if required for traffic.

MDW ATCT Order 7210.2A, Standard Operating Procedures for Line Up and Wait (LUAW) paragraph 4a(2):

Departure prior to arrival: Inform the aircraft of the closest arriving aircraft that is expected to land on a parallel or intersecting runway.

SWA844 contacted ground control and was provided the telephone number to the tower. The pilot of SWA844 called the tower on an unrecorded line and discussed the event with of the FLMs. The pilot of SWA844 advised that they would be filing a report regarding the tower clearing them to cross a runway that an aircraft was departing from. The FLM assured the pilot that this was not a normal event and that the ATC facility would be filing a report as well.
http://www.ntsb.gov/aviationquery/brief.aspx?ev_id=20111209X35527&key=2

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Added: May-6-2012 Occurred On: Dec-1-2011
By: pm0n3y
In:
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Tags: atc, airplane, airline, runway incursion, mdw
Location: Chicago, Illinois, United States (load item map)
Views: 1893 | Comments: 8 | Votes: 0 | Favorites: 0 | Shared: 0 | Updates: 0 | Times used in channels: 1
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