November 10, 2004

LAX got 'lucky' in near-hit; safety system questioned
As agencies argue over reporting of Aug. 19 landing incident, safety statistics are under scrutiny. "Safety should never be dependent on luck," official says.

By Toby Eckert and Ian Gregor

A runway collision at Los Angeles International Airport was narrowly avoided in August by a combination of good weather and an alert flight crew, exposing the shortcomings of the system currently used to avert such accidents, federal safety officials said Tuesday.

The Aug. 19 incident was not reported by the Federal Aviation Administration to the National Transportation Safety Board, raising questions about whether such incidents are being under-reported and skewing statistics that show recent runway safety improvements, the officials added.

FAA officials said they did inform the NTSB of the incident and denied that any serious runway events go unreported.

In the incident, an incoming Asiana Airlines Boeing 747 came within 185 feet and several seconds of crashing into a Southwest Airlines Boeing 737 that was waiting to take off on the same runway, the safety board heard in a briefing.

Although a ground-radar known as Airport Movement Area Safety System, or AMASS, alerted an air traffic controller of the impending collision, it took the controller -- who was clearing a plane for landing on another runway at the time -- 10 seconds to react, an NTSB staff member said. The Asiana crew spotted the Southwest plane before that and veered off.

"AMASS did not prevent this incursion and a collision was avoided only because it was a clear day and the Asiana flight crew saw the Southwest airplane," said Sandy Rowlett of the board's operational factors division. "If the weather had been less than perfect or had it been nighttime, we may have had a very different outcome."

The incident clearly alarmed board members.

"I think we were very lucky on August 19," said NTSB Chairwoman Ellen Engleman Conners. "And safety should never be dependent on luck."

Board member Carol J. Carmody said the incident underlined the urgency of the NTSB's long-standing call for the FAA to develop a system that provides a direct warning to pilots about runway incursions.

AMASS "doesn't go far enough. We've said that repeatedly," Carmody stressed. "I don't know how many times we have to reiterate this to the FAA that we think it's crucial that not only the controllers know something's happening, but also the pilots, who can take some action to avoid an accident."

The FAA is testing systems that flash warning lights to pilots when a runway is unsafe to enter.

FAA spokesman Donn Walker said AMASS is just one of many tools controllers use to maintain runway safety.

"There are different layers of redundancies built into our system. They worked here," Walker said. "The pilot of Asiana went around. That's what they're trained to do."

Board members concerned

Other NTSB board members expressed concern that their agency was first notified of the incident by Southwest Airlines, rather than the FAA. They suggested that raised questions about FAA statistics showing a decline in close calls on runways nationwide.

"I think there's a reporting issue," said board member Deborah Hersman. "Regardless of what the trend line is telling us, I think the fact that this highly visible close call wasn't reported may suggest that there are some reporting problems."

Walker said the FAA initially determined that the event was not technically a runway incursion and therefore didn't require that the NTSB be notified. That determination was made because the Asiana pilot aborted his landing before he reached the runway's eastern threshold, Walker said.

But when FAA officials in Washington, D.C., reviewed the event and concluded it was an incursion, the NTSB was immediately notified, he said.

"Let me be really emphatic here: We cannot report events like this to the NTSB until we have investigated them and classified them," Walker said.

"We're completely confident that all serious incidents like this are communicated to the board and as quickly as all parties are able to do so."

The FAA classified the incident as the second most serious type of runway incursion.

LAX has had three incursions so far this year, Walker said. The world's fourth-busiest airport had 11 incursions last year, eight in 2002 and six in 2001 after leading the nation in these potentially deadly events in the late 1990s.

Controller wasn't decertified

The controller who was directing the planes on Aug. 19 has been on the job for 17 years and had an "impeccable" record, Walker said. Because of this, he was given additional training and supervision but was not decertified, Walker said.

Mike Foote, the air traffic controllers union representative at LAX, declined to comment on the incident or the NTSB meeting, citing a pending investigation into the matter.

On Tuesday, the NTSB watched an animated re-creation of the incident based on air traffic control tapes.

It showed the Asiana flight, which was arriving from South Korea, swooping close over the Southwest jet.

"That was close," one person can be heard saying on the tapes.

The incident occurred around 3 p.m., during a shift change in the control tower. Rowlett said the incoming controller was notified that the Asiana flight was coming in on runway 24-Left, but the controller's first transmission was an instruction to the Southwest flight to taxi to the same runway and hold there.

Twelve seconds later, the controller cleared the Southwest flight for takeoff, with the Asiana jet 1.26 miles away. The Southwest pilot later told the NTSB he saw the Asiana flight coming in but assumed it would be landing on runway 24-Right.

When the Asiana plane got within a half-mile of the runway, AMASS alerted the controller to the problem. At the time, the controller was giving a clearance to another plane approaching runway 24-Right.

"The first action taken by the controller was 10 seconds after the AMASS alerted the controller," Rowlett said. "He canceled the takeoff clearance (for the Southwest plane) two seconds before the collision would have occurred."

The NTSB listened to the scenario during a daylong hearing on its "most wanted" safety recommendations for air, highway, railroad and marine safety.

"The aviation group stands out for their lack of progress," said board member Richard F. Healing. "It's quite clear that they have failed to do as much as the others."