The National Transportation Safety Board has published an abstract of its final report on a near-miss collision between an American Airlines Boeing 777 and a Delta Air Lines Boeing 737 on the runway at John F. Kennedy International Airport in New York in January of last year.

The NTSB finds that the American Airlines pilot’s multitasking in the cockpit and similar distraction at the air traffic control tower were the most likely contributors to the near-miss incident. What prevented tragedy on that day was the proper function of technology introduced at the airport to prevent runway incursions.

In the evening of January 13, 2023, air traffic controllers cleared a Delta Air Lines B737 for take-off on Runway 4L. Twenty seconds after the Delta plane began its takeoff roll, the American Airlines plane crossed the runway without clearance.

“​As the Delta 737 accelerated down the runway, Airport Surface Detection Equipment – Model X, or ASDE-X, issued aural and visual alerts in the air traffic control tower, warning of a potential collision,” the NTSB reports. “Five seconds after the alerts, the controller cancelled the takeoff clearance of the Delta airplane, which quickly decelerated from its top speed of 121 mph as the American 777 was crossing in front of it.”

Runway Incursion Technology Saved Lives

Runway incursion technology saved lives, NTSB investigators determined, by alerting the air traffic controller of imminent danger. The Delta Air Lines 737 had 159 passengers and crew onboard. The American Airlines 777 had 149 passengers and crew onboard headed for London’s Heathrow Airport. A collision at speed between two aircraft fully fueled for flight would have likely led to intense fire.

“The NTSB had recommended such technology in 1991, which led to the development of ASDE-X. The Federal Aviation Administration installed ASDE-X at JFK in 2009, one of just 35 major airports in the U.S. so equipped,” the NTSB states. It also recommends “additional risk mitigation strategies” to decrease the likelihood of similar occurrences.

“The whole reason U.S. aviation has such an exemplary safety record is because we’ve built in extra layers of protection, which is why we need lifesaving technology at more of the nation’s airports,” said NTSB Chair Jennifer Homendy. “Our investigation also makes clear why we’ve long supported systems that warn flight crews of risks directly: because every second matters. Thankfully, the controllers acted quickly in this case, but safety shouldn’t be all on their shoulders. Instead, we must back up every single component of the system; direct crew alerts do just that.”

Pilot Multitasking And ATC Distraction Probable Cause Of Incident

NTSB investigators found multiple factors led the American Airlines captain to continue a path along the wrong taxiway and cross the runway assigned to the Delta Air Lines plane without a clearance.

Specifically, the NTSB reports, “interruptions and multitasking that were happening on the flight deck during critical moments of ground navigation. The other two flight crewmembers didn’t catch the captain’s error because they were both engaged in tasks that diverted their visual attention from outside the airplane.”

At the same time, the ground controller giving taxi instructions to the crew of the American Airlines 777 failed to see the aircraft turn onto the wrong taxiway because “he was performing a lesser priority task that involved looking down.”

Also, investigators found the ATC tower team was working on other operations tasks “related to switching runways,” and didn’t scan the airport for potential trouble.

NTSB Recommendations To FAA

The NTSB several safety recommendations to the Federal Aviation Administration related to this incident including:

  • Flight crew should verbally state the number of the runway they will cross in the absence of an automated system that alerts ATC.
  • Airlines should take a closer look at surface mitigation errors by their crew and develop strategies to reduce the risks.
  • The FAA should evaluate the effectiveness of the technology that manages runway status light systems activation and update as necessary.
  • The FAA should work with aircraft and avionics manufacturers “to develop a system that would alert flight crews of traffic on a runway or taxiway and traffic on approach to land.” Furthermore, the FAA should require this cockpit alert system to be installed on new and existing aircraft.

The NTSB also highlighted the need for 25-hours of Cockpit Voice Recorder records, which were unavailable for this incident and might have shed more light on crew distractions on the American Airlines plane. The FAA Reauthorization which passed last month required adoption of 25-hour CVR recordings.

Recent Ground Collision Near Misses Emphasize Need For Systemic Improvements

A number of recent similar near-miss incidents at U.S. airports have raised questions about air traffic controller overtasking and highlight a need to improve runway safety management.

The FAA is investigating an incident at Ronald Reagan Washington National Airport on May 29 when American Airlines Flight 2134 avoided a collision with another aircraft which was cleared to land on an intersecting runway. In this case, the air traffic controller cancelled the takeoff clearance for the American Airlines Airbus A319 just in time to avoid a crash.

In April of this year, Southwest Airlines and JetBlue aircraft also averted a collision at this airport after air traffic controllers noticed the JetBlue flight was cleared for takeoff on a runway the Southwest plane had been cleared to cross. Controllers quickly commanded the two planes to stop, but the near-miss highlights the challenges for air traffic controllers and pilots both overtasked on the nation’s busiest airports.

Last February, a Fedex 747 and Southwest Airlines 737 came within a 100 feet of each other when ATC cleared the cargo plane to land on the same runway as the Southwest Airlines plane was cleared for take-off at Austin Airport. In this case, the FedEx pilot’s quick reaction averted disaster.

While U.S. commercial aviation remains safe, there is growing concern that a shortage of trained ATC staff and significant traffic recovery after the COVID-19 pandemic, increases risks. Automation of the kind the NTSB recommends in this latest report, with systems looking out at the environment both on planes and at air traffic control towers, would lessen the burden on human eyes.

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