Rep. Doggett Reacts to the National Transportation Safety Board Review of Near-Collision at Austin Airport

Contact: Alexis.Torres@mail.house.gov

Washington, D.C.—Today, U.S. Representative Lloyd Doggett (D-Texas) released the following statement regarding the National Transportation Safety Board (NTSB) findings on its investigation into the February 4, 2023, near-collision between a Southwest Airlines and FedEx aircraft at Austin-Bergstrom International Airport (AUS):

“I appreciate this thorough NTSB review of a near catastrophe, which could have resulted in more than 100 deaths when a Southwest Airlines B-737 and a FedEx B-767 came within 150 feet of each other. The NTSB findings reaffirm what I’ve been saying and working toward achieving for months. A lack of critical safety equipment increases the odds of potentially catastrophic incidents at our airport. I am pleased that the Surface Awareness Initiative is finally being installed at our airport. This is the safety equipment, which I was assured last November, that Austin would be the first to receive.

“While getting this new system operational is important, I will not be satisfied with the needed level of safety at our airport until our severe shortage of air traffic controllers is resolved.”

Background:

The National Transportation Safety Board in its meeting today on the Austin Near-Collision voted unanimously to approve the following probable causes, findings and safety recommendations.

The below has been pulled from a lightly edited transcript of the oral proceedings provided by the NTSB. An executive summary of today’s meeting is slated to be released tomorrow by the NTSB, with the final report available in a few weeks.

Probable Cause

The National Transportation Safety Board determined the probable cause of this incident was the local controller's incorrect assumption that the Southwest Airlines SWA airplane would depart from the runway before the Federal Express airplane arrived on the same runway. Which resulted in a loss of separation between both airplanes. Contributing to the controller's incorrect assumption was his expectation of bias regarding the SWA airplane's departure. His lack of situational awareness regarding the SWA airplane position and that's when the flight crew requested takeoff. And the lack of training before the incident on low visibility training and operation. Contributing to the incident was the SWA flight crew member's failure to account for the traffic for the final approach and to notify the controller they would need additional time on the runway before the takeoff roll. FAA failure to require surface detection equipment at Austin-Bergstrom International Airport and direct alerting for flight crews.

Findings

• Number one, none of the following were factors in the incident.
  • One, pilot in control of qualification.
  • Two, control or fatigue.
  • Three, air-traffic staffing at the time of the incident.
  • Four, flight crew fatigue.
• Number two, the control is an inaccurate mental model of the Southwest Airlines position on the taxiway resulted from his one, expectation that the SWA airplane would be at the hold-short line for runway 18L when the flight crew requested takeoff clearance and two, failure to verify the SWA airplane's position on the taxiway at the time of the takeoff clearance request.
• Number three, the controller's lack of training and low visibility conditions and his expectation that the Southwest Airlines SWA airplane would depart quickly were factors that led to his inaccurate mental model of the SWA airplane's position on the taxiway.
• Number four, the controller's failure to fully understand the Southwest Airlines SWA airplane's position upon entering and while on the runway resulted in insufficient separation between the SWA and Federal Express airplanes.
• Number five, the control's incorrect assumption that the Southwest Airlines airplane would depart before the FedEx airplane would arrive set up a hazardous situation that could have resulted in an accident. The situation could have been avoided altogether if the controller had followed established air-traffic control of seizures to ensure proper separation.
• Number six, the controller could still have appropriately separated both airplanes if he had either 1.) held the Southwest Airlines airplane until after the arriving Federal Express landed, or 2.) if the SWA airplane had already received a takeoff clearance, canceled the clearance and instructed the FedEx airplane to go around.
• Number seven, the quick reaction of the Federal Express first officer after seeing the Southwest Airlines airplane and the quick response of the FedEx captain in performing the missed approach avoided a collision between the SWA and led to the successful loss of separation.
• Number eight, the Southwest Airlines flight crew's action to shallow the airplane's climb in response to an advisory from the traffic alert and collision avoidance system contributed to the increased separation between the two airplanes.
• Number nine, if surface detection equipment had been installed in the air traffic control tower, the system would have allowed the controller to track the position of Southwest Airlines while it was on the taxiway and runway, which could have provided an opportunity for the controller to detect the insufficient separation between the SWA and Federal Express airplanes and take action to mitigate the situation.
• Number 10, the implementation of a flight deck alerting system on air carrier aircraft could further improve safety.
• Number 11, even though the Southwest Airlines flight crew members were not required to inform the controller about their plan to stop the airplane on the active runway, it would have been prudent for them to do so, given that they were notified of traffic on short final approach.
• Number 12, the Southwest Airlines flight crew members might have informed the controller of their plan to perform an engine run.
• Number 13, to avoid potential conflicts, it is critical for 1.) controllers to consider when providing takeoff clearance to an aircraft whether ambient conditions might affect the timing of the takeoff roll, and 2.) the pilot to concisely communicate pertinent aircraft position information during low visibility conditions that might prevent a controller from seeing the aircraft.
• Number 14, although the visibility before and at the time of the incident required the activation of the airport's surface movement guidance and control system plan, the operations supervisor's failure to implement the plan was not a factor in this incident because the local controller should have been able to appropriately manage the Southwest Airlines’ air plying departure using other control traffic procedures.
• Number 15, it is important for surface movement guidance of the control system plan and the related letter of agreement to have aligned information giving the controller is required to comply with all LOA's.
• Number 16, controllers need to be sufficiently trained on their airport surface movement guidance and control system plan, so they are able to effectively implement it when necessary.
• Number 17, refresher training on low visibility operations would benefit air-traffic control tower personnel at all operating towers in the national airspace system. Such conditions can affect operations throughout the U.S.
• Number 18, cockpit voice recorders, CVR, with a 25-hour recording capability are necessary because annual valuable information continues to be overwritten in CVR is designed to record only two hours of audio data.

Safety Recommendations

• Number one, for airports that are certificated under Title 14 Code of Federal Regulations part 139, and are currently not equipped with airport surface detection equipment, model acts, or airport surface surveillance capability, implement surface detection equipment that tracks the movement of arriving and departing aircraft. This determines the proximity between those aircraft and provides air traffic controllers with visual and all cues of surface movement to aid in the decision-making processes.
• Number two, require air traffic controllers to advise pilots through direct communication and automatic terminal information system broadcast with visual contact with the aircraft operated in taxiways and runways cannot be established or maintained, and instruct pilots to provide accurate position reports to aid the controller into determining an aircraft's location in conditions.
• Number three, brief ultrafast air traffic control is about the circumstances of this incident, emphasizing the Effexor in conditions may have on a pilot's ability to begin takeoff in a timely manner, including low visibility weather, such as fog, and ambient conditions, such as temperature, and surface conditions, such as ice, snow, and other precipitation, as noted in order 711016 five air traffic control paragraph 584, departure and arrival.
• Number four, instruct pilots to inform controllers before entering an active runway with the intent to depart when they need time for any reason before beginning the takeoff roll.
• Number five, require all airport parts with the surface movement plan to ensure the plans and the associated letters correspond with each other and the stakeholder duties and responsibility describe an advisory circular 120 e-57 surface movement guidance.
• Number six, direct training administrators and airports with surface movement guidance and control system plan to require initial and annual refreshers for all stakeholders, including air-traffic controllers and airport personnel.
• Number seven, require training administrators at all operating air-traffic control towers to conduct annual training on low visibility operations.
• Staff further proposes reiterating the following five safety recommendations to the FAA.
  • Collaborate with aircraft and manufacturers and software designers for a flight deck system that would provide visual and aural alerts for traffic on a runway or taxiway.
  • Number two, require the technology developed to be installed in all newly certificated transport category airplanes.
  • Number three, require the existing category airplane to be retrofitted with the technology developed.
  • Number four, require all newly manufactured airplanes that must have a cockpit voice recorder and CVR, be fitted with a CB, and are capable of hoarding the last 25 hours of audio.
  • Number five, require retrofit of all cockpits on all airplanes required to carry a CVR, with a CVR capable of recording the last 25 hours of audio.