OPS06IA001

History of flight

On November 9, 2005, at 2346 Coordinated Universal Time (UTC), the pilot of Comair flight 5026 (COM26), a Canadair Regional Jet operating as a 14 Code of Federal Regulations (CFR) part 121 scheduled air carrier flight from Fort Lauderdale-Hollywood International airport (FLL), Fort Lauderdale, Florida, to Tallahassee, Florida, reported a near-collision with US Airways flight 1251 (USA1251), a Boeing 737-400 operating under 14 CFR 121 as a scheduled air carrier flight from Pittsburgh, Pennsylvania, to FLL. At the time of the incident, COM26 was holding in takeoff position on runway 9L, and USA1251 was on approach to runway 9L. Neither aircraft was damaged, and there were no reported injuries. Weather conditions at FLL at 2253 UTC were reported as wind 060 at 12 knots, visibility 10 miles, with scattered clouds at 3,500 feet.

USA1251 contacted FLL tower at 2342, and was cleared to land on runway 9L. The local controller advised that there would be several departures before USA1251's arrival, and the pilot acknowledged. At 2342:48, the controller cleared Southwest flight 221 for takeoff and instructed Comair 716 (COM716) to taxi into position and hold, advising the pilot that there was arrival traffic on 9 mile final. At 2343:52, the controller cleared COM716 for takeoff and instructed COM26 to taxi into position and hold on runway 9L, advising the pilot of COM26 that there was arrival traffic on 4 mile final. At 2344:46, COM716 was instructed to contact departure control. At 2344:52, the controller advised an arriving Gulfstream 4 that they were number 2 for the runway, following a 737 on 2 mile final. At 2345:15, the controller began a series of exchanges with a helicopter that was 38 miles from FLL and trying to contact Miami approach control. At 2345:48, USA1251 asked if they were cleared to land, and the controller responded, "USA1251 cleared to land runway 9L." Immediately, an unidentified voice on the frequency stated, "Traffic on 9 left." The controller transmitted, "USAir go around, USAir go around, USAir 1251 go around." USA1251 did go around, and, according to recorded radar data, passed about 100 feet above COM26. USA1251 was issued a 060 heading and given back to Miami approach for resequencing. The flight returned and landed uneventfully at 0003 UTC.

The Local Control North (LCN) controller notified the tower supervisor of the incident as soon as it occurred, and she initiated a quality assurance review (QAR) that was logged in the Daily Record of Facility Operation. According to the QAR summary, the supervisor interviewed both the local and ground controllers and reviewed the tape, concluding that there was no loss of separation between USA1251 and COM26 because USA1251 was instructed to go around when approximately one mile from the runway. The pilot of COM26 filed a near midair collision report with FLL tower on the day after the incident.

At the time of the incident, the LCN controller was responsible for both the LCN and Local Control South (LCS) positions, and was therefore required to monitor operations on all runways. The tower is located between runways 9L and 9R, so the LCN controller was therefore required to divide his attention in opposite directions while handling aircraft on both of those runways. Runway 9L is normally used for jet traffic, and runway 9R is normally used for general aviation traffic. While USA1251 was on approach there were multiple departures and arrivals operating on runway 9L, and a Seneca waiting to depart on runway 9R.

The controller said that operations were normal in the cab during the shift. His first contact with USA1251 was when the pilot checked on frequency about ten miles from the airport. He advised the pilot that there would be several departures prior to his arrival. There was a Southwest Airlines flight and two Comair regional jets waiting to depart from 9L, COM716 and COM26, and Seneca 92C waiting to depart from runway 9R. He cleared the Southwest flight for takeoff, cleared COM716 into position and hold on 9L, and Seneca 92C into position and hold on 9R. As soon as there was enough spacing behind the Southwest departure, the local controller cleared COM716 for takeoff and instructed COM26 to taxi into position and hold. His plan was to launch COM716, then COM26, then the Seneca from runway 9R. After he cleared COM26 into position, a helicopter called, attempting to contact Miami Approach. The local controller stated that he spent some time working with the helicopter pilot, trying to establish his altitude and position in order to give the pilot the correct frequency. At that point, the controller said he mistakenly believed that he had already cleared COM26 for takeoff.

When USA1251 questioned his landing clearance, the controller stated that he scanned the runway and radar display and didn't see anything, so he repeated the landing clearance. He realized that he had lost track of COM26, so he scanned the radar display looking for a "tag up" on COM26 or for a primary return and didn't see either one. He looked at the runway again and saw COM26 still holding in position. He immediately issued go-around instructions, repeating the clearance three times. He said that he did not hear the unidentified "traffic on the runway" transmission at the time, but instead initiated the go-around on his own. He heard the transmission while reviewing the tape in preparation for his interview. By this time the controller had also cleared the Seneca to depart from runway 9R, so he needed to establish separation between USA1251 and Seneca 92C, clear COM26 for takeoff, and separate COM26 from the Seneca as well. He did so through application of both vertical and lateral separation, and then transferred the departures to the radar controller at Miami terminal radar approach control (TRACON).

Asked about taxi into position and hold (TIPH) management, the controller stated that his personal practice used to be to slide the departure strip to the left when clearing an aircraft into position on the runway, and then cock the stripholder to the left when clearing the aircraft for takeoff. Starting in September, the tower adopted a standard procedure requiring that the strip be cocked to the left when an aircraft is cleared into position and hold, and that the paper strip be slid left out of the holder when the takeoff clearance is issued. He had been trying to adapt to the new procedure and believes he was using it at the time of the incident, but it is not second nature to him yet. He is not sure how the new procedure was developed except that it was the result of collaboration between management and the controllers union.

The local controller stated that he should have possibly asked for help in locating COM26 a little sooner, as the extra set of eyes might have resulted in locating the plane faster and prevented the incident.

He also stated that the local assist position is opened as staffing permits. It's not usually necessary to use a local assist in the summer, but the tower gets a lot busier from November through April or May and that's when the position is most needed. Asked about whether a local assist controller would have helped in this scenario, he said that another set of eyes can always help. LCN and LCS are open or closed as traffic dictates, sometimes to relieve frequency congestion caused by traffic on runway 9R, and might or might not be combined in the early evening. Working LCN and LCS combined requires that the LCN controller turn around and stand up (at least partially) in order to scan runway 9R and monitor traffic on the south side of the airport. The local controllers are also responsible for using the tower radar displays, and in this situation the controller stated that he was distracted by locating and communicating with the helicopter. He stated that his workload was moderate at the time of th