ANALYSIS: Controller Error & NMAC at Newark, on 4/24/2014

20140424.. UAL1243 KEWR.apdg20140424.. UAL1243 go-around KEWR20140424.. UAL1243 descent chart

FAA had no choice but to release the info, because among other things the flight data was all posted at Flightaware. The flight profile clearly shows the near-landing, the go-around and the second (final) landing attempt. The satellite view shows a Bridge Visual approach with some early corner-cutting (the wide loop), followed by a second approach not on the Bridge Visual, thus nearly two miles west of the Bayonne Bridge.

Here’s the weather sequence (incident at 3:03pm, thus approx. 1903 UTC):
KEWR 241951Z 34022KT 10SM FEW250 17/M12 A2988 AO2
KEWR 241851Z 34024KT 10SM FEW250 17/M11 A2988 AO2
KEWR 241751Z 34022KT 10SM FEW250 16/M12 A2989 AO2

This weather sequence shows that the weather was fine, except for strong northwest winds. These winds fit ATC’s decision to use the more hazardous runway combination of RWY29 and RWY04R. Not that it had to be hazardous, but at 3PM on a Thursday, at one of the busiest airports in the world, a chain of dumb/weak management decisions may lead to a situation where a controller is working without an effective supervisor or cab coordinator … that extra set of eyes that would see the error before it became an error — and promptly speak up to stop it. There may have been a Supe; he/she may have been doing scheduling paperwork or making calls to set up an overtime controller after getting a sick call from one of the controllers scheduled later that night, on the graveyard. Bottom line is, when the investigation is done it will likely show that, even for just a few seconds or a minute, FAA’s guard was let down and a collision nearly happened.

NTSB’s Preliminary Report is a bit disturbing as an apparent whitewash. It attempts to attribute the error to pilot delay on takeoff, but the audio evidence shows there was no such delay. Specifically, the report declares that ATC issued the takeoff clearance when UAL1243 “…was about three miles from the runway 29 threshold.” The audio shows ATC had loaded the departure onto the runway and even instructed them to power up and be ready in twenty seconds. Tower issued the takeoff clearance at 01:30 on the audio clip; tower issued the ‘Go Around’ to UAL1243 at 02:20, and transmissions suggest the departing Embraer passed through the intersection at 02:40. Given the winds, these times are all consistent with an immediate takeoff in front of an arrival on roughly a mile final. Yet, in their Preliminary Report, NTSB stated ASQ4100 “…did not actually begin its takeoff roll until the B737 was about 1 mile from the runway 29 threshold.”

Doubtless, at least a couple ATSAP reports were filed by controllers and/or supervisors in the Newark tower, to secure immunity. FAA encourages these reports which they contend cannot be shared with the media or citizens. In truth, ATSAP only protects the reporting controller (or supervisor) from any disciplinary action; ATSAP does NOT protect filed reports from public disclosure. Nonetheless, FAA is so hell-bent on hiding failure, they will reject all inquiries to produce these ATSAP reports — thus concealing the most critical and timely data on this near-collision. So, if FAA has their way, no citizen outside FAA will ever see these critical ATSAP reports.