OPS12IA849
OPS12IA849

On July 31, 2012, at 1408 eastern daylight time, losses of required air traffic control separation occurred involving Republic Airlines flight 3329, an Embraer 170 regional jet arriving at Washington-Reagan National Airport (DCA) from Portland, Maine; Chautauqua Airlines flight 3071, an Embraer 135 regional jet departing from DCA to Columbus, Ohio; and Republic Airlines flight 3467, an Embraer 170 regional jet departing DCA to Kansas City, Missouri. The call sign for the two Republic Airlines flights was "Brickyard." All three aircraft were operating on instrument flight rules (IFR) flight plans under Title 14 Code of Federal Regulations part 121. There was no damage to any of the aircraft, and no injuries to passengers or crew.

History of Flight

According to the DCA facility operations log, runway 1 had been the primary runway for arrival and departure aircraft since 0548 that morning. At 1400:34, the Potomac Terminal Radar Approach Control (PCT) Mount Vernon (MTV) supervisor called the DCA supervisor's line. Because the DCA supervisor was occupied with administrative duties on a different phone line, a traffic management coordinator (TMC1) answered the call. The MTV supervisor stated that PCT was having, “…a problem getting these guys into the airport, I was wondering if I could flush them all into [runway] one nine." TMC1 advised that there were eight departures waiting to depart. However, she noted that some of the flights were encountering departure delays and could not leave, so there was not a lot of demand at the runway. After further discussion, TMC1 advised the MTV supervisor that she would call him back and the call terminated.

At 1401:50, TMC1 called the MTV supervisor and told him to, "…go ahead and run them in quickly." When interviewed, TMC1 stated that she had not heard the MTV supervisor’s request to use runway 19, and thought he wanted to decrease the arrival spacing on the final for runway 1. The MTV supervisor asked if there were any other departures, and TMC1 responded that there was one waiting. The MTV supervisor then went offline briefly to coordinate the change with the Ojaay sector controller. He returned to the line a few seconds later to implement the change with DCA. In the meantime, a second DCA traffic management coordinator (TMC2) had taken over the call. The MTV supervisor said, "We’re gonna start running them in to the south, get all those guys (inbound aircraft) flushed in real quick..." TMC2 responded, "You know that’s fine – whatever you’ve got, no problems with that, run them (inbound aircraft) in." The MTV supervisor responded, "I appreciate it" and the call ended.

The DCA local controller instructed CHQ3071 to line up and wait (move onto the runway and wait for takeoff clearance) on runway 1 at 1405:09, and cleared the flight for takeoff at 1405:45. A few seconds later, the local controller instructed RPA3467 to line up and wait on runway 1. At 1406:46, she directed CHQ3071 to change to departure frequency. RPA3467 was cleared for takeoff at 1406:58.

At 1407:12, RPA3329 contacted the DCA local controller, stating that the inbound aircraft was, "...on the river." The local controller began to reply, "Brickyard…" and then stopped. After a pair of unrelated transmissions from other aircraft that she did not acknowledge, at 1407:27 the local controller transmitted, "And Brickyard 30…Brickyard 3329 are you with me?" The pilot replied, "Yeah, I’m with you on the river." At 1407:32, the local controller instructed RPA3329 to turn south heading 180, and the pilot acknowledged.

At 1407:37, the MTV supervisor called the DCA supervisor, who had no knowledge of the traffic manager’s previous discussion with the MTV supervisor, and asked, "Hey, what are you guys doing launching north? Yeah, remember?" The DCA supervisor responded, "Yeah...uh." According to information provided during his interview, the supervisor immediately went to the local control position to attempt to resolve the problem.
At 1407:42, the local controller provided a traffic advisory to RPA3329, advising the crew, "...traffic just ahead and to your left, a CRJ departing through 2,200." The pilot acknowledged the traffic, stating, "We got him, 3329", and continuing, "You have an altitude for us?" The controller did not acknowledge the altitude request. At 1407:54, the local controller transmitted, "Brickyard...Brickyard 3467 traffic 2 mi...uh traffic at your 11:00 and 2 miles is a 170 at 1,800 southbound." The pilot responded, "Brickyard 3467 we’re looking."
At 1408:05, the MTV supervisor again came on the line, stating, "tower don’t launch anybody else, please," but there was no response.

At 1408:11, the local controller instructed RPA3329 to turn right heading 020, and at 1408:18 amended the heading to 090. The pilot acknowledged the instructions, continuing, "Is 2,000 [feet] good for you here?" The controller did not respond to the question. According to information provided by the supervisor, he had directed the local controller to issue those headings but intended the instructions for RPA3467, the second departing aircraft, not RPA3329. He did not immediately recognize that the local controller had misunderstood his direction because both aircraft were Republic Airlines flights, he heard her instruct a Republic flight to turn, and he was uncertain about the flight numbers of each aircraft.

At 1408:20, the MTV supervisor again called the DCA supervisor line. The DCA TMC responsible for the initial coordination about using runway 19 answered the call, saying "I thought you were going to run them in on 1, I didn’t think 19." The MTV supervisor responded, "No, 19, I said it over and over again." The TMC responded, "Oh no, I didn’t hear 19, I’m sorry about that. I said just run them in on 1 – that we didn’t have any you know [unintelligible]..." The MTV supervisor then stated, "...no more departures." The TMC responded, "Yeah, we stopped them, we stopped them – it was miscommunication."

At 1408:40, the local controller instructed RPA3467 to contact Potomac departure and the pilot acknowledged. At 1409:19, the local controller stated, "And Brickyard 3329 you can uh contact uh stand by." At 1409:30, she transmitted, "...Brickyard 3329 turn right heading 180." The pilot acknowledged, and continued, "We were cleared the river back there – what happened?" The local controller did not respond because she was instructing an aircraft that had been holding on runway 1 awaiting takeoff clearance to exit the runway. At 1410:30, the pilot of RPA3329 asked, "What’s your plans for us?" The local controller responded, "Brickyard 3329 standby we’re...we’re trying to figure this out too, stand by." At 1410:44, the local controller transmitted, "All right, Brickyard 3329 climb maintain 2,000 on heading 180 and contact final approach on 124.75." The pilot replied, "All right we’re at 2 [thousand feet] on a 180 heading, 124.75, good day."

The local controller then issued additional taxi instructions to the aircraft exiting runway 1. At 1411:28, RPA3329 returned to the frequency, asking, "Tower you got something else for [Brickyard] 3329? Nobody’s answering [frequency] 2475 [124.75]." The controller then amended the frequency to 124.7 and RPA3329 again switched back to Potomac TRACON.

At 1412:14, the local controller advised all aircraft waiting to take off that there was a temporary stop on all departures. At 1412:22, RPA3396 contacted the tower inbound on the visual approach to runway 19, and became the first aircraft to land on that runway. Aircraft continued to land on runway 19, normal operations gradually resumed, and because of a change in the wind direction and speed that favored runway 19, DCA continued to use runway 19 for the remainder of the shift.

At 1412:50, the DCA supervisor called the MTV supervisor, saying, "...OK well I think we had an error there." The MTV supervisor replied, "Yeah, probably a couple of them." During an extensive conversation the DCA supervisor stated, "...my TMC answered the line and she thought you were referring to [runway] 1 arrivals around the weather to the south... We tried to turn that guy (Republic 3467)...we lost separation on that I think." The DCA supervisor also noted that the reason he had not taken the coordination call was that he had been on another line making overtime assignments for the following day.

At 1412:13, after being transferred back to PCT to be set up for another approach to DCA, the pilot of RPA3329 advised the PCT Final controller, "We really don't have the fuel for this...we gotta get on the ground here pretty quick." Information later provided by Republic Airlines stated that their company policy is for crews to advise ATC of "minimum fuel" when the aircraft's fuel state reached 3000 pounds, and "emergency fuel" at 2000 pounds. The Final controller vectored the flight back toward the airport for a second approach and (although the pilot had not used the exact words) informed DCA tower that the aircraft was "minimum fuel." The remainder of the flight was completed without further incident or delay, and the aircraft arrived at the gate with 2600 pounds of fuel aboard. According to the FAA's "Pilot-Controller Glossary," the term "minimum fuel" indicates that, "...an aircraft's fuel supply has reached a state where, upon reaching the destination, it can accept little or no delay. This is not an emergency situation but merely indicates an emergency situation is possible should any undue delay occur." The pilot's report and subsequent ATC handling were consistent with that definition, and the aircraft landed without ever reaching an "emergency fuel" state.

Radar Data

Radar data for this report was obtained from the airport surveillance radar located at DCA. Review of targets for CHQ3071 and RPA3329 showed that the first target for CHQ3071 was seen by the radar system at 1406:48 climbing through 300 feet above sea level. At 1406:48, RPA3329 was eastbound, approximately 7 miles northwest of DCA descending through 2,400 feet. At 1407:34, RPA3329 was descending through 1,900 feet. CHQ3071 was climbing through 2,000 feet and 2.9 nm away. At 1407:48, RPA3329 began a right turn to approximately heading 140 at 1,800 feet. Shortly afterward, CHQ3071 passed RPA3329 on offset parallel courses along the Potomac River. Minimum lateral separation between RPA3329 and CHQ3071 occurred at 1407:57, when the two aircraft passed each other about 0.8 nm apart. RPA3329 was level at 1,800 feet and CHQ3071 was climbing through 2,600 feet.

While minimum separation standards applicable to these aircraft (3 miles laterally or 1,000 feet vertically) were violated, CHQ3071’s departure climb rate resulted in increasing vertical separation beginning when the two aircraft were 2.9 nm apart, and the turn instructions issued by the DCA local controller established the two aircraft on diverging courses so that their flight paths never intersected.

RPA3467 was first seen on radar at 1407:53 climbing through 200 feet above sea level. After RPA3467 departed, the aircraft followed roughly the same track as CHQ3071 northwest along the Potomac River. Following instructions from the DCA tower controller, RPA3329 continued a right turn and was established on an easterly heading at 1409:20. By then, RPA3467 had crossed RPA3329’s extended courseline and was continuing northwest bound. RPA3329 passed behind RPA3467, with minimum lateral separation of approximately 2.05 nm and vertical separation of 800 feet.

Comparison of the flight track for RPA3329 with the Minimum Vectoring Altitude (MVA) chart for the DCA area showed that the flight was maneuvering at 1800 feet in an area where the MVA was 2000 feet.

Radar graphics have been placed in the docket.

Weather Information

Although DCA traffic had been landing and departing on runway 1 before the incident, discussions between the MTV supervisor at PCT and the DCA traffic management coordinator indicated that weather conditions south of the airport were interfering with arrivals, hence the MTV supervisor’s request to temporarily land aircraft on runway 19. Review of National Weather Service radar data for the area south of DCA did show areas of precipitation on and near the ground track of the Mount Vernon Visual Approach. A graphic showing the location of the convective activity overlaid on the Mount Vernon Visual Approach chart has been placed in the docket.

DCA METAR reports from 1300 to 1500 local time were as follows:
2012-07-31 12:52 METAR KDCA 311652Z 00000KT 10SM SCT050 SCT250 31/18 A2996 RMK AO2 SLP144 T03110183 =
2012-07-31 13:52 METAR KDCA 311752Z VRB03KT 10SM SCT055TCU SCT250 31/18 A2994 RMK AO2 SLP138 TCU VC SE-S T03110178 10317 20250 58020 =
2012-07-31 14:37 METAR KDCA 311837Z 15010KT 10SM FEW025 SCT045CB SCT110 SCT250 31/21 A2992 RMK AO2 CB NE MOV NE CB DSNT SE-S MOV NE =
2012-07-31 14:52 METAR KDCA 311852Z 16010G17KT 10SM FEW025 SCT045CB SCT110 SCT250 32/20 A2993 RMK AO2 SLP135 CB VC NE MOV NE CB DSNT SE-S MOV NE VCSH NE T03170200 =

DCA Runway Change Procedures

According to the Potomac TRACON and Washington Tower Letter of Agreement dated August 9, 2011, changes to the active runway(s) at DCA required specific coordination. The LOA stated in part:

b. Runway Configuration/Operation.
(1) The Tower shall select the runway configuration and coordinate with the TRACON prior to change.

OPERATION LANDING RWYS DEPARTING RWYS
NORTH OP 1/33/4 1/33/4
SOUTH OP 19/22/15 19/15/22

(2) The TRACON area shall select the approach in use and coordinate with Tower prior to change. If an aircraft is conducting other than the advertised approach in use, to the service runway, coordination shall be effected either verbally or through the use of the ARTS quick look function on the RACD. [tower radar display]
(3) The TRACON shall coordinate the first and last arrival for each runway whenever a change in traffic flows is coordinated.
(4) The Tower shall forward the identification of the last aircraft that will depart prior to a runway change. For the first aircraft departing after the runway change, the Tower shall obtain a release from TRACON.

These procedures were not invoked at the time of the incident because the intent of the MTV supervisor was to temporarily use runway 19 until the weather south of the airport cleared. At the time of the coordination call, he estimated that runway 19 would be needed for 10 to 15 minutes.

Personnel Interviews

Evening Shift Traffic Management Coordinator (TMC1)

TMC1 arrived for work at 1340. When she came to the tower cab, she noticed that the traffic management hotline was active and staffed by another traffic management specialist (TMC2). She went to the traffic manager position in the back of the cab and began to familiarize herself with traffic conditions, weather, wind, traffic management restrictions in effect, and other information contained in the facility information management system. Under normal conditions, TMC1 would also receive a verbal briefing from TMC2. However, because of the workload involved in managing the hotline, TMC2 was unable to provide a personal briefing.

TMC1 stated that because of her experience level, she had a good picture of what was going on in the facility even without the verbal briefing. TMC1 noted that the traffic management hotline is typically put into use when weather conditions are affecting departure routes, and is used by Washington area air traffic facilities to communicate with each other and with aircraft operators about severe weather avoidance plans, ground stops, and other traffic management issues. The weather conditions that caused the hotline to be put into to use began early in the shift and continued all night.

TMC1 was about to take over responsibility for the hotline call from TMC2 when she answered a call from the Potomac TRACON Mount Vernon area supervisor. He asked her how many departures the tower had waiting. TMC1 looked at the airport resource management tool list for departures, and noted that there were at least eight aircraft waiting to depart. The MTV supervisor asked about bringing arrival aircraft in to DCA at a higher rate. TMC1 thought that would probably be all right, but she told the MTV supervisor that she would call him back. She went off-line, talked to TMC2, and obtained his concurrence. She then spoke with the local controller and assistant local controller about the TRACON’s request to provide minimum spacing on the final approach course, telling them to expect to not be able to clear many departure aircraft for takeoff. The MTV supervisor called back, and TMC2 told him it would be fine. The next thing TMC1 knew, the MTV supervisor was calling the tower to instruct them to stop departures.

TMC1 noted that coordination by the TRACON for temporary opposite direction arrivals was very unusual, and that both she and TMC2 had never seen that happen before. She was uncertain how she missed the TRACON supervisor’s request to land aircraft on runway 19 instead of runway 1, but noted that at the time of the phone call the DCA supervisor was standing next to her also on a phone call, the hotline conversations were going on, and there was training in progress at the clearance delivery position. There were no specific distractions that she believed caused her to misunderstand the TRACON’s request, but there was a lot going on in the tower. The local control frequency was the only communication that was being monitored on the tower cab speakers.

TMC1 first realized that something was wrong either when RPA3329 called the tower or when PCT called to stop departures. She looked up and saw RPA3329 on the local controller's radar display. At the time, the aircraft was on a right base for runway 19. When the pilot checked on frequency, he stated that he was "on the river." TMC1 believed that his statement was ambiguous because the aircraft could have been either north or south of the airport. When she identified the aircraft's position, she thought maybe it had missed the downwind turn for runway 1. She did not immediately recognize that the pilot was on a visual approach to runway 19.

Once the local controllers and the supervisor recognized that there was a problem and began to try to correct the situation, TMC1 had no particular input into the process. The supervisor terminated his phone call and went to the local control position to assist. TMC1 called the MTV supervisor to explain that she believed they had been talking about landings on runway 1, and that there had apparently been some miscommunication. Subsequently, the DCA supervisor also called the MTV supervisor to discuss the incident.

When asked what would have helped to prevent the situation, TMC1 stated that if the MTV supervisor had ensured that she understood their request or had her read it back, or specifically asked DCA to stop departures during the coordination, she might have realized that something was unusual about the request. There was nothing entered in the data tag for RPA3329 showing that the airplane was inbound for runway 19. Such an entry would have helped the controllers recognize the problem when they saw the aircraft on the tower radar display. When aircraft are inbound to DCA on the approach being advertised on the automatic terminal information service broadcast, no additional data tag entries are required. PCT only enters additional data tag information if an aircraft is on other than the advertised approach, or the pilot is applying visual separation between his aircraft and a preceding arrival.

TMC1 has worked at DCA during periods where the airport weather conditions were below landing minimums for runway 19. In such cases, it was not unusual for aircraft to fly the instrument approach to runway 1, and then for departing aircraft to take off on runway 19 in the opposite direction. However, when the operation is in use, there is specific coordination in effect with PCT.

Traffic management coordinators are permitted to adjust arrival spacing on the final approach course on their own authority by initiating coordination with PCT. They might accomplish that by calling either the traffic management coordinator at the TRACON or the supervisor for the area handling DCA traffic.

TMC1 stated that the DCA supervisor on duty at the time of the incident was normally very engaged in the operation.

The instrument approach in use at DCA was normally advertised on both the ATIS and in the tower information display system. Changes in the information display system are also reflected at Potomac TRACON, at least to the traffic management unit. TMC1 was uncertain whether the information changes were also displayed at individual PCT sectors. Anyone in the tower may amend information display system entries if necessary, but the normal practice was for the clearance delivery controller to enter the updates. Updates involving runway changes normally propagated through the system very quickly, possibly even before the airport has begun operating on the new runway. The information system was not updated in this case because the airport runway configuration was not actually being changed. When a runway change occurs, the procedure is for the local controller and assistant local controller to physically relocate to the side of the tower cab closest to the arrivals. Relocation was not accomplished in this case because there was no expectation that a runway change was in progress. Even so, because the wind shifted shortly after the incident the airport remained on a runway 19 operation for the remainder of the shift.

TMC1 noted that opposite direction departures were used at DCA to some extent, but that opposite direction arrivals were very unusual. The normal procedure for a runway change involved coordination of specific call signs, headings, and identification of the first and last arrivals and departures to use the old and new runway configuration.

Day Shift Traffic Management Coordinator (TMC2)

On the day of the incident, TMC2 was working as the day shift traffic management coordinator, scheduled to work until 1430 local time.
TMC2 saw TMC1, the evening shift traffic management coordinator, come to work but at the time he was occupied in the front of the cab working with the controllers to coordinate weather avoidance routes and departure releases. The traffic management hotline was in use because of weather in the area affecting aircraft routing, and TMC2 had been working to obtain releases for approximately 8 departures.

TMC1 had taken a call from Potomac TRACON back in the traffic management coordinator area. She advised TMC2 that PCT was having trouble getting arrivals into the airport and wanted to reduce spacing on the final approach course. TMC2 was initially worried about having sufficient space on the ramp for the arriving aircraft, but told her to go ahead and have the approach control run a "tight final." A couple of minutes later, TMC1 told him that the TRACON would be running a tight final from the south. TMC1 provided the same information to the local controller and assistant local controller. After that, TMC2 advised the local control team not to worry about the departures. His understanding was that the TRACON was going to be providing arrival aircraft in rapid succession. Shortly afterward the MTV supervisor called to ask about what had happened to their south arrivals. TMC2 said that he had no idea that the MTV supervisor had been talking about using runway 19 for arrivals. His understanding had been that the TRACON was going to be packing the runway 1 final approach course.

TMC2 realized something was wrong when the supervisor came to the local control position and advised the local controller to, "…turn that guy right." At the time, TMC2 was standing between the assistant local controller and the ground control positions, and had no idea how the incident had happened. The supervisor was working directly with the local controller, and TMC2 said that he had no idea exactly what was discussed. TMC2 looked at the tower radar display to determine what was happening with the traffic, and began trying to get organized for a shift to using runway 19.

TMC2 did not speak with TMC1 about what had happened. However, the supervisor asked TMC1 if she had approved southbound arrivals. TMC2 described the atmosphere in the tower around the time of the incident as loud and chaotic.

TMC2 stated that it was extremely rare to have opposite direction coordinated arrivals. There had been times in the past when controllers would approve opposite direction operations, but it led to problems. After that, the facility became much more inflexible about the direction of operation, which he described as, "when you're north, your north -- when you’re south, you’re south." No deviations. In TMC2's opinion, DCA now had good procedures that worked.

TMC2 had reviewed the recorded coordination that precipitated the incident, and in his opinion the incident involved an unusual weather situation coupled with an unusual coordination request. That caused confusion, and subsequently both facilities "had a problem." DCA and Potomac needed to develop procedures that would keep this event from ever happening again.

TMC2 said that the nature of the coordination that the TRACON thought they were engaging in, changing to runway 19, would have required supervisory intervention at DCA. Requests to only increase or decrease the spacing of traffic on the final approach course could be approved by a traffic management coordinator and reported to the supervisor later on.

DCA Supervisor

On the day of the incident, the DCA supervisor was scheduled to work a shift from 0600 until 1400. He stayed past the end of his shift to cover for another supervisor who needed to be late to work. About 1345, a controller had called to report that he would need to be on extended sick leave. The DCA supervisor was talking to the tower operations manager about coverage, and discussing overtime with the facility union representative. He was also trying to use the scheduling program to look at coverage for upcoming shifts, but had difficulty and was obtaining telephone technical support from the software developer.

The first time he became aware of a problem was when the supervisor from Potomac TRACON called and asked, "What are you doing?" The DCA supervisor dropped the phone, went to the local control position, and looked up at the tower radar display where he saw that Chautauqua 3071 was passing a Republic Airlines flight inbound toward the airport from the north. The aircraft were approximately 1 mile apart. There was another Republic Airlines flight just lifting off from runway 1. The DCA supervisor told the local controller to turn the second departure aircraft to heading 020, and then to heading 090. The controller misunderstood the directions and instead gave the heading instructions to RPA3329, the arriving aircraft. There was a third aircraft waiting on the runway for departure. The DCA supervisor told the local controller to have the aircraft exit the runway. The assistant local controller then asked what he should do with the Republic arrival. The DCA supervisor saw the arriving aircraft turning, but was unsure why. He did not realize that the controller issued the turn instructions to the arrival aircraft instead of the second departure aircraft. The DCA supervisor instructed the assistant local controller to have the aircraft turn south, and then hand it off to the final approach controller at Potomac.

The DCA supervisor then turned to the remainder of the tower staff and asked who had approved the runway 19 arrival. The evening shift traffic management coordinator (TMC1) said that she had approved changes to the arrival flow to runway 1, not to runway 19. The DCA supervisor then told the ground controller to taxi all future departures to runway 19.

The DCA supervisor called the MTV supervisor at Potomac TRACON to discuss the incident and begin to figure out what had happened. He also verified with PCT that DCA was now in a south operation and told the MTV supervisor to have his controllers use runway 19 for arrivals. The DCA supervisor held over some of the controllers from the day shift, and got the local controller and the assistant local controller relieved from their positions.

Asked if the coordination of opposite direction arrivals by the Potomac MTV supervisor was unusual, the DCA supervisor stated "not totally." Occasionally, there is supervisor to supervisor coordination for issues such as departure stops to permit opposite direction operations. However, that always involved very specific coordination between the two facilities.

Asked what he believed may have contributed to the breakdown in communication, the DCA supervisor stated that the traffic management coordinators may have crossed some lines and inadvertently misled Potomac into thinking they were coordinating with the DCA supervisor. All of the coordination between the traffic management coordinators and Potomac occurred without the DCA supervisor's knowledge.

Asked about the headings issued by the local controller to the aircraft, the DCA supervisor stated that he gave the local controller directions to do that, and that he was in charge. He was prepared to take responsibility for sending the second departing flight through the prohibited area north of the airport in order to separate it from RPA3329. He did not believe it was proper to protect airspace and then risk a collision. He told the local controller to turn the aircraft to heading 020, and then heading 090. He believed that pointing out the window was the most effective way to indicate to the local controller which aircraft needed to be turned. He was unaware that the LC had misunderstood and issued the heading instructions to the arriving flight instead of the second departing flight. As a result, he could not understand why the departing aircraft was not turning.

In his experience, it was not common to have to intervene and direct controllers to do something. During non-standard operations such as opposite direction events, the DCA supervisor's practice was to be right with the controllers involved during the operation.

DCA does train for opposite direction operations. During the summer, for aircraft performance reasons it may be necessary for pilots to request departure on runway 19 while arrivals are using runway 1. If so, there would be specific coordination between DCA and PCT before conducting the operation.

Asked to describe the training provided on radar control to DCA controllers, the DCA supervisor described it as "less than zero." Controllers received a video map test, and that was about it. There was no training on ARTS entries or other radar operations. The DCA supervisor stated, "...We're a VFR tower." The only time DCA controllers take radar contact on aircraft is for presidential movements. Many of the tower controllers are unaware of the significance of position symbols associated with radar data tags. The assistant local controller did not recognize what was going on with the arrival aircraft. DCA does not provide radar service.

In the DCA supervisor's opinion, DCA controllers should receive training at the radar training facility in Oklahoma City and on the radar simulator at Potomac TRACON. Controllers need to be able to handle non-standard go-arounds, issue vectors, altitudes, and headings. There was no specific direction on how to handle go-arounds in particular scenarios. DCA did try to get controllers out to Potomac TRACON to observe approach control operations, but there was no structured program to do so.

The management expectation for supervisors is for them to be engaged in the operation. The operations manager is reasonable about it, but supervisors are still expected to be aware of emails and other administrative tasks. Supervisors still receive many administrative calls during the shift. Many tasks seem to be pushed onto operational supervisors that could be handled outside operational circumstances. There used to be a reluctance to use controller-in-charge staffing at DCA, but that has been changing.

DCA Assistant Local Controller (ALC)

The ALC controller had been on position for an estimated 30 to 40 minutes at the time of the incident. He recalled no unusual conditions except "a little weather south of the airport." TMC1 notified the local controllers that the TRACON would be tightening up the final. There were not a lot of departures ready to go, so the controllers just waited for the approach control to begin pushing in the arrivals. The local controller cleared CHQ3071 for takeoff, and put the next Republic Airlines departure in position on the runway. She then cleared the Republic aircraft for takeoff. RPA3329 then checked in on frequency, and the local controller tried to confirm the aircraft’s call sign. The ALC controller saw RPA3329 on the tower radar display, and thought the pilot had missed a turn on to the downwind for runway 1. He told the local controller to turn the arrival to heading 180 to stay clear of the departure course, and she did so. PCT then called and told them to stop departures. The ALC turned around and repeated the instruction to everyone in the tower. At that point the DCA supervisor came up to the local control position to assist, PCT called again, and everything was "a little chaotic."

The local controllers were trying to decide what to do with RPA3329, and the ALC was wondering why the aircraft was turning. He heard the supervisor issuing instructions to turn an aircraft to heading 020 and 090, and thought he was talking about the departing flight. When RPA3329 started turning, the ALC controller thought perhaps the pilot had taken the instructions by mistake. Throughout this period he was busy coordinating, and was not necessarily picking up all the details. RPA3329 turned all the way around, and the ALC began directing his attention to the nearby Chautauqua flight. He also started coordinating with PCT about what to do with RPA3329. There was some confusion about which PCT sector to give the aircraft to, and the pilot was also inadvertently given an incorrect frequency to contact PCT.

There was another Republic Airlines departure on the runway waiting to take off. The local controller instructed the pilot to exit the runway and the tower stopped all other departures until they figured out what happened. There was no immediate discussion of the incident, but later that day the people involved decided that there must have been some kind of miscommunication. Potomac TRACON thought the tower was in a southbound operation, but DCA had actually been in a northbound operation instead.

The local controllers were "a little rattled" by the event, and were relieved from position a few minutes afterward. There were no other discussions with TMC1 or TMC2 about what happened.

Asked if he'd ever seen the airport operating a configuration where it was below weather minimums for runway 19 approaches, therefore requiring opposite direction operations, the ALC controller responded that he had seen that but it was seldom needed. He had seen some opposite direction operations in training.

Radar training at DCA was very limited, consisting of a computer-based instruction module and a video with information on radar identification procedures. The qualification test included basic questions about radar and how to radar identify aircraft. There was also a test on the minimum vectoring altitude chart included in local controller training. The radar training provided the basics, but many of the current tower controllers had no previous radar experience.

Asked if there were frequent difficulties with coordination between the tower and the TRACON, the ALC said that they were usually using standard procedures that worked.

When RPA3329 came back to the airport for the second time, the TRACON did advise that the arrival aircraft was minimum fuel. That was an advisory to the tower that they should be careful to avoid a go-around if possible.

The ALC controller said that he was assisting the local controller with suggestions about how to handle the problem with RPA3329 until the supervisor arrived at the position, but once the supervisor intervened there was no doubt that he was then directing the response.

DCA Local Controller (LC)

The LC controller recalled no unusual conditions affecting the operation around the time of the incident other than some weather south of the airport. TMC1 came to the position and advised her and the ALC controller that PCT needed to reduce spacing on the final approach to get in more arrivals. While they were waiting for that to occur, she cleared CHQ3071 for takeoff from runway 1 and put RPA3467 in position on the runway. RPA3329 then called inbound "on the [Potomac] river", and she looked for the aircraft on the south side of the airport using the tower radar display. When she didn’t see anything there, she verified the call sign and the pilot again responded that he was "on the river." She checked the radar again and saw the flight about 5 miles northwest of the airport.

As soon as she realized where he was, the LC controller instructed the pilot to turn to heading 180 to clear the departure corridor. The aircraft was coming from an unusual place that didn’t immediately cause her to realize that the aircraft was on a visual approach to runway 19. CHQ3071 had been switched to departure frequency already, so she gave RPA3329 a traffic advisory and the pilot reported the other aircraft in sight. By then, RPA3467 was also airborne, so she informed the pilot about RPA3329. The supervisor told her to "turn him right" to heading 020 and then heading 090. The supervisor was standing was behind her, and she couldn’t see him. The LC controller thought the supervisor was referring to RPA3329, so she told the pilot to turn and he did so. She later turned the aircraft to heading 180. The pilot then asked what the plan was and she told him to stand by. Shortly afterward, she told him to fly heading 180 and maintain 2000 feet, and then switched the aircraft to PCT.

The LC controller said that she did not see any opposite direction scenarios during training, and had not seen this particular scenario before at all. However, she had seen opposite direction departure operations.

Before the event, there had been no indication that anything was supposed to happen with runway 19 at all. When she saw RPA3329 inbound, her first instinct was to turn the aircraft. The turn provided sufficient separation to avoid a more serious conflict, so she issued only a traffic advisory, not a safety alert.

The ALC controller was trying to coordinate with PCT about what to do with RPA3329. They sent the aircraft back to PCT, instructed the Republic flight holding for departure to vacate the runway, stopped all departures, and landed the remaining arrivals on runway 19. The LC and ALC controllers were relieved from position about 10 minutes later.

Radar training received by LC as part of her certification process included a computer-based instruction module, a minimum vectoring altitude test, and some information on separation requirements. She had similar training at her previous facility. DCA owns class B airspace in a 7 mile radius from the airport at 1500 feet and below. The term "radar contact" is used only involving Presidential movements or other priority flights.

PCT Ojaay Sector Radar Controller

The only unusual conditions affecting the Ojaay sector involved weather developing south of the airport. There was a small cell east of the final approach course that was expanding to affect an area from the airport to about 20 miles south. Under normal circumstances, aircraft inbound to runway 1 would be vectored to join the final from the east and turned inbound, but because of the weather the Ojaay controller was bringing the aircraft over the top of the airport to join a left downwind on the west side of the final approach course. One aircraft did ask to deviate south and was brought in from the south side of the weather.

The Ojaay controller stated that while he was working aircraft around the weather, the supervisor came to Ojaay and told him that the airport did not have a lot of departures, so that if the controller thought it was workable he could start bringing the arrivals around to land on runway 19. The Ojaay controller agreed to do so, and selected RPA3329 as the first arrival to that runway because of the aircraft’s position in relation to the airport. The supervisor coordinated the new plan with the tower.

The Ojaay controller started vectoring RPA3329 and subsequent flights toward the runway 19 final approach course. He cleared RPA3329 to descend to 2000 feet and resolved a conflict with a nearby aircraft, then told the pilot to report the river in sight. The pilot did so, and the controller then cleared RPA3329 for the River Visual approach runway 19. He then began setting up the next aircraft for the approach, and instructed RPA3329 to call the tower. As he began to clear RPA3396 for the same approach, the Ojaay controller noticed the first departure coming off runway 1. He instructed RPA3396 to turn away from the airport. He was intending to bring the aircraft back toward the runway when it cleared CHQ3071, but then the second departure came off the airport. He instructed RPA3396 to continue eastbound and told the pilot to maintain 2000 feet. Until that point, Ojaay and the Final sector had been combined, but another controller opened up the final approach sector and took responsibility for it. The Tyson sector was handling the departures and was ensuring that the aircraft climbed quickly so as to minimize any conflicts.

The Ojaay controller stated that when the supervisor advised him that he could begin running arrivals to runway 19, he believed that a formal runway change was in progress.

Potomac TRACON (PCT) Mount Vernon Area (MTV) Supervisor

Around the time of the incident, the MTV supervisor was responsible for both operational and administrative duties, and had been addressing some sick leave coverage and overtime issues. He spoke with the operations manager about calling in overtime for the evening shift and was actively working on the issue when the problems began at the Ojaay sector.
There was some unforecasted convective activity affecting the final approach course for runway 1 at DCA, which was unusual. Such weather usually appeared southwest of the airport or to the northwest over the mountains. The MTV supervisor checked the traffic situation display to assess demand and then combined the Ojaay and final positions. He assigned an experienced controller to work the Ojaay position.

While working on the staffing issue, the MTV supervisor was notified by a controller at the Krant sector that the Ojaay sector was being affected by building weather and associated flight deviations. The MTV supervisor began working to get the final approach sector opened, and went to the Ojaay sector to see if he could assist. After observing the situation, the MTV supervisor noticed that there were only a few departures from DCA. He called the tower to ask how many departures they had waiting, and proposed that the TRACON begin sending arrivals to runway 19. After some discussion with the tower staff, the MTV supervisor was told to go ahead and "run them in." He spoke with the controller at the Ojaay sector to ensure that runway 19 would be acceptable, and the controller agreed to use it. The MTV supervisor then called DCA back on a different phone line, and was told to go ahead and run the traffic. The MTV supervisor returned to his workstation to monitor the situation.

Shortly afterward, he heard the flight data controller "gasp," and the flight data controller then pointed out two aircraft taking off from runway 1 at DCA. The MTV supervisor then called the tower to ask what they were doing. He spoke with the DCA supervisor, but did not receive much of a response. The DCA supervisor then called back later to discuss the apparent losses of separation, and the investigation of the event began.

The MTV supervisor agreed with the statements made by the DCA controllers that temporary changes in the arrival runway were unusual. Usually for opposite direction operations, individual coordination occurs. However an effectively "temporary" runway change was not a common practice. At the time, the MTV supervisor thought that he had a good escape plan for coping with the weather issues that were affecting the Ojaay sector south of the airport.

The MTV supervisor noted that when an actual runway change occurred, the procedures worked fine and the changeover usually went well. However, changing runways in the middle of an arrival push could be difficult.

The MTV supervisor stated that the facility management expectation for supervisors is that they would be "engaged." Asked to elaborate, he noted that the expectation was that supervisors would be engaged in monitoring and supervising the operation, but that they were also responsible for administrative duties such as processing leave requests, shift swaps, etc.

Asked about his recorded comment that he, "… told her to stop departures," the MTV supervisor said that the instruction was normally given during regular runway changes. In this case he believed that he had told DCA to stop departures, but in hindsight he may have just implied it. For normal runway changes, the procedure was for the supervisor to advise the tower of the full call sign of the first arrival to the airport after the change. However, because of the way the traffic was set up west of the airport, the MTV supervisor was uncertain which aircraft the Ojaay controller was going to make first.

Post-Incident Corrective Actions

Following this incident, FAA published national directives suspending opposite direction operations at all tower-controlled airports pending management review of the procedures in use. Those notices are included in the docket for this case.

In addition to the national directives, Potomac TRACON management took the following actions:
1. Training Department to develop and deliver supervisory training on opposite direction operations, with a comprehensive training package under development. Expected completion and implementation date is 8/20/12.
2. Posted Operational Briefing Items on opposite direction operations:
a. 2012-08-07 – Air Traffic Safety Action Program (ATSAP) Opposite Direction Briefing posted 8-7-12. 198 employees completed as of 8/15/2012.
b. 2012-08-07 – N7110.596_Opposite Direction Operations Briefing Posted 8 7 12, 198 employees completed as of 8/15/2012.
c. 2012-08-10 – Opposite Direction Operations at DCA (Briefing Posted 8-10-12, 135 employees completed as of 8/15/2012.
d. Team Briefing for August 12-25, 2012 Team Briefing Cycle - 2012-08-12 - Replay of Opposite Direction Events [DCA/BHM]. Briefing Posted 8-12-12. 43 employees completed as of 8/15/2012.
e. 2012-08-14 - Runway Change Checklist on ACE IDS (Briefing Posted 8-14-12, 27 employees as of 8/15/2012.
3. FAA Notice JO 7110.596 – Interim Same Runway Opposite-Direction Arrival/Departure Procedures, briefed and implemented on 8/8/12.
4. Reviewed all DC area airport traffic control tower Letters of Agreement, runway change and opposite direction operations procedures with the local towers.
a. Telephone conference with all DC area airport traffic control towers to review opposite direction procedures completed on August 9th.
b. Runway change procedures for all local DC area ATCT's currently being reviewed and modified to mirror each other in our respective Letters of Agreement. A second follow up telephone conference with towers is scheduled for August 15.
c. DCA Opposite Direction Operations Notice developed and validated by the Office of ATO Safety and Technical Training on 8/10/12. Baltimore, Charlottesville, Dulles, and Richmond Opposite Direction Operations Notices are currently under development. Daily reminders are provided to front-line managers by the Operations Manager at the day and evening shift briefings that opposite direction operations at these airports are suspended until further advised, except for emergencies and flight checks.
5. PCT management and NATCA personnel participated on a national joint manager and facility representative telephone conference on 8/10/12 to receive updates and clarification on opposite direction operations.
6. PCT front-line manager and controller-in-charge Runway Change Checklist currently being reviewed and refined to comply with the requirements of FAA Notice JO 7110.596.
7. PCT quality control staff are conducting random audits of local runway changes and confirming compliance with current directives.
8. PCT submitted a Needs Assessment Program request for surface Area Surveillance Detection Equipment (ASDE) displays showing the DCA/BWI/IAD airports. ASDE equipment displays real time surface operations. If an ASDE presentation of DCA had been available to PCT at the time of this incident, confusion between the tower and the TRACON would not have occurred and this situation would have been avoided. The ability to visually observe the Washington area airports via ASDE will increase situational awareness and avoid confusion by allowing all parties to observe the same information without coordination.

Washington Tower (DCA) Post-Incident Actions:

Washington Tower ceased all opposite direction operations, pending development of new procedures with PCT.

In coordination with PCT, new opposite direction operation procedures were developed and approved by AJI [FAA headquarters]. 97% of operational personnel have been briefed on the new procedure. Implementation of the new joint procedure was effective August 11, 2012.
Washington Tower will conduct All Hands briefings on the event. The briefing will consist of an in-depth review of the incident, complete with [an event replay] and all associated voice file replay. All operational personnel will be briefed by August 31, 2012.
A System Service Review (SSR) has been completed.

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