Safety Recommendation A-15-009
Details
Synopsis: The National Transportation Safety Board (NTSB) urges the Federal Aviation Administration (FAA) to take action on the safety recommendations issued in this letter. These recommendations address the issuance of landing clearances with multiple airports in the vicinity and minimum safe altitude warning (MSAW) software limitations. The recommendations are derived from our investigations of wrong airport landing events. As a result of these investigations, we have issued two safety recommendations, both of which are addressed to the FAA. Information supporting these recommendations is discussed below.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Amend air traffic control procedures so that controllers withhold landing clearance until the aircraft has passed all other airports that may be confused with the destination airport.
Original recommendation transmittal letter: PDF
Overall Status: Open Acceptable Alternate Response
Mode: Aviation
Location: Branson, MO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA14IA037
Accident Reports:
Report #: None
Accident Date: 1/12/2014
Issue Date: 5/4/2015
Date Closed:
Addressee(s) and Addressee Status: FAA (Open Acceptable Alternate Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/22/2020
Response: We note that you believe the procedural guidance contained in FAA Order JO 7110.65Y, paragraph 7-4-3, is sufficient, and you do not intend to amend the guidance; however, to reinforce this procedure, you created a briefing sheet and a training video that narrates a controller’s actions during an actual attempted wrong airport landing. We note that, in June 2019, you distributed the video and a mandatory face-to-face, “Wrong Airport Landing” briefing document to all FAA Air Traffic Organization operational personnel and management. We also note that you are in the process of enhancing the Standard Terminal Automation Replacement System (STARS), which will considerably reduce the possibility of wrong airport landings. As part of this enhancement, when an aircraft track is headed to the wrong airport, an aural alarm will sound, the color of the datablock will change, and the datablock will also display “WA” in line 0. We believe the training video and briefing document, along with the STARS enhancement (including implementation and training), will constitute an acceptable alternate solution to Safety Recommendation A-15-9. We also believe that the STARS enhancement, once completed, represents an acceptable alternate solution to Safety Recommendation A-15-10. Accordingly, pending completion of those actions, Safety Recommendation A-15-9 is classified OPEN--ACCEPTABLE ALTERNATE RESPONSE, and Safety Recommendation A-15-10 remains classified “Open—Acceptable Alternate Response."

From: FAA
To: NTSB
Date: 2/18/2020
Response: -From Steve Dickson, Administrator: Since our initial response to the Board on July 31, 2015, the Federal Aviation Administration (FAA) has completed its review of all pertinent data and have determined that the procedural guidance contained in FAA Order JO 7110.65Y, paragraph 7-4-3, is sufficient and does not require change. In this order, the FAA states: In those instances where airports are located in close proximity. also provide the location of the airport that may cause the confusion. EXAMPLE- Cessna Five Six November, Cleveland Burke Lakefront Airport is at 12 o' clock, 5 miles. Cleveland Hopkins Airport is at 1 o'clock 12 miles. Report Cleveland Hopkins insight. Additionally, the FAA reinforced this procedure by creating a briefing sheet that was disseminated to the air traffic facilities in December 201 4. More recently, a training video was developed that narrated the actions of the controller during an actual attempted wrong airport landing. This video was distributed along with a mandatory face-to-face Wrong Airport Landing briefing document to all FAA Air Traffic Organization operational personnel and management in June 2019. These preventative measures, in addition to the forthcoming Standard Terminal Automation Replacement System (STARS) enhancement, will considerably reduce the possibility of wrong airport landings. When an aircraft track is headed to the wrong airport (i.e. intruding into a geographic area around the airport), the STARS enhancement will: • Change the datablock color; • Display "WA" in line 0 of the data block; and • Sound an aural alarm. The STARS R10 Software Release l was delivered for operational testing in August 2019 and is expected to be installed at key sites by March 2021. In conclusion, the FAA met with the NTSB to discuss Safety Recommendation A- 15-9 on March 6, 2019. This meeting resulted in the FAA reinforcing existing guidance by creating and distributing the aforementioned instructional video. Since this recommendation and the video’s dissemination, there have not been any wrong airport attempts.

From: NTSB
To: FAA
Date: 11/12/2015
Response: We note that you do not concur with this recommendation. You believe that the wrong airport landing event at Branson, Missouri, we described in our letter issuing this recommendation involved an approach clearance instead of a landing clearance and, consequently, the controller would not have been able to ascertain the aircraft position in relation to the airport mistaken for the destination airport because radar coverage does not extend to the ground. In your letter, you discussed several provisions in FAA Order JO 7110.65, “Air Traffic Control,” and in Title 14 Code of Federal Regulations Part 91.129 that you believe address the issues that are the focus of this recommendation. You stated that, because you recognize that wrong airport landings are a hazard, you plan to continue collecting and monitoring wrong airport landing information as a special emphasis item and to assemble a cross-organizational workgroup (1) to assess wrong runway landing events and (2) to determine any additional needed mitigations by air traffic control to address the safety problem of wrong airport landings. We issued this recommendation because we believe that withholding a landing clearance until the aircraft has passed all other airports that could be confused with the destination airport will keep pilots from actually landing at a wrong airport—at least without checking with the controller again. We believe that the reason why the pilot came to be pointed at the wrong airport is immaterial in this regard. The ATC procedures and practices that you reviewed in your letter were not effective in preventing the wrong airport landings that we investigated. We continue to believe that the action specified in Safety Recommendation A-15-9 would be effective in preventing a wrong airport landing. We are currently scheduling a meeting with your staff to discuss your response to this recommendation; in particular, to learn what actions you plan to take to address the problem of wrong airport landings, which you agree is a hazard. We ask that your cross organizational workgroup evaluating mitigations associated with such landings give serious consideration to the role that the timing of landing clearances may play in preventing such landings. In the meantime, pending your taking action that satisfies Safety Recommendation A 15 9, it is classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 7/31/2015
Response: -From Michael P. Huerta, Administrator: The Federal Aviation Administration (FAA) does not concur with this recommendation due to several concerns. First, we determined that the scenario at Branson, Missouri , pertains to an approach clearance and not a landing clearance, as cited in Safety Recommendation A-15-09. In the Branson, Missouri, wrong airport landing event, air traffic controllers would not have been able to ascertain the aircraft position in relation to the airport that was mistaken for the destination airport due to the fact that radar coverage does not extend to the ground. We are also concerned that withholding an approach clearance until passing other nearby airports could result in increased go-arounds and potential confusion when the aircrews are in stabilized approach, which is the most vulnerable phase of flight. The FAA has several provisions already in place that address approach clearance procedures. Further, FAA Order JO 71 I 0.65, Air Traffic Control Paragraph 3-10-8, prohibits the withholding of a landing clearance, stating. "Do not withhold a landing clearance indefinitely. even though it appears a violation of Title I 4 of the Code of Federal Regulations has been committed. The apparent violation might be the result of an emergency situation. In any event, assist the pilot to the extent possible." A copy of this document is located at the following Web site: https://www.faa.gov/docurnentLibrary/media/Order/ATC.pdf In addition, Air Traffic Control (ATC) is also required to issue a landing clearance in a timely manner to meet the provisions of part 91.1 29(i), which states that •'No person may, at any airport with an operating control tower, operate an aircraft on a runway or taxiway, or take off or land an aircraft, unless an appropriate clearance is received from ATC." Provisions in Order JO 71 I 0.65, Paragraph 3-1 0-7, also address this requirement by stating. "When an arriving aircraft reports at a position where he/she should be seen but has not been visually observed, advise the aircraft as a pat1 of the landing clearance that it is not in sight and restate the landing runway." In the case that a controller cannot see the aircraft, this provision is unusable, as the controller would not be able to determine whether or not the aircraft has passed all potentially confusing airports. Furthermore, part 91.129(e) states: (1) Unless required by the applicable distance-from-cloud criteria, each pilot operating a large or turbine-powered airplane must enter the traffic pattern at an altitude of at least 1,500 feet above the elevation of the airport and maintain at least 1.500 feet until further descent is required for a safe landing; (2) Each pilot operating a large or turbine-powered airplane approaching to land on a runway served by an instrument approach procedure with vertical guidance, if the airplane is so equipped, must; (i) Operate that airplane at an altitude at or above the glide path between the published final approach fix and the decision altitude (DA). or decision height (DH), as applicable; or (ii) If compliance with the applicable di stance-from-cloud criteria requires glide path interception closer in, operate that airplane at or above the glide path, between the point of interception of glide path and the DA or the DH; and (3) Each pilot operating an airplane approaching to land on a runway served by a visual approach slope indicator must maintain an altitude at or above the glide path until a lower altitude is necessary for a safe landing. Order JO 7110.65. paragraph 5-9-1, establishes requirements that. "Except as provided in para 7- 4- 2, Vectors for Visual Approach, vector arriving aircraft to intercept the final approach course" must meet: (a) At least 2 miles outside the approach gate; (b) For a precision approach, at an altitude not above the glideslope/glide path or below the minimum glideslope intercept altitude specified on the approach procedure chart; and (d) For a nonprecision approach, at an altitude which will allow descent in accordance with the published procedure. The FAA believes that if approach clearances are withheld, then it is possible the safety provisions stated above may not be met. Additionally, withholding landing clearances are not an option at airports where the tower is closed or there is no control tower. The FAA recognizes that wrong airport landings in the National Airspace System are a hazard and issued an Air Traffic Safety Action Program Briefing Sheet in December 2014 to address this problem. A copy of this document is enclosed. Additionally, the FAA will continue to collect and monitor wrong airport landing information as a special emphasis item in the Comprehensive Electronic Data Analysis and Reporting system. The FAA also plans to assemble a cross-organizational workgroup of subject matter experts to work collaboratively in assessing wrong runway landing events, and determine whether additional mitigations should be taken by air traffic control specialists or aircrew personnel.