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Atlas / ASRS / ACN 2085581

NASA · Aviation Safety Reporting System

Tower Controllers reported they did not notice an aircraft lined up on short final for the wrong runway with another aircraft holding in position on the runway until the ASDE X alerted them.

ACN 2085581 2024-02 Learjet 45 Air Traffic Controller Reports
Final ApproachPart 135Part 121

What is ASRS?

The Aviation Safety Reporting System is NASA's voluntary, confidential, non- punitive incident-reporting system, established 1976. Pilots, controllers, dispatchers, and maintenance technicians file reports describing safety- relevant events. NASA de-identifies every report before adding it to the public database. Reports are not investigated by NASA, the FAA, or the NTSB — they represent the reporter's perspective.

Pilot narratives

Verbatim from the de-identified NASA record. First-person account by the reporter. NASA strips identifying details (names, company, specific time); anonymization placeholders are ZZZ, X, Y.

Reporter 1

As I was working the Traffic Management position, I was scanning the ASDE monitor located at my position. As I was watching the monitor, I noticed the runway lights on Runway XXR light up like it usually does when an aircraft is either on departure roll, or on short final and touching down on Runway XXR. It struck me as odd that the runway was lighting up because at the same time, I noticed Aircraft crossing Runway XXR downfield, and that there was no aircraft on departure roll. I immediately ran over to the Local position to alert them of possible traffic lined up to land on the wrong runway. At that point, the audible alert activated of a "WARNING" to runway XXR. I yelled out to send the traffic around!! Local immediately sent Aircraft X around. I strongly recommend a change both locally and nationally at the position of record in the control tower. The Local controller and local assist are scanning and listening to read backs and could easily miss noticing if an aircraft is lined up to the correct runway. Here are my recommendations. Start Staffing a position called, "Final Surveillance" or "Local Surveillance". The Final Surveillance position would utilize the TMC (traffic management center) radar scope located next to the Local position to Surveil a close range of 3-5 miles surrounding the finals for ZZZ [airport]. This position of record would be responsible for monitoring to ensure that each arrival on BOTH complexes are correctly lined up to the assigned runway based on the depicted radar data. At the 3 mile final point, if the aircraft isn't correctly lined up to its assigned runway, that controller would alert the affected Local position by calling on a landline and/or alerting them by stating it audibly in the cab. This layer of safety would ensure that ALL inbound aircraft to its assigned runway are correctly lined up to the correct runway. This Local Surveillance position would not monitor any frequencies, only monitor the final. We've had runway closures and complex taxiway closures adding to the unfamiliar scenario to both our flight crews and our controllers. We've had wintry weather affecting the configuration of ZZZ with more forecasted before the end of the month, which will add risk to the situation. Finally, this landing on wrong surfaces issue has been a top nationwide issue. Lets not wait to implement safety related tools which will help fix the problem now. Lets not rely on an ASDEX equipment which is routinely out of service either planned or unplanned to alert us to aircraft lined up for the wrong runway. Lets get ahead of this thing NOW!

Reporter 2

Aircraft X was on Visual approach Runway XXL and was cleared to land. Traffic was given that traffic in position will depart prior to their arrival. The aircraft on Runway XXL departed and I was trying to give traffic on another aircraft that departed Runway XXL. As I was looking west to give the traffic. Aircraft X on a Visual Approach lined up for the wrong runway. I had lined up Aircraft Y on Runway XXR with traffic crossing down field. That's when the alarm went off the send Aircraft X around. So I did. The departing traffic on the upwind was no factor with Aircraft X Go around so traffic wasn't given. It was standard go around instructions. Suggestion: Better scan from me.

Reporter 3

I was Local Assist when Aircraft X checked in for [Runway] XXL. Local Control told Aircraft X that traffic would hold in position and XXL cleared to land. Meanwhile the spacing was looking tight to get the GA aircraft holding in position out while having 3 miles with the previous departure off of XXR. Being a local flight, I offered to coordinate an inside turn to 200 with the GA aircraft off XXL to get them airborne before arrival of Aircraft X. Local Control opted for a turn at the shoreline instead of early turn to 200 with the GA. This required some focus on the upwind to get visual separation applied until the GA had turned inside the previous XXR departure. With attention on the upwind, alarm for XXR went off. I shouted "Aircraft X go around" hoping Local Control would say exactly that, and they did. I coordinated the go around with departure. I do wish there was an easier way to decipher the track on the arrival. The markings on the map are so close together for XXL or XXR. ZZZ is such a compact airport, it's hard to get much improvement in that area I suppose. I personally mitigate this with a map that isn't zoomed out very far.

NASA classification — Anomalies

  • ATC Issue
  • Conflict
  • Deviation - Track / Heading
  • Deviation / Discrepancy - Procedural

NASA classification — Assessments

Contributing Factors / Situations
ATC Equipment / Nav Facility / Buildings · Human Factors · Procedure
Primary Problem
Human Factors

ASRS reports are voluntarily submitted, de-identified by NASA, and represent the reporter's perspective. The presence of reports on a topic cannot be used to infer prevalence in the National Airspace System. The authoritative source is the NASA ASRS Database Online at asrs.arc.nasa.gov ↗.