DCA23LA179

The local controller’s failure to prioritize and properly monitor the runway and airport environment along with his erroneous assumption that ROU 1633 would depart from runway 14 before AAL2172 arrived to land on the same runway, which resulted in a loss of separation between both airplanes.

At the time of the incident, the flight crews of Air Canada Rouge flight 1633 (ROU1633) and American Airlines flight 2172 (AAL2172) were in communications with and were operating in the Sarasota-Bradenton International Airport (SRQ) Air Traffic Control Tower (ATCT) airspace. Two FAA controllers were on duty at the time, but one was on break, and the local control (LC) controller was the only person in the tower at that time. All ATCT positions including that of the operational supervisor were combined, and the workload was stated as normal for the time of day and for one controller being in the ATCT cab. NTSB postincident examination of SRQ radar data revealed that AAL2172 was about twelve miles northwest of SRQ on a visual approach to runway 14 when communications were established with the FAA local controller (LC). The LC then cleared AAL2172 to land on Runway 14. About three minutes later, the LC asked ROU1633 if they were ready for departure, and ROU1633 responded affirmatively. The LC then cleared ROU1633 for takeoff on Runway 14, with instructions to fly the runway heading, and issued ROU1633 a traffic advisory that AAL2172 was on a 3-mile final. The LC stated that he then turned while at the LC position and picked up flight strips and talked to another aircraft. ADS-B data indicated that AAL2172 was about 4.1 nm from the threshold of runway 14. About 13 seconds later, when AAL2172 was on 3.4-mile final, the LC issued AAL2172 a traffic advisory informing AAL2172 that ROU1633 was departing runway 14. When AAL2172 was on a 2.5-mile final, ROU1633 asked the LC to confirm the departure heading, to which the LC affirmed that ROU1633 was to fly the runway heading. The LC further stated that ROU1633 had not yet started their takeoff roll. He stated that he then turned away from his position and walked to the Automatic Terminal Information Service (ATIS) equipment located on the other side of the tower cab to update the latest ATIS information. About 53 seconds later, while at the ATIS equipment, the local controller heard that AAL2172 was executing a pilot-initiated go-around, and he looked and saw that ROU 1633 was passing the intersection of runway 14/22 and climbing, and AAL2172 was abeam taxiway C2 on the go-around. The controller relied on visually monitoring both airplanes to ensure that their courses diverged, and that lateral separation was assured. However, the local controller turned his attention to a lower priority task before confirming that ROU1633 had departed. The estimated closest proximity between ROU1633 and AAL2172 was 0.6 miles horizontally and about the same altitude; ROU1633 was departing runway 14 and climbing through 100 feet, and AAL2172 was about 100 feet, and crossing over the runway 14 numbers. Figure 1. Position of aircraft involved when local controller looked up and outside the ATCT cab after hearing AAL2172 report “going around”.

The SRQ weather at 2053 EST, was wind from 230 degrees at 4 knots, 10 statute miles visibility, clear skies below 12,000 ft agl, temperature 22 degrees C, dew point temperature 18 degrees C, altimeter 30.09 inHg. On February 16, 2023, about 2059 eastern standard time, Air Canada Rouge flight 1633 (ROU1633), an Airbus 321-200, registration C-GKFB, was cleared to take-off on runway 14 at Sarasota-Bradenton International Airport (SRQ), Sarasota, Florida, and American Airlines flight 2172 (AAL2172), a Boeing 737-800, registration N826NN, was cleared to land on the same runway. AAL2172’s crew self-initiated a go-around. Of the 2 pilots, 4 flight attendants, and 188 passengers on board ROU1633, and the 2 pilots, 4 flight attendants, and 172 passengers aboard AAL2172, there were no injuries. There was no damage to either airplane. ROU1633 was a 14 Code of Federal Regulations (CFR) Part 129 foreign scheduled international passenger flight from SRQ to Lester B. Pearson International Airport (CYYZ), Toronto, Canada. AAL2172 was a 14 CFR Part 121 scheduled domestic passenger flight from Charlotte/Douglas International Airport (CLT), Charlotte, North Carolina to SRQ. Night visual meteorological conditions prevailed at the time of the incident. The flight crew of AA2172 stated that while on the approach, about 3 nautical miles from Runway 14, Sarasota tower cleared ROU1633 for takeoff on runway 14 and notified them of the departing traffic ahead. The crew said that they saw the flight ahead of them as a potential threat and said that their threat mitigation plan was to go-around if the departing ROU1633 was still on the runway when they transitioned from the approach to landing phase. The crew further stated that as they approached the threshold of runway 14, it appeared that ROU1633 was still on the takeoff roll and not yet airborne. They executed the go-around and notified SRQ ATCT and then complied with heading and altitude instructions and returned for a subsequent uneventful approach and landing on runway 14. The NTSB reviewed a summary of ATC communication services provided to ROU1633 and AAL2172 while operating in Tampa International Airport terminal radar approach control (TPA TRACON) and SRQ Air Traffic Control Tower (ATCT). The communications with TPA TRACON were routine and uneventful. The runway incursion occurred while both flight crews were in communications with and operating in the SRQ ATCT airspace. Two FAA controllers were on duty at the time, but one was on break, and the local control (LC) controller was the only person in the tower at that time. All ATCT positions including that of the operational supervisor were combined, and the workload was stated as normal for the time of day and for one controller being in the ATCT cab. At 2050:20, the crew of ROU1633 advised the LC controller that he was ready to taxi. The LC controller instructed the crew to taxi to runway 14 via taxiway A, and cross runway 22. The crew readback the instructions as issued. At 2052:13, the crew of ROU1633 asked the LC controller to confirm they were cleared to cross runway 22. The LC controller responded affirmative and instructed the crew to cross runway 22. At 2054:09, the crew of AAL2172 contacted SRQ ATCT and reported they were on a visual approach to runway 14. The LC controller provided the crew the wind and cleared them to land on runway 14. Automatic Dependent Surveillance–Broadcast (ADS-B) data indicated that AAL2172 was approximately 12 nautical miles (nm) northwest of SRQ airport. At 2057:01, the LC controller asked the crew of ROU1633 if they were ready. The crew responded that they were ready. At 2057:07, the LC controller instructed the crew of ROU1633 to fly runway heading, cleared the flight for takeoff runway 14, and advised them that traffic (AAL2172) was on a 3-mile final. The crew read back “cleared for takeoff runway 14”, and at the time ADS-B data indicated that AAL2172 was about 4.1 nm from the threshold of runway 14, see figure 2. Figure 2. Graphic depicts the location of AAL2172 and ROU1633 during noted times. At 2057:20, the LC controller informed the crew of AAL2172 that an Airbus will be departing runway 14. The crew then acknowledged by stating their call sign. ADS-B data indicated that AAL2172 was about 3.4 nm from the threshold of runway 14. At 2057:39, the crew of ROU1633 asked the LC controller to confirm they were to fly runway heading. The LC controller stated, “affirmative, fly runway heading”. ADS-B data showed that at the time AAL2172 was about 2.5 nm from the threshold of runway 14. At 2058:35, the crew of AAL2172 stated they were “going around”. The LC controller stated “roger”. At that time, ADS-B data indicated that AAL2172 had crossed the threshold of runway 14 and was abeam taxiway A3, and ROU1633 was airborne from runway 14 and abeam taxiway B and subsequently departed the airport environment uneventfully. AAL2172 was then given instructions to turn right to a heading of 270 degrees and to contact the TPA TRACON for re-sequencing. AAL2172 subsequently landed uneventfully. ROU1633 continued to CYYZ and landed uneventfully. There was no damage to either airplane. There were no injuries to occupants of either airplane during this incident. The SRQ airport was owned by the Sarasota Manatee Airport Authority and was located 3 miles north of downtown Sarasota and 6 miles south of Bradenton. It was situated on approximately 1,100 acres and had an elevation of 30 feet. SRQ was a medium sized primarily business and general aviation facility. SRQ airport consisted of two asphalt intersecting runways; runway 4/22 was 5,006 by 150 feet and runway 14/32 was 9,500 by 150 feet. The airport had a parallel taxiway (Taxiway A), which ran the entire length of runway 14/32. The airspace at SRQ was Class C with a 4000’ msl ceiling. To the north of SRQ, the airspace lies directly adjacent to TPA Class B airspace and underlies the TPA 30 nm Mode C and ADS-B Out veil. The Mode C and ADS-B Out veil refers to a specific airspace surrounding a primary class B airport where all aircraft operating within that area must be equipped with a transponder capable of transmitting altitude information (Mode C) and also have ADS-B Out capability. SRQ ATCT operating hours were 0600 to midnight, 7 days a week. The FAA control tower was located on the west side of the airfield near the runways intersection and was 128 feet tall. The design was a standard FAA low activity level tower with a 525 square foot (SF) control cab and a 9,000 SF administrative base building. The 10-sided polygon tower was integrated with the control cab. Local Control Controller The LC controller’s air traffic control career with the FAA began in August 2007 when he was hired under the Veteran’s Recruitment Appointment (VRA) direct hire program. He worked at the Miami Executive Airport (TMB) from 2007 to 2012, Orlando Executive Airport (ORL) from 2012 to 2015, Fort Worth air route traffic control center (ZFW), from 2015 to 2018, and SRQ from 2018 to present. In December 2019, he was promoted to OS, but also actively controls traffic. He was qualified on all positions in the tower and remained current on all positions. He held the required second-class medical certificate with a restriction to wear corrective lenses, which he stated he was in compliance with during his interview. Prior to working for the FAA, he served 5 years as an air traffic controller in the United States Navy. FAA Order JO 7110.65Z, Air Traffic Control Chapter 2, Section 1, paragraph 2-1-1, ATC Service, stated in part: a. The primary purpose of the ATC system is to prevent a collision involving aircraft operating in the system. Chapter 2, Section 1, paragraph 2-1-2, Duty Priority, stated in part: a. Give first priority to separating aircraft and issuing safety alerts as required in this order. Good judgement must be u