Close Call Cover-Up: FAA Not Notified Jets Outside Honolulu Were on Collision Course
Posted: Apr 30, 2012 5:24 PM EDT
Updated: May 01, 2012 6:32 PM EDT
By Keoki Kerr
HONOLULU (HawaiiNewsNow) - A mistake by an air-traffic controller resulted in two jets being put on a collision course as they approached Honolulu International Airport in January. A Hawaii News Now investigation revealed the incident was never reported to higher ups at the Federal Aviation Administration, resulting in an FAA probe and the retirement of the longtime head of air traffic control in Hawaii.
Honolulu is the 27th busiest airport in the country, with about 265,000 takeoffs and landings last year. But Honolulu air-traffic controllers handled much more traffic – roughly 654,000 flights in 2011 -- many of them flying through Hawaii air space but not landing in Honolulu.
On Saturday, Jan. 14, at about 9:09 a.m., a close call happened between a Japan Airlines 767 jet arriving from Tokyo and a United Parcel Service MD11 jet when the planes were about 15 miles west of Honolulu, both approaching HNL for a landing.
Hawaii News Now filed a Freedom of Information Act request to obtain written investigative reports and a video radar replay of the incident from the FAA.
The air-traffic controller who caused the close call was handling eight planes at the same time, with air traffic the FAA considers of "average complexity," according to an FAA error/deviation report about the incident.
He later told investigators his attention to JAL flight 72 and UPS 36 was diverted to a potential conflict involving two planes from Hawaiian and Go! Airlines.
The controller had mistakenly directed the JAL and the UPS jets on a collision course. At one point, their altitude separation dropped to 0, meaning they were headed straight for each other, traveling hundreds of miles an hour with about one and a half miles between them.
The video radar replay shows the two planes on the left side of the screen, with circles around them and the radio communications between the controller and the pilots are audible on the recording. An audible alarm can be heard going in the background and the tone of the controller's voice rose as he realized the gravity of the situation.
"UPS 36 heavy, fly heading 180. Japan Air 72 heavy, descend and maintain 1, 3,000," the controller said on the radio recording. Then the JAL pilot said, "Japan Air 72 heavy, now TCAS descend." With that, the Japan Airlines pilot told the controller he received what's called a "TCAS alert," which stands for traffic collision avoidance system.
The JAL flight descended while the UPS jet climbed to avoid a collision after getting instructions from their on-board TCAS systems. TCAS systems monitor airspace around planes and -- independent of air traffic controllers -- warn pilots of collisions and tell them to either climb or descend to avoid a crash.
"Today, TCAS, with its sophistication, is very reliable, very accurate and requires the pilots to follow those commands, when they're given," said Bruce Mayes, an aircraft safety expert who's flown military and commercial aircraft for 40 years, 23 of them as a pilot at Aloha Airlines.
After Hawaii News Now showed him the radar video replay, Mayes said, "This is a serious incident because anytime you have two aircraft trying to occupy the same airspace at the same time, it's a recipe for catastrophe."
In spite of the seriousness of the incident, sources told Hawaii News Now FAA officials in Hawaii never reported the close call to FAA authorities on the mainland, as they were supposed to.
Employees said the FAA's Honolulu air traffic manager for more than 20 years, Bob Rabideau (pronounced Rabi-doo), told the supervisors he oversaw not to report the incident to FAA officials on the mainland, and they did not.
In a telephone interview Saturday from Las Vegas, where Rabideau is on vacation, he denied covering up the close call. "I did not direct anybody to cover anything up. It's unfortunate that people are not being honest about this thing and I have no idea why," Rabideau said. He claimed two lower-level managers he oversaw covered up the incident.
"It appeared an operations manager and another front line manager covered this up and took no corrective action, as far as I know," he said "There's no point in covering it up, that I can see," said Bob Gould, who spent 33 years as a pilot for Northwest Airlines and was the senior Honolulu captain when he retired in 1998.
"It's not the kind of thing you can cover up. And to do so is kind of foolish, it would seem to me, 'cause you're going to get caught. I mean it's almost impossible that you're not going to get caught," Gould said. He noted that an incident like this is well documented, with radar, radio communications and computer records of the incident, while pilots involved are often required to file reports with their airlines about any close call incidents.
Sources said one of the UPS pilots filed a report about the Jan. 14 incident with the National Transportation Safety Board and when the NTSB asked the FAA about the close call, mainland FAA officials had no record of it nearly two weeks after it occurred. "As soon as we learned of this incident, we took quick and decisive action. We pulled the controller off operational duties and assigned him to skill enhancement retraining," the FAA said in a statement.
"The FAA is committed to ensuring the safety of our nation's airspace for the traveling public, and we take seriously and investigate all reported infractions," the agency said.
Hawaii News Now obtained results of the investigation that followed in February when five FAA officials traveled to Honolulu from the West Coast to find out what happened and to make an overall operational assessment of the Honolulu air traffic control facility.
The probe found the air traffic controller who made the mistake was relatively new, having been on the staff of FAA's Honolulu control tower for two years.
He had just been fully certified on Dec. 24, 2011, only a few weeks before the potentially deadly close call on Jan. 14, according to an FAA memo about the investigation.
The controller said he was "flustered" by the close call and asked for another controller to take over his position immediately following the incident, according to an FAA summary of the incident. But most troubling was this finding of the investigators: "… the controller stated he was not ready for certification, and had actually requested additional training through his training team."
While the FAA blacked out portions of the memo to protect employees' privacy, sources have helped fill in the blanks in a report about the investigative team's safety roundtable meeting with managers at FAA Honolulu in mid February, a month after the close call. The memo said, "The roundtable ended when (Rabideau) declared the meeting 'over' and abruptly walked out."
"One of the assessment team members overheard (Rabideau) yelling obscenities" at his managers after the meeting, the memo said. Rabideau denied swearing and yelling at his underlings that day. "Was I upset? Yeah, I was upset. Did I talk to anybody, no, I didn't," Rabideau said.
The FAA investigation and Hawaii News Now's interviews with six current and former FAA employees found a culture of fear existed at the Honolulu air traffic control center. Employees there referred to Rabideau as "God," someone who could change their shifts or ruin their careers if they upset him.
Rabideau called that charge "unfounded," noting that FAA employees have rights and a union, the National Air Traffic Controllers Association, to back them up. He said if air-traffic controllers were mistreated, they could file complaints. "The union decided that my tenure as a manager was up, so they started making stuff up," Rabideau added.
In their memo, FAA investigators said "...most individuals interviewed did not want to be identified out of fear of reprisal."
Honolulu control facility managers, including Rabideau, were encouraged to participate in the FAA's operational assessment, an FAA memo said, "… and to provide ideas where the assessment team could provide assistance with addressing safety issues. No suggestions were provided."
FAA employees told Hawaii News Now that Rabideau commuted on Hawaiian Airlines between Oahu and Maui, since he owns homes on both islands. Sources said air-traffic controllers were always told which Hawaiian flight Rabideau was taking and gave that plane priority. If Rabideau's flight experienced a delay, he would admonish the supervisors and the controllers on duty, sources said.
Sources said the FAA placed Rabideau, 65, on administrative leave Feb. 21 and he chose to retire a week later, after 42 years at the FAA. He previously had told his staff that he never planned to retire and wanted to "die in the job," a source said.
"Ultimately, the guy who sits on the top is held responsible for the actions or inactions of the people he oversees," Rabideau said. "I just felt that the honorable thing was to take responsibility for the cover up and walk out the door." Rabideau's salary was $179,700 at the time he retired, according to FAA records. He oversaw 163 employees in Honolulu, Hilo and Maui, the FAA said.
The FAA said its managers and members of the air-traffic controllers' union "… have developed a professional standards pilot program that provides an opportunity for employees to address the conduct of their peers, and the facility is conducting regular safety briefings." "The FAA also has taken specific steps to ensure any future events are reported in a timely manner," the agency said in a statement.
The investigation team interviewed seven people and analyzed control room phone records, the cell phone records of Rabideau and his second in command, the UPS pilot's statement and the UPS TCAS report, data from the Jan. 14 incident and various emails regarding incident reporting, according to an FAA memo summarizing the investigation.
In March, the FAA appointed Jamie Erdt as the acting air-traffic manager in Honolulu to oversee operations for the next few months while the FAA searches for Rabideau's replacement. Erdt has been the FAA's Seattle center manager, where she was responsible for one of the agency's 21 high-altitude traffic centers.
The FAA also brought in Don Kirby, traffic manager of Northern California approach control, to evaluate training programs in Honolulu and recommend improvements. Kirby has recommended Honolulu controllers get more training in unanticipated situations to learn how to quickly respond to unexpected scenarios, a source said.
The FAA said an incident like the one involving JAL and UPS outside Honolulu is extremely rare and the vast majority of air-traffic controllers never have something like this happen on their watch during their entire careers. The close call is known as a "loss of separation" in FAA parlance, because the planes lost a safe amount of separation for a brief period.
The controller who made the error was not disciplined and after undergoing retraining is back on the job, handling the complex task of keeping planes safe in the skies above Hawaii.