How a Series of Air Traffic Control Lapses Nearly Killed 131 People

On a cold, foggy Saturday morning in February, an air traffic controller cleared a FedEx cargo plane to land on Runway 18L at Austin-Bergstrom International Airport in Texas. A Southwest Airlines jet was on the same runway, but the controller said it would take off before FedEx’s hulking Boeing 767 got too close.

As the FedEx plane descended through thick clouds, though, the pilots saw something terrifying: the silhouette of the Southwest 737. The two planes were seconds from colliding.

One of the FedEx pilots commandeered the air traffic control radio frequency. He ordered Southwest to abort its takeoff. It didn’t. The FedEx crew blasted the engines to climb away from the Southwest plane. “On the go,” a FedEx pilot radioed.

The FedEx plane, which had three crew members, skimmed less than 100 feet over the other jet. The 128 people aboard Southwest Flight 708 continued on their way to Cancún, Mexico. Passengers were unaware that they had nearly died.

In a year filled with close calls involving U.S. airlines, this was the one that most unnerved federal aviation officials: A disaster had barely been averted, and multiple layers of the vaunted U.S. air-safety system had failed.

While the incident’s basic contours have been made public, a New York Times reconstruction of the near collision shows that an air traffic controller made virtually catastrophic mistakes.

But the errors by the controller — who has continued to direct some plane traffic in Austin — were far from the whole story, according to 10 current and former controllers there, as well as internal Federal Aviation Administration documents reviewed by The Times.

Austin-Bergstrom, like the vast majority of U.S. airports, lacks technology that allows controllers to track planes on the ground and that warns of imminent collisions. The result is that on foggy days, controllers can’t always see what is happening on runways and taxiways. Some have even resorted to using a public flight-tracking website in lieu of radar.

In addition, for years Austin has had a shortage of experienced controllers, even as traffic at the airport has surged to record levels. Nearly three-quarters of shifts have been understaffed. Managers and rank-and-file controllers have repeatedly warned that staffing levels pose a public danger. The controller on that February morning was working an overtime shift.

In June, Stephen B. Martin, then Austin’s top manager, and a local union representative wrote a memo pleading for more controllers. “Drastic steps are needed to allow the facility to adequately staff for existing traffic,” they wrote to F.A.A. and union officials.

Austin is a microcosm of a systemic crisis. The safety net that underpins air travel in America is fraying, exposing passengers to potential tragedies like the episode in February.

There has not been a fatal crash involving a major U.S. airline since 2009, but close calls have been happening, on average, multiple times a week this year, The Times reported in August.

One reason is mistakes by air traffic controllers. Waves of retirements and the slow pace of training new recruits have contributed to a nationwide staffing shortage. Ninety-nine percent of the nation’s air traffic control facilities, including Austin’s, were understaffed this year. Controllers around the country said in interviews that they and their colleagues were exhausted, making it harder for them to act as a crucial line of defense against mistakes by pilots. In some cases, controllers use alcohol and sleeping pills to cope with stress and round-the-clock schedules.

Technological problems have made the situation worse.

In Austin, a system that gauges the speed and direction of the wind was down for weeks, leaving controllers to rely on a windsock. In New Mexico and Southern California, controllers reported that the radio frequencies they used to communicate with pilots had cut out at dangerous moments. At other facilities, radar feeds that allow controllers to track planes in the sky failed. Runway lights malfunctioned.

The Times based its investigation on an analysis of F.A.A. records, thousands of pages of federal safety reports, and interviews with more than 50 current and former pilots, air traffic controllers and federal officials. Many spoke to The Times on the condition of anonymity to protect their jobs.

“The close call in Austin should have never happened,” said Matthew Lehner, an F.A.A. spokesman. “The F.A.A. immediately took a hard look and required training to reinforce current procedures at the facility.”

The National Transportation Safety Board is investigating the February incident. It has released its preliminary report into what the agency’s chairwoman, Jennifer Homendy, described as nearly a “disastrous collision.” She added that “as close as that was, it’s just one of seven serious close calls and near misses involving commercial airlines that we have initiated investigations on this year.”

Those don’t include several other close calls in Austin in the past year, according to internal F.A.A. safety reports and other documents reviewed by The Times.

Last November, for example, Southwest and American Airlines planes came perilously close. In April, a mistake by an exhausted air traffic controller caused a SkyWest Airlines jet to fly into the path of a Southwest plane. And last month, a fighter jet nearly crashed into two other aircraft, including a private jet that veered abruptly to avoid a collision.

Six Fraught Minutes

It was still dark outside when Damian Campbell started his overtime shift in the Austin control tower about 5:45 a.m. on Saturday, Feb. 4. This was supposed to be one of his days off, but a manager had asked him to come in because they were short staffed.

A Navy veteran and self-published poet, Mr. Campbell, 43 at the time, had been working in air traffic control since around 2010, with stints in South Bend, Ind., and elsewhere. By 2019, he was in Austin.

That morning, Mr. Campbell was overseeing departures and arrivals. The only other person with him in the tower was a supervisor who was busy directing planes on the ground. (Mr. Lehner, the F.A.A. spokesman, said the facility was not understaffed that morning.)

The thick layer of fog — an unusual condition in Austin — meant that Mr. Campbell couldn’t see much of anything, including the airport’s runways nearly 200 feet below. That was bad enough. But Austin also lacked ground radar, which meant Mr. Campbell had no way to visually monitor the location of planes on taxiways and runways. He had to rely on pilots on the ground to accurately tell him where they were.

About 6:34 a.m., the voice of a pilot on FedEx Flight 1432, inbound from Memphis, crackled through Mr. Campbell’s radio. The Boeing 767 was about 18 miles away, according to an internal F.A.A. report reviewed by The Times. The pilot was seeking permission to land.

“One Eight Left cleared to land,” Mr. Campbell rat-a-tatted in response, using code for the 9,000-foot runway 18L. He added that visibility was extremely low.

About four minutes later, he cleared the Southwest flight to Cancún for takeoff on 18L. The FedEx plane was on its final approach, just three miles away, he told the Southwest pilots. The distance between the two planes was closing fast.

Another 43 seconds passed. The FedEx pilot, knowing the Southwest plane was on the runway, asked for confirmation that it was safe to land.

“That is affirmative,” Mr. Campbell responded. “You are cleared to land.”

The FedEx plane was about 150 feet from the ground when its pilots caught sight of the airport, obscured by the dense clouds. That was when they saw it: the outline, barely visible at first, of the Southwest plane rolling down the same runway that the FedEx jet was about to land on.

Both planes were moving fast. A crash was imminent. There was no time to ask permission. “Southwest, abort!” one of the FedEx pilots radioed.

They yanked the cargo plane up and gunned the engines to avoid landing on top of the smaller jet, which continued accelerating and then was airborne.

The aircraft came within roughly 50 feet of each other when accounting for the Southwest plane’s tail and the FedEx jet’s landing gear, according to F.A.A. officials. (The N.T.S.B. said the planes were less than 200 feet apart.)

The emergency was averted, but the confusion continued. Mr. Campbell heard the FedEx pilot radioing to Southwest to cancel its takeoff, but he got mixed up about who was speaking, according to the internal F.A.A. report. Pilots typically don’t issue commands, and Mr. Campbell thought it was one of the Southwest pilots broadcasting that their plane was aborting.

“Roger, you can turn right when able,” Mr. Campbell said, directing it off the runway.

“Negative,” a Southwest pilot said, his plane roaring into the sky.

Minutes later, the FedEx plane circled around for its second landing attempt.

“You have our apologies,” Mr. Campbell radioed to the pilots after they had landed. “We appreciate your professionalism.”

Mr. Campbell has not previously been publicly identified. The names of individuals involved in serious aviation incidents often emerge in the course of N.T.S.B. investigations.

Mr. Campbell declined to comment, citing F.A.A. rules against speaking to the media. He referred The Times to Galen Munroe, a spokesman for the controllers’ union. Mr. Munroe said he would not comment on incidents under investigation. He said it was “wholly irresponsible to identify and release personal details of aviation safety professionals that are potentially involved in an ongoing N.T.S.B. investigation.” Controllers, he added, “are dedicated to keeping the airspace running safely and efficiently.”

The Times asked the F.A.A. for permission to speak to Mr. Campbell. The agency didn’t grant it.

‘Trying to Kill Us’

In Austin, the mood was somber. Susan Green, the supervisor who had been working alongside Mr. Campbell, sat in an office alone reviewing the incident. She had a “ghostly look” on her face, according to a person who saw her. She didn’t respond to requests for comment.

That evening, the N.T.S.B. announced that it was investigating what it described as “a possible runway incursion and overflight” at the Austin airport.

Some passengers aboard the Southwest flight began to hear about what had happened.

Caroline Weise and her husband had been flying to Cancún for a getaway at an all-inclusive resort. She said nothing about the Southwest flight had seemed out of the ordinary. Reggie Hale, who was with his pregnant wife en route for a “babymoon,” said the flight had felt “super smooth.”

Ms. Weise and Mr. Hale said they had learned about the close call only after it made headlines. “We went straight to relief knowing that we had gotten through something,” Mr. Hale said. With two children at home, he said, he was glad he and his wife had previously prepared their will.

Several Austin controllers said they felt sick after watching video replays of the near collision and realizing how close passengers had come to dying.

Controllers say they are taught not to waste time between takeoffs and landings, even when traffic is light, to avoid creating logjams. Even so, current and former controllers who reviewed the Austin incident said they were baffled by Mr. Campbell’s actions. There was no rush for the Southwest flight to take off, since the FedEx 767 was the only plane queued up to land.

Mr. Campbell submitted a confidential report through the Air Traffic Safety Action Program, in which controllers can report safety concerns, according to people with knowledge of the submission. The F.A.A. generally will not take disciplinary action against the controller as long as the mistakes were not caused by gross negligence or illegal activity.

Two days after the incident, investigators with the N.T.S.B. arrived in Austin. At one point while Mr. Campbell was being interviewed, he asked to be excused and broke down crying in the parking lot, according to a person who witnessed it.

Mr. Campbell told the F.A.A. that he had expected the Southwest plane to begin its takeoff sooner, according to two people with knowledge of the remark.

In the weeks that followed, controllers and pilots around the country said they had dissected the close call. Some wondered why the Southwest pilots had proceeded with the takeoff when they knew that the FedEx plane was so close and visibility was so low. (A Southwest spokeswoman said the airline was cooperating with federal investigations.)

Some pilots flying into and out of Austin started second-guessing controllers’ orders. In early March, a Delta Air Lines pilot who was cleared to land by a controller aborted at the last second, later saying in an internal F.A.A. report that he had been “uncomfortable” with how close his jet was getting to a plane in front of him.

Another time, an employee in the control tower said he had heard a pilot on the radio frequency saying controllers have been “trying to kill us here in Austin.”

10,642 Hours of Overtime

Since at least 2018, controllers and managers in Austin had been warning their superiors, F.A.A. officials and even their local congressman that insufficient staffing was leaving them overwhelmed.

A big part of the problem: Even as air traffic has soared more than 50 percent over the past decade, the ranks of controllers haven’t kept up. Today, Austin has 35 fully certified controllers, according to the F.A.A. That is about 40 percent below the target level set by the F.A.A. and the union representing controllers.

Justin Faircloth was a controller in Austin until last year, when he quit, he said, because he was exhausted and worried that working conditions were jeopardizing safety. He recalled telling Mr. Martin, the top manager there, that it was “only a matter of time until we’re so overworked that something is going to happen.”

After the February incident, the Austin facility descended into a deepening crisis.

The F.A.A. began mandating additional training in Austin, but controllers said it largely consisted of providing them with materials that described existing rules and procedures.

To make up for the staffing shortfall, many controllers were working six-day weeks and hundreds of hours of overtime. In September, someone taped a sign to a door in the building that said Austin controllers and supervisors had worked a total of 10,642 hours of overtime so far this year.

Another time this year, an internal F.A.A. report attributed a controller’s mistake to “fatigue,” which the report described as “a systemic problem.”

Controllers also said problems with their radio frequency made it difficult to communicate with pilots. And because the airport lacks ground radar, some controllers said they were using a free version of the website FlightRadar24.com to help keep track of planes on the ground, even though the site is not approved by the F.A.A. for air traffic control purposes.

Even the control tower’s elevator went out of service, forcing controllers to trudge up nearly 400 steps in the summer heat.

Mr. Lehner, the F.A.A. spokesman, didn’t comment on Austin’s equipment problems. He said the controllers’ schedules and workloads were negotiated by their union. He said controllers nationwide are spending less time during their shifts directing traffic now than they were 15 years ago. (During their workdays, controllers also undergo training and take breaks.)

After the February incident, Mr. Campbell spent weeks working a desk job and was required to go through additional training. He has returned to directing ground traffic at the airport, his colleagues said. It isn’t clear whether he will face repercussions after the N.T.S.B. investigation is complete.

On April 5, a different controller in Austin made another mistake, instructing a SkyWest plane en route to Houston to ascend into the path of a Southwest flight. A collision warning sounded in the Southwest cockpit, and the pilots stopped their descent to avert a crash.

The error reflected a “momentary lack of judgment,” the controller later said in a confidential safety report. The controller blamed the close call in part on the shortage of air traffic controllers, as well as fatigue. The controller reported having engaged in increased risk taking, as well as yawning and staring blankly, in the hours before the incident.

Less than two months later, in another safety report, a controller described a recent day in which the facility had been “overwhelmed with aircraft.” Not enough controllers were on duty. A supervisor had been instructed to help but “was unsure what to do and couldn’t provide any assistance.”

“These all continue to be systemic issues,” the controller wrote. “If it’s not corrected in a way that makes sense, rather than putting a band aid on things, this is going to end very badly.”

Kirsten Noyes contributed research.