Interruptions, distractions and multitasking led to a near-collision between an American Airlines flight and a Delta flight moving at 120 MPH down a runway at John F. Kennedy International Airport last year, according to a report released on Tuesday by the National Transportation Safety Board.
The agency's abstract report on the Jan. 13, 2023, incident provided more details about what led to the incident and how a specialized detection system prevented a worse outcome.
Air traffic controllers cleared a Delta Air Lines 737 for takeoff on Runway 4L, however, 20 seconds after the Delta plane began its takeoff an American Airlines B-777 destined for London crossed the same runway without a clearance, according to the report.
NTSB investigators said numerous factors contributed to the American Airlines captain's mistake, including "interruptions and multitasking that were happening on the flight deck during critical moments of ground navigation."
"The other two flight crewmembers didn't catch the captain's error because they were both engaged in tasks that diverted their visual attention from outside the airplane," the agency said in a statement.
Additionally, investigators said the ground controller who provided taxi instructions to the American flight, "didn't notice the aircraft turned onto the wrong taxiway because he was performing a lesser priority task that involved looking down," the report said.
The probe found that when the Delta flight accelerated down the runway, JFK's Airport Surface Detection Equipment – Model X, or ASDE-X, issued aural and visual alerts in the air traffic control tower.
Five seconds after the alerts were issued, the controller canceled the Delta plane's takeoff clearance, which prompted its pilot to decelerate as the American jet crossed in front of it, according to the NTSB.
The NTSB has pushed for ASDE-X technology to be installed at airports since 1991. JFK installed its ASDE-X in 2009 and is one of 35 major airports to have it equipped, according to the NTSB.
"Our investigation also makes clear why we've long supported systems that warn flight crews of risks directly: because every second matters," NTSB Chair Jennifer Homendy said in a statement.
The agency has issued several recommendations in light of the incident including encouraging flight crews to verbalize the number of the runway they are about to cross, and pushing aircraft and avionics manufacturers to develop an improved system that would alert flight crews of traffic on runways.
Additionally, the NTSB called on the Federal Aviation Administration to require all planes to be fitted with cockpit voice recorders that record 25 hours of audio instead of two hours.
The American flight's recordings were lost in this case because the plane continued to London and the data was overwritten, according to the agency.