REVIEW OF REPORTED NEAR MID-AIR 

COLLISIONS IN THE NEW YORK 

METROPOLITAN AIRSPACE 

Federal Aviation Administration 

Report Number: AV-2008-050 

Date Issued: April 24, 2008 
U.S. Department of 

Memorandum

Transportation 

Office of the Secretary 

of Transportation 

Office of Inspector General 

Subject: ACTION: Review of Reported Near Mid-Air 

Collisions in the New York Metropolitan Airspace 

Federal Aviation Administration 

Report Number AV-2008-050 

Date: April 24, 2008 

From: David A. Dobbs 

Principal Assistant Inspector General 

 for Auditing and Evaluation 

Reply to 

Attn. of: JA-1 

To: Acting Federal Aviation Administrator 

This report provides the results of our review of reported near mid-air collisions 

(NMACs) in the New York metropolitan airspace. The review was initiated in 

response to a June 11, 2007, letter from Senator Hillary Rodham Clinton. In her 

letter, Senator Clinton expressed concern regarding five reported NMACs 

involving commercial aircraft in the New York metropolitan airspace during May 

2007 and requested that we investigate the incidents. A copy of Senator Clinton’s 

request can be found at exhibit D. 

The objectives of our review were to address the following questions posed by 

Senator Clinton: (1) What is the root cause of the near misses in May 2007 in the 

New York airspace? (2) How is the Federal Aviation Administration (FAA) 

addressing these problems and what measures has the FAA taken to prevent repeat 

occurrences? (3) Do any of the New York area airports practice a similar type of 

procedure that FAA ordered a halt to at the Memphis airport where FAA allowed 

planes to simultaneously land and depart from nearby runways that have 

intersecting flight paths? Additionally, Senator Clinton’s staff requested that we 

determine if air traffic controller staffing may have been a contributing factor to 

the incidents. 

We conducted the review between June 2007 and January 2008. Our scope and 

methodology can be found at exhibit A. Exhibit B lists the organizations we 

contacted or visited. 
 2

FAA defines a NMAC as “an incident associated with the operation of an aircraft 

in which a possibility of collision occurs as a result of proximity of less than 

500 feet to another aircraft, or a report is received from a pilot or flight 

crewmember stating that a collision hazard existed between two or more aircraft.” 

Only a pilot or flight crew member may report a NMAC. The preliminary report 

is filed with FAA’s Air Traffic Organization (ATO) and submitted to the Flight 

Standards line of business. Flight Standards inspectors conduct the NMAC 

investigation in response to the preliminary NMAC report. They determine the 

cause and hazard classification and then create the final NMAC report. Flight 

Standards inspectors classify each NMAC according to the following collision 

hazards. 

• Critical—a collision was barely avoided by chance rather than pilot actions 

with less than 100 feet separation. 

• Potential—a collision was avoided due to pilot action with less than 500 feet 

separation. 

• No Hazard—a collision was improbable regardless of any evasive action taken. 

NMAC reports are not reclassified or omitted from the NMAC system, regardless 

of the final hazard classification. For example, a NMAC report determined by 

Flight Standards to be “no hazard” remains in the NMAC system, counted and 

referred to as a “near mid-air collision.” 

Four of the five NMAC events in the New York area, during May 2007, involved 

incidents between commercial aircraft and unidentified general aviation aircraft. 

In these incidents, the commercial aircraft were operating under instrument flight 

rules (IFR), and were under direction of controllers at the New York Terminal 

Radar Approach Control (TRACON) (N90). The unidentified general aviation 

aircraft were operating under visual flight rules (VFR) and using “see and avoid” 

techniques, meaning they were not under direction of controllers. 

The fifth NMAC event involved two commercial aircraft (one operating under IFR 

and one operating under VFR); both were under control of the tower at John F. 

Kennedy International (JFK) Airport. 
 3

Table 1. Five Reported NMACs During May 2007 

in New York Airspace 

Date Facility/NMAC 

Number 

Reporting 

Aircraft/Flight 

Rules 

2nd 

Aircraft/Flight 

Rules 

Hazard 

Classification

5/1/07 N90-003 JetBlue/IFR Unidentified/VFR No Hazard 

5/5/07 N90-004 JetLink/IFR Unidentified/VFR Potential 

5/8/07 N90-005 JetBlue/IFR Unidentified/VFR No Hazard 

5/21/07 N90-006 Continental/IFR Unidentified/VFR No Hazard 

5/17/07 JFK-001 American 

Eagle/IFR 

US 

Helicopter/VFR No Hazard 

As shown in table 1, four of the five incidents were classified as no hazard. Only 

one incident (N90-004) was classified as a potential hazard. This incident 

involved a glider that did not have a transponder, which provides controllers with 

data on the location, altitude, speed, and type of aircraft. When the commercial 

pilot saw the glider directly ahead of him, he initiated an immediate descent to 

avoid a collision. The 2 aircraft came within approximately 200 feet of each other. 

While the other four incidents were determined to be no hazard, they will continue 

to be classified and counted as a NMAC under FAA’s current reporting system for 

NMACs. In our opinion, the lack of a procedure for reclassifying no-hazard 

events may contribute to misperceptions regarding the actual safety risk posed by 

an incident. 

RESULTS IN BRIEF 

Overall, we found that the five NMACs were independent, unrelated events with 

no obvious common root causes. Four of the five events were later determined to 

be no hazards; only one was classified as “potential.” These NMACs were 

reported by commercial IFR pilots who may have been initially “surprised” by the 

location of the VFR aircraft in nearby airspace, but the incidents actually posed no 

risk to safety regardless of any actions taken by the pilots. However, the four nohazard incidents continue to be classified and counted as “near mid-air collisions,” 

a term that we believe misrepresents the actual safety risk posed by an incident. 

While we found no common root causes among the five events, there were similar 

characteristics associated with four of the five NMACs while the aircraft were 

under direction of controllers at the New York TRACON (NMACs N90 003 

though 006). These included the following: 
 4

• The type of airspace in which the NMAC occurred—all four events were in 

airspace that allows both commercial IFR aircraft (under direction of air traffic 

controllers) and general aviation VFR aircraft (operating under “see and avoid” 

techniques and not under direction of controllers) to operate simultaneously. 

• A change in the type of airspace—three of the four events occurred near the 

boundary of airspace that is less restrictive (where VFR aircraft are not under 

direction of controllers), and more restrictive airspace (where commercial 

aircraft operate under direction of controllers), for aircraft departing from or 

arriving at New York area airports. 

• A change in the controller responsible for directing the aircraft—three of the 

four events occurred near the time when the responsibility for directing the 

commercial IFR aircraft was in the process of being “handed off” from one 

controller to another. 

To address vulnerabilities associated with the existing airspace, the current routes 

used by commercial aircraft over New York would need to be altered or restricted. 

FAA has an ongoing project to redesign the airspace in the New York/New 

Jersey/Philadelphia metropolitan areas. The intent of the project is primarily to 

accommodate growth in aviation operations while enhancing safety and reducing 

delays. 

As part of the review and development of new or revised air traffic procedures 

implemented under airspace redesign, FAA must evaluate whether commercial 

IFR arrival and departure routes into and out of the New York metropolitan area 

should be redesigned or restricted to minimize potential conflicts with general 

aviation VFR air traffic. 

FAA also determined that better Air Traffic services could have been provided by 

the controllers in two of the four N90 NMACs by alerting the commercial IFR 

pilots that an unidentified VFR aircraft was in their vicinity. As a result of those 

events, Air Traffic management issued an Air Traffic Bulletin in September 2007 

to remind all controllers of procedures for merging targets and the importance of 

providing traffic advisories to pilots. 

The NMAC at JFK (JFK 001) differed from the other four N90 NMACs as it 

occurred at the airport near the runway surface. While the incident did not pose a 

safety risk, FAA took action to prevent a reoccurrence by changing a departure 

procedure for helicopters. At the time of our site visit, the new departure 

procedure was only agreed upon verbally between JFK Air Traffic management 

and that particular helicopter operator. We recommended that JFK formalize the 

new procedure by amending the existing written Letter of Agreement (LOA) 

between the helicopter operator and the tower that outlines the standard operating 
 5

procedures and coordination actions used by the two parties. In response to our 

recommendation, FAA and the helicopter operator revised the LOA in November 

2007. 

None of the five NMACs were the result of a controller operational error (when a 

controller fails to maintain required separation between two aircraft). In the four 

N90 NMACs, only the commercial aircraft were under the direction of air traffic 

controllers at the time of the incidents. The other aircraft involved were operating 

under VFR. In the NMAC at JFK, the two aircraft were being directed by 

different controllers; however, in the final NMAC report the inspector determined 

there was no loss of separation between the two aircraft. 

None of the New York metropolitan area airports use an Air Traffic procedure 

similar to the procedure that FAA discontinued at Memphis International Airport. 

FAA determined that the former procedure at Memphis (which allowed aircraft to 

land on a runway while overflying an aircraft that landed on a nearby runway with 

an intersecting flight path) violated Air Traffic procedures. 

While Newark Liberty International Airport does not use that specific procedure, 

there is an unresolved issue between the New York TRACON and the Newark 

tower. The issue involves which facility should assume responsibility for 

staggering arrivals when a certain runway configuration is in use at the airport. 

FAA should conduct a safety analysis of this runway configuration to identify 

measures needed to enhance safety and reduce the potential for “go-arounds.”1

 

The analysis also should designate responsibility for staggering approaches when 

that configuration is in use. 

Finally, since events determined to be no hazard remain classified as a NMAC, 

there may be significant misperceptions regarding the proximity and the risk to 

safety of reported mid-air events. FAA should restructure the existing NMAC 

reporting process so that the actual safety risks posed by reported events are 

accurately reflected. Actions to better reflect actual safety risk could include 

developing a procedure to reclassify no-hazard events, redefining the NMAC 

criteria, or revising the term “NMAC.” 

Our recommendations, listed on page 16, include the following: 

 

1

 A “go around” is when a pilot decides—or a controller instructs an arriving aircraft—to abort its landing 

and go around for a second attempt. 
 6

• Evaluating, as part of the review and development of new or revised air traffic 

procedures under airspace redesign, whether commercial IFR routes into and out 

of the New York area should be redesigned or restricted to minimize potential 

conflicts with VFR air traffic. 

• Restructuring the existing NMAC reporting process so that the actual safety 

risks posed by reported events are accurately reflected. 

FAA’s comments and our response are discussed on pages 16 and 17. 

FINDINGS 

Four of the Five NMACs Had Similar Characteristics 

We found that the five NMACs that occurred in May 2007 in the New York 

metropolitan airspace were independent, unrelated events with no obvious 

common root causes. However, our review of the four N90 NMACs found three 

similar characteristics that may have contributed to the events. Those are: (1) the 

nature of Class E airspace, (2) the proximity to a change in the class of airspace, 

and (3) the proximity to change of Air Traffic Control responsibility. Table 2 

depicts which characteristics were evident in each of the four N90 NMACs. 

Table 2. Similar Characteristics of the Four N90 NMACs 

Date Facility & 

NMAC 

Number 

Nature of 

Class E 

Airspace 

Proximity to 

Change of 

Airspace 

Proximity to 

Transfer of 

Control 

5/1/07 N90-003 Yes Yes No 

5/5/07 N90-004 Yes Yes Yes 

5/8/07 N90-005 Yes No Yes 

5/21/07 N90-006 Yes Yes Yes 

Airspace is divided into various classes with varying entry requirements. For 

example, in Class A airspace (high altitude), and Class B, C, and D airspace (near 

airports), all aircraft must establish two-way communications with Air Traffic 

Control before entering that airspace. In Class E airspace, however, VFR aircraft 

can operate without establishing communication or receiving direction from Air 

Traffic Control, and they are responsible for ensuring separation from other 

aircraft by simply applying “see and avoid” techniques. Class B is the most 

restrictive airspace while Class E is the least restrictive. Figure 1 represents 

various classes of airspace in the New York metropolitan area and the locations of 

the four N90 NMACs and the NMAC at JFK. 
 7

Figure 1. Various Classifications of New York Airspace 

Note: Not to scale, NMAC locations are not actual representations. 

Nature of Class E Airspace 

As shown in figure 1, each of the four N90 NMACs occurred in Class E airspace. 

The four NMACs occurred between a commercial aircraft (operating under IFR 

and in communication with Air Traffic Control) and an aircraft operating under 

VFR using “see and avoid” techniques (not in communication with Air Traffic 

Control). In each event, both aircraft were legally operating in Class E airspace. 

Proximity to a Change of Airspace Class 

In three of the four N90 NMACs (N90 003, 004, and 006), the incidents occurred 

near the boundary of Class E airspace and Class B or D airspace where 

commercial aircraft are departing from or arriving at New York area airports. This 

may have contributed to the pilots’ “surprise factor,” thus leading to the pilots’ 

decision to report a NMAC. Commercial pilots leaving one class of airspace and 

entering another may not maintain an awareness of the transition in airspace and 

may be surprised when encountering an unidentified VFR aircraft in Class E 

airspace. Conversely, VFR pilots in Class E are more likely to maintain an 

awareness of the boundary of Class E airspace, as VFR pilots entering another 

class of airspace could result in a violation (i.e., a pilot deviation). 
 8

Proximity to the Time of a Transfer of Control 

For three of the four N90 NMACs (N90 004, 005, and 006), the proximity to a 

transfer of control was a shared characteristic. These NMACs occurred near the 

time when the control responsibility for the commercial IFR aircraft was 

transferred (handed off) from one controller to another. 

To adequately address these three issues, the existing airspace used by commercial 

aircraft over New York would need to be altered. FAA has an ongoing redesign 

project for the New York/New Jersey/Philadelphia metropolitan airspace. The 

primary intent of the project is to accommodate growth in aviation operations 

while enhancing safety and reducing delays. As part of the review and 

development of new or revised air traffic procedures implemented under airspace 

redesign, FAA must evaluate whether commercial IFR arrival and departure routes 

into and out of the New York metropolitan area should be redesigned or restricted 

to minimize potential conflicts with general aviation VFR air traffic. Further 

details on the four N90 NMACs follow. 

• NMAC N90-003: The controller issued traffic advisories to the pilot and 

instructed the pilot to turn so that the commercial aircraft would pass behind 

the unidentified VFR aircraft. This incident occurred in Class E airspace 

shortly after the IFR aircraft transitioned from Class D to Class E airspace. 

• NMAC N90-004: This incident occurred with a glider that did not have a 

transponder, which provides controllers with data on the location, altitude, 

speed, and type of aircraft. When the Continental Express pilot saw the glider 

directly ahead of him and within 200 feet, he initiated an immediate descent to 

avoid collision with the glider. The pilot stated that a collision would have 

been imminent had he not taken evasive action. 

Since the glider was not visible on radar until the last second, the controller 

was unable to provide traffic advisories regarding the glider; however, the air 

route traffic control center controller advised the pilot of glider activity before 

handing the aircraft off to the New York TRACON. 

The FAA inspector responsible for investigating the incident told us that 

gliders legally operate in the major arrival corridor in Class E airspace for 

Stewart Airport, John F. Kennedy Airport, La Guardia Airport, Teterboro 

Airport, and Newark Liberty Airport. The inspector also suggested that the 

airspace be changed or restricted. This incident occurred in Class E airspace 

shortly after the IFR aircraft was handed off from one controller to another. 
 9

• NMACs N90-005 and N90-006: Both NMACs occurred in Class E airspace 

near the time when the IFR aircraft were handed off from one controller to 

another. FAA determined that the controller alerting the pilots of unidentified 

general aviation aircraft in their vicinities could have provided better Air 

Traffic Control services (e.g., a traffic advisory). Those actions may have 

prevented the NMAC by eliminating the pilots’ surprise factor. FAA issued an 

Air Traffic Bulletin in September 2007 to remind controllers of the importance 

of providing safety alerts and traffic advisories to pilots. 

One NMAC Was Unique to Circumstances Related to JFK Airport 

The NMAC at JFK (JFK 001) differed from the four N90 NMACs in that it 

occurred at the airport near the runway surface. The NMAC occurred when a 

helicopter operated by U.S. Helicopters (operating under VFR) took off from a 

controlled helipad and made a right turn towards runway 13R. The helicopter did 

not enter or cross runway 13R. Nevertheless, a departing American Eagle pilot 

(operating under IFR) was surprised by the location of the helicopter and 

subsequently filed the NMAC. The report investigation revealed, however, that 

the helicopter had the departing jet in sight and maintained visual separation with 

that aircraft. 

As shown in figures 2 and 3 below, the helipad is behind the terminal; once a 

helicopter lifts off from the pad, it appears close to runway 13R at the point where 

some aircraft begin to lift off. Additionally, under the previous procedures used, 

departing helicopters were not restricted from turning towards runway 13R. 

Figure 2. Helicopter Departing Helipad at JFK 

 

Runway 

13R

Helicopter 

Departing 

Helipad at JFK 
 10

Figure 3. Aircraft Departing Runway 13R 

A contributing factor to the incident was that the helicopter operation had 

relocated just 7 days prior to the NMAC from American Airline’s terminal on the 

north side of the airport to Delta’s terminal on the south side of the airport; 

therefore, the pilot may not have been accustomed to seeing a helicopter in the 

area adjacent to the runway. In addition, the helicopter departure was being 

controlled by a different controller than the one working the American Eagle 

departure; therefore, the American Eagle pilots would not have been aware of the 

departure instructions issued to the helicopter on another frequency. 

FAA management at JFK and the helicopter operator agreed to change the 

helicopter departure procedure to a left turn when Runway 13R is in use. We 

observed the revised helicopter departure procedure in use at JFK and found that it 

eliminates the potential conflict between departing helicopters and aircraft 

departing runway 13R. 

At the time of our site visit, however, this verbal agreement and the preceding 

change of helicopter departure location were not formalized in the LOA that exists 

between JFK Air Traffic management and the helicopter operator. In response to 

our recommendation to formalize the procedure, FAA and the helicopter operator 

revised their LOA in November 2007. 

None of the NMACs Resulted From Controller Error or Staffing 

We also reviewed the five NMACs to determine if controller actions (or inactions) 

may have contributed to the incident. We found that none of the five NMACs 

were the result of a controller operational error (when a controller fails to maintain 

required separation between two aircraft) or staffing levels. 
 11

In the four N90 NMACs, only the commercial aircraft were under the direction of 

air traffic controllers at the time of the incident. The other aircraft involved were 

operating under VFR and were not being directed by controllers. In the NMAC at 

JFK, the two aircraft were being directed by different controllers; however, in the 

final NMAC report the inspector determined that there was no loss of separation 

between the two aircraft. 

While operational errors did not contribute to any of the five NMACs, controller 

staffing has been a concern for many FAA stakeholders, given the high number of 

projected controller retirements during the next 10 years. For example, at the New 

York TRACON, overall staffing (the number of fully certified controllers) 

decreased by 16 percent, from 213 in October 2001 to 178 in October 2007. 

Because of controller staffing concerns, we analyzed controller staffing during the 

five NMACs to determine whether that issue contributed to the incidents. We 

determined that controller staffing did not appear to contribute to any of the five 

NMACs, based on the information shown in table 3. 

Table 3. Controller Staffing at the Time of the N90 NMACs 

Date Facility & 

NMAC 

Number 

Scheduled 

Staffing 

Actual 

Staffing 

Number of Controllers 

Off Position (Percentage 

of Staffing for that Shift) 

Position 

Combined?

5/1/07 N90-003 11 12 7 (58 percent) No 

5/5/07 N90-004 13 11 3 (27 percent) No 

5/8/07 N90-005 11 10 4 (40 percent) No 

5/17/07 JFK-001 12 10 5 (50 percent) No 

5/21/07 N90-006 17 16 5 (31 percent) No 

As shown in table 3, the actual staffing (fully certified controllers reporting to 

work) was slightly less than the scheduled staffing (fully certified controllers 

scheduled to work) when four of the NMACs occurred. However, between 

27 percent and 50 percent of the controllers working that shift were not working 

an operational position at the time of those events (i.e., they were on meal breaks, 

in training, etc.). Further, none of the controllers were working combined 

positions of operation when the NMACs occurred. 

We are monitoring FAA’s efforts on controller staffing. In a separate audit, we 

are evaluating FAA’s progress in implementing key staffing and training elements 

of its Controller Workforce Plan. We will report the results of our review in early 

2008. 

As a result of the August 2006 Comair accident in Lexington, Kentucky, the 

National Transportation Safety Board (NTSB) identified controller fatigue as a 

safety concern. NTSB recommended that FAA revise work schedule policies and 
 12

practices to provide sufficient controller rest. Because of this recommendation, 

we reviewed rest periods and shift rotations for controllers working on position 

during the reported New York NMACs. We determined that controller fatigue did 

not appear to be a contributing factor to the five NMACs. 

Table 4. Individual Controller Shift Metrics 

When the NMACs Occurred 

Date Facility 

and 

NMAC 

Number 

Number of 

Hours Off Duty 

Prior to NMAC 

Shift 

Number of 

Consecutive 

Minutes Worked 

at Time of NMAC 

Overtime 

Scheduled 

Week of 

NMAC? 

Hours of 

Overtime 

Worked Week 

of NMAC 

5/1/07 N90-003 39 37 No 0 

5/5/07 N90-004 15 67 No 0 

5/8/07 N90-005 16 36 No 0 

5/17/07 JFK-001 14 56 No 2 

5/21/07 N90-006 16 61 No 8 

As shown in table 4, all five controllers had rest periods ranging from 14 to 

39 hours (a 20-hour average) before the NMAC shift, indicating there was ample 

time for rest between shifts. Further, the five controllers worked between 36 and 

67 consecutive minutes (averaging 51.4 minutes on position) when the NMACs 

occurred, well below the goal of no more than 2 hours.2

 

In addition, the five controllers were scheduled for 5-day work weeks with 8-hour 

shifts and no scheduled overtime (OT) shifts during the week of the NMACs. 

However, two of the five controllers incurred OT during the week of the NMACs, 

one of whom worked the OT shift during the portion of the work week prior to the 

incident. The controller working the position on May 17 during the NMAC at 

JFK incurred 2 hours of overtime the previous day but was allotted a 14-hour 

available rest period between the two shifts. 

New York Area Airports Do Not Have Standard Operating Procedures 

Similar to the Simultaneous Arrival Procedure FAA Discontinued at 

Memphis 

Prior to April 2007, controllers at Memphis International Airport used a local 

standard operating procedure to clear an aircraft to land on a runway while 

overflying another aircraft that had landed on a separate intersecting runway and 

was taxiing off the runway. 

The Air Traffic Control manual, FAA Order 7110.65, paragraph 3-10-4, 

Intersecting Runway Separation, establishes Air Traffic procedures for arriving 

 

2

 Per the FAA contract with NATCA, controllers can work a maximum of 2 hours on position before 

receiving a break. 
 13

aircraft with intersecting paths (see figure 4 below). The order requires that Air 

Traffic: 

Separate an arriving aircraft using one runway from another aircraft using an 

intersecting runway or a nonintersecting runway when the flight paths 

intersect by ensuring that the arriving aircraft does not cross the landing 

threshold or flight path of the other aircraft until [a] preceding arriving 

aircraft is clear of the landing runway, completed landing roll and will hold 

short of the intersection/flight path, or has passed the intersection/flight path. 

This order sets the parameters for ensuring proper runway separation to protect the 

intersection (or runway flight paths’ intersection). 

Figure 4. Diagram of Arriving Aircraft With Intersecting Paths 

Methods of complying with this requirement include but are not limited to: speed 

control, spacing techniques, staggering approaches, and use of radar displays to 

establish cut-off points. 

In April 2007, Air Traffic Oversight Services group (part of FAA’s Safety line of 

business) halted the Memphis overflight procedure, citing a violation of FAA 

Order 7110.65 paragraph 3-10-4. The Oversight Services group determined that 

to conduct the Memphis procedure, a legitimate waiver for Order 7110.65 

paragraph 3-10-4 would be required. The Memphis tower began complying with 

those requirements, and the Memphis TRACON began using equipment designed 

to stagger simultaneous arrivals. 

We observed operations at JFK, Newark, LaGuardia, and Stewart Air Traffic 

Control towers and found that none of those conduct an overflight procedure 
 14

similar to the procedure discontinued at Memphis. However, we found that there 

is an unresolved dispute over application of FAA Order 7110.65 paragraph 3-10-4 

procedures in regard to arrivals on Runways 22L and 11, when that runway 

configuration is in use at the airport. 

The local National Air Traffic Controllers Association (NATCA) official at 

Newark tower told us that while controllers apply procedures to comply with those 

provisions of Order 7110.65 when using the 22L-11 runway configuration, the 

New York TRACON, which hands off arrivals to Newark, should assume 

responsibility for staggering simultaneous arrivals to ensure compliance with 

paragraph 3-10-4. The NATCA official expressed safety concerns about using goarounds for landing aircraft when this runway configuration is in use. 

In another circumstance, officials from the Air Traffic Organization worked with 

Newark Air Traffic management and on October 5, 2007, FAA’s Air Traffic 

Oversight Services granted a waiver to paragraph 3-10-4 in conducting a specific 

operation using Runways 4R and 29. Officials from Safety Services stated that 

this procedure increases safety and reduces go-arounds of landing aircraft. 

We met with officials from the Air Traffic Organization, and they agreed to 

commit resources to conduct a similar review of the Newark Runway 22L and 11 

arrival configuration to see what procedures could be implemented to increase 

safety and reduce go-arounds. Those plans are clearly steps in the right direction; 

however, the analysis should also designate responsibility for staggering 

simultaneous arrivals. In addition, local NATCA representatives should be 

afforded the opportunity to provide input. 

FAA’s Current Process for Reporting NMACs May Lead to 

Misperceptions Regarding the Level of Safety Risk Posed by NMAC 

Events 

The lack of a procedure for reclassifying no-hazard events, the term “near mid-air 

collision,” and the definition of a NMAC may contribute to misperceptions 

regarding the actual safety risk posed by a NMAC event. We found that FAA’s 

current reporting process for NMACs does not allow no-hazard events to be 

reclassified, which can exaggerate the historical perspective of NMACs. For 

example, four of the five New York NMACs were subsequently determined to be 

no hazard, i.e., a collision was improbable regardless of evasive actions taken. 

However, the four events will continue to be classified and counted as NMACs, 

potentially masking early recognition of a trend in the highest risk NMACs.

FAA, union, and industry officials we spoke with agreed that the term “near midair collision” is misleading. One top airline official stated that the public is misled 

by the use of this term to describe an event where there was no danger. Since 
 15

events determined to be no hazard remain classified as NMACs, aviation users 

may greatly misunderstand the proximity and the risk to safety of reported NMAC 

events. For example, in FY 2007, 16 of the 66 total NMACs (or 24 percent), 

where a collision hazard was identified, were determined to be no-hazard events—

yet they are still considered to be NMACs. 

FAA’s criteria for defining a NMAC also may contribute to misperceptions 

regarding events where no collision hazard existed. As defined by FAA, a NMAC 

happens when either an actual collision hazard between two aircraft occurs or 

when a pilot reports his or her perception that a collision hazard existed. 

Therefore, when the outcome of the NMAC investigation reveals that there was no 

collision hazard, the reported pilot perception of a collision hazard still meets the 

near mid-air collision criteria as defined by FAA. The no-hazard event is 

therefore still classified as a NMAC, and users may erroneously view the event as 

a collision risk. 

FAA must take action to mitigate misperceptions of safety risks posed by a 

NMAC event. FAA’s Director of Air Traffic Safety Oversight Services stated that 

he would like FAA to review the terminology of all air proximity events, including 

NMACs, operational errors, and pilot deviations. He also stated that if all 

proximity events, such as NMACs, remained unclassified until FAA completed an 

investigation, they could be accurately classified. The ATO Safety Services 

officials we spoke with concurred that NMAC reporting processes need to be 

revised. 

Accordingly, FAA should restructure the existing NMAC reporting process so that 

the actual safety risks posed by reported events are accurately reflected. Actions 

to better reflect actual safety risks could include developing a procedure to 

reclassify no-hazard events, redefining the NMAC criteria, or revising the term 

“NMAC.” 
 16

RECOMMENDATIONS 

We recommend that FAA: 

1. As part of the review and development of new or revised air traffic 

procedures under airspace redesign, evaluate whether commercial IFR arrival 

and departure routes into and out of the New York TRACON’s airspace 

should be redesigned or restricted to minimize potential conflicts with general 

aviation VFR air traffic. 

2. Conduct a safety analysis of the simultaneous arrival procedures at Newark 

Liberty International Airport when the runway 22L and 11 configuration is in 

use to identify measures needed to enhance safety and reduce go-arounds. 

That analysis also should designate responsibility for staggering approaches 

when that runway configuration is in use. 

3. Restructure the existing NMAC reporting process so that the actual safety 

risks posed by reported events are accurately reflected. Actions to better 

reflect actual safety risks could include developing a procedure to reclassify 

no-hazard events, redefining the NMAC criteria, or revising the term 

“NMAC.” 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

We provided FAA with a draft of this report on January 30, 2008, and received 

FAA’s reply on April 1, 2008. FAA’s full response is included in the appendix to 

this report. FAA concurred with each of our recommendations and provided 

appropriate planned actions and target dates. 

• Recommendation 1: FAA stated that as it reviews and develops new or 

revised air traffic procedures under airspace redesign, it will conduct the 

recommended evaluation to minimize potential conflicts with general 

aviation VFR air traffic. 

• Recommendation 2: FAA stated the ATO Safety office will work with the 

ATO Terminal office, New York TRACON, and Newark tower to complete 

an initial safety assessment of the simultaneous arrival procedure at Newark 

Liberty International Airport by May 1, 2008. The managers of the New 

York TRACON and the Newark tower are already working this issue, and 

results of this initial work will be included in the assessment. If the 

assessment determines that changes are required, the process will be 

completed by July 1, 2008. 
 17

• Recommendation 3: FAA stated the ATO Safety office will work with the 

Air Traffic Safety Oversight office and consult with ATO Systems 

Operations, ATO Enroute and Oceanic Safety, as well as ATO Terminal 

Safety to research the history behind the existing NMAC definition and, if 

appropriate, will initiate the proposed change to the definition. By 

May 30, 2008, the appropriate groups will meet to determine required 

changes. No later than October 1, 2008, the appropriate groups will write the 

change proposal to the definition of a NMAC, request comments from 

interested parties, and implement the change through the appropriate office. 

ACTIONS REQUIRED 

FAA’s response and planned actions address the intent of our recommendations. 

We therefore consider these recommendations resolved. 

We appreciate the courtesies and cooperation of FAA representatives during this 

audit. If you have any questions concerning this report, please contact Lou Dixon, 

Assistant Inspector General for Aviation and Special Program Audits, at (202) 

366-0500 or Dan Raville, Program Director, at (202) 366-1405. 

# 

cc: FAA Acting Deputy Administrator 

 Anthony Williams, ABU-100 

 Martin Gertel, M-1 
18

EXHIBIT A. SCOPE AND METHODOLOGY 

We conducted this performance audit in accordance with generally accepted 

Government Auditing Standards prescribed by the Comptroller General of the 

United States. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence that provides a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe the evidence 

obtained provides a reasonable basis for our findings and conclusion based on our 

audit objectives. We conducted this review between June 2007 and January 2008 

using the following methodology. 

To determine the root cause of the near misses in May 2007 in the New York 

airspace and FAA’s measures to address these problems, we visited FAA 

Headquarters in Washington, D.C., and the New York area air traffic facilities in 

which the five near misses occurred. These included the New York TRACON and 

John F. Kennedy, Newark, LaGuardia, and Stewart Airports. We interviewed key 

FAA officials from the Air Traffic Organization Safety and Terminal Services 

Offices and the Air Traffic Oversight Services division to discuss possible root 

causes and the status of any FAA actions. We reviewed FAA’s investigation 

report of the five NMACs to identify any recommended actions. 

At each air traffic facility where a NMAC occurred, we interviewed Air Traffic 

management and union representatives to obtain their view of possible root causes 

and actions taken at the local level in response to the NMACs. We examined 

controller staffing, time on position, workload, and work schedules at the time of 

each incident to determine if staffing or fatigue were contributing factors. We 

reviewed radar data associated with each incident and analyzed each of the five 

NMAC preliminary reports. We interviewed Safety Inspectors that investigated 

the NMACs and reviewed each of five NMAC final investigation reports. 

To determine if any of the New York airports allow arriving aircraft to fly directly 

over aircraft on another runway—a procedure that FAA halted at Memphis 

Airport in April 2007—we interviewed FAA officials from the Air Traffic 

Organization Safety Office, Air Traffic Organization Terminal, and the Air Traffic 

Oversight Services division to obtain a detailed explanation of the halted Memphis 

procedure and the reason it was halted. We met with Air Line Pilots Association 

headquarters officials to obtain their concerns regarding the Memphis procedure. 

We also interviewed management and union representatives and observed the 

operations at Newark, John F. Kennedy, LaGuardia, and Stewart Airports to 

determine if a similar procedure was in use. 

We did not rely on automated databases as part of this audit. 

Exhibit A. Scope and Methodology 
 19

EXHIBIT B. AGENCIES VISITED OR CONTACTED 

• FAA officials from Safety Services and Terminal within the Air Traffic 

Organization. 

• FAA officials from the Air Traffic Safety Oversight Services group within 

FAA’s Safety line of business. 

• Air Line Pilots Association, International (ALPA) Headquarters officials in 

Herndon, VA. 

• Facility management and National Air Traffic Controllers Association 

(NATCA) facility representatives from the New York TRACON (N90), and 

Kennedy, LaGuardia, and Newark Air Traffic Control towers. 

• Facility management from Stewart Air Traffic Control tower. 

• Local Flight Standards District Offices (FSDO) representatives responsible for 

investigating the NMACs. 

• JetBlue Headquarters officials (2 of the NMACs were from this airline). 

• Continental and Express Jet (Jetlink) airline officials (1 NMAC each from 

these airlines). 

• Program Manager for the New York/New Jersey/Philadelphia metropolitan 

Area Airspace Redesign. 

Exhibit B. Agencies Visited or Contacted 
 20

Exhibit C. Major Contributors to This Report 

EXHIBIT C. MAJOR CONTRIBUTORS TO THIS REPORT 

THE FOLLOWING INDIVIDUALS CONTRIBUTED TO THIS REPORT.

Daniel Raville Program Director 

Mary (Liz) Hanson Project Manager 

Annie Glenn Senior Analyst 

Mark Gonzales Senior Analyst 

Ben Huddle Analyst 

Amy (Tasha) Thomas Analyst 

Andrea Nossaman Writer-Editor 

Jean Diaz Writer-Editor 

 
21

EXHIBIT D. REQUEST FROM SENATOR CLINTON 

HILLARY RODHAM CLINTON COMMITTEES: 

NEW YORK ARMED SERVICES 

ENVIRONMENT AND PUBLIC WORKS 

SENATOR HEALTH, EDUCATION, LABOR, AND PENSIONS 

SPECIAL COMMITTEE ON AGING 

RUSSELL SENATE OFFICE BUILDING SUITE 476 

WASHINGTON, DC 20510-3204 

202-224-4451 WASHINGTON, DC 20510-3204 

June 11, 2007

The Honorable Calvin L. Scovel III 

Inspector General 

United States Department of Transportation 

400 Seventh Street, S.W. 

Washington, D.C. 20590 

Dear Mr. Scovel: 

I write in regard to the disturbing reports that in the month of May, there were five nearmisses involving commercial aircraft In the New York metropolitan area. This is especially shocking 

in light of the fact that there were only three such occurrences in all of 2006. 

The New York metropolitan region is the busiest, most complex and compact airspace in the 

country. There is no room for error. Safe and efficient operations are critical to the traveling public 

and the economy of the New York metropolitan area. It is imperative that this pattern is corrected 

before the onset of the busy summer travel season. 

I understand that the Federal Aviation Administration (FAA) has begun its internal 

investigation; however these incidents call for a broader investigation into the safety of our nation’s 

busiest system and our ability to avoid catastrophic airline collisions. I request that you immediately 

conduct an investigation into the root causes for these near misses in the New York region and the 

actions the FAA is taking to resolve these issues. 

Specifically, I would ask that your investigation review the following questions: 

• What is the root cause of the near misses in May of 2007 in the New York airspace? 

• How is the FAA addressing these problems and what measures has the FAA taken to prevent 

repeat occurrences? 

• In April of this year, the FAA ordered a halt to the practice at Memphis International Airport 

that allowed arriving aircraft to fly directly over planes on another runway that had nearly 

resulted in a midair collision. Do any of the airports in the New York area practice this type 

of procedure? 

I look forward to your response and thank you for attention to this matter. 

 Sincerely yours, 

Hillary Rodham Clinton 

Exhibit D. Request From Senator Clinton 
 22

APPENDIX. AGENCY COMMENTS 

Federal Aviation 

Administration 

Memorandum 

Date: April 1, 2008 

To: Lou E. Dixon, Assistant Inspector General for Aviation and Special Program Audits 

From: Ramesh K. Punwani, Assistant Administrator for Financial Services/CFO 

Prepared by: Anthony Williams, x79000 

Subject: OIG Draft Report: Review of Reported Near Mid-Air Collisions in the New York 

Metropolitan Airspace 

Thank you for the opportunity to review and comment on the findings and recommendation of the 

subject draft report dated January 30. FAA concurs with each of your recommendations and the 

agency’s planned actions for each is as follows: 

OIG Recommendation 1: As part of the review and development of new or revised air traffic 

procedures under airspace redesign, evaluate whether commercial instrument flight rules (IFR) arrival 

and departure routes into and out of the New York Terminal Radar Approach Control’s (TRACON) 

airspace should be redesigned or restricted to minimize potential conflicts with general aviation visual 

flight rules (VFR) air traffic.

FAA Response: Concur. As we review and develop new or revised air traffic procedures under 

airspace redesign, we will conduct the recommended evaluation. 

OIG Recommendation 2: Conduct a safety analysis of the simultaneous arrival procedures at 

Newark Liberty International Airport when the runway 22L and 11 configuration is in use to identify 

measures needed to enhance safety and reduce go-arounds. That analysis should also designate 

responsibility for staggering approaches when that runway configuration is in use. 

FAA Response: Concur. The Air Traffic Organization (ATO) Safety office will work with 

ATO-Terminal office, N90 and EWR ATCT to complete an initial Safety assessment. This initial 

assessment will be completed by May 1 and if further safety analysis is required, the ATO-Terminal 

office will be asked to complete with whatever assistance from the ATO-Safety office is requested. 

Although this issue stems from issues other than the original near mid-air collision (NMAC) 

investigation, we feel that its inclusion in the report is appropriate due to the possibility of go-arounds 

and missed approaches at the Newark Airport which affects the New York Area Airspace. The 

Manager of the New York TRACON and the Manager of Newark ATCT are already working this 

issue and initial work will be included in the assessment. If the assessment determines that changes 

are required we will encourage that process to be concluded by July 1. 

Appendix. Agency Comments 
 23

Appendix. Agency Comments 

OIG Recommendation 3. Restructure the existing near mid-air collision (NMAC) reporting process 

so that the actual safety risks posed by reported events are accurately reflected. Actions to better 

reflect actual safety risk could include developing a procedure to reclassify no-hazard events 

redefining the NMAC criteria, or revising the term “NMAC.” 

FAA Response: Concur. The ATO Safety office will work with the Air Traffic Safety Oversight 

Office and consult with ATO Systems Operations, ATO-Enroute and Oceanic Safety, as well as 

ATO-Terminal Safety to research the history behind the existing definition and if appropriate will 

initiate the Change Proposal. We will meet with the appropriate groups referred to by May 30 and 

determine the requirements and accept all input. Following May 30, we will write the change 

proposal, accept all comments and implement through the appropriate office if necessary. Final date 

will be no later than October 1.

If you have any questions or need further information, please contact Anthony Williams, Budget 

Policy Division, ABU-100 on (202) 267-9000. 
The following pages contain textual versions of the graphs and charts included in 

this document. These pages were not in the original document but have been 

added here to accommodate assistive technology. 
Review of Reported Near Mid-Air Collisions in the New York Metropolitan 

Airspace 

Section 508 Compliant Presentation 

Table 1. Five Reported Near Mid-Air Collisions (NMAC) During May 2007 in 

New York Airspace 

Date of Near 

Mid-Air 

Collision (or 

NMAC)

Facility and NMAC 

Number 

Reporting 

Aircraft and 

Flight Rules 

Second Aircraft 

and Flight Rules 

Hazard 

Classification

May 1, 2007 N90-003 Reporting aircraft 

involved: 

JetBlue, 

operating under

instrument flight 

rules 

Second aircraft 

involved: 

Unidentified 

aircraft, operating 

under visual flight 

rules 

No Hazard 

May 5, 2007 N90-004 Reporting aircraft 

involved: 

JetLink, 

operating under

instrument flight 

rules 

Second aircraft 

involved: 

Unidentified 

aircraft, operating 

under visual flight 

rules visual flight 

rules 

Potential 

May 8, 2007 N90-005 Reporting aircraft 

involved: 

JetBlue, 

operating under

instrument flight 

rules 

Second aircraft 

involved: 

Unidentified 

aircraft, operating 

under visual flight 

rules visual flight 

rules 

No Hazard 

May 21, 2007 N90-006 Reporting aircraft 

involved: 

Continental, 

operating under

instrument flight 

rules 

Second aircraft 

involved: 

Unidentified 

aircraft, operating 

under visual flight 

rules visual flight 

rules 

No Hazard 

May 17, 2007 JFK-001 Reporting aircraft 

involved: 

American Eagle, 

operating under

instrument flight 

rules 

Second aircraft 

involved: US 

Helicopter, 

operating under 

visual flight rules 

visual flight rules 

No Hazard 
Table 2. Similar Characteristics of the Four N90 Near Mid-Air Collisions 

Date Facility 

and 

NMAC 

Number 

Nature of 

Class E 

Airspace 

Proximity 

to Change 

of 

Airspace 

Proximity 

to 

Transfer 

of Control 

May 1, 2007 N90-003 Nature of 

Class E 

Airspace: 

Yes 

Proximity 

to Change 

of 

Airspace: 

Yes 

Proximity 

to Transfer 

of Control: 

No 

May 5, 2007 N90-004 Nature of 

Class E 

Airspace: 

Yes 

Proximity 

to Change 

of 

Airspace: 

Yes 

Proximity 

to Transfer 

of Control: 

Yes 

May 8, 2007 N90-005 Nature of 

Class E 

Airspace: 

Yes 

Proximity 

to Change 

of 

Airspace: 

No 

Proximity 

to Transfer 

of Control: 

Yes 

May 21, 2007 N90-006 Nature of 

Class E 

Airspace: 

Yes 

Proximity 

to Change 

of 

Airspace: 

Yes 

Proximity 

to Transfer 

of Control: 

Yes 

Figure 1. Various Classifications of New York Airspace 

Picture chart showing the various types of airspace in and around the New York 

metropolitan area. 

Source: FAA 

Figure 2. Helicopter Departing Helipad at JFK 

Photograph shows a helicopter departing the helipad at JFK airport. 

Source: OIG 

Figure 3. Aircraft Departing Runway 13R 

Photograph of an aircraft taking off from runway 13R which shows the adjacency 

of the runway to the helipad at JFK. 

Source: OIG 
Table 3. Controller Staffing at the Time of the N90 Near Mid-Air Collisions 

Date Facility & 

NMAC 

Number 

Scheduled 

Staffing 

Actual 

Staffing 

Number of 

Controllers 

Off Position 

(Percentage of 

Staffing for 

that Shift) 

Position 

Combined?

May 1, 2007 N90-003 Scheduled 

Staffing: 11 

Actual 

Staffing: 12 

Number of 

Controllers Off 

Position 

(Percentage of 

Staffing for that 

Shift) 7 (58 

percent) 

No combined 

position 

May 5, 2007 N90-004 Scheduled 

Staffing: 13 

Actual 

Staffing:11 

Number of 

Controllers Off 

Position 

(Percentage of 

Staffing for that 

Shift) 3 (27 

percent) 

No combined 

position 

May 8, 2007 N90-005 Scheduled 

Staffing: 11 

Actual 

Staffing:10 

Number of 

Controllers Off 

Position 

(Percentage of 

Staffing for that 

Shift) 4 (40 

percent) 

No combined 

position 

May 17, 2007 JFK-001 Scheduled 

Staffing: 12 

Actual 

Staffing:10 

Number of 

Controllers Off 

Position 

(Percentage of 

Staffing for that 

Shift) 5 (50 

percent) 

No combined 

position 

May 21, 2007 N90-006 Scheduled 

Staffing: 17 

Actual 

Staffing:16 

Number of 

Controllers Off 

Position 

(Percentage of 

Staffing for that 

Shift) 5 (31 

percent) 

No combined 

position 
Table 4. Individual Controller Shift Metrics When the Near Mid-Air 

Collisions Occurred 

Date Facility and 

NMAC 

Number 

Number of 

Hours Off 

Duty Prior 

to NMAC 

Shift 

Number of 

Consecutive 

Minutes 

Worked at 

Time of 

NMAC 

Overtime 

Scheduled 

Week of 

NMAC? 

Hours of 

Overtime 

Worked 

Week of 

NMAC 

May 1, 2007 N90-003 Number of 

Hours Off 

Duty Prior to 

NMAC Shift:

39 

Number of 

Consecutive 

Minutes 

Worked at 

Time of 

NMAC: 37 

Overtime 

Scheduled 

Week of 

NMAC? No 

Hours of 

Overtime 

Worked 

Week of 

NMAC: 0 

May 5, 2007 N90-004 Number of 

Hours Off 

Duty Prior to 

NMAC Shift: 

15 

Number of 

Consecutive 

Minutes 

Worked at 

Time of 

NMAC: 67 

Overtime 

Scheduled 

Week of 

NMAC? No 

Hours of 

Overtime 

Worked 

Week of 

NMAC: 0 

May 8, 2007 N90-005 Number of 

Hours Off 

Duty Prior to 

NMAC 

Shift:16 

Number of 

Consecutive 

Minutes 

Worked at 

Time of 

NMAC: 36 

Overtime 

Scheduled 

Week of 

NMAC? No 

Hours of 

Overtime 

Worked 

Week of 

NMAC: 0 

May 17, 2007 JFK-001 Number of 

Hours Off 

Duty Prior to 

NMAC 

Shift:14 

Number of 

Consecutive 

Minutes 

Worked at 

Time of 

NMAC: 56 

Overtime 

Scheduled 

Week of 

NMAC? No 

Hours of 

Overtime 

Worked 

Week of 

NMAC: 2 

May 21, 2007 N90-006 Number of 

Hours Off 

Duty Prior to 

NMAC 

Shift:16 

Number of 

Consecutive 

Minutes 

Worked at 

Time of 

NMAC: 61 

Overtime 

Scheduled 

Week of 

NMAC? No 

Hours of 

Overtime 

Worked 

Week of 

NMAC: 8 

Figure 4. Diagram of Arriving Aircraft With Intersecting Paths 

Diagram showing how arriving aircraft can be positioned with intersecting paths. 

Source: FAA