Go Back  Airline Pilot Central Forums > Pilot Lounge > Safety
Runway Incursion/Near Miss JFK 13-JAN-2023 >

Runway Incursion/Near Miss JFK 13-JAN-2023

Notices
Safety Accidents, suggestions on improving safety, etc

Runway Incursion/Near Miss JFK 13-JAN-2023

Old 01-16-2023, 11:41 AM
  #11  
Gets Weekends Off
 
RI830's Avatar
 
Joined APC: Mar 2011
Position: Left seat on a kite
Posts: 1,884
Default

Did Les Abend make a impromptu flight to catch up on writing material?
Every article seemed to be about some emergency on every flight he took from his 75/76 days thru his retirement on the 777.

Last edited by RI830; 01-16-2023 at 12:10 PM.
RI830 is offline  
Old 01-16-2023, 01:33 PM
  #12  
New Hire
 
Joined APC: Oct 2022
Posts: 9
Default

Originally Posted by 450knotOffice View Post
From 120-66B, the Advisory Circular that governs he ASAP program:


9. GUIDELINES FOR ACCEPTANCE OF REPORTS UNDER ASAP.

b. Criteria for Acceptance. The following criteria must be met in order for a report involving a possible violation to be covered under ASAP:

(2) The alleged regulatory violation must be inadvertent, and must not appear to involve an intentional disregard for safety.

So unless these pilots can be shown to have intentionally disregarded safety (possibly by disregarding sterile cockpit during taxi), then theyíll likely be accepted into the ASAP program.
B was replaced by C. The large change was ERC is voting on exclusion, not acceptance and redefined exclusion criteria.

120-66C states the following,

GUIDELINES FOR EXCLUSION OF REPORTS UNDER THE ASAP. This paragraph discusses exclusion criteria for ASAP reports.


18.2 Reckless Conduct. Reports of an apparent violation involving reckless conduct are excluded. Reckless conduct is an act (or failure to act) demonstrating a gross disregard for, or deliberate indifference to, safety or a safety standard.

18.3 Intentional Conduct. Reports involving intentional conduct are excluded. Intentional conduct is an act (or failure to act) while knowing that such conduct is contrary to a regulation or statute, or is otherwise prohibited.

Both are fairly steep tasks to prove. Even a violation of sterile won't necessary cause an exclusion. You would need the crews to state or gather through the investigative process that they knew they were violating sterile and said screw it. Something to acknowledge they knew what they were doing was wrong and did it anyway. Had tons of ASAP's sole-source and non-sole source where crews cited sterile violations that were accepted.

Even with an accepted report, the corrective action will have remedial training in this event.
joepilot50 is offline  
Old 01-16-2023, 02:25 PM
  #13  
Gets Weekends Off
 
Joined APC: Jul 2017
Posts: 1,145
Default

I doubt there was willful disregard here. ASAP should cover it. It also gets details into the system for improvements. On one of the planes I used to fly we used to consistently taxi to 31L in the sim. With busy radios and a little expectatiob-bias I could totally see myself hearing "Cross 31L and hold short of 4L." then thinking "Cross 4L and hold short of 31L". Getting the crew's input into SMS will probably yield more results than smacking them on the head.
Elevation is offline  
Old 01-16-2023, 02:28 PM
  #14  
Gets Weekends Off
 
Joined APC: Jul 2017
Posts: 1,145
Default

Originally Posted by JohnBurke View Post
ASAP does not consider the severity of the event in covering what may be reported, only that it not be illegal or intentional; if a severe hazard were not covered, then it would eliminate the intent of the program, which is to encourage disclosure of safety-related events.

It is evident from the tapes that traffic was departing both 31L and 4L, as aircraft are cleared to line up and wait, and takeoff, on both runways.

The initial clearance, and the subsequent taxi clearance, should have included the destination runway. In fact, that's recorded: "106 Heavy, Kennedy Ground, runway 4 left, taxi left bravo, hold short of kilo."

There are those occasions when one does not know the departure runway at the outset (or, of course, it changes). In this case, absent any information regarding changes, we can only go by what's given; the crew doesn't ask for additional time to re-brief or re-calculate or re-program, if if they do, it's not presented. The departure briefing should have already been done, along with the taxi briefing. The FMC should have included the departure runway, and the crew should have written down the clearance, and in many cases, highlighted the taxi route and discussed it prior to brake release. This may very well have been done, as it's standard procedure and very basic. Any changes to what had been planned, should have resulted in stopping the aircraft while the new routing was discussed and briefed, and verification made on the taxi diagram of the routing, hotspots, etc. JFK, as most of us know, is one big hot spot. It's easy to make a mistake, which means one must be particularly vigilant. Basic.

On the recording, AA106 received taxi clearance with the runway as the destination, but the readback (which may have been edited) does not include the runway reference ("bravo, hold short of kilo, American 106"), which is required. The controller is not recorded as requiring it, and as we also all know, JFK can be a very busy place. The first recording omits a lot of talk, and the second one focuses only on the time of the incursion. That said, the taxi clearance limit was given, and read back: hold short kilo.

A basic tenet of ATC clearances is that any time there is a misunderstanding, we request clarification. But what if we have no sense that there's a misunderstanding?

Confirmation bias: we hear what we expect to hear. The initial clearance does not mention runway 31L. The only runway given is 4L. The subsequent clearance to cross is to cross 31L. Does the crew hear this and transpose the runways, thinking they're going to 31L? Logically, improbable, but practically? Maybe. Regardless, there are safeguards here, starting with the initial clearance and briefing, programming the FMC, and of course, the takeoff data planned for the departure runway: the crew was cleared to 4L; had they planned a different runway, would we have heard them question the runway assignment, or is that simply missing from the tape? We don't know. But, based on what we are given, as presented, there is no such interaction with ATC. The appearance is that the crew had performance numbers for, FMC programming for, and had briefed runway 4L; they never question the clearance and except for reading back the runway assignment, accept the clearance, read back the routing, and the hold short clearance. So, that gets them to holding short of Kilo, on Bravo.

The next clearance, however does invoke runway 31L: "American 106, cross runway 31 left at Kilo." It was read back the same. As the initial taxi clearance was to the departure runway 4L, the clearance to cross does not repeat 4L, as that's already been given (the crew failed to read it back, or at least, was not recorded on the youtube rendering, reading 4L back). Now, with only a clearance to cross, the crew hears cross 31L at Kilo. The obvious question is whether 31L now figures into confirmation bias, whether the crew was disoriented on the runway or location, or some other factor. Given runway and taxiway markings and a clearance given and read back, however, it's difficult to argue that the crew didn't have a clear direction on what to do. If they misunderstood, the obligation was on them to stop the aircraft and query, and certainly to stop the aircraft, verify on the charts, and agree on the next course of action. Given that they seem unaware that something happened, or that they'd gone to the wrong runway, it also seems that the felt in agreement about the taxi path; any discussion otherwise would be on the CVR, not on youtube.

Here's my problem: when I cross a runway, I light the airplane up like a christmas tree, and most places I've operated require confirmation of a clearance to cross, prior to crossing. Places like JFK where it can be an endless sea of lights, and a continuous daisy chain of aircraft, getting any extra verbiage can be a problem. However, personally, if I'm going to cross a runway, after I light the airframe up so it can be seen from outer space on a cloudy day, I seek confirmation of clearance to cross. Cheap insurance. Especially if an aircraft is lined up and waiting, or lining up to wait. My healthy paranoia and fear of anything that makes a shadow prompts me to have that same hair-on-the-back-of-my-neck spidey sense as crossing a train track or covering a body part with the muzzle of a firearm...runways are dangerous places. Given that both intersecting runways, 4L and 31L were active with aircraft lining up to wait, and departing, crossing either one should have merited that same caution. I don't really care if my company requires a confirmation to cross or not: I'm getting confirmation and someone can slap my wrist later if they thought I talked too much.

What could the 777 crew have possibly been thinking was their game plan, as they taxied to runway 31L? We don't know, and shouldn't speculate. Wrong taxiway, wrong routing, wrong runway, wrong direction, wrong signage, wrong clearance, no confirmation. This, in the face of having run performance numbers for a different runway (4L), accepted a clearance for 4L, received taxi directions for 4L, been given a hold short on the way to 4L at Kilo, and almost certaily having briefed the taxi to 4L. What could they have been thinking? I'm quite certain of what they were not thinking: they were not thinking they'd intentionally taxi somewhere they weren't cleared. They were not thinking they'd taxi to a wrong runway. They were not thinking they'd create a runway incursion.

On Bravo, taxiway Kilo intersects at a right angle; there is no direct path forward to cross runway 4L, meaning there is no sign in front of AA106, when holding short of Kilo on Bravo, identifying 4L. The nearest runway sign for 4L is ahead and to the left on Juliet. Immediately to the right, on Kilo, is the runway sign for runway 31L; this would be the nearest and most obvious sign; both Kilo and Juliet should have had red stop bars where they entered the runway. To me, personally, that red stop bar elicits and inner voice that says "get confirmation."

After making the big circle around the airport, perhaps the crew got a little disoriented as to what direction they were going; that's why we have taxi diagrams. Let the first one among us who hasn't at least once either missed a turn, taken the wrong taxiway, or become disoriented at a busy place, throw the first stone (ever try taxiing at Madrid? The person who designed the ramp, runway, and taxi designators should be shot, dragged through broken glass, soaked in lighter fluid, set ablaze, then urinated upon by a troupe of baboons on an all-garlic diet, before being thrown headfirst into a vat of sulfuric acid. I've thought this through).

In Incheon, there's a wonderful system when landing and taxiing to the runway, in which the controller simply identifies the runway and taxi clearance, and says "follow the green." Green lights illuminate for the immediate portion of the taxi to be made, and go no further than the taxi clearance. When cleared to cross, the next portion lights up, and so on, making orientation and identification easy...they do that right into the parking spot. It's great. JFK is neither ICN nor MAD...but it can be, at times, confusing. This appears to be a case in which confusion existed, but was not perceived: the crew did not know, or seem to know, what had happened.

This brings up perhaps the most immediate salient point. At what point did the departing Delta flight become aware of the incursion and reject? A youtube video guesses where the airplanes were in relation to one another, but at what point did AA106 enter the runway and where did the Delta crew see and become aware? At what point did the controller become aware? It appears that the American crew was not aware; there are multiple players. so the question is dynamic with variables. Clearly the Delta crew and the controller both moved to avert what could have been a very bad outcome, and the calm in the voices of both the Delta crew and the controller(s) is commendable. It was handled quite professionally.

The easy choice to to point fingers at the AA crew; it was their incursion. Better to explore why it got there, went there, and how to ensure it doesn't. I think, in general, we all have a keen understanding of what is required to prevent events like this from occurring. We have multiple safeguards, and yet we do continue to see incursions that include crossing the wrong runway, or events such as landing or taking off from the wrong runway, a taxiway, or a closed runway, or even landing at the wrong airport. Rare, but they continue. The procedures and practices to prevent such events are well known, standard procedure, and nearly universal. Perhaps the takeaway here is that failure to adhere to all the standard procedures, omitting even one (if that's what happened here), can place not only us, but others, in jeopardy.

Personally, when taxiing, I like to call out the next turn (coming up on Kilo, hold short Kilo, or approaching kilo, right turn on kilo), with a confirmation. If I'm in a cockpit with additional crew, such as a heavy crew, I want them to have their taxi diagrams out and be following along, too.

This event will go to ASAP, and we probably, as the peanut gallery, won't get the full picture, which is unfortunate. It's still a good object lesson, though.
Well put, man.
Elevation is offline  
Old 01-17-2023, 05:30 AM
  #15  
Gets Weekends Off
 
RI830's Avatar
 
Joined APC: Mar 2011
Position: Left seat on a kite
Posts: 1,884
Default

Dubai also has the ďfollow the greens to stand 105Ē system.
Itís fabulous!!
RI830 is offline  
Old 01-17-2023, 10:37 AM
  #16  
Prime Minister/Moderator
 
rickair7777's Avatar
 
Joined APC: Jan 2006
Position: Engines Turn Or People Swim
Posts: 36,359
Default

Originally Posted by Twin Wasp View Post
Not according to the FAA RWSL page. https://www.faa.gov/air_traffic/technology/rwsl/

There are RELs on Juliet crossing 4L but no THLs on 4L.
Correct, typo on my part, I meant to say *no* RWSL on the 4's.

That is the systemic issue IMO. We can't rely on single-points of failure for runway incursions, either pilot or controller (since the FO may be heads down or talking to the cabin, ops, etc you can't rely on pilot redundancy at all times). I've personally experienced both controller and pilot errors related to runway incursions, and one of them was close. RWSLs provide an extra layer of defense.
rickair7777 is offline  
Old 01-17-2023, 10:45 AM
  #17  
Prime Minister/Moderator
 
rickair7777's Avatar
 
Joined APC: Jan 2006
Position: Engines Turn Or People Swim
Posts: 36,359
Default

Originally Posted by joepilot50 View Post
Both are fairly steep tasks to prove. Even a violation of sterile won't necessary cause an exclusion. You would need the crews to state or gather through the investigative process that they knew they were violating sterile and said screw it. Something to acknowledge they knew what they were doing was wrong and did it anyway. Had tons of ASAP's sole-source and non-sole source where crews cited sterile violations that were accepted.
I have heard rumblings over the years from gatekeeper and ERC members that granting asap relief for sterile violations is a point of contention.

I kind of get that, it's one thing to forget yourself and say "that's a nice sunrise". It's another to have a sustained non-sterile conversation while taxiing... that's starting to seem intentional. On the descent it might be plausible that you didn't notice through 10 and kept chatting for a while.
rickair7777 is offline  
Old 01-17-2023, 11:32 AM
  #18  
New Hire
 
Joined APC: Oct 2022
Posts: 9
Default

Originally Posted by rickair7777 View Post
I have heard rumblings over the years from gatekeeper and ERC members that granting asap relief for sterile violations is a point of contention.

I kind of get that, it's one thing to forget yourself and say "that's a nice sunrise". It's another to have a sustained non-sterile conversation while taxiing... that's starting to seem intentional. On the descent it might be plausible that you didn't notice through 10 and kept chatting for a while.
Absolutely.

Violation of sterile is not an automatic exclusion is my main point. If a violation of sterile occurred in this event, if the violation of sterile was a one off comment that led to distraction and SA, crew should be fine. If itís sustained talking about sports, contract, whatever itís going to be hard to defend. And if there was sustained talking, you damn well know a question in their interviews will be about sterile. Crews canít lie as that will lead to exclusion as well.
joepilot50 is offline  
Old 01-19-2023, 05:58 AM
  #19  
In a land of unicorns
 
Joined APC: Apr 2014
Position: Whale FO
Posts: 5,934
Default

Originally Posted by joepilot50 View Post
Absolutely.

Violation of sterile is not an automatic exclusion is my main point. If a violation of sterile occurred in this event, if the violation of sterile was a one off comment that led to distraction and SA, crew should be fine. If itís sustained talking about sports, contract, whatever itís going to be hard to defend. And if there was sustained talking, you damn well know a question in their interviews will be about sterile. Crews canít lie as that will lead to exclusion as well.
Did they pull the CVR in time though? They never went back to the gate, I don't think 777 CVR holds 8 hours of data?
dera is offline  
Old 01-19-2023, 07:31 AM
  #20  
Prime Minister/Moderator
 
rickair7777's Avatar
 
Joined APC: Jan 2006
Position: Engines Turn Or People Swim
Posts: 36,359
Default

Originally Posted by dera View Post
Did they pull the CVR in time though? They never went back to the gate, I don't think 777 CVR holds 8 hours of data?
If flights ops told them they could go, they're good.

Not unreasonable, since they're doing an asap anyway they should be honest about what happened. Almost certainly an honest goof, safe to assume they weren't watching movies or sleeping while taxiing at kennedy.
rickair7777 is offline  
Related Topics
Thread
Thread Starter
Forum
Replies
Last Post
AUS_ATC
Cargo
29
02-02-2007 06:17 AM
miker1369
Major
4
11-24-2006 12:55 AM
JustAMushroom
Regional
31
10-10-2006 07:20 AM
AUS_ATC
Cargo
9
04-15-2006 09:10 AM
Boeingguy
Major
10
12-17-2005 08:27 AM

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off
Trackbacks are On
Pingbacks are On
Refbacks are On


Thread Tools
Search this Thread