Originally Posted by
ATC Watcher
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My wild guess here , having followed tis thread since the beginning , is that the , rush to depart plus this " Nr 1 " and the 40 seconds idle are the keys. If that is the case , we do not need to change procedures but enforce existing ones. (i.e. training)
I agree however I think one thing should change, assuming I’ve understood their AIP, and that is to change to use of 24/7/365 stop bars for runway entry points. If they had been used, (from current transcript) the CG crew would have had the red stop bars preventing them from entering.
The ATCO had only cleared them to the hold, and wouldn’t have deselected the stop bar. The CG crew thinking they’re cleared to enter would have called to the tower the stop bars were still at “stop”. Without the illuminated bars there was no visual clue to break the ‘enter’ mindset.
For those unfamiliar when an ATCO gives the enter clearance be it take off or Line up, they simultaneously press OFF for the stop bar. That then turns off the red lights which are normally on a timer to automatically turn back on, E.g. one minute. If they forget or miss the button the stop bar stays on, and a crew must challenge ATC and not cross the line of reds.
I have a thought re the 40 secs. We know the CG crew almost certainly didn’t hear the JAL516 landing clearance, but heard the slow down for JAL116.
I’ve experienced similar type mission aircraft requiring 25secs or more stationary to align systems prior to departure.
My Tom Clancy bit :
So the line up mindset gets them on the runway, sensor operator says I need 25 seconds to align system X. CG Crew knows they have a gap as they heard tower making it for them by slowing Jal116 for the CG departure. The crew are lulled into a false sense of security, they have the gap, sensors are aligning, therefore no immediate threat. They don’t flag it up to tower because they’re just waiting for the sensor operator to confirm system’s alignment, before starting to roll. So there’s a scenario where they are happy, stationary, on the centre line for 30 seconds or so before any doubts flag up.