AA 106 @ JFK (13 Jan 23)
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AA 106 thought they were taking off on 31L despite being cleared to 4L and from that point on, classic confirmation bias took over. Confirmation bias is pervasive in much of human endeavors....politics, investing, medicine and certainly aviation.
One of the most extreme examples of confirmation bias in aviation was the Comair CRJ crew at LEX. They were so certain that they were on the right runway, and they hurled down a 3000 foot unlit runway, passing the correct lit runway on the way. Tenerife was also largely due to this bias as well.
One of the most extreme examples of confirmation bias in aviation was the Comair CRJ crew at LEX. They were so certain that they were on the right runway, and they hurled down a 3000 foot unlit runway, passing the correct lit runway on the way. Tenerife was also largely due to this bias as well.
Last edited by Lake1952; 12th Mar 2023 at 14:44.
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AA 106 thought they were taking off on 31L despite being cleared to 4L and from that point on, classic confirmation bias took over. Confirmation bias is pervasive in much of human endeavors....politics, investing, medicine and certainly aviation.
One of the most extreme examples of confirmation bias in aviation was the Comair CRJ crew at LEX. They were so certain that they were on the right runway, and they hurled down a 3000 foot unlit runway, passing the correct lit runway on the way. Tenerife was also largely due to this bias as well.
One of the most extreme examples of confirmation bias in aviation was the Comair CRJ crew at LEX. They were so certain that they were on the right runway, and they hurled down a 3000 foot unlit runway, passing the correct lit runway on the way. Tenerife was also largely due to this bias as well.
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One of the most extreme examples of confirmation bias in aviation was the Comair CRJ crew at LEX. They were so certain that they were on the right runway, and they hurled down a 3000 foot unlit runway, passing the correct lit runway on the way. Tenerife was also largely due to this bias as well.
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I remember a discussion about the accident and how powerful the power of confirmation bias can be. When was the last time any of you air carrrier pilots have had to take off on an unlit runway a half hour or so before sunrise without being NOTAMed to death about the lights being OTS? And after just a few seconds into their roll, a long lit runway goes by...
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Sorry, but on their unfortunate takeoff roll down the unlit 26, they crossed the lit runway 22 used by air carriers. I didn't mean they crossed 22 on their taxi to 26, but they did cross 22 on their roll.
I remember a discussion about the accident and how powerful the power of confirmation bias can be. When was the last time any of you air carrrier pilots have had to take off on an unlit runway a half hour or so before sunrise without being NOTAMed to death about the lights being OTS? And after just a few seconds into their roll, a long lit runway goes by...
I remember a discussion about the accident and how powerful the power of confirmation bias can be. When was the last time any of you air carrrier pilots have had to take off on an unlit runway a half hour or so before sunrise without being NOTAMed to death about the lights being OTS? And after just a few seconds into their roll, a long lit runway goes by...
regardless.. due to their strong bias as you mentioned, prob no chance they would have recognized their error that far into their takeoff roll as they crossed the lit (correct) runway.
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But having rolled onto an unlit 3500 foot runway in the pre-dawn darkness, Comair could have still saved the day with a simple, "Tower, lights please."
The Comair crew even commented “That’s weird with no lights” at the start of their takeoff. FAR 139 requires runways used for air carrier operations to be lit so I’m fairly certain that was their first dark runway airline takeoff. But they were so locked into thinking they were doing it right that warning signs like a dark runway were overlooked.
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The Comair crew even commented “That’s weird with no lights” at the start of their takeoff. FAR 139 requires runways used for air carrier operations to be lit so I’m fairly certain that was their first dark runway airline takeoff. But they were so locked into thinking they were doing it right that warning signs like a dark runway were overlooked.
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But in the case of AA 106, they thought they were departing on 31L despite clear instructions to taxi to 4L. And the bizjet crew in the BOS incident believed they were cleared for takeoff. Tackling confirmation bias is a difficult task which must include CRM.
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In the late 70s and 80s, the concept of CRM expanded enormously in response to several well publicized accidents. It remains an important theme in the culture of aviation safety to this day. In many ways, the insidious nature of confirmation bias relates to CRM. But aviation needs to now shine an intense spotlight on confirmation bias and figure out what to do about it.
Another piece of the JFK puzzle I have not heard brought up...how many clues and cues did the crew of AA 106 ignore on their taxi before crossing 4L? How many takeoffs on 4L did they have a chance to see pass before them before the DL flight? Assuming that 4R was the main arrival runway, how many landings did they have a chance to see? Was there a "string of pearls " in the sky to their right perpendicular to their taxi route? Or was the crew thoroughly busy with their checklists. Did they notice that while taxiing parallel to 31L for a mile or more, there wasn't a single takeoff on that runway?
Obviously this is not a easy problem to solve... there's simply not enough frequency time for everything to be be verified ad infinitum.
Another piece of the JFK puzzle I have not heard brought up...how many clues and cues did the crew of AA 106 ignore on their taxi before crossing 4L? How many takeoffs on 4L did they have a chance to see pass before them before the DL flight? Assuming that 4R was the main arrival runway, how many landings did they have a chance to see? Was there a "string of pearls " in the sky to their right perpendicular to their taxi route? Or was the crew thoroughly busy with their checklists. Did they notice that while taxiing parallel to 31L for a mile or more, there wasn't a single takeoff on that runway?
Obviously this is not a easy problem to solve... there's simply not enough frequency time for everything to be be verified ad infinitum.
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The power of bias is shown in these examples and I know you think your process will solve the issue but i didn't see everyone agreeing. It has been discussed but not concluded. It has been shown that the brain will, in some circumstances, see, hear or feel what it expects to, not always what is actually there. Or in the comair case, see what is there, question it but still proceed. I don't know the answers but I don't think just adding more cross checks alone will overcome bias.
That is why most airlines now have their pilots independently crosscheck the runway number for departure. I believe that this is a direct result of the Comair accident.
There are all kinds of simple cross checks we can do. Check that the flight plan that we received has the proper flight number(along with things such as the weight and balance form. Check that the logbook on board is the proper one for the aircraft, checking the proper frequency before transmitting, checking that the MEL listed on the paperwork is the same MEL number written in the logbook, check that there is no ground equipment that would create a hazard is at the gate area prior to taxiing in an focusing on marshalling signals etc.
Many of these things are not written down as procedures, they are just good practice.
I certainly think that taking approximately one second to look at a runway sign is a better solution than saying that one doesn't know the answers and simply accepting that it will not be possible to overcome biases.
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In the late 70s and 80s, the concept of CRM expanded enormously in response to several well publicized accidents. It remains an important theme in the culture of aviation safety to this day. In many ways, the insidious nature of confirmation bias relates to CRM. But aviation needs to now shine an intense spotlight on confirmation bias and figure out what to do about it.
Another piece of the JFK puzzle I have not heard brought up...how many clues and cues did the crew of AA 106 ignore on their taxi before crossing 4L? How many takeoffs on 4L did they have a chance to see pass before them before the DL flight? Assuming that 4R was the main arrival runway, how many landings did they have a chance to see? Was there a "string of pearls " in the sky to their right perpendicular to their taxi route? Or was the crew thoroughly busy with their checklists. Did they notice that while taxiing parallel to 31L for a mile or more, there wasn't a single takeoff on that runway?
Obviously this is not a easy problem to solve... there's simply not enough frequency time for everything to be be verified ad infinitum.
Another piece of the JFK puzzle I have not heard brought up...how many clues and cues did the crew of AA 106 ignore on their taxi before crossing 4L? How many takeoffs on 4L did they have a chance to see pass before them before the DL flight? Assuming that 4R was the main arrival runway, how many landings did they have a chance to see? Was there a "string of pearls " in the sky to their right perpendicular to their taxi route? Or was the crew thoroughly busy with their checklists. Did they notice that while taxiing parallel to 31L for a mile or more, there wasn't a single takeoff on that runway?
Obviously this is not a easy problem to solve... there's simply not enough frequency time for everything to be be verified ad infinitum.
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Very important questions! Also, was 31L being used for departures too? At Kilo Alpha I think? No.matter how many clues, bias is very powerfull and subconscious, so not easy to spot by the conscious mind... Agree it will difficult to solve but only by examination in great detail and ensuring we have the ability to do that examination (availability of CVR for example) will we succeed.
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FAA SAFO (Safety Alert for Operators)
FAA issued a SAFO (Safety Alert fir Operators) by its Flight Standards Service - addressing the several incidents recently.
The SAFO is linked in this news release by FAA, as of March 22, 2023.
https://www.faa.gov/newsroom/faa-urg...safety-actions
The SAFO is linked in this news release by FAA, as of March 22, 2023.
https://www.faa.gov/newsroom/faa-urg...safety-actions
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Text of SAFO
http://www.faa.gov/other_visit/aviat...ne_safety/safo
A SAFO contains important safety information and may include recommended action. Besides the specific action recommended in a SAFO, an alternative action may be as effective in addressing the safety issue named in the SAFO. The contents of this document do not have the force and effect of law and are not meant to bind the public in any way. This document is intended only to provide clarity to the public regarding existing requirements under the law or agency policies.
Subject: Aviation Safety Call to Action.
Purpose: This SAFO informs the aviation community that several highly visible and notable recent events demonstrate the need for continued vigilance and attention to mitigation of safety risks. This SAFO applies to all aircraft operations conducted under Title 14 of the Code of Federal Regulations (14 CFR) Parts 91, 91 subpart K (Part 91K), 121, 125, 129, and 135.
Background: In recent months, a number of notable and high visibility events have occurred in the National Airspace System (NAS). While the overall numbers do not reflect an increase in incidents and occurrences, the potential severity of these events is concerning. Six serious runway incursions have occurred since January 2023, including an incident at John F. Kennedy International Airport in New York City involving a taxiing aircraft narrowly avoiding a departing aircraft and a landing aircraft coming within 100 feet of a departing aircraft at Austin-Bergstrom International Airport in Texas.
In February 2023, the acting Administrator of the Federal Aviation Administration (FAA) issued a Call to Action comprised of a series of events and initiatives to ensure focus and attention on risks to the aviation system. Senior leaders from the FAA, other government agencies, commercial and general aviation operators, labor partners and others attended a Safety Summit on March 15, 2023. Attendees discussed these recent incidents, as well as ways to enhance aviation safety.
Discussion: Safety management requires adapting to continual change. Effective safety management is designed to detect emerging safety issues, assess the level of risk and address those risks through mitigations. Those mitigations may be a change in processes, procedures or training. Operators should evaluate information collected through their safety management processes, identify hazards, increase and improve safety communications with employees and enact mitigations. Safety management systems,
policies and procedures must be able to account for a high rate of change.
Recommended Action: Recent events have highlighted several areas of focus. Directors of Operations, Chief Pilots, Directors of Training, Check Airmen, Directors of Safety, Program Managers, Pilots and Operators should review the following items and consider taking additional steps to ensure operations are conducted at the highest level of safety, including changes to procedures or training, if appropriate.
• Use all available internal communication processes to specifically highlight recent events and existing issues.
• Reinforce adherence to published processes and procedures, including checklists, Air Traffic
Control instructions, and internal company procedures.
• Ensure pilots and flight attendants have the same understanding of what “sterile flight deck” means and the risks associated with extraneous communication during this time.
• Explore helpful resources available for all pilots at: FAA Safety Team - FAASafety.gov.
• Encourage crews to diligently follow Crew Resource Management (CRM) procedures and principles to control workload and reduce distractions.
• Encourage personnel to identify and report existing and emerging safety issues through voluntary reporting programs and understand the usefulness of the voluntary reporting system.
• Review information about runway safety here: Runway Safety | Federal Aviation Administration
(faa.gov).
• Review the following previously published SAFOs:
o17012, High Collision Risk During Runway Crossing;
o11004, Runway Incursion Prevention Actions;
o08001, Flightcrew techniques and procedures to enhance taxi, pre-takeoff, and after landing
safety to reduce the risk of runway incursions.
• Apply Safety Management System principles to analyze safety data and assess risk associated with emerging hazards. Evaluate existing risk mitigations to determine if they are effectively controlling risk, or if additional action is required.
Contact: Questions or comments regarding this SAFO should be directed to the Air Transportation
Division at [email protected] or the General Aviation & Commercial Division at 9-
[email protected].
A SAFO contains important safety information and may include recommended action. Besides the specific action recommended in a SAFO, an alternative action may be as effective in addressing the safety issue named in the SAFO. The contents of this document do not have the force and effect of law and are not meant to bind the public in any way. This document is intended only to provide clarity to the public regarding existing requirements under the law or agency policies.
Subject: Aviation Safety Call to Action.
Purpose: This SAFO informs the aviation community that several highly visible and notable recent events demonstrate the need for continued vigilance and attention to mitigation of safety risks. This SAFO applies to all aircraft operations conducted under Title 14 of the Code of Federal Regulations (14 CFR) Parts 91, 91 subpart K (Part 91K), 121, 125, 129, and 135.
Background: In recent months, a number of notable and high visibility events have occurred in the National Airspace System (NAS). While the overall numbers do not reflect an increase in incidents and occurrences, the potential severity of these events is concerning. Six serious runway incursions have occurred since January 2023, including an incident at John F. Kennedy International Airport in New York City involving a taxiing aircraft narrowly avoiding a departing aircraft and a landing aircraft coming within 100 feet of a departing aircraft at Austin-Bergstrom International Airport in Texas.
In February 2023, the acting Administrator of the Federal Aviation Administration (FAA) issued a Call to Action comprised of a series of events and initiatives to ensure focus and attention on risks to the aviation system. Senior leaders from the FAA, other government agencies, commercial and general aviation operators, labor partners and others attended a Safety Summit on March 15, 2023. Attendees discussed these recent incidents, as well as ways to enhance aviation safety.
Discussion: Safety management requires adapting to continual change. Effective safety management is designed to detect emerging safety issues, assess the level of risk and address those risks through mitigations. Those mitigations may be a change in processes, procedures or training. Operators should evaluate information collected through their safety management processes, identify hazards, increase and improve safety communications with employees and enact mitigations. Safety management systems,
policies and procedures must be able to account for a high rate of change.
Recommended Action: Recent events have highlighted several areas of focus. Directors of Operations, Chief Pilots, Directors of Training, Check Airmen, Directors of Safety, Program Managers, Pilots and Operators should review the following items and consider taking additional steps to ensure operations are conducted at the highest level of safety, including changes to procedures or training, if appropriate.
• Use all available internal communication processes to specifically highlight recent events and existing issues.
• Reinforce adherence to published processes and procedures, including checklists, Air Traffic
Control instructions, and internal company procedures.
• Ensure pilots and flight attendants have the same understanding of what “sterile flight deck” means and the risks associated with extraneous communication during this time.
• Explore helpful resources available for all pilots at: FAA Safety Team - FAASafety.gov.
• Encourage crews to diligently follow Crew Resource Management (CRM) procedures and principles to control workload and reduce distractions.
• Encourage personnel to identify and report existing and emerging safety issues through voluntary reporting programs and understand the usefulness of the voluntary reporting system.
• Review information about runway safety here: Runway Safety | Federal Aviation Administration
(faa.gov).
• Review the following previously published SAFOs:
o17012, High Collision Risk During Runway Crossing;
o11004, Runway Incursion Prevention Actions;
o08001, Flightcrew techniques and procedures to enhance taxi, pre-takeoff, and after landing
safety to reduce the risk of runway incursions.
• Apply Safety Management System principles to analyze safety data and assess risk associated with emerging hazards. Evaluate existing risk mitigations to determine if they are effectively controlling risk, or if additional action is required.
Contact: Questions or comments regarding this SAFO should be directed to the Air Transportation
Division at [email protected] or the General Aviation & Commercial Division at 9-
[email protected].
Last edited by WillowRun 6-3; 23rd Mar 2023 at 09:34.
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Can I ask a question... the AA 106 crew refused to be interviewed on multiple occasions if the interview was going to be recorded in any way. What possible excuse is there for their adamant refusal to be recorded? What rules and regs are in place that might require cooperation with an FAA or NTSB inquiry?
I have other questions about why that flight was allowed to complete its flight to LHR? What was emotional state of the flight crew? They were told to make a phone call. Who had the authority to tell that crew to return to their terminal? The tower supervisor? Obviously the event took on a life if its own by the time they arrived in London. What happened to that flight crew after reaching the UK? Did they crew a return flight two days later as they would have done on an ordinary rotation?
I have other questions about why that flight was allowed to complete its flight to LHR? What was emotional state of the flight crew? They were told to make a phone call. Who had the authority to tell that crew to return to their terminal? The tower supervisor? Obviously the event took on a life if its own by the time they arrived in London. What happened to that flight crew after reaching the UK? Did they crew a return flight two days later as they would have done on an ordinary rotation?
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Maybe that's more than one question....
Based on several statements and other information publicly available at the time of the interview controversy, and despite holding only SLF/attorney status here, I'll take a swing at part of this. The primary basis articulated by the labor union representing the AA aviators was that recording of interviews imposes an unwarranted and unnecessary atmosphere of formality and even an adversarial posture, whereas the interview is supposed to be more aligned with purely investigatory factual inquiry and reflective of a "just culture" approach., (This is only my description of the APA's position and I'm not quoting anything or anyone.)
My understanding is that there was an airline labor-management issue that was part of the context, or background or backstory - or at the very least, the issue very likely could have been part of the context. IIRC, the APA had objected to some changes in flight deck procedures being implemented - perhaps "imposed" would be the correct word - by management without participation by and/or consultation with APA that the union understood to be required by the collectively bargained labor agreement. The issue concerned how the airline management requires the PM to deal with checklist items in the time period immediately prior to departure, including taxiing to position for takeoff. I apologize for imprecise terminology if I've used any here - although I'm pretty certain APA had stated concern over a change management had imposed about the specific workload and task items to be completed by the PM during that time period.
The change had been imposed just a short time before the incident The linkage is that some reporting at the time indicated that the PM of the incident flight had been focused on getting these new procedures done correctly, to the detriment of what otherwise would have been more complete and/or intense focus on clearances for taxi and takeoff. (I realize the thread has included comments on the tasks to be completed by the PF, and it could be that APA's actual interactions with management had included discussion of how the new procedures would affect not just the F/O (in this case) but the PIC as well.)
If this much is correct, then in addition to a general sense that the incident was ripe for finding a bus, grabbing a couple of pilots, and tossing them under said bus, the union also was concerned with not compromising its issue over the implementation of the new procedures - and also guarding against its position being co-opted by the inevitable attention-payers swarming in - competent press and media; the rest of the press and media; the Congress, et cetera. (My observation of a "general sense" of blame looming over this incident relates back, and it relates all the way back, to the way the Executive Branch has run the Department of Transportation and the FAA, but let's not get political or anything.)
As to how and why the crew continued on to LHR and the rest, I can't say anything useful.
Based on several statements and other information publicly available at the time of the interview controversy, and despite holding only SLF/attorney status here, I'll take a swing at part of this. The primary basis articulated by the labor union representing the AA aviators was that recording of interviews imposes an unwarranted and unnecessary atmosphere of formality and even an adversarial posture, whereas the interview is supposed to be more aligned with purely investigatory factual inquiry and reflective of a "just culture" approach., (This is only my description of the APA's position and I'm not quoting anything or anyone.)
My understanding is that there was an airline labor-management issue that was part of the context, or background or backstory - or at the very least, the issue very likely could have been part of the context. IIRC, the APA had objected to some changes in flight deck procedures being implemented - perhaps "imposed" would be the correct word - by management without participation by and/or consultation with APA that the union understood to be required by the collectively bargained labor agreement. The issue concerned how the airline management requires the PM to deal with checklist items in the time period immediately prior to departure, including taxiing to position for takeoff. I apologize for imprecise terminology if I've used any here - although I'm pretty certain APA had stated concern over a change management had imposed about the specific workload and task items to be completed by the PM during that time period.
The change had been imposed just a short time before the incident The linkage is that some reporting at the time indicated that the PM of the incident flight had been focused on getting these new procedures done correctly, to the detriment of what otherwise would have been more complete and/or intense focus on clearances for taxi and takeoff. (I realize the thread has included comments on the tasks to be completed by the PF, and it could be that APA's actual interactions with management had included discussion of how the new procedures would affect not just the F/O (in this case) but the PIC as well.)
If this much is correct, then in addition to a general sense that the incident was ripe for finding a bus, grabbing a couple of pilots, and tossing them under said bus, the union also was concerned with not compromising its issue over the implementation of the new procedures - and also guarding against its position being co-opted by the inevitable attention-payers swarming in - competent press and media; the rest of the press and media; the Congress, et cetera. (My observation of a "general sense" of blame looming over this incident relates back, and it relates all the way back, to the way the Executive Branch has run the Department of Transportation and the FAA, but let's not get political or anything.)
As to how and why the crew continued on to LHR and the rest, I can't say anything useful.