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AA 106 @ JFK (13 Jan 23)

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AA 106 @ JFK (13 Jan 23)

Old 29th Jan 2024, 23:18
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NTSB Docket
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Old 30th Jan 2024, 11:52
  #202 (permalink)  
 
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Investigators detail how an American Airlines jet crossed a runway in front of a Delt

If the report is true - Its a bit naughty for the AA flight crew not to report the runway incursion and deliberately allow the voice recording to overwrite. I thought that civil aviation had got over the blame culture and was willing to admit and learn from mistakes, which is how safety is improved. At least in this chain of events, the controller was able to intervene before the last resort of the 737 crew seeing the 777 on the runway, possibly too late

Investigators detail how an American Airlines jet crossed a runway in front of a Delta plane at JFK (msn.com)
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Old 30th Jan 2024, 16:17
  #203 (permalink)  
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I must admit I do not have the courage to read the 294 pages of the crew interviews on the Docket, but reading the msn article resume , I find it noteworthy to read that 2 of the 3 crew on that aircraft apparently admitted they did not know where they were on the airport. during taxi. There might be reasons for this distraction or lack of monitoring but this needs serious addressing by the airline I would say.
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Old 30th Jan 2024, 16:44
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Having read them, all three crew had a slightly different immediate reaction to being on the runway, but all independently seemed to think the “red glow” from the RELs didn’t illuminate until the cockpit was already over the runway.

Interesting difference in perspective between how close the AAL pilots and the ATC staff perceived the event to be, even with a bit of hindsight.

Last edited by Request Orbit; 30th Jan 2024 at 17:12. Reason: BFSGrad said most of it better
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Old 30th Jan 2024, 16:56
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Originally Posted by ATC Watcher
I must admit I do not have the courage to read the 294 pages of the crew interviews on the Docket, but reading the msn article resume , I find it noteworthy to read that 2 of the 3 crew on that aircraft apparently admitted they did not know where they were on the airport. during taxi. There might be reasons for this distraction or lack of monitoring but this needs serious addressing by the airline I would say.
No courage required, just time. Both pilot and ATC interviews worth the read. Please don’t trust the typically abysmal media reporting to form an opinion.

But regarding 2 of 3 pilots being somewhat out of the loop, correct. CA inexplicably reverted to original departure/taxi brief for 31L even though he acknowledged being aware of and briefing the revised 4L departure. IOW, he was driving the aircraft where he intended and believed he was cleared to go. FO was head down at a critical point (B/J/K intersection) doing admin and believed aircraft was crossing 31L as authorized when she went head up. FB was head down doing admin from mid-B until actually crossing 4L. He was also aware 4L was the intended departure runway.

Troubling inconsistency between pilot interviews and performance study regarding the runway entrance lights (REL). All pilots said that, by the time RELs illuminated, aircraft was already midpoint 4L such that they couldn’t directly see the RELs and could only see the red glow off to the side of the aircraft. Performance study states (p. 17) that RELs illuminated as the aircraft crossed the 4L hold bar. Pilots should have been able to directly see RELs #3-6 and possibly #2. Only REL #1 would have definitely been out of view.

Also wondering about exterior lighting. Appears AA was operating exterior lighting consistent with company procedures, which gives the pilot the option of when to use logo lights. Do 121 pilots turn on logo lights when crossing runways? No mention of this in the interviews. Seems a logo light (if this aircraft was so equipped) would have given the DL pilots the best opportunity to see the crossing AA. Based on interviews, the DL did not see the crossing AA until after the RTO had been initiated. IOW, the RTO was initiated based on ATC instruction instead of observing the crossing AA.
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Old 30th Jan 2024, 21:47
  #206 (permalink)  
 
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Because the incident wasn't ATC related, I had a rather quick reading through the most interesting parts of the ATC interviews and from one of the interviews I copied a few text-lines that were rather ... interesting

about ASDE-X:
* So the ASDE and me donít have a good relationship because itís as far as Iím concerned, itís totally hit or miss.
* Thereís a flashing thing thatís broken, thatís been broken, which Iíve reported probably 100 times on the ASDE forms. Youíll find them with my initials on them
* Iíve seen - without getting into storytelling, I watched an entire emergency response team line up on the runway with an aircraft on final, not show up on the ASDE and the ASDE not go off. I watched five firetrucks line up on 22 Right with an aircraft while we were using 22 Right, thinking they were on Yankee and the ASDE didnít go off and the local control had to send the aircraft around on 22 Right.
* Yes, so the MLAT will flash, and it says MLAT not working. Great. So I have reported that hundreds of times to the FAA, officially on paperwork, in writing, and I keep getting told itís a Verizon issue. Now that means nothing to me. Thatís your problem. Iím telling you that the equipment that youíre telling me I need to rely on that people donít die, especially when we canít see out the window
* -- doesnít work properly. And I actually was yelled at by my manager for saying, on a relief briefing, that the ASDE is either out of service or not working properly. That was after I ran a runway sweep with a vehicle that the vehicle never showed up on the runway and the ASDE didnít show them at all.
* So thatís the culture that goes on about the ASDE is that Iíve become more of a pain in the ass for constantly filling out this form to say that the ASDE doesnít work where it goes downstairs and probably just goes into the garbage, because itís a no, quote-unquote, known issue. They take it out of the logs, so it doesnít cause FAA issues at wherever the FAA has to deal with that issue being on their log every day.

about pilots:
* No, I expect that all pilots will listen to nothing I say at all times, because thatís how they operate.
* They all switch, they do it all the time, itís a common thing, they -- because theyíre hotshots, and Iím just a, you know, a radio operator and they know everything, and they do this all the time. They switch frequencies when theyíre not supposed to. They act like a bunch of amateurs all the time. Every day, all day dealing with having to say things. And let me tell you something. After COVID, it has been 10 times worse, and Iím sure that this is not a JFK issue, that this is a NAS problem. Ten times worse after COVID where youíre having to repeat simple, basic, taxiing instructions to every pilot from top to bottom, from seniors to, you know -- from Saturday pilots to international pilots and everyone in between. Youíre having to say things four and five times, basic instructions to pilots.
* Because if you give them more than three things, their brain turns to mush and they forget everything, and then they say, say again, and -- or they say something wrong and you canít work ground control, because you will be constantly talking to the same pilot three and four times. So if you donít break it down into turn left Bravo, hold short of Kilo. Because if I gave a Bravo, Kilo, cross 31 Left, forget about it. Sheíd be -- you know, some of them can, obviously, some of them can't, but you canít work that way because youíll -- youíre just working uphill.
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Old 31st Jan 2024, 10:41
  #207 (permalink)  
 
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It’s all well having a go at the flight crew but it can be a bloody difficult job especially setting priorities with the bull**** of paperwork, checklists and when they can be completed, fatigue, strange airfields and languages (I include American regional accents in that sans le FranÁais ) without the ridiculous long duty days and jet lag.
The airlines want more and more blood out of the stone. In my day 650 flying hours left me knackered and as soon as I could afford it I took unpaid leave as a 40 year old..ok electronics have changed things and you don’t need the flying skills of 30 years ago but it is still a hands on job and airfields aren’t the easiest thing to navigate even in daylight. I’ve called for a follow me at home base for the local captain who got lost whilst I was doing the after landing checklist.
BA managed to take the wrong taxiway Twice in SA hitting a building the second time - that takes some doing.
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Old 31st Jan 2024, 12:20
  #208 (permalink)  
 
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Originally Posted by blind pew
Itís all well having a go at the flight crew but it can be a bloody difficult job especially setting priorities with the bull**** of paperwork, checklists and when they can be completed, fatigue, strange airfields and languages (I include American regional accents in that sans le FranÁais ) without the ridiculous long duty days and jet lag.
The airlines want more and more blood out of the stone. In my day 650 flying hours left me knackered and as soon as I could afford it I took unpaid leave as a 40 year old..ok electronics have changed things and you donít need the flying skills of 30 years ago but it is still a hands on job and airfields arenít the easiest thing to navigate even in daylight. Iíve called for a follow me at home base for the local captain who got lost whilst I was doing the after landing checklist.
BA managed to take the wrong taxiway Twice in SA hitting a building the second time - that takes some doing.
The sesnse of "having a go at the flight crew" pervaded the initial phases of the aftermath of this incident. As is widely known, the union for American pilots - assessing only from the public statements at the time - had significant concern about the workload factor. And IIRC how the company had imposed changes on procedures without having engaged properly or sufficiently with the union about these changes first. The changes, in turn, were reported as having been a factor in why one or more of the pilots did not realize their taxiing mistake (the F/O was concentrating on getting through the procedures, as recently changed).

These concerns were, at least in part, the basis for the union challenging the process NTSB intended to follow for gathering information from the pilots (recording of interviews).

Not having worked through very much of the Docket, I don't know whether any statements from the union, about the dispute with the company about procedures being changed, or about the process for interviews, were provided to NTSB and are somewhere on the Docket. But even so, as an SLF/attorney (whose practice for many years focused on employment and labor law matters) I have to wonder what views are held inside the union and obviously not being publicized - or not publicized yet.
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Old 5th Jun 2024, 20:44
  #209 (permalink)  
 
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The NTSB determines that the probable cause of this incident was the American Airlines flight 106 (AAL106) crew’s surface navigation error due to distractions caused by their performance of concurrent operational tasks during taxi, which resulted in a loss of situational awareness. Contributing to the incident was the air traffic control tower team’s nondetection of the AAL106 crew’s deviation from taxi instructions while performing concurrent operational tasks; the timing of the runway status light system, which activated too late to prevent the AAL106 crew from crossing the runway hold short line; and American Airlines’ lack of adequate risk controls to prevent concurrent flight crew tasks from leading to distraction, loss of situational awareness, and deviation from an authorized taxi clearance. Reducing the severity of the incident, and likely preventing an accident, was the activation of the ASDE-X warning in the air traffic control tower and the local controller’s prompt cancellation of DAL1943’s takeoff clearance.

NTSB Releases Abstract of Final Report on 2023 JFK Airport Runway Near-Collision
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Old 6th Jun 2024, 04:15
  #210 (permalink)  
 
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I was holding short of runway 22R at J after landing 22L awaiting several departures on 4R. I noticed the REL was off while the aircraft was lined up at takeoff position. It came on only when the departing aircraft initiated takeoff (like 1000’ down the runway). So the REL came on and off infront of me several times.
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Old 13th Jun 2024, 16:17
  #211 (permalink)  
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Final report published today (13 June 2024): https://www.ntsb.gov/investigations/...ts/AIR2401.pdf
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