AA 106 @ JFK (13 Jan 23)
"Chuffing wait will you!"
Join Date: Nov 2004
Location: Here, there, and everywhere
Posts: 1,125
Likes: 0
Received 13 Likes
on
8 Posts
One note concerning the controllers. I do seem to remember from reading past incident reports, that when a controller clears an aircraft to cross a runway, they have certain responsibilities, such as looking to confirm a runway is clear and possibly looking at the aircraft being cleared to cross to confirm its position for where it will cross. I do wonder how they do all this at busy times in complicated situations when the chatter is non-stop. In addition, the crossing clearance may have been given well before the aircraft reached Kilo taxiway making such a task more difficult in a busy environment.
After all, the immediate threat was resolved; the next one is departing from procedures and missing steps
Join Date: Feb 2009
Location: UK
Age: 65
Posts: 138
Likes: 0
Received 0 Likes
on
0 Posts
Having operated out of JFK two days before the incident with the same runways in use I can see exactly how the Swiss cheese holes lined up. The incident actually started at the gate.
The JFK ATIS gives runway 04L and runway 31L for departure. You do not know which one you will get so you guess one and plan for that although you get the figures for the other runway too.This is the first Swiss cheese hole.
The datalink clearance comes through with a SID. However the SID, i.e. a Kennedy 5 does not specify which runway. At other airports around the world the SID name defines which runway you use. This is the second Swiss cheese hole.
So you brief for departure and push back from the gate still without knowing which runway you are departing from. This is not desirable.
When you come out of the ramp at TA you do not know if you are going to go clockwise or anteclockwise, it can be either, and so you are listening hard to whether it is Alpha or Bravo taxiway and where your holding point limit is.
Crucially the ground controller in the initial taxi clearance to AA106 did say runway 04L at the start of the transmission but this was not read back by the female pilot who just read back the taxi instructions. The taxi instructions they were given were relevant from their taxi position to both runway 31L and runway 04L. The next Swiss cheese hole lines up.
I think they believed they were taxiing to runway 31L for departure. They taxied as instructed on Bravo and held at Kilo. The next instruction they were expecting to receive was to cross the runway in front of them and continue to the hold for 31L. As a bit of confirmation bias they could see a plane at the hold for 31L.
As expected they then received clearance to "Cross runway...." and taxied forward but did not take the first right and went ahead believing they were cleared to cross that runway in their route to 31L. They did not realise they were cleared to cross runway 31L and not 04L. The final cheese hole lined up for the incident to happen.
I have sympathy for the crew and had they been given a departure runway in their original clearance and briefed the taxi route in advance before pushback I do not think this would have happened.
The JFK ATIS gives runway 04L and runway 31L for departure. You do not know which one you will get so you guess one and plan for that although you get the figures for the other runway too.This is the first Swiss cheese hole.
The datalink clearance comes through with a SID. However the SID, i.e. a Kennedy 5 does not specify which runway. At other airports around the world the SID name defines which runway you use. This is the second Swiss cheese hole.
So you brief for departure and push back from the gate still without knowing which runway you are departing from. This is not desirable.
When you come out of the ramp at TA you do not know if you are going to go clockwise or anteclockwise, it can be either, and so you are listening hard to whether it is Alpha or Bravo taxiway and where your holding point limit is.
Crucially the ground controller in the initial taxi clearance to AA106 did say runway 04L at the start of the transmission but this was not read back by the female pilot who just read back the taxi instructions. The taxi instructions they were given were relevant from their taxi position to both runway 31L and runway 04L. The next Swiss cheese hole lines up.
I think they believed they were taxiing to runway 31L for departure. They taxied as instructed on Bravo and held at Kilo. The next instruction they were expecting to receive was to cross the runway in front of them and continue to the hold for 31L. As a bit of confirmation bias they could see a plane at the hold for 31L.
As expected they then received clearance to "Cross runway...." and taxied forward but did not take the first right and went ahead believing they were cleared to cross that runway in their route to 31L. They did not realise they were cleared to cross runway 31L and not 04L. The final cheese hole lined up for the incident to happen.
I have sympathy for the crew and had they been given a departure runway in their original clearance and briefed the taxi route in advance before pushback I do not think this would have happened.
Something missing in my mind...
Acc this YT including full Taxi clrs from the very beginning issued by the TWR and ack by the lady pilot, all the clrs and taxi instructions were given regarding RWY 4L for dep.
The readbacks either, BUT...missing the RWY at 0:26 by the lady (only twys), wich ATCer included few seconds before as 04L(0:20).
However they were heading for 31L, wich acc some ppruners here it was in facto the rwy they used for departure minutes later...so, here is my question:
I presume they had loading all the T/O perf // data // SID's, etc, acc RWY31L, and also having such in their minds.
But all the way they were readbacking it to the ATC as acting for a 4L dep, including when the lady said in readback "cross 31 at kilo"
So...maybe some biased since the start to use 31L insted of 4L??
Sorry for this humble question...anyway, kudos to those who saved the day
EDIT: Ppruner colleague Draglift posting at the same time of me, said much of what i think too...my apologies (not copying at all his/her way of thinking).
Acc this YT including full Taxi clrs from the very beginning issued by the TWR and ack by the lady pilot, all the clrs and taxi instructions were given regarding RWY 4L for dep.
The readbacks either, BUT...missing the RWY at 0:26 by the lady (only twys), wich ATCer included few seconds before as 04L(0:20).
However they were heading for 31L, wich acc some ppruners here it was in facto the rwy they used for departure minutes later...so, here is my question:
I presume they had loading all the T/O perf // data // SID's, etc, acc RWY31L, and also having such in their minds.
But all the way they were readbacking it to the ATC as acting for a 4L dep, including when the lady said in readback "cross 31 at kilo"
So...maybe some biased since the start to use 31L insted of 4L??
Sorry for this humble question...anyway, kudos to those who saved the day
EDIT: Ppruner colleague Draglift posting at the same time of me, said much of what i think too...my apologies (not copying at all his/her way of thinking).
Last edited by JanetFlight; 17th Jan 2023 at 16:59.
I don't know if this was a factor, but having operated in and out of both JFK and LHR, the quality of ATC communications is very challenging at JFK.
I am sorry, but the JFK controllers all talk as if their hair is on fire, like a machine gun, and it can be very challenging to understand the instructions, whereas at LHR, controllers are calm and speak calmly.
I can't help feeling that if the JFK controllers were to speak slowly and calmly, aircraft would have a much less confusing and less stressful time at JFK. There may be valid reasons why they don't speak slowly, such as there not enough enough controllers, and if so this should be addressed.
I am sorry, but the JFK controllers all talk as if their hair is on fire, like a machine gun, and it can be very challenging to understand the instructions, whereas at LHR, controllers are calm and speak calmly.
I can't help feeling that if the JFK controllers were to speak slowly and calmly, aircraft would have a much less confusing and less stressful time at JFK. There may be valid reasons why they don't speak slowly, such as there not enough enough controllers, and if so this should be addressed.
draglift, A very succinct analysis of what we know so far. It is a very long time since I last operated out of JFK and, without being derogatory to my American friends, I do think that the lack of R/T discipline by the controllers (and the pilots) plus the rapid-fire way in which American ATCOs like to give their instructions all contribute to rendering the safety nets less effective in plugging the holes in this Swiss cheese.
Join Date: Nov 2010
Location: Canada
Posts: 132
Likes: 0
Received 0 Likes
on
0 Posts
IS it possible to swap out crew to one already onboard as deadhead/pax? six minutes would not be enough to brief flight plan/weather etc....
Such wasn't exactly run of the mill or routine where I worked (not US) though not completely unknown and even when there was such a crew onboard they weren't required to be on stand-by to jump into the operating seats at any time in the flight.
Pegase Driver
The Swiss cheese model described by Draglift is a good description of what is likely to have happenned. Taxying in the US major airports is not easy and is not helped by the rapid local phraseology/slang used by the ramp guys. I have not been inside the TWR in JFK for decades, but before the guys doing ramp control were not among the best trained .. Do not know if this is stil the case.
But to take the defence of the TWR controllers here, well, first the runway crossing clearance was clear , and confirmed/acknoledged by the AAL lady : " Cross 31 L at K " it was not to cross 4L at J..
Next the tlephone number; this is the standard procedure , you do not discuss errors on the ffrequency , and you have to tell the pilots if you are going to make a report on them. So it is not arrogance or showing who is the boss, , it is just following the procedure.
As to the speed at which they speak, well it is the same everywhere , if, as a controller, you are alone on a position and it is very busy you do not have much other choice. Getting more staff to open another frequency/ postion would definitivelyhelp but it is not possible with the chronic satff shortage in so many places, and all the 3 New York
I would still like to know if there were red stop bars light on around 4L though., to eliminate one more possible cheese hole. .
But to take the defence of the TWR controllers here, well, first the runway crossing clearance was clear , and confirmed/acknoledged by the AAL lady : " Cross 31 L at K " it was not to cross 4L at J..
Next the tlephone number; this is the standard procedure , you do not discuss errors on the ffrequency , and you have to tell the pilots if you are going to make a report on them. So it is not arrogance or showing who is the boss, , it is just following the procedure.
As to the speed at which they speak, well it is the same everywhere , if, as a controller, you are alone on a position and it is very busy you do not have much other choice. Getting more staff to open another frequency/ postion would definitivelyhelp but it is not possible with the chronic satff shortage in so many places, and all the 3 New York
I would still like to know if there were red stop bars light on around 4L though., to eliminate one more possible cheese hole. .
Next the tlephone number; this is the standard procedure , you do not discuss errors on the ffrequency , and you have to tell the pilots if you are going to make a report on them. So it is not arrogance or showing who is the boss, , it is just following the procedure.
Pegase Driver
Personally, if it was me making the rules, I would ask ATC to simply cancel the departure slot, taxi the aircraft back to the ramp, and get someone debrief they crew and secure the CVR . I can see the airlines agreeing to those procedures already
Not ideal I agree but what alternative proposal would you make ? Saying nothing and let the aircraft go and inform the crew when it returns 2 days later is not really an option is it?
Personally, if it was me making the rules, I would ask ATC to simply cancel the departure slot, taxi the aircraft back to the ramp, and get someone debrief they crew and secure the CVR . I can see the airlines agreeing to those procedures already
Personally, if it was me making the rules, I would ask ATC to simply cancel the departure slot, taxi the aircraft back to the ramp, and get someone debrief they crew and secure the CVR . I can see the airlines agreeing to those procedures already
No one wants to delay a widebody full of passengers, but after a serious incident the judgement and performance of the crew is likely to be impaired and to have them stewing on such an event when they could have returned to the gate, downloaded the recorders and called out a standby crew in a couple hours to continue the flight would appear to have been preferable - and I think the NTSB will concur when they address the lack of availability of the CVR data on what is a (very) serious near miss.
Legitimate question - could ATC have refused AA106 clearance to depart until any evidence was secured? I know that's supposed to be the responsibility of the Operator, but where it is clear they are not going to do so as in this case, is there a precedent for Ground directing them to return to the gate?
I'm amazed "someone" at American, the CP/Duty Pilot/Ops/Whoever this crew would have contacted actually thought having the crew continue the flight was a reasonable course of action - and that's not even considering away the loss of evidence with the overwriting of the CVR.
No one wants to delay a widebody full of passengers, but after a serious incident the judgement and performance of the crew is likely to be impaired and to have them stewing on such an event when they could have returned to the gate, downloaded the recorders and called out a standby crew in a couple hours to continue the flight would appear to have been preferable - and I think the NTSB will concur when they address the lack of availability of the CVR data on what is a (very) serious near miss.
Legitimate question - could ATC have refused AA106 clearance to depart until any evidence was secured? I know that's supposed to be the responsibility of the Operator, but where it is clear they are not going to do so as in this case, is there a precedent for Ground directing them to return to the gate?
No one wants to delay a widebody full of passengers, but after a serious incident the judgement and performance of the crew is likely to be impaired and to have them stewing on such an event when they could have returned to the gate, downloaded the recorders and called out a standby crew in a couple hours to continue the flight would appear to have been preferable - and I think the NTSB will concur when they address the lack of availability of the CVR data on what is a (very) serious near miss.
Legitimate question - could ATC have refused AA106 clearance to depart until any evidence was secured? I know that's supposed to be the responsibility of the Operator, but where it is clear they are not going to do so as in this case, is there a precedent for Ground directing them to return to the gate?
It’s possible the AA crew did not contact or discuss the incident with any company management entity, or if they did the full gravity of the incident might not have been understood
If they had decided to return to the gate and request a replacement crew then that discussion would most certainly have taken place although initially contact could well be with a union safety rep
In the moment the decision to continue might have seemed logical bearing in mind no actual collision occurred and how well did they see the approaching Delta Aircraft if at all considering the geometry of the two aircraft ?
Of course it’s not known how detailed the telephone conversation was between the AA captain and the tower, that may or may not have impressed on him what a close call it was
I don’t think there’s any question the AA crew should have returned to the gate
Join Date: Mar 2006
Location: USA
Posts: 2,527
Likes: 0
Received 0 Likes
on
0 Posts
This has surprisingly few comments. It could have easily been an award winning disaster.
Listening to the voices of the two pilots and two controllers was enlightening. It will be interesting to see the experience levels of some of the players if a report IS made public..
Listening to the voices of the two pilots and two controllers was enlightening. It will be interesting to see the experience levels of some of the players if a report IS made public..
Join Date: Mar 2006
Location: USA
Posts: 2,527
Likes: 0
Received 0 Likes
on
0 Posts
Cross runway 31L at Kilo
Takeoff runway should have been briefed as 4L, as should the usual route to it that is to turn down Kilo.
How did AA106 crew think they were going to get to 4L by crossing it (not even at Kilo) and continuing on Juliet towards 4R.
This seems to have been far more than spatial disorientation.
Next issue for the investigators: is the CVR of this taxiing time going to be available to them? (which should be the reason why their take-off should also have been cancelled).
Takeoff runway should have been briefed as 4L, as should the usual route to it that is to turn down Kilo.
How did AA106 crew think they were going to get to 4L by crossing it (not even at Kilo) and continuing on Juliet towards 4R.
This seems to have been far more than spatial disorientation.
Next issue for the investigators: is the CVR of this taxiing time going to be available to them? (which should be the reason why their take-off should also have been cancelled).
That particular runway configuration is almost the standard at JFK in the winter. The crew was JFK based and I find it hard to believe they did not expect to depart 4L as that is the norm for all international flights. In fact while taxiing out they passed intersection KE on 31L where another AA flight was cleared into position and hold at KE. The investigation will certainly find out both the expected runway briefed and what was loaded in the FMS.
Look right / left crossing?
Surely the crew would have glanced right / left before crossing the runway and noticed the blinding lights of an airliner taking off on that runway? All other holes of the cheese withstanding, surely the whole 'airmanship' mantra the chaps upfront pride themsleves on would call for such an obvious check?!
I don't know if this was a factor, but having operated in and out of both JFK and LHR, the quality of ATC communications is very challenging at JFK.
I am sorry, but the JFK controllers all talk as if their hair is on fire, like a machine gun, and it can be very challenging to understand the instructions, whereas at LHR, controllers are calm and speak calmly.
I can't help feeling that if the JFK controllers were to speak slowly and calmly, aircraft would have a much less confusing and less stressful time at JFK. There may be valid reasons why they don't speak slowly, such as there not enough enough controllers, and if so this should be addressed.
I am sorry, but the JFK controllers all talk as if their hair is on fire, like a machine gun, and it can be very challenging to understand the instructions, whereas at LHR, controllers are calm and speak calmly.
I can't help feeling that if the JFK controllers were to speak slowly and calmly, aircraft would have a much less confusing and less stressful time at JFK. There may be valid reasons why they don't speak slowly, such as there not enough enough controllers, and if so this should be addressed.
Who designed that rabbit warren of a taxiway system?