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AA 106 @ JFK (13 Jan 23)

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AA 106 @ JFK (13 Jan 23)

Old 18th Jan 2023, 05:21
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Originally Posted by LandIT View Post
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).
Unfortunately not that simple, JFK often operates mixed mode RWYs for take off with both 04L and 31L in use.

However when this is the case 31L take offs are normally from KE intersection rather than full length to avoid crossing 04L on the take off roll.
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Old 18th Jan 2023, 10:05
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AA changed procedures

Haven't seen this elsewhere in the thread: there's an interesting piece here commenting that cockpit procedures changes may have been a factor.... .
Christine NegroniNew AA Pilot Procedures Could be Part of Investigation into Near Collision at JFK
and a related one here from January 3: Pilots Balk As American Airlines Enforces New Cockpit Procedures (forbes.com)
That one refers to "Allied Pilots Association said the implementation involves an attempt to alter critical procedures through a 35-page bulletin and changes in a 65- page manual rather than through in person training." Anyyone here have a copy of the bulletin and/or manual ?

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Old 18th Jan 2023, 11:12
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As a layman (albeit a fairly knowledgeable one) I always find these sorts of situation almost unbelievable. Having received taxi clearance for a 4L departure and a further clearance to cross 31L how can such a fundamental mistake be made by an experienced crew in good visibility and at their home airport?

I also agree with the other posters who have questioned ATC terminology as being too long-winded. As pilots simply say "STOP" during the take-off run to abort, I am surprised that ATC don't use the same terminology. "Delta 1943, STOP STOP STOP" would take less time and project far more urgency.
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Old 18th Jan 2023, 12:32
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Originally Posted by slast View Post
Haven't seen this elsewhere in the thread: there's an interesting piece here commenting that cockpit procedures changes may have been a factor.... .
Christine NegroniNew AA Pilot Procedures Could be Part of Investigation into Near Collision at JFK
and a related one here from January 3: Pilots Balk As American Airlines Enforces New Cockpit Procedures (forbes.com)
That one refers to "Allied Pilots Association said the implementation involves an attempt to alter critical procedures through a 35-page bulletin and changes in a 65- page manual rather than through in person training." Anyyone here have a copy of the bulletin and/or manual ?
APA Press Release re changes: Unwise and Unsafe
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Old 18th Jan 2023, 14:06
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Originally Posted by MechEngr View Post
This is New York. For them that is slow. You want drawl, go to EL Paso.

Who designed that rabbit warren of a taxiway system?
I realise you are joking, but I don't want 'drawl' I just want safe, clear instructions that I can understand and write down (in short-hand). But the speed of vocal delivery at JFK can prevent this, and is, I think, a safety issue; being at least twice the speed at LHR, AMS, even CDG !

Every time we flew into JFK, all three of the heavy crew were nervously ears-peeled to hopefully hear and understand the machine gun taxi instructions first time. Having to ask for a repeat was pointless, as the controller then got really pissed off and would speak even more quickly, as if s/he thought we were stupid.

By speaking so quickly, ATC cause themselves problems and extra work. Slooooooow Dooooown a bit and give yourselves and everyone a break !

The taxiways are complex but not particularly worse than LHR or CDG, but the way ATC is set up leaves a lot to be desired - a separate ramp controller frequency doesn't help, (aircrews), with having to contact ramp on box 2 as you taxi in, to find out your stand to tell the controller. Can't the controller themselves just look over at the ramp screen - we have too much to do trying to understand the machine gun instructions and get them right without one of us going away to box 2.

Something needs to be done though. A better traffic system could be developed at JFK, such as SIDs linked to specific runways, as has been mentioned, and perhaps a standard 'one way' circulatory taxi system?
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Old 18th Jan 2023, 14:35
  #66 (permalink)  
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Originally Posted by Uplinker View Post
Something needs to be done though. A better traffic system could be developed at JFK, such as SIDs linked to specific runways, as has been mentioned, and perhaps a standard 'one way' circulatory taxi system?

No need to reinvent the wheel, aan excellent system exsist already since a long time : it is called SMGCS , exepensive though , and I think that it is always the same issue : money, How much you are willing to spend on safety. that has no direct return on investment.
From ICAO :
SMGCS :
At airports where Category II and III operations take place or where ground movement requirements are complex, a Surface Movement Guidance and Control System (SMGCS) may be installed in order to simplify the ATC GND task. Such a system has selective switching of taxiway centreline lighting so that individually defined blocks of taxiway, each beginning and ending at a lit Stop Bar, can be individually illuminated ahead by ATC when a valid clearance has been issued. The associated stop bars are extinguished as an aircraft with a valid clearance approaches the next section of taxiway and the centreline lighting for that block is selected.
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Old 18th Jan 2023, 16:28
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Retired now and have't been to JFK for about 30 years. My wife said don't they have red stop lights to prevent aircraft entering the active runway? I am sure these modern airports have this but presumably JFK does not.
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Old 18th Jan 2023, 16:39
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Originally Posted by Mike6567 View Post
Retired now and have't been to JFK for about 30 years. My wife said don't they have red stop lights to prevent aircraft entering the active runway? I am sure these modern airports have this but presumably JFK does not.
In post #6, I noted that JFK has Runway Status Lights, which includes Runway Entrance Lights at J crossing 4L.

JFK also has ASDE-X.

But we don’t know (do we?) at this point if either or both systems were operational at the time of the incident.
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Old 18th Jan 2023, 16:58
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Originally Posted by BFSGrad View Post
In post #6, I noted that JFK has Runway Status Lights, which includes Runway Entrance Lights at J crossing 4L.

JFK also has ASDE-X.

But we don’t know (do we?) at this point if either or both systems were operational at the time of the incident.
Thanks. Missed your info on Runway Status Lights.
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Old 18th Jan 2023, 17:22
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Hi ATC Watcher.

Yeah, but really is a hugely complex electronic system really needed?

I visited the old control tower at (London) Heathrow, where the taxiway lights were controlled by the controllers via a big board with the airport runways and taxiways drawn out and manual switches - "follow the greens" - which worked really well.
And as a pilot, the old block number system at LHR - " follow the greens and hold at block 202" - worked very well, but was outlawed by ?Europe.

There are probably many more short interconnecting taxiways at JFK, which complicate the issue, but surely a general traffic flow pattern could be devised that would reduce the amount of instructions required ?
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Old 18th Jan 2023, 17:43
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Originally Posted by Uplinker View Post

There are probably many more short interconnecting taxiways at JFK, which complicate the issue, but surely a general traffic flow pattern could be devised that would reduce the amount of instructions required ?
I agree the interconnectors can be a problem but of course as I recall it there is a general flow - around the inner, A, clockwise and the outer, B, counter clockwise, so on taxing from the ramp instructions such as "Taxi on Bravo, hold short of Kilo Delta" would get you a long way..

Always found taxiing in was potentially a bit more difficult but once you were onto A or B it was fairly straight forward.


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Old 18th Jan 2023, 22:23
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Originally Posted by Uplinker View Post
I realise you are joking, but I don't want 'drawl' I just want safe, clear instructions that I can understand and write down (in short-hand). But the speed of vocal delivery at JFK can prevent this, and is, I think, a safety issue; being at least twice the speed at LHR, AMS, even CDG !

Every time we flew into JFK, all three of the heavy crew were nervously ears-peeled to hopefully hear and understand the machine gun taxi instructions first time. Having to ask for a repeat was pointless, as the controller then got really pissed off and would speak even more quickly, as if s/he thought we were stupid.

By speaking so quickly, ATC cause themselves problems and extra work. Slooooooow Dooooown a bit and give yourselves and everyone a break !
Agreed. The interesting thing for me was that in the immediate aftermath of the incident, the controller’s delivery was very measured and much more like what you get from ATC elsewhere. So it can be done.
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Old 18th Jan 2023, 22:50
  #73 (permalink)  
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Agree - the quick fire delivery at JFK has been oft criticized but never defended. Is that because it is undefendable or because the controllers at JFK are too busy to be involved in PPRuNe discussions?

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Old 19th Jan 2023, 03:04
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From CNN:
A source familiar with the near-collision of two airliners on a John F. Kennedy International Airport runway tells CNN that special flashing lights which warn pilots against taxiing across a runway were in fact working. On Wednesday, the source told CNN that following the incident, airport staff “went out immediately” to confirm Runway Status Lights were working properly.
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Old 19th Jan 2023, 09:58
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Originally Posted by BFSGrad View Post
From CNN:
A source familiar with the near-collision of two airliners on a John F. Kennedy International Airport runway tells CNN that special flashing lights which warn pilots against taxiing across a runway were in fact working. On Wednesday, the source told CNN that following the incident, airport staff “went out immediately” to confirm Runway Status Lights were working properly.
But were they also correctly configured? This is different from working.
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Old 19th Jan 2023, 10:28
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Complacency during taxi is too common. A three person flight deck and still things get omitted. If unsure, they should've held position, runway warning lights or not...
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Old 19th Jan 2023, 12:03
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Originally Posted by 737pilotguy View Post
If unsure, they should've held position, runway warning lights or not...
That's an important if. Judging from the ATC recording they were not unsure at all; they were just wrong, which is a big difference.

Last edited by xetroV; 19th Jan 2023 at 13:13.
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Old 19th Jan 2023, 16:40
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Originally Posted by draglift View Post
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.

This is the root of the problem. The departure runway is not specified on the ACARS departure clearance, only the SID, initial altitude, transition and squawk. The only mention of the departure runway is on the ATIS and, as in this case, is sometimes more than one runway. I operate to JFK frequently and am only too familiar with this 'clearance by osmosis' problem. Sometimes you can tell which runway it is or isn't from the SID designator but not always. Checking FR24 for traffic flows can help but it really shouldn't be necessary. Another hole they have awaiting in the cheese is then to change the departure runway after taxi has commenced, which if you're not there often can cause problems with SA too. We all know what assumptions are... assume nothing at JFK!
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Old 19th Jan 2023, 16:47
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Another Swiss cheese hole is when the AA crew were holding and expecting to cross the runway ahead of them ATC said "Cross runway 31L at Kilo"

If ATC had said to them, "Turn right on Kilo and cross 31L" I do not think the incident would have happened as the instruction to turn right would have been different to what they were expecting and would have made them realise.
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Old 20th Jan 2023, 09:19
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Originally Posted by draglift View Post
Another Swiss cheese hole is when the AA crew were holding and expecting to cross the runway ahead of them ATC said "Cross runway 31L at Kilo"

If ATC had said to them, "Turn right on Kilo and cross 31L" I do not think the incident would have happened as the instruction to turn right would have been different to what they were expecting and would have made them realise.
Good point
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