AA 106 @ JFK (13 Jan 23)
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Nowadays all calls to ATC operational ops rooms are to be recorded , I do not know the specific JFK procedures but it would be extremely unlikely if they were not recorded. As to have not heard about it , again talking from my Europan experience , those recordings can only be accessed by the persons involved including the supervisor and the incidents investigators, no way they would be leaked to the outside, The person doing this will be fired .
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Court of Public Law and Policy
The Chairman of the Transportation and Infrastructure Committee of the House of Representatives kicked off the hearing last week (February 7) to begin the process of FAA reauthorization. (For readers not quite familiar with U.S. legislative processes, authorization creates the legal mandate for federal agencies to conduct their activities; appropriations legislation is the funding. Hence authorization (and periodic reauthorization) holds by far the heavier policy implications and effects. Sorry for the pedantic detour, but after all, this is PPRuNe, where information is cheap, cheap, yet understanding may be dear.)
The Chairman, Congressman Sam Graves, stated as follows:
However, note the comments by former NTSB Chair Robert Sumwalt, as reported by the Journal:
"the close calls didn't appear related or part of a broader trend. Both appear to have resulted from human error, [Sumwalt] said, and the outcomes point to the exceptional safety record of the U.S. air-traffic system and aviation industry. 'It shows that given there there were failures, that there was enough resiliency or enough redundancy in the system to have prevented a catastrophic event in both cases.', Mr. Sumwalt said." (emphasis in quotation added)
So, first, with regard to a video representation of the events (and/or non-events) in Austin that is highly inaccurate, count this poster as one who sees no utility or usefulness whatsoever in such a video, for informing, aiding, facilitating, or otherwise being helpful, in the nascent public policy and legislation process which ultimately will lead to FAA reauthorization. Wanting to play with computers and video programs? - fine, no problem. But posting such output here is only about ten (10) years or more behind the times (see, for example, the thread on the accident in August 2013 in Birmingham AL, UPS Fl. 1354, in which thread a good number of posters contributed very informative graphics and computational items.) And, needless to remind the serious pro's who populate this forum, the video showing Air Canada 759 in San Francisco in 2017 was indeed very informative, helpful, and so on.... but it was evidence, not fun-time.
Second, I think there is a fair question - possibly even an important question - about what meaning to take away from both incidents, whether looked at as only quite marginally related or connected to each other - or as connected in some as yet-undefined manner beyond being in close temporal proximity. Is it actually random chance that small steps in each incident - for example, the Southwest flightcrew not "aborting" their takeoff roll (if they even had heard the FedEx call) - contribued to a serious tragic accident not occuring? Or is it something other than random chance, something closer to what most people fluent enough in English to parse definitions would identify as "resiliency" or "redundancy"?
Or, . . did a previous poster make this all less interesting, by saying there are no "reserves" - the term I had tried to apply to what Chairman Sumwalt called resiliency and redundancy - but instead there are "layers and back-ups"?
The Chairman, Congressman Sam Graves, stated as follows:
"[R]ecently there have been incidents that reemphasize why getting an FAA reauthorization done on time is critical. On January 13th, a runway incursion occurred at JFK International Airport when two passenger planes nearly collided as one crossed an active runway. And just this past weekend, at Austin International Airport, a cargo plane was attempting to land on the same runway where a passenger plane was beginning to take off.
It shows that even following the safest decade in our history, our aviation system is clearly in need of urgent attention. As Mr. Boulter says in his testimony, complacency and stagnation are equal threats to a safety culture. The previous conventional wisdom for regulating safety focused on addressing concerns after aviation accidents. Now, the FAA seeks to mitigate risks before accidents happen.
In addition, the National Transportation Safety Board (NTSB) has several open safety recommendations that warrant review. The Committee will be reviewing all such recommendations while reauthorizing the NTSB as part of the FAA bill." [Note: David Boulter is the Associate Administrator for Aviation Safety (Acting) of FAA.]
In reporting on the opening reauthorization hearing, the Wall Street Journal (Feb. 8) noted that current NTSB Chair Jennifer Homendy (in an interview) had cautioned against, with regard to the two runway incursion incidents, saying "this is a trend." The WSJ article also quoted a former investigator for FAA and NTSB as saying, "two incidents so close together is more of a coincidence than an indication of a systemic problem." (This SLF/attorney isn't using that person's name here since he is not afaik a public official or public figure.)However, note the comments by former NTSB Chair Robert Sumwalt, as reported by the Journal:
"the close calls didn't appear related or part of a broader trend. Both appear to have resulted from human error, [Sumwalt] said, and the outcomes point to the exceptional safety record of the U.S. air-traffic system and aviation industry. 'It shows that given there there were failures, that there was enough resiliency or enough redundancy in the system to have prevented a catastrophic event in both cases.', Mr. Sumwalt said." (emphasis in quotation added)
So, first, with regard to a video representation of the events (and/or non-events) in Austin that is highly inaccurate, count this poster as one who sees no utility or usefulness whatsoever in such a video, for informing, aiding, facilitating, or otherwise being helpful, in the nascent public policy and legislation process which ultimately will lead to FAA reauthorization. Wanting to play with computers and video programs? - fine, no problem. But posting such output here is only about ten (10) years or more behind the times (see, for example, the thread on the accident in August 2013 in Birmingham AL, UPS Fl. 1354, in which thread a good number of posters contributed very informative graphics and computational items.) And, needless to remind the serious pro's who populate this forum, the video showing Air Canada 759 in San Francisco in 2017 was indeed very informative, helpful, and so on.... but it was evidence, not fun-time.
Second, I think there is a fair question - possibly even an important question - about what meaning to take away from both incidents, whether looked at as only quite marginally related or connected to each other - or as connected in some as yet-undefined manner beyond being in close temporal proximity. Is it actually random chance that small steps in each incident - for example, the Southwest flightcrew not "aborting" their takeoff roll (if they even had heard the FedEx call) - contribued to a serious tragic accident not occuring? Or is it something other than random chance, something closer to what most people fluent enough in English to parse definitions would identify as "resiliency" or "redundancy"?
Or, . . did a previous poster make this all less interesting, by saying there are no "reserves" - the term I had tried to apply to what Chairman Sumwalt called resiliency and redundancy - but instead there are "layers and back-ups"?
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@ WillowRun6-3
For me they are not related and are both very different in nature. One JFK was crew related was saved by a back up ( which you call reserve ) system : the ASDE which alerted the controller of the runway incursion.
The secondi ncident in Austin was ATC related and was not saved by any back up. I still maintain good luck saved the day. Not by any action by any of 3 parties involved, and not by an external factor like in JFK , since there is no ASDE in Austin .
The only possible ( emphasis on possible) common feature in both cases would be ATC staffing .Things like how long were the controllers on duty on the day and the days before, were they working alone where there should have been two, etc..there the FAA migh have to look at themselves.
The pace of R/T delivery on both cases , too fast in one , too slow and sounding tired in the other might give a clue. But I am fully speculating here.
Another issue coming from the Austin case is standard phraseology , totally disregarded by all 3 participants. If I was the US regulator I would definitively have a serious look at this. As should the correct phraeology had be used , that would have been a safety layer ( what you call reserve) that could have saved the day in a far better way..
Second, I think there is a fair question - possibly even an important question - about what meaning to take away from both incidents, whether looked at as only quite marginally related or connected to each other - or as connected in some as yet-undefined manner beyond being in close temporal proximity.
The secondi ncident in Austin was ATC related and was not saved by any back up. I still maintain good luck saved the day. Not by any action by any of 3 parties involved, and not by an external factor like in JFK , since there is no ASDE in Austin .
The only possible ( emphasis on possible) common feature in both cases would be ATC staffing .Things like how long were the controllers on duty on the day and the days before, were they working alone where there should have been two, etc..there the FAA migh have to look at themselves.
The pace of R/T delivery on both cases , too fast in one , too slow and sounding tired in the other might give a clue. But I am fully speculating here.
Another issue coming from the Austin case is standard phraseology , totally disregarded by all 3 participants. If I was the US regulator I would definitively have a serious look at this. As should the correct phraeology had be used , that would have been a safety layer ( what you call reserve) that could have saved the day in a far better way..
Except that, in a way, they are:
"however, we cannot offer any guarantee of confidentiality or immunity, and the transcription of this interview will eventually be made part of the public docket for this investigation"
We shouldn't underestimate the influence of The Court of Public Opinion, or more specifically that of the experts (and "experts") in the media, who will be all over the testimony once it's in the public domain.
"however, we cannot offer any guarantee of confidentiality or immunity, and the transcription of this interview will eventually be made part of the public docket for this investigation"
We shouldn't underestimate the influence of The Court of Public Opinion, or more specifically that of the experts (and "experts") in the media, who will be all over the testimony once it's in the public domain.
Last edited by ethicalconundrum; 13th Feb 2023 at 17:51.
ATC Watcher,
How can you say “Good Luck saved the Day” in the Austin incident. The FedEx crew had good situational awareness and knew the Southwest crew was cleared on to the runway. That’s why he asked if he was still cleared to land. Then when Tower queried the Southwest crew if they had started their takeoff roll, and Southwest didn’t respond, FedEx initiated his go around while asking SW to abort. So in my mind FedEx had very good situational awareness, not so much for SW and ZERO for the Tower controller. If luck was involved it was how both jets , on the same runway heading didn’t converge vertically as SW took off on climb out, and FedEx was climbing out on the go-around. The other 800lb gorilla in this story is the Tower Controllers employment qualifications and prior record. There are rumblings under the surface.
How can you say “Good Luck saved the Day” in the Austin incident. The FedEx crew had good situational awareness and knew the Southwest crew was cleared on to the runway. That’s why he asked if he was still cleared to land. Then when Tower queried the Southwest crew if they had started their takeoff roll, and Southwest didn’t respond, FedEx initiated his go around while asking SW to abort. So in my mind FedEx had very good situational awareness, not so much for SW and ZERO for the Tower controller. If luck was involved it was how both jets , on the same runway heading didn’t converge vertically as SW took off on climb out, and FedEx was climbing out on the go-around. The other 800lb gorilla in this story is the Tower Controllers employment qualifications and prior record. There are rumblings under the surface.
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The other 800lb gorilla in this story is the Tower Controllers employment qualifications and prior record. There are rumblings under the surface.
This is the first post in there accusing the controller :
Rumor has it the controller in question faked a hate crime at his old facility which he then leveraged to get into his new facility and possibly the reason he certified as well. This is a rumor I got from the internet and does not necessarily represent fact.
Which of course it becomes and slandering the guy continues in a harder tone afterwards, mentioning his skin color and even his supposed religion . Internet at its best.
Only half a speed-brake
Since WR double posted his piece #163 AA 106 @ JFK (13 Jan 23) identical in the AUS thread, my reply there: This last one turned out as a non-accident due to pure coincidence. And the incident happened without really breaching much if anything at all.
Chiefttp IMO what stopped that accident from unfolding was one crew's cognitive performance exercised well in an area they were not supposed to be visiting as per their job requirement or training. Thus not a layer nor backup.
As an example from a computer chair, my first gut reaction was I may had taken a self-authorized break left 90 deg, staying at 2000', and not attempt to control the other plane to safety. The G/A is a layer and this time it did not resolve the situation satisfactorily.
Chiefttp IMO what stopped that accident from unfolding was one crew's cognitive performance exercised well in an area they were not supposed to be visiting as per their job requirement or training. Thus not a layer nor backup.
As an example from a computer chair, my first gut reaction was I may had taken a self-authorized break left 90 deg, staying at 2000', and not attempt to control the other plane to safety. The G/A is a layer and this time it did not resolve the situation satisfactorily.
Last edited by FlightDetent; 13th Feb 2023 at 04:52.
When did the rules change about testimony to the NTSB cannot be used in a subsequent civil or criminal action against the crewmember involved? What are the crew scared of?
Hell, Australia is a third-world backwater in terms of civil aviation and even we have that protection down here, to ensure you can speak frankly without fear of being pineappled for your testimony.
Hell, Australia is a third-world backwater in terms of civil aviation and even we have that protection down here, to ensure you can speak frankly without fear of being pineappled for your testimony.
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Reporting by Wall Street Journal today (Feb. 15, evening, on website) states that the American pilots will comply with the subpoenas issued by NTSB and appear for interviews.
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Isn't the key bit here "Cross runway 31L"? Even at the little puddle jumper airports I fly into there are big red signs telling you what the ahead runway is and the holding point.
Surely you would want to visually confirm the identity of any active runway you are about to enter?
Surely you would want to visually confirm the identity of any active runway you are about to enter?
Did someone check the runway was clear before crossing? I don't know but that would be a question to ask as I make a habit of checking every runway before I cross. Have I ever not done this? I don't know but I suspect I have based on what I know about how the brian works...
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Unconfirmed report from the Delta crew that the 777 had very minimal exterior lights on during the runway crossing, most likely only the taxi light.
Not sure how it is at your airline - but AA has historically never required all exterior lights to be on when crossing runways. It was never really trained or mandated in our manuals, and until only recently it became a “suggestion” during low visibility and/or night conditions. “Suggestion” - not “requirement.” That has always been shocking to me. Personally as a 737 CA I switch on my lights (landing and runway turnoff) every time when crossing and if the FO does not switch on the strobes/wing illumination I turn those on too. About half of them do it, mainly due to it having been a requirement at their previous airline, not because AA trained them to do it.
Compare this to the Delta flight ops manual which REQUIRES all exterior lights to be on when crossing runways - every time no matter the conditions.
Moral of all this, illuminate your aircraft anytime crossing runways for safety.
Not sure how it is at your airline - but AA has historically never required all exterior lights to be on when crossing runways. It was never really trained or mandated in our manuals, and until only recently it became a “suggestion” during low visibility and/or night conditions. “Suggestion” - not “requirement.” That has always been shocking to me. Personally as a 737 CA I switch on my lights (landing and runway turnoff) every time when crossing and if the FO does not switch on the strobes/wing illumination I turn those on too. About half of them do it, mainly due to it having been a requirement at their previous airline, not because AA trained them to do it.
Compare this to the Delta flight ops manual which REQUIRES all exterior lights to be on when crossing runways - every time no matter the conditions.
Moral of all this, illuminate your aircraft anytime crossing runways for safety.
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Given the lack a definite departure runway as per previous comments at JFK, ensuring a readback of the Departure runway seems critical. Of course that takes up airtime but never the less, it should always be required.
Having read the whole thread, i suspect the PF thought they were departing on 31L so was expecting to be cleared to cross 4L and that's where Conformation or expectation bias stepped in. Hence he expected to see 4L, which he did, so he crossed as per the clearance he thought he had. Ironically, being JFK based & very familiar with JFK may make this *more* likely as once he had the departure runway set in his mind as 31L,
..
Having read the whole thread, i suspect the PF thought they were departing on 31L so was expecting to be cleared to cross 4L and that's where Conformation or expectation bias stepped in. Hence he expected to see 4L, which he did, so he crossed as per the clearance he thought he had. Ironically, being JFK based & very familiar with JFK may make this *more* likely as once he had the departure runway set in his mind as 31L,
..
If you freeze this video at 13:52, you will notice that you can see the hold short painting markings and the runway signs even when very close to the hold short line. Think of a clearance to cross the runway as a clearance to move beyond paint markings/signs of the same number.
Last edited by punkalouver; 11th Mar 2023 at 00:46.
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FAA Safety Summit March 15
Presumably this incident will receive a good deal of attention next week, on Wednesday 15 March, when FAA convenes a specially arranged safety summit.
The website of a prominent aviation law firm (with which I'm not affiliated at all) posted a link for livestream of the summit.
"The FAA’s March 15 safety summit is being live streamed: https://bit.ly/3muh30Z"
(I'm posting this item on this particular thread, because of all the recent incidents, it was the one at JFK that produced some difficulty, if not drama, for some of the aviators involved - referring to the short-lived dispute over the format of interviews with NTSB investigators.)
The website of a prominent aviation law firm (with which I'm not affiliated at all) posted a link for livestream of the summit.
"The FAA’s March 15 safety summit is being live streamed: https://bit.ly/3muh30Z"
(I'm posting this item on this particular thread, because of all the recent incidents, it was the one at JFK that produced some difficulty, if not drama, for some of the aviators involved - referring to the short-lived dispute over the format of interviews with NTSB investigators.)
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Shouldn't matter if done in a manner designed to minimize incidents like this. That would be: The controller says "American 106 cross 31 Left". The pilot on the radio reads back "Cross 31 Left American 106". The pilot taxiing says out loud "Cleared to cross 31L" and looks at the hold short sign or painted markings that have the runway number and says "31L cleared to cross, clear left". If they find themselves saying 4 Left so soon after saying 31 Left, it should trigger doubt and the aircraft does not proceed until confirmation that they are cleared to cross 4L. At first, they will think that ATC made the error and just want confirmation to cross 4L. After some back and forth with ATC, it will eventually become apparent to the AA pilots that they had become confused and eventually things get figured out. But everything is figured out safely because the pilots never moved beyond the 4L sign because they never heard the words "cleared to cross 4 Left".
If you freeze this video at 13:52, you will notice that you can see the hold short painting markings and the runway signs even when very close to the hold short line. Think of a clearance to cross the runway as a clearance to move beyond paint markings/signs of the same number.
https://www.youtube.com/watch?v=3YyScI9vSUc
If you freeze this video at 13:52, you will notice that you can see the hold short painting markings and the runway signs even when very close to the hold short line. Think of a clearance to cross the runway as a clearance to move beyond paint markings/signs of the same number.
https://www.youtube.com/watch?v=3YyScI9vSUc
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I still think knowing your departure runway before taxi and reading it back is not to be underestimated. I don't know for sure in this case but it seems likely the PF *thought* they were departing 31L, hence my answer to the previous poster. This may explain why he thought he was cleared to cross 4L. I am not convinced your process would solve this as it doesn't address the bias that may override what seems like a solid approach. After all, the actual clearance to cross was clear but was not digested fully by either crew. *my assumption based on what happened next* I am theorising why. You may disagree but we for sure need understand and account for its cause in whatever solutions are put forward.
We visually verify the proper runway that we takeoff from, using markings/signs. If we see that the markings/signs do not match up with the clearance(and the runway we were planning to use), we do not takeoff. The same thing should apply while taxiing. If we see that the runway markings/signs does not match up with what we were cleared to cross, do not cross.
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Knowing your departure runway helps a lot. But there can be other situations such as unknowing becoming lost at an airport can lead to an improper runway crossing. Ensuring one properly identifies a runway that they are cleared to cross will prevent most improper crossings.
We visually verify the proper runway that we takeoff from, using markings/signs. If we see that the markings/signs do not match up with the clearance(and the runway we were planning to use), we do not takeoff. The same thing should apply while taxiing. If we see that the runway markings/signs does not match up with what we were cleared to cross, do not cross.
We visually verify the proper runway that we takeoff from, using markings/signs. If we see that the markings/signs do not match up with the clearance(and the runway we were planning to use), we do not takeoff. The same thing should apply while taxiing. If we see that the runway markings/signs does not match up with what we were cleared to cross, do not cross.
I just listened to the audio again and the AA PFs question to JFK TWR after the possible pilot deviation message was: "The last clearance we were given, we were cleared to cross. Is that correct?" He seems to be validating they were cleared to cross. He didn't question which runway they were cleared to cross. I think this is significant as it potentially implies he was still unaware they were in the wrong place. IE he genuinely believed he had crossed the right runway and was seeking Conformation that there were cleared to cross. Based on the way he phrases the question, it implies he was pretty sure they were cleared. IE Question asked in the positive sense...
When the tower replies, without commenting on what the clearance was but did say "We're departing Rwy 4L you were supposed to be departing Rwy 4L... you are currently holding short rwy 31L" Only at this point does it appear to dawn on tha AA PF that something it not right. Or so it would appear from the tone and content of the reply.. "Err.. Roger. AA106 heavy"
The tower controller just stated the facts. Which runway was being used for departure and where AA106 was located. This seems to be a text book response. No judgement was passed.
The other question I and others asked is why didnt they see the Delta Jet already moving on 4L when they looked before crossing? Or did no one on the FD look... or..? This seems to be the last chance of saving the day before the incursion but it didn't. We need to find out why, if at all possible.
Last edited by Compton3fox; 11th Mar 2023 at 06:02.
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I argee but despite all what has been stated, it didn't work in this case and there are many other examples too. So unless we understand why and use this understanding to take whatever action is needed, it will continue to happen.
I just listened to the audio again and the AA PFs question to JFK TWR after the possible pilot deviation message was: "The last clearance we were given, we were cleared to cross. Is that correct?" He seems to be validating they were cleared to cross. He didn't question which runway they were cleared to cross. I think this is significant as it potentially implies he was still unaware they were in the wrong place. IE he genuinely believed he had crossed the right runway and was seeking Conformation that there were cleared to cross. Based on the way he phrases the question, it implies he was pretty sure they were cleared. IE Question asked in the positive sense...
When the tower replies, without commenting on what the clearance was but did say "We're departing Rwy 4L you were supposed to be departing Rwy 4L... you are currently holding short rwy 31L" Only at this point does it appear to dawn on tha AA PF that something it not right. Or so it would appear from the tone and content of the reply.. "Err.. Roger. AA106 heavy"
The tower controller just stated the facts. Which runway was being used for departure and where AA106 was located. This seems to be a text book response. No judgement was passed.
The other question I and others asked is why didnt they see the Delta Jet already moving on 4L when they looked before crossing? Or did no one on the FD look... or..? This seems to be the last chance of saving the day before the incursion but it didn't. We need to find out why, if at all possible.
I just listened to the audio again and the AA PFs question to JFK TWR after the possible pilot deviation message was: "The last clearance we were given, we were cleared to cross. Is that correct?" He seems to be validating they were cleared to cross. He didn't question which runway they were cleared to cross. I think this is significant as it potentially implies he was still unaware they were in the wrong place. IE he genuinely believed he had crossed the right runway and was seeking Conformation that there were cleared to cross. Based on the way he phrases the question, it implies he was pretty sure they were cleared. IE Question asked in the positive sense...
When the tower replies, without commenting on what the clearance was but did say "We're departing Rwy 4L you were supposed to be departing Rwy 4L... you are currently holding short rwy 31L" Only at this point does it appear to dawn on tha AA PF that something it not right. Or so it would appear from the tone and content of the reply.. "Err.. Roger. AA106 heavy"
The tower controller just stated the facts. Which runway was being used for departure and where AA106 was located. This seems to be a text book response. No judgement was passed.
The other question I and others asked is why didnt they see the Delta Jet already moving on 4L when they looked before crossing? Or did no one on the FD look... or..? This seems to be the last chance of saving the day before the incursion but it didn't. We need to find out why, if at all possible.
I like to share my solution on what can be done to prevent a situation like this. I guarantee you, they didn’t use my method. Those who do use my method will most likely prevent what happened that night in JFK.
We know why they crossed the wrong runway. Because they didn’t confirm that the runway they were cleared to cross was the runway they were crossing. If one already has a personal procedure to ensure that the the runway they just heard a clearance to cross matches the hold short markings and to always question any discrepancy, it will go a long way toward preventing this sort of error.
The similar procedure that is now widely used to prevent wrong runway/taxiway takeoffs seems to work well as we rarely hear about it anymore.
What the pilots said after the incident is not really relevant except to prove what we already knew…..that they were confused.
In a certain way, it really doesn’t matter why they were confused(in terms of the validity of this procedure). The procedure is based on the reality that pilots become confused sometimes for a variety of reasons and this is the safety net.
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When I see an incident like this(and many others), I understand that I am the kind of pilot who could definitely make the same mistake. Therefore, I try to figure out a procedure that is most likely to prevent it from happening again.
I like to share my solution on what can be done to prevent a situation like this. I guarantee you, they didn’t use my method. Those who do use my method will most likely prevent what happened that night in JFK.
We know why they crossed the wrong runway. Because they didn’t confirm that the runway they were cleared to cross was the runway they were crossing. If one already has a personal procedure to ensure that the the runway they just heard a clearance to cross matches the hold short markings and to always question any discrepancy, it will go a long way toward preventing this sort of error.
The similar procedure that is now widely used to prevent wrong runway/taxiway takeoffs seems to work well as we rarely hear about it anymore.
What the pilots said after the incident is not really relevant except to prove what we already knew…..that they were confused.
In a certain way, it really doesn’t matter why they were confused(in terms of the validity of this procedure). The procedure is based on the reality that pilots become confused sometimes for a variety of reasons and this is the safety net.
I like to share my solution on what can be done to prevent a situation like this. I guarantee you, they didn’t use my method. Those who do use my method will most likely prevent what happened that night in JFK.
We know why they crossed the wrong runway. Because they didn’t confirm that the runway they were cleared to cross was the runway they were crossing. If one already has a personal procedure to ensure that the the runway they just heard a clearance to cross matches the hold short markings and to always question any discrepancy, it will go a long way toward preventing this sort of error.
The similar procedure that is now widely used to prevent wrong runway/taxiway takeoffs seems to work well as we rarely hear about it anymore.
What the pilots said after the incident is not really relevant except to prove what we already knew…..that they were confused.
In a certain way, it really doesn’t matter why they were confused(in terms of the validity of this procedure). The procedure is based on the reality that pilots become confused sometimes for a variety of reasons and this is the safety net.
I agree a good solid process, like the one you described, helps reduce deviations and provides a safety net and although we don't know what process was being followed that night, I agree it likely wasn't yours but even yours will get circumvented at some point. If say it's too complex, steps will be skipped. If it's not validated, it may hold flaws we don't know about etc..
Good discussion BTW.