Runway Collision Narrowly Averted at LAX

[RatherBeFlying]

http://www.latimes.com/news/printedition/la-me-lax6oct06,0,2162838.story?track=mostviewed-homepage
Free registration required.

A SkyWest regional jet taking off for San Antonio had accelerated to 115 mph when a Gulfstream business jet strayed in front, forcing the pilot to slam on his brakes. The SkyWest jet, with about 39 people on board, shuddered to a stop less than 100 feet from the Gulfstream... "SkyWest 6430, I apologize. We never talked to the Gulfstream. He crossed without a clearance,"...

[TooL8]

Another quote from the same article;

"Controller workload and controller staffing had nothing to do with this," Gregor said. "It's disingenuous to suggest otherwise. The system worked exactly as it should."

That's comforting then :ugh:

[120.4]

From what I am reading it seems to me that the original layout of LAX is a significant contributor in incidents like this? (there not being a taxiway on which traffic can hold prior to crossing the inner). The fact of the matter is that with human beings in the loop, mistakes will always be made and it is therefore ABSOLUTELY essential that we do not design airports or ATC systems with compromises in them. Of course, the ideal cannot itself prevent accidents but in our business every compromise on the ideal increases the probability that human error will lead to an accident.
The LTMA has one or two such compromises designed into it which have been identified as requiring urgent solution (quote) "...on the grounds of passenger safety." The solution is due in 2009, by which time this significant danger will have existed unaddressed for over 5 years.:ugh: :ugh: :ugh:
Relying on human beings not to be human in a safety related business is insanity.
.4

[aviator]

October 6, 2006
In yet another dramatic incident at Los Angeles International Airport, two aircraft came so close to colliding on a runway Saturday that one pilot can be heard hyperventilating on air traffic control tapes.
A SkyWest regional jet taking off for San Antonio had accelerated to 115 mph when a Gulfstream business jet strayed in front, forcing the pilot to slam on his brakes. The SkyWest jet, with about 39 people on board, shuddered to a stop less than 100 feet from the Gulfstream.
After the incident, a shaken tower controller can be heard on the radio apologizing to the SkyWest pilot and asking him to immediately leave the runway to make room for a landing aircraft.
"SkyWest 6430, I apologize. We never talked to the Gulfstream. He crossed without a clearance," says the controller, who was so traumatized by the near-collision that she left her post seconds later. "I apologize. If you could make a right turn, please, and exit the runway."
The SkyWest pilot comes onto the frequency next.
"Exiting right," he says, exhaling heavily.
Controllers in the tower at LAX — the world's fifth-busiest passenger airport — said it was the closest they'd seen two airplanes come to each other at the facility without actually colliding. Aviation officials agreed that the incident is likely to be classified as the most serious close call at LAX since 2000. It was the eighth near miss there this year, compared with six in 2005.
The incident comes just nine weeks after a serious near-collision at LAX involving two airliners on the same runway and underscores long-standing safety issues with the airport's configuration. The unusual layout, which features two sets of parallel runways, requires pilots who land on an outer runway to cross the inner runway on a series of taxiways.
The rate of close calls at LAX has remained high despite years of efforts by local and federal officials to ensure that pilots and controllers follow federal rules allowing only one plane at a time on or near a runway. Among the nation's airports, LAX is unusual, because airplanes cross active runways about 900 times a day.
On Thursday, airport officials said such incidents should be prevented once construction workers finish moving the southernmost runway 55 feet and installing a center taxiway that pilots can use to turn and wait for clearance to cross the inner runway.
Starting in July 2008, when the center taxiway is scheduled to open, "pilots will be directed on a route that will reduce the likelihood of them inadvertently crossing an active runway without authorization," said Paul Haney, deputy executive director of airports and security for the city agency that operates LAX.
Such an inadvertent crossing is what happened Saturday about 6 p.m., officials said, when the pilot of the Gulfstream, registered in the United Kingdom, taxied from a hangar on the airfield's south side on his way to take off. Controllers told the pilot to cross the outer runway and then stop short of the inner runway.
The pilot repeated the instructions. Then he passed the taxiway that controllers had told him to use to cross the runways, prompting them to repeat their directions. The pilot again read them back, turned around, and proceeded to turn onto the correct taxiway. But rather than stop, he entered the runway that the SkyWest jet was using.
Federal Aviation Administration officials said the SkyWest pilot, the tower controller and the ground radar that audibly alerts controllers to impending collisions all noticed — at the same time — the Gulfstream crossing the runway.
"We had three layers of redundancy," said Ian Gregor, an FAA spokesman. "This is just a clear and clean pilot mistake."
The Gulfstream pilot told officials he was certain that the controller had cleared him to cross both runways, even though he twice read back the "hold short" instructions correctly, Gregor said. Officials did not know if other people were aboard the business jet.
The FAA has yet to classify the incident — the agency uses a four-level system to grade close calls on the ground — but it will probably fall into one of the top two most serious categories, he said. Officials at the airport agreed that the close call would probably receive an "A" rating, meaning the pilot needed to take extreme action to prevent a crash.
The last close call at LAX to receive a similar ranking occurred March 5, 2000, when an airplane landed on the outer runway on the north side and failed to stop short of the inner runway, crossing into the path of a departing jet.
The last serious near-collision at the airport happened July 26 and received a "B" ranking, meaning there was a considerable danger of a crash. In that case, a SkyWest turboprop rolling for takeoff averted disaster by suddenly lifting into the air — risking a stall — to avoid a Mesa Air regional jet that had strayed onto its runway.
Officials later said the planes were not in danger of hitting one another because the nose of the Mesa Air jet was 50 feet away from the SkyWest plane as it flew over.
Controllers disagree, saying the planes came closer to each other than the agency's investigation showed.
In Saturday's incident, officials said runway construction — which involves hundreds of machines tearing up the south side of the airport, piling rubble and mounds of dirt just several hundred yards from the runway the SkyWest pilot used — had nothing to do with the close call.
The SkyWest captain, who has been with the airline seven years and eight months, mentioned in an after-action report that there was construction on the airfield at the time of the incident, said Sabrena Suite, a company spokeswoman.
Controllers said runway construction, which has forced them to funnel all traffic onto the airport's three other runways, and understaffing in the tower have left them less able to catch blunders by pilots that might lead them to cross an active runway.
"You're having controllers working too long and too hard on position," said Mike Foote, a controller in the LAX tower and a spokesman for the National Air Traffic Controllers Assn. "This was all pilot error — you can't say it wasn't — but the fact is this didn't use to happen. People would catch it. We still do … but more frequently it's not being caught."
The FAA disagreed, saying controllers' staffing and workload played no role in Saturday's incident, adding that the tower controller who instructed the SkyWest jet to take off had been on duty only 65 minutes when the close call occurred.
"Controller workload and controller staffing had nothing to do with this," Gregor said. "It's disingenuous to suggest otherwise. The system worked exactly as it should."

[Airbubba]

There aren't many UK registered Gulfstreams (I count four), any idea which one it was?

[Sqwak7700]

"You're having controllers working too long and too hard on position," said Mike Foote, a controller in the LAX tower and a spokesman for the National Air Traffic Controllers Assn. "This was all pilot error — you can't say it wasn't — but the fact is this didn't use to happen. People would catch it. We still do … but more frequently it's not being caught."

You know, LAX ATC are very good, just like other major busy airports in the States. But this kind of incident is a warning sign, and I think they have used up all the warnings in LAX. It is a broken system and it needs a fix. You can't just fix it by telling pilots and controllers to be "extra" carefull. What do you think we do? You think we are only mostly carefull unless the FAA says we should be more??

How about hiring some more ATC for Christ's sake. You have loads of useless TSAs standing arround. Why don't you fire half of them and use the money where it would be really appropriate; train and hire new controllers. I can understand a small little airport tower being understaffed (then again, look at LEX with Comair??) but LAX is a major international airport with lots of heavies with 300-400 people on board. This is the gateway airport for flights from Asia and the Pacific regions. It's not only embarrasing, but dangerous and scary as well.:=

I don't care what it is; stop bars, a system like DFW has, or simply modding the instructions like not letting someone cross only one runway. Or make everyone go to the end before crossing.

I know that LAX likes using the outers for landings because it allows simultaneous ops. I think the FAA should look at this and allow simultaneous ops to the inner runways. It might not make the criteria (runways too close), but I think the risk of pilots straying from their approach on short final are very rare. Most of us are well established on centerline from 5 miles in. Just stagger them a bit, or even separate by altitude till established on the loc, and that should help out lots. Then you can depart on the outers, avoiding the trap of landing aircraft crossing the takeoff runway.

Something needs to be done. I don't want LAX to out-do Tenerife someday. You only get a few close calls before something goes majorly wrong. :uhoh:

[BYOD]

Simple fix, cross only at the end. So parallel taxiway needed. :)

[Ignition Override]

Flying into LAX between about 7-10 years ago left some unique impressions on me. Not only was the 757 difficult to slow down anywhere, mostly on the Civet Arrival (it required a constant descent path), even with only one runway change at a very busy time. But once we were given three runway changes and SOCAL or Approach control gave us an EXTRA altitude restriction which was not published! At about 10 or 11,000', the Captain called for "gear down". Fortunately, he had flown there often on the B-727. After a very long leg from Asia or Europe, this might be more of a challenge, even without language difficulties. Leaving one morning at 0200 :ugh: , I had no idea what an MD-11 pilot was saying on the radio, who taxied out for a very long flight westbound.

As a group, the voices of the LAX Approach and Tower Controllers back then, at least from my perspective, indicated more stress than I remembered hearing at any other US airport, including Chicago O'Hare, La Guardia, Boston etc. Atlanta (and STL etc) was designed with a parallel taxiway between each pair of runways, with time after landing to recheck a clearance and unwind just a little bit. Cleveland (CLE), Chicago Midway (MDW: also the length of each runway), Houston Hobby (HOU) and Boston (BOS), even Milwaukee (MKE) at times, can be just as hazardous as LAX, maybe more so. The trickiest and most hazardous runway layouts seem to be at CLE (three closely-spaced parallel runways, intersected by 10/28 on the north side) and BOS, most of all. Even crossing Milwaukee's runway 01L and 01R requires extra concentration just to finish the "taxi checklist" due to a controller constantly calling you.

Even a First Officer Instructor in the right seat was required to explain to the MKE controller that we needed to be left alone, so that we could remember where we were on the checklists. The weather was good, no traffic holding short for us, or that required us to hold short, no traffic on short final and no wheels up times issued - nothing that required us to hurry things up. He just wanted us to switch to the (for runway 25L) tower freq very early so that he could forget about us. Even my FO, an excellent highly-experienced jet simulator instructor and excellent line pilot with about fifteen-eighteen years of flying was forced to tell ATC to leave us alone for about 30 seconds. Talk about unnecessary distraction with low traffic volume! :hmm: This might be one extra reason why MKE is reported to be a high runway-incursion airport. Do some ATC guys believe that in a two-person 'steam-gauge' c0ckp1t, we have nothing to do on a short taxi route, as we cross two or even three runways? Soon this will combined with double-checking de-icing holdover times, perhaps next Wednesday for those in North Dakota (MOT or GFK) or Winnepeg. The tragedy in Lexington, Kentucky enlightened laymen and reminded flightcrews as to what can happen when an operation is rushed.

An article in a newspaper last week claimed that new US Controllers might be hired at 10% less salary and in the near-future might have a workload 10% MORE than many controllers have now. The theme of the article, often quoting a Controller directly or indirectly, suggested that their FAA bosses are indifferent and callous about the results, including two solid hours on the radar scope with no break during a peak workload period

[Check 6]

There aren't many UK registered Gulfstreams (I count four), any idea which one it was?
Airbubba, use www.flightaware.com to search the G registered Gees. The one departing LAX would be the likely suspect.:=

[Astra driver]

Here we go again, trying to blame ATC for an obvious crew screw up.

The crew recieved and read back two seperate clearances to hold short of rwy 25R, and then crossed anyway.

Not much to discuss here.

[Jerricho]

How about hiring some more ATC for Christ's sake.

This is an organisation that wants to cut controller numbers by 10% and is focusing their efforts on implementing a dress code.............sorry mate, I wouldn't hold my breath.

[Scurvy.D.Dog]

.. bazaar eh! :( .... seems to me that all the alarm bells are ringing, and the people who should be beside themselves with concern are seemingly more interested in other peoples attire!!! :uhoh:
.
.. **** oh dear :mad:

[Jerricho]

You may have an incident, but damn, are you gonna look good.

[Airbubba]

Airbubba, use www.flightaware.com to search the G registered Gees. The one departing LAX would be the likely suspect.

I'm not able to make this work, can you do it?

[Ignition Override]

Astra Driver:

That might have been the case at LAX, but when the Tower Controller, anywhere, calls you as you are still stowing the thrust reverser levers at 70 knots with a totally unexpected clearance at the wrong time, to cross an active runway, that is out of bounds and uncalled for.

We must then check and clarify this critical clearance
{this abrupt interruption} by ATC, after the plane has cleared the high-speed turnoff exit.

In such situations our plane was never on fire, which would have justified an immediate radio call.

[westhawk]

I was just at LAX twice over the last month for pax pickups, and boy what a mess! This 25L closure throws a big wrench in the works. Most of the intersections normally available for use to cross 25R are closed due to the construction project. More of the freighter and bizjet traffic than ever must land and take off from the 24s, requiring even more than the normal amount of taxi traffic between the north complex and the south. All things considered, it's working more smoothly than I might have thought. ATC really has their work cut out for them, and IMHO, are doing an admirable job under difficult circumstances.

But there are some problems related to the taxiway A painted ground markings and taxiway signage. Since most of the north/south taxiways between taxiway A and 25R are closed for the rwy work, the signs along taxiway A have been removed and the closed taxiways marked XXX. Also the painted taxiway markings are faded or dirty, rendering them difficult to see and read. I don't know how you guys do it, but I like to follow along on the airport diagram comparing the charted taxiway intersections to the ones I am seeing out the window as an aid to positional awareness. Trouble is, this is darned difficult to do with the designation signs removed and the surface markings obscured or difficult to see.

I couldn't help wondering if this was a possible contributing factor to the part of the story where the Gulfstream crew missed their assigned turn at the north/south taxiway on which they were to hold short of 25R, requiring that they turn around and proceed back to that taxiway. That, and the fact that at 18:00L, the westbound taxiway is nearly aligned with the setting sun. (if not obscured by cloud) So the potential for a little confusion, frustration, embarassment etc... Distraction.

Note:In my experience, it is normal for south ground to issue taxi instructions to taxi to the departure runway and hold short of the runway to be crossed and to contact the tower for crossing. There may be certain exceptions to this normal practice, but this is usually how they handle it.

Now I know that more than a few non-US pilots have issues with our "implied" clearance to cross all runways as part of a normal clearance to taxi to the departure runway. Unless explicitly instructed to hold short of, or at, a point along your taxi route, you are cleared to cross all runways along your taxi route except the runway you were cleared to taxi to. So I cannot help but wonder if this could have, in some part, been a factor.

Okay, so much for the musings. That was a really close call! Very good SA and reaction time on the part of the Skywest crew, thank goodness. Apparently, good brakes too. Assuming for a moment that the news report is accurate, I really don't know what else the controller or anyone else could have done once the G taxied onto the runway. There would have been very little time to act once the RJ was rolling. How was anyone to know that the G would taxi onto a runway they had just read back that they would hold short of. Perhaps this is even the reason for LAX's normal practice of handing aircraft off to the local controller for crossing instead of ground clearing aircraft across, I don't know. The holes sure lined up here! It certainly appears that good eyes and quick decision making on the RJ flightdeck narrowly averted another conflagration at LAX. Good job!

As always, I await official information before I commit to any particular beliefs about what did happen, or what caused it. The above are just some thoughts that came to mind given the story as it has been told so far.

Anyone have anything else to add?

Best regards,

Westhawk

[PaperTiger]

Anyone have anything else to add?Not really except to concur that LAX south side is very confusing right now (shades of LEX ?).

With only the media reports, I was trying to work out where the GV 'missed' the taxiway and where he was trying to go. I assumed from a 'hangar' (more likely just one of the ramps) on Imperial he was making for 25R so was cleared to cross one (closed 25L) runway. But if as you point out he was bound for the north pair on the straight crossing taxiway, it is just conceivable that 25R was the one he thought he was cleared across, the 24s being visible to him at the time.

How about some "Follow Me" jeeps during the construction ??

[yellowdog]

I'm not able to make this work, can you do it?

Airbuuba,

Looked on flightaware yesterday and there were no G- registered G's out of LAX. The only one maybe VP-BIP a new G550 but I don't know who is operating it or where it is based. That departed KLAX at 2330z on Saturday.

YD

[Airbubba]

The only one maybe VP-BIP a new G550 but I don't know who is operating it or where it is based. That departed KLAX at 2330z on Saturday.

Would that be Saturday, September 30? That seems to be the date of the incident from the LA Times article posted above. Thanks for taking a look in the archives.

Quite possibly the plane did not depart on the same day since the crew probably had some paperwork to fill out and maybe an interview with a fed or two. But for the grace of God it could have been any of us...

[ViciousSquirrel]

Now I know that more than a few non-US pilots have issues with our "implied" clearance to cross all runways as part of a normal clearance to taxi to the departure runway. Unless explicitly instructed to hold short of, or at, a point along your taxi route, you are cleared to cross all runways along your taxi route except the runway you were cleared to taxi to. So I cannot help but wonder if this could have, in some part, been a factor.



This is not totally accurate, though it's definitely true that a lot of non-US pilots would be rightly a little nervous about this particular clearance issue. You also hear a lot of US trained crews (particularly biz jets it seems) that will request crossing clearance when it's not strictly required. Sometimes this actually pisses off the ground controller, but of course it's always far better to ask than risk a violation or possible aircraft in the face.

Anyhow, the caveat to the above statement is that you may cross any INACTIVE runway along your taxi route without a specific crossing clearance, an inactive runway being a runway that is not mentioned in the ATIS as a departing or arriving runway. Seems obvious, but it's a very important distinction and one that can be misunderstood. I've been cleared to taxi to an active runway where my route would have crossed a seperate active runway without being given a hold short instruction. Though it's rare, such an occurance is fraught with potential if the crew does not have a complete understanding of this particular rule and decides to cross an active runway without clearance.

[Capt737AA]

Flying out of LAX as my home base, I can certainly testify to the fact that you truly have to be watching where you're going there with the two parallel runways on each side... especially 25 L/R on the south side of the airport. It's not as simple a task as one would think. I have on more than one ocassion thought I was going to a taxiway only to look a bit harder and see that it was a runway hold line I was heading for.... amazing

Pat

[westhawk]

This is not totally accurate, though it's definitely true that a lot of non-US pilots would be rightly a little nervous about this particular clearance issue. You also hear a lot of US trained crews (particularly biz jets it seems) that will request crossing clearance when it's not strictly required. Sometimes this actually pisses off the ground controller, but of course it's always far better to ask than risk a violation or possible aircraft in the face.

Anyhow, the caveat to the above statement is that you may cross any INACTIVE runway along your taxi route without a specific crossing clearance, an inactive runway being a runway that is not mentioned in the ATIS as a departing or arriving runway. Seems obvious, but it's a very important distinction and one that can be misunderstood. I've been cleared to taxi to an active runway where my route would have crossed a seperate active runway without being given a hold short instruction. Though it's rare, such an occurance is fraught with potential if the crew does not have a complete understanding of this particular rule and decides to cross an active runway without clearance.

It appears that I should revise my statement so as to include US pilots as well!:)

Here's the deal according to FAR 91.129(i). This information is repeated in the AIM:

FAR 91.129 (http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=68f59efc32250a0ea9f5043a6806eea5&rgn=div8&view=text&node=14:2.0.1.3.10.2.4.16&idno=14)


(i) Takeoff, landing, taxi clearance. No person may, at any airport with an operating control tower, operate an aircraft on a runway or taxiway, or take off or land an aircraft, unless an appropriate clearance is received from ATC. A clearance to “taxi to” the takeoff runway assigned to the aircraft is not a clearance to cross that assigned takeoff runway, or to taxi on that runway at any point, but is a clearance to cross other runways that intersect the taxi route to that assigned takeoff runway. A clearance to “taxi to” any point other than an assigned takeoff runway is clearance to cross all runways that intersect the taxi route to that point.



AIM 4-3-18 (http://www.faa.gov/atpubs/aim/Chap4/aim0403.html#4-3-18). Taxiing:

5. When ATC clears an aircraft to "taxi to" an assigned takeoff runway, the absence of holding instructions authorizes the aircraft to "cross" all runways which the taxi route intersects except the assigned takeoff runway. It does not include authorization to "taxi onto" or "cross" the assigned takeoff runway at any point. In order to preclude misunderstandings in radio communications, ATC will not use the word "cleared" in conjunction with authorization for aircraft to taxi.
6. In the absence of holding instructions, a clearance to "taxi to" any point other than an assigned takeoff runway is a clearance to cross all runways that intersect the taxi route to that point.
7. Air traffic control will first specify the runway, issue taxi instructions, and then state any required hold short instructions, when authorizing an aircraft to taxi for departure. This does not authorize the aircraft to "enter" or "cross" the assigned departure runway at any point.
NOTE-
Air traffic controllers are required to obtain from the pilot a readback of all runway hold short instructions.


This just might be the most commonly misunderstood ATC clearance on the books. There are many other "implied clearances" which are known to be commonly misunderstood of course, but this one is very well known in the instructor community. Don't feel too bad, you're not alone!

Bottom line: Absent any specific instructions to hold short of any point along the taxi route to any other point on the airport, clearance to taxi to an assigned departure runway or other point on the airport IS a clearance to cross all runways along the taxi route except the assigned departure runway. If you are not 100% sure what you are cleared to do, request clarification from ATC. It is always better to risk the ire of the busy controller than to risk the consequences of a runway incursion.

However, I do not think it unreasonable to expect that pilots should understand the nature of all standard clearances listed in the AIM which apply to the type of operation being conducted. I would tend to be more understanding of this deficiency of knowledge in pilots who do not hold a FAA issued certificate than those who do, since it is very likely that foreign pilots are not accustomed to operating under these rules. Charitable tendancies toward understanding aside, all pilots are indeed required be familiar with the rules in effect in whatever countries they conduct flight operations. A daunting, but necessary task for pilots who fly in many countries.

As I implied in my earlier post, I do not know this to be a factor in the incident which is the subject of this thread. I pose it as one of several factors which might be worthy of consideration and discussion. I hope some benefit is derived!

Best regards,

Westhawk

[av8boy]

Well said, Westie. Your correction of VS saved me a lot of typing! :ok:

[DC-Mainliner]

I was based in LAX in the late 90's flying Boeing and McD equipment. LAX is by far a very busy airport, with a lot of heavy aircraft and thick accents - in other words, it's a typical large international airport. The difference at LAX is that the control tower has several "blind" spots where they can't see traffic on the ground, and it also has a very high concentration of commuter airliners and corporate jet traffic. At LAX, there is a good chance you are going to see a very high density traffic operation taking place and you will also see complex airspace surrounding the airport with arrivals and departures with multiple altitude crossing restrictions and lots of traffic to spot in the air and on the ground.

I can't imagine LAX with fewer controllers than they have now. They are already over taxed - as the other guy said, you can hear the strain in the voices during the big traffic pushes.

Everytime I take a guy into LAX who's never been there, we spend a lot of time talking about LAX ops before we even take off for LAX.

To me, however, ORD (Chicago O'Hare) still seems more screwed up on the taxiways than LAX. That place begs you to commit a runway incursion.

[refplus20]

LAX GV Pilot Urged To Call the FAA
The FAA is trying to interview the pilot of a non-U.S. registered Gulfstream V involved in a Class A runway incursion at Los Angeles International Airport (LAX) on September 30. During the incident, a departing SkyWest Airlines CRJ700 stopped within about 100 feet of the Gulfstream, which was on the same runway. The Gulfstream then continued on its planned flight to Long Beach, according to an FAA spokesman. The pilot contacted the tower but did not have to delay his trip, the spokeman said. The pilot did provide contact information to tower controllers before departing for Long Beach, but telephone messages left by FAA flight standards inspectors have not been returned, according to the spokesman. The agency’s next step is to send a letter of investigation, which the agency planned to do yesterday. If the pilot responds to the letter within five days, he can participate in the FAA’s runway incursion safety program and avoid certificate action. At the present time, it was not known if the GV pilot holds an FAA pilot certificate.

[Danny]

Listen to the tapes here courtesy abc7: http://abclocal.go.com/kabc/story?section=local&id=4634099

Individual mp3 for Ground Freq: http://abclocal.go.com/three/kabc/kabc/101306laxnearmiss/GROUND.mp3
Tower Freq: http://abclocal.go.com/three/kabc/kabc/101306laxnearmiss/GROUND.mp3

[westhawk]

Listen to the tapes here courtesy abc7: http://abclocal.go.com/kabc/story?section=local&id=4634099

Individual mp3 for Ground Freq: http://abclocal.go.com/three/kabc/kabc/101306laxnearmiss/GROUND.mp3
Tower Freq: http://abclocal.go.com/three/kabc/kabc/101306laxnearmiss/GROUND.mp3

Danny:

Thanks very much for providing that link to the tower and ground audio. It adds some clarity to the story.

First, Taxiway G ends at the entrance to the Landmark (formerly Garrett) ramp entrance. The ramp is shared with the Singapore Airlines cargo facility just west of Korean cargo and east of Landmark. As soon as you leave the ramp northbound and cross the vehicle service road, you are at the intersection of taxiways G and A facing to the North. A is perhaps 100 to 150' North of the ramp and a similar distance South of 25L. The turnoff from taxiway A onto the ramp is designated A5. Here is the link to the LAX airport diagram (http://www.naco.faa.gov/d-tpp/0610/00237AD.PDF).(pdf)

The phraseology used to clear the Gulfstream to taxi to rwy 25R from Landmark was "Runway two-five right, taxi via Alpha and Golf, hold short of two-five right." This was then read back by an American sounding voice verbatim. A very short time later, ground informs BIP that they have missed taxiway G. The Gulfstream crewmember responds, indicating that he understands, but then his voice seems to trail off before the microphone button is released. A voice can be heard in the background at this time, but I'm unable to tell if it was the other Gulfstream crewmember or perhaps something else. After a short time,the ground controller then clears the Gulfstream to "Cross two-five left, hold short 25R." This too is read back verbatim. Gulfstream is then instructed to "Monitor tower one two zero point niner-five." This is also read back.

The southside local controller seems to have been relieved by another controller within less than a minute. (probably SOP after a "deal") The New controller instructs the Skywest RJ to finish clearing the runway. When the Gulfstream checks in on the tower frequency, he tells tower that ground cleared them across both runways.

This is where the question of misunderstanding the meaning of the clearance they were issued may come into play. Going back to the original taxi clearance issued, did the crew understand that clearance to mean that they were cleared to cross the departure runway as part of their clearance to taxi to 25R? The person operating the radio said they had been cleared across BOTH runways by ground control, yet no such clearance is heard on this recording. See my earlier post for the rule regarding the taxi clearance which IS on the recording.

I don't know that we'll ever learn what conversation took place in that airplane, or what the thought the processes of the crew were either. I guess the second controller heard on tower frequency said it best when he said that everyone was safe and that's the important thing.

Best regards,

Westhawk

[Airbubba]

Hmmm, the Gulfstream registration on the ATC tapes doesn't sound British at all, sounds like VP-BIP perhaps.

And, the pilot sounds like a gringo.

[Fokker28]

Danny:
The phraseology used to clear the Gulfstream to taxi to rwy 25R from Landmark was "Runway two-five right, taxi via Alpha and Golf, hold short of two-five right." This was then read back by an American sounding voice verbatim.

Nope, not read back verbatim at all. Listen again. I think the variance is actually the key to his misunderstanding. Sounded like he thought he was cleared all the way to the runway, via crossing the runway.

I've listened to the tape several times, and I really don't detect any ambiguity at all on the part of the controller. I think the controller used nearly perfect, if not perfect, phraseology. This guy taxiing BIP had his head up and locked and nearly killed a bunch of people.

[westhawk]

Nope, not read back verbatim at all. Listen again. I think the variance is actually the key to his misunderstanding.

I listened again and noticed that the pilot dropped the "via" from the readback. Is that what you mean?

[Fokker28]

No, VP-BIP reads back, "Alpha & Golf, 25R, hold short of 25R." As though he believes he is cleared all the way to the departure end of 25R, at which point he is to hold short. Instead of, "Runway 25R. Taxi via Alpha & Golf, hold short of runway 25R [or very similar as cleared by ATC]"

[India Four Two]

After listening to the tapes and looking at the airport diagram (thanks Danny and Westhawk), I have a question about the taxi clearance. Was it a clearance to taxi and hold short for an intersection takeoff on 25R from Golf, or was it a partial clearance, with further instructions to follow after clearance to cross 25R at Golf? If it was a partial clearance, is that a normal procedure at LAX?

VP-B - is that Bahamas registry? If so, then that would explain the British reference. Obviously, the west coast media still think the Bahamas are a British colony.

[westhawk]

I have a question about the taxi clearance. Was it a clearance to taxi and hold short for an intersection takeoff on 25R from Golf, or was it a partial clearance, with further instructions to follow after clearance to cross 25R at Golf? If it was a partial clearance, is that a normal procedure at LAX?

The wording used by the ground controller in the original (initial) clearance ("Runway two-five right, taxi via Alpha and Golf, hold short of two-five right.") constitutes the assignment of the takeoff runway (for planning purposes) and appears only to be a clearance for VP-BIP to taxi from it's present location to the hold line at the intersection of taxiway G and runway 25R. If the controller had used the words "taxi to runway two-five right", that would mean the BIP was cleared all the way to hold short line abeam the full length takeoff position of runway 25R. Referring to the rule regarding this clearance,
A clearance to “taxi to” the takeoff runway assigned to the aircraft is not a clearance to cross that assigned takeoff runway, or to taxi on that runway at any point, but is a clearance to cross other runways that intersect the taxi route to that assigned takeoff runway.
they would still have been required to hold short of 25R on taxiway G since the clearance does not include authorization to cross or taxi ON any part of the assigned departure runway. Had the crew not missed taxiway G by making a wrong turn, the originall recieved clearance would have been the clearance in effect. Instead, following that, a revised clearance was issued by the ground controller to "cross two-five left, hold short of two-five right." (note that 25L has been closed for construction) This was correctly read back by the crewmember. Then they were instructed to monitor tower on 120.95. This is SOP at LAX. Ground clears you to a point where the runway(s) are to be crossed with instructions to hold short, then switches you to tower for the actual crossing.

I can't help wondering if the crew believed they were crossing 25L, when they were in fact crossing 25R. 25L is barely recognizable as a runway in it's current state. It might be possible to taxi across it without recognizing it as a runway.

So it seems to me that this incident may come down to one of two primary factors. Either a misunderstanding of the clearance that was issued, or a mistaken belief that they were crossing 25L (as cleared) when in fact, they were crossing 25R. (which they were to hold short of and await clearance from the tower to cross.) Only the crew can say which it was. As I said before, LAX is currently a real mess on the south side due to the construction project. I don't know how this may have affected the crew's perceptions. According to the tracking history on Flightaware.com, the aircraft had probably arrived from Narita earlier that day. I say probably because Flightaware tracking is only fully functional between US city pairs. Flight tracks arriving to the US from international airspace often begin at a lat/lon fix near the border. Is this the same crew who flew that leg? Again, no way to know. In any case, the crew in question did not have hours or days to consider this as we do here. We really have to know this stuff!

VP-B - is that Bahamas registry? If so, then that would explain the British reference. Obviously, the west coast media still think the Bahamas are a British colony.

I believe ICAO annex VII identifies VP-B as currently being assigned to Bermuda. IIRC, the VP designation was formerly assigned as "protectorates and colonies of the United Kingdom" under an older version of annex VII. And yes, in the US, the distinctions between " the UK", "Britain" and "England" tend to be somewhat blurry. Sorry! :confused:

Best regards,

Westhawk

[India Four Two]

Westhawk,

Thank you for your detailed and informative reply. The reason for my interest in this particular incident is that (in spite of my current location), I occasionally operate light aircraft out of Calgary (CYYC), where I have often received taxi clearances for an intersection takeoff on 16, which sometimes include hold-short instructions for 07/25, when multiple runways are in use.

However, because of the airport layout, I have never had taxi instructions which required crossing my departure runway on the way to the cleared holding point, so I had never thought about this issue before.

After reading your post carefully, it seems that Ground could (ignoring the Tower frequency SOP for the moment) in theory issue a clearance along the lines of "Taxi to runway two-five right via Alpha, Golf, Bravo and Foxtrot", which would still require holding short of 25R on Golf, even though it was not explicitly mentioned in the clearance. Is that correct?

With regards to Bermuda, Bahamas - they're all islands in the Atlantic - not much difference really:) And no apologies necessary about the UK, Britain, England distinction. Having grown up in southern England, I know a lot of people there who don't know the difference either - it really annoys my Scottish and Welsh friends!

Regards,
I42

[westhawk]

Westhawk,After reading your post carefully, it seems that Ground could (ignoring the Tower frequency SOP for the moment) in theory issue a clearance along the lines of "Taxi to runway two-five right via Alpha, Golf, Bravo and Foxtrot", which would still require holding short of 25R on Golf, even though it was not explicitly mentioned in the clearance. Is that correct?

Regards,

I42

Affirmative, 142. The clearance would not include authorization to cross the assigned departure runway, only to cross all other runways along the taxi route. In this case, the absence of any instructions beyond the intersection of G and rwy 25 would appear to indicate that the controller intended to clear the Gulfstream only to that point, not all the way to the takeoff end of 25R. Even if the full taxi clearance had been issued, it did not constitute authorization to cross 25R. You've got it right!

Best,

Westhawk

[Fokker28]

Even if the full taxi clearance had been issued, it did not constitute authorization to cross 25R. You've got it right!




Especially since he was told to HOLD SHORT 25R!

[westhawk]

Especially since he was told to HOLD SHORT 25R!

I agree completely Fokker!

Best,

Westhawk

[DC-Mainliner]

This is a pretty typical taxi clearance out of Landmark at LAX. Also, the big red "RWY 25R" signs at the intersection serve as a good marker as to what runway was being approached, no mystery there. The Gulstream also affords good taxi visibility too, it stands nearly as tall as the smaller DC-9's and such at the cockpit, giving a better perspective of upcoming taxiways and markings than a typical business jet does. So on the surface, this appears to be an unfortunate example of the "black and white basics" coming into play, being set aside - in our sometimes otherwise complex world of navigating grey areas and judgement calls.

Where things would get interesting is the analysis of what sort of communication was going on between the Captain who was taxiing the airplane and the Pilot Monitoring, who was working the radios. The taxi briefing before the taxi request, the interperatation of the clearance, and the monitoring of the operation - the whole thing. That is where the real study in CRM, error management and such would be valuable to the industry.

The Feds will want blood but hopefully they can glean some understanding of the human factors behind this too.

[Astra driver]

I can't help wondering if the crew believed they were crossing 25L, when they were in fact crossing 25R. 25L is barely recognizable as a runway in it's current state. It might be possible to taxi across it without recognizing it as a runway.

I agree Westie, that could be a possibility. If the crew were somewhat familiar with LAX, in their minds they were expecting to cross 2 "runways"; crossing the first runway and hold short of the second one. Is it possible that this is what they were doing and hence did not pay attention to the red signs "25R"?

Of course the counter point to this is that the crew later stated "We were cleared across 25 left and right,..to join..errr...hold short of 25 right on the other side" which indicates to me they thought they were cleared across both runways, and that the "Hold short 25R" portion of the intial clearance applied to them holding short on the other side of the runway while waiting for takeoff clearance.

[DC-Mainliner]

Of course the counter point to this is that the crew later stated "We were cleared across 25 left and right,..to join..errr...hold short of 25 right on the other side" which indicates to me they thought they were cleared across both runways, and that the "Hold short 25R" portion of the intial clearance applied to them holding short on the other side of the runway while waiting for takeoff clearance.

From an advocacy point of view, this very statement by the crew in question could be the most damaging evidence to their defense. It suggests a misunderstanding of elementary regulation on the books and shows clear intent to cross runway 25R.

I don't like pondering the misfortunes of others, but at least in this case we have not seen one piece of bent metal or one scratch to an innocent passenger, and this can and should serve as a catalyst to increased ground safety in the future.

"... whatever you say or do can, and will, be held against you..."

[westhawk]

Some very good discussion of this incident. Thanks to all. :ok:

You're right Astra driver, The comments made by the Gulfstream crewmember upon clearing runway 25R do appear to indicate that they believed they were cleared across 25R.

As DC-Mainliner points out, it could turn out that this was not the best thing to have said though.

For me, this incident serves as a reminder of how costly a simple error could be.

Best,

Westhawk

[Mercenary Pilot]

A voice can be heard in the background at this time, but I'm unable to tell if it was the other Gulfstream crewmember or perhaps something else.

I tried isolating and adjusting the background voice (also adjusting pitch and speed) to try and make out what's being said.

In my opinion, it is the other gulfstream crew member and he says "I've just missed Alpha [Unintelligible]". It sounds like the last word is "golf" but its extremly hard to make out.

[Bedder believeit]

In Hong Kong, we (the controller's) have developed a non standard practice of using the phrase "Cross inactive runway 07R" as part of a taxy instruction to freighters that are taxying at night from the cargo area to or from rwy 07L. This is when we are on single "North" or rwy 07L between midnight and 9am due to runway works. Admittedly, the departure does not have to cross the active runway again to get to the threshold holding point, so we don't have that risk. It seems to me listening to the tape a few times, that confussion could have been instilled in the crews mind on the Gulfstream. The clearance is shot out in fairly truncated and rapid fire manner. I like to work on the basis that if something is going to go wrong, then it will. However, I don't work at LA and I understand that they have a heap of aircraft crossing runways all the time, and I guess it is easy to keep things simple. And of course one extra word like "inactive" can slow things down a bit at times, but it sure helps to make things that little bit clearer as to the controller's intent. If that was me on ground in LA I would like to think that I would phrase the clearance "Via Golf, cross inactive rwy 25L and then hold short of rwy 25R". I have never worked in the States, but I have seen many incidents and close calls over the years caused often by the very phrases that are supposed to be in use. Ergo, I like to try and anticipate that I have bases covered. Please don't take this as any form of "opinion forming" on the part of how the guys in LA run their tower. I am merely saying how I do things.

[Tree]

1. They were not cleared to cross 25R. They were cleared to hold short and they read that back verbatim twice. There was nothing unusual or "obscure" in the clearance from ground control. That type of clearance is standard and routine.

2. They crossed the active runway at one of the worlds busiest airports without contacting the tower. That is deplorable airmanship/common sense.

3. It appears that they did not look down the runway before crossing to check for conflicting traffic in the takeoff position and possibly already on the roll. Again deplorable airmanship.

I am a frequent user of LAX.

[Bedder believeit]

Hi Tree

I don't think that I implied that they had not been told to cross 25R. What I am trying to say is that there were two aspects to the "Hold short 25R" that come into play, firstly the taxing out aspect, and secondly the holding at the departure holding point for 25R. I guess I was trying to say, that if confusion will raise it's head, then often it will. We all talk about the "chain of events" theory. I will leave it to you to suggest poor airmanship etc, and that I guess is open for others to form an opinion on. I work in an environment where a large percentage of the radio transmissions are made to at best, poor English speaking individuals. Airports can be very confusing and difficult places to get around, particularly for itinerant aircraft. I try to be very careful with what I say, and what is said back to me.

[Bedder believeit]

Further to that Tree, I forgot to say. Imagine when 10 to 15 thousand VLJ's are supposedly let loose on the system. They are small, difficult to see, will often be manned by a single pilot (sometimes with minimal experience), down low to the ground, so very difficult for the crew to gain a visual perspective of the airport. I guess the proponents will say that they will be principally used only at minor airports. But I can't see it. I would think that they will be trying to operate from fairly large airports to small destinations. So should be interesting uhh!

[DC-Mainliner]

1. They were not cleared to cross 25R. They were cleared to hold short and they read that back verbatim twice. There was nothing unusual or "obscure" in the clearance from ground control. That type of clearance is standard and routine.
2. They crossed the active runway at one of the worlds busiest airports without contacting the tower. That is deplorable airmanship/common sense.
3. It appears that they did not look down the runway before crossing to check for conflicting traffic in the takeoff position and possibly already on the roll. Again deplorable airmanship.
I am a frequent user of LAX.

It is a stark reality. We have the obligation to step up to the plate when we go to work. We all knew what we were in for, as much as we may like a nice day in the skies, this is not a hobby.

[Fokker28]

1. They were not cleared to cross 25R. They were cleared to hold short and they read that back verbatim twice.

I say again, they did NOT read it back verbatim both times! This is not pedantism on my part, because the details MATTER sometimes, and this is one of them. Look upward on the thread for an earlier discussion of the ACTUAL readback versus the first clearance. The devil is often in the details in this business, no?

http://www.pprune.org/forums/showpost.php?p=2909108&postcount=29

[DC-Mainliner]

http://abclocal.go.com/kabc/story?section=local&id=4634099

Hi Fokker. I understand what you are saying, however I disagree, respectfully. Listen to Part II again. The pilot may have accentuated the phrase "25R" in the initial clearance, but he clearly followed that by the plain English phrase of "Hold Short 25R" in the read back. Air crews do not say they will hold short of a runway and then cross it 10 seconds later without an additional clearance to cross it. It just does not work this way.

Besides all this, the FAR/AIM clearly gives guidance on taxi clearance protocol, and even mails ATP's "Ground Safety" DVD's for their viewing pleasure and recurrent education on a voluntary basis. This action went against published and practiced protocols.

Tree is correct in that they were issued twice a clearance to hold short of an active runway and they read back the hold short clearance, twice. Innuendos and subtle pauses do not count in radio communication at a busy international airport, or anywhere, for that matter, but especially at LAX. Accurate, clear, concise and standard radio phrasology - and a clear understanding of the protocols there within, is the minimum standard a professional pilot must consistantly rise to or exceed.

Now, I agree, the subtle pause and vocal reinforcement of the "Runway 25R" is probably where we hear a sign of confusion while we all pick apart the nuances of this at our desktops and laptops in a warm room sipping coffee, but this does not pass for an acceptable excuse to a clear abrogation of the basics. It never hurts to clarify a clearance, I have seen it done and I have done it many times, and it is always a comfortable feeling knowing you have a darn good idea nothing has been left to chance, no matter how annoyed the controller may get at repeating themselves.

I say all this with the full knowledge that we are all fallable. I'd like to see this situation add to future aviation safety by the FAA/ICAO gleaning better ways to promote recurrent training in these situations and for better standardization the world over. This was a CRM brakdown. Excuses only taint the reality of it and the learning potential. We should learn from it rather than bury the crew and move on to the next incident that could involve you or me.

[Fokker28]

Did you even read my earlier post?

My point was simply that the bizjet driver swapped the order of the elements in the first clearance, which I think indicated his confusion right there. Not sure how you can 'disagree' with my pointing out that he didn't read back the clearance verbatim. It's a simple fact. Verbatim means EXACTLY the same terms, in the same order (obviously). The readback wasn't. Normally I wouldn't think it a big deal, but in this case I think it highlights the very cause of the confusion. I couldn't care less about 'subtle pauses' or whatever you said. That's not what I was talking about.

I don't think the crew should be 'buried', but I don't expect others to coddle me if I make a clearcut error on the job, either.

[Bedder believeit]

This might be an appropriate time where some would like to visit another runway incident, but one with catastrophic results. I guess most people professionaly invloved in aviation are aware of the incident at Tenerife when 2 B747's collided. Whilst most of the basics vary a great deal from the LAX discussion that we are involved with here, I find it interesting to read the CVR tapes from both aircraft and ATC and note that on a number of occassions, actions taken by any of the three groups of people involved (ATC, KLM crew, PANAM crew) could have stopped the "chain of events" that preceded the disaster. Why did the Controller instruct the KLM 747 to backtrack the full length and to then line up on the runway in poor visibility when there was another aircraft (Clipper B747) also backtracking. Why did the Controller include the words "After Take-off..." in the ATC clearance. What was in the mind of the KLM captain to allow him to act in the way that he did, so that throttles were advanced to take-off power when he should have been sufficiently aware of the big picture, that this should never have happened. One can read the CVR transcripts at www.dnausers.d-n-a.net/dnetGOjg/270377.htm (http://www.dnausers.d-n-a.net/dnetGOjg/270377.htm) or if that doesn't work, google search to "B747 collision Tenerife" and then "CVR transcript KLM/PAA B747 Tenerife" should.

[Tree]

Bedder believeit;
Hello and thanks for your comments.
Ground control cannot/does not issue clearances to "position and hold" or "line up and wait" (as the Euros say) on the active runway. That clearance is the domain of the tower. Therefore there is never a reason to believe/assume/etc. that Hold Short 25R (from gound control) means to hold short of the takeoff position, that instruction would only be heard after checking in with the tower controller. We all know you do not proceed beyond the takeoff hold line without tower clearance. Since there is no option there is no reason for ground control to issue it.
When ground control instructs you to Hold Short 25R it means just that, hold short of that runway the FIRST time you approach it at any location whether it be midfield, end, or whatever. If you are going to cross it a second time then you will be holding short again.
In addition, all "hold short" clearances are legally required to be read back by the pilot in the USA and Canada to eliminate errors.
Let's hope the G-V crew take advantage of some serious training opportunities before sharing space with the rest of us.

[DC-Mainliner]

Hi Fokker, I did not intend to make you feel like I was jumping all over everything you said. Yes, I read you post. I simply, and respectfully, believe when you boil this down to the facts, they speak for themselves. The fact is, they replied to a hold short clearance with a "hold short" reply, and they did not hold short.

The whole "verbatum" thing: The rest of the swapping orders, sublte pauses, et al - it is for the human factors guys to look at over time. I believed this was what you were talking about, so I brought up what was "different" between the controller instruction and the pilot readback to highlight that a verbatum readback was not required but the "difference" was a hint to what might have been the confusion. I was understanding your comment to mean they did not actually read back a hold short clearance. We are simply talking about "verbatum" ;) In that, I really have no beef.

Fly safe.

[Tree]

Further to that Tree, I forgot to say. Imagine when 10 to 15 thousand VLJ's are supposedly let loose on the system. They are small, difficult to see, will often be manned by a single pilot (sometimes with minimal experience), down low to the ground, so very difficult for the crew to gain a visual perspective of the airport. I guess the proponents will say that they will be principally used only at minor airports. But I can't see it. I would think that they will be trying to operate from fairly large airports to small destinations. So should be interesting uhh!


I know what you are thinking re the VLJ's and I fully agree.
Interesting-yes!

[Bedder believeit]

Hi Tree

Thanks. Having been a tower instructor for more years than I care to remember, I am fully aware of who does what. I have just re-listened for the umpteenth time to the tapes, both Ground and Tower, and there is no doubt that the G5 was given and read back the appropriate instructions. However, it seems obvious to me that there was confussion in the exec jet cockpit, after all they missed "Golf", and it also appears that they assumed that the "Hold short of RWY 25R" related to the departure point. I could be wrong, but that is how I read it. As I said before, maybe part of the confussion stems from what the G5 people construed as a runway that needed a crossing clearance. Is a "closed runway" relevant to a clearance. To me it is. It is black and white to me (and obviously to you) that the initial clearance to cross 25L related to just that...RWY25L. However, I get the sneaking impression that this vital point was misinterpreted. They had already become lost once, and were probably a bit rattled because of that. It doesn't take much for the tree of confussion to take root. It would be interesting to be a fly on the wall when the G5 crew read these musings here, as I guess they do! Good luck. BB

[Smurfjet]

Crossing 25R at golf, from left to right, is the departure end visible? Does 25R have significant slope?

[PaperTiger]

Crossing 24R at golf, from left to right, is the departure end visible? Does 24R have significant slope?25R, Golf goes nowhere near the 24s which are the Northern pair: http://www.naco.faa.gov/d-tpp/0610/00237AD.PDF
But yes, in VMC the 25R threshold is visible (as is the normal line of airplanes waiting on Bravo*) from Golf approaching the intersection. There is no slope.
* which had not been part of their clearance