Finnair A340 attempts takeoff from taxiway

[klantto]

Accident Investigation Board Finland - Entry page (http://www.onnettomuustutkinta.fi/en/Etusivu/1290609240897)

"Serious incident occurred at Hong Kong international airport when an Airbus A340 aircraft operated by Finnair Plc on a scheduled flight from Hong Kong to Helsinki initiated takeoff from a taxiway which was located next to and parallel to the runway in use. The air traffic control noticed the occurrence and ordered the pilots to abort the takeoff."

Incredible.

[KENNEDY TOWER]

Well spotted by the tower, this could have been a real problem considering the A/C would have been loaded to the gills with fuel and considered a "HEAVY". Find this difficult to understand what the guys in the cockpit were thinking. Sounds like sombody is going to be in serious trouble considering the heavy hitters who are going to conduct the investigation. However I wish the cockpit crew the best in this unfortunate incident, good luck.:ok:

[Mike-Bracknell]

How many times before someone has the bright idea of colouring the taxiways with red asphalt?

:ok:

[Dengue_Dude]

I don't think there is any excuse that would justify an error of that magnitude.

Passengers have a right to expect high levels of professionalism from the front - and that's why we had taxi charts for each airport . This could so easily have had fatal consequences.

BTW, yes I've operated into there - but we did have 3 sets of eyes in those days.

[fireflybob]

This incident if, of course, serious but frankly I am surprised it doesn't happen more often. Airports seem to be becoming much more complex with a plethora of signs, taxiway designations and routing, designated holding points etc and, generally, more pressure on crews in terms of slot time, exhausting schedules and having to "expedite".

I don't think there is any excuse that would justify an error of that magnitude.

Dengue_Dude, that's very easy to say. Of course, it shouldn't happen but we have to recognise that human beings are capable of error and that they are part of the "system". As you adriotly point out we used to have 3 (and sometimes 4 or even 5 in my young day) pairs of eyes and ears watching what was going on. I wonder how many incidents in the "olden days" were prevented by a sharp Second Officer in the jumpseat speaking up? - I know as I was one of them and did so on a couple of occasions.

We should not be premature to "blame" the crew. No crew sets off to work with the intention of making a major blunder - will be interesting to see how all the holes in the cheese lined up on this one.

[trauha]

"Well spotted by the tower, this could have been a real problem considering the A/C would have been loaded to the gills with fuel and considered a "HEAVY" "

Are the taxiways not as long as the runways in Hong Kong?

[His dudeness]

Our RAAS shoutes "on Taxiway,on taxyway" should you try to... if not on a runway and above 40 kts...

see here:
Honeywell : Runway Safety (http://www.honeywellrunwaysafety.com/)

[Finn47]

Finnish media now report the Finnair head office spokesman saying there were indeed three pilots in the cockpit "and they all agreed the aircraft was where it was supposed to be" :hmm: when they were accelerating down the taxiway... so much for the three sets of eyeballs :rolleyes:

[uberwang]

In Russia they ask you if your gear is down and locked.. Why not start asking if the runway is identified or have an electronic sign with random letters you have to read back to the tower located next to the thresh hold:-) Sound dumb? then so is the blue, orange and green line at Munich airport. I like the earlier post of having taxiways in different colour or just have small speed bumps on taxiways so a take off would be obvious. There is no excuse for this except that its human error and we are humans, so it does, can and will happen.

[protectthehornet]

have the localizer "on" on the runways

have the aircraft's nav radios on the assigned takeoff runway...tuned and identified (at the gate if you can).

make sure needle is centered before starting takeoff roll.

[Dengue_Dude]

Oh here we go again with the " You can't possibly blame the crew yet as you don't know the facts" ish arguments.

Fact: Irrefutably the aircraft commenced its take off run on the taxiway (I've taxied down them, I do KNOW what they're like).

Apparently there was a 3rd set of eyes on the flightdeck too.

Yes modern airports are more complex than they used to be, so even more reason to concentrate - that's why airline front ends usually get paid the big bucks.

I reiterate that the punters have the right to expect high levels of professionalism from the crew. This couldn't have happened here because of the fact above. Whatever happened to the old adage 'don't assume - check'.

I flew from 1973 to 2009, no crew I was on did anything like this. We've even taxied around crappy airports in Africa in the middle of the night, with controllers that barely spoke the language - and we still didn't do this.

10/10 for the Chep Lap Kok tower/local.

The PC brigade can now have a go at me, but frankly, I don't give a ****. The only possible understandable mitigation would be LVPs which can be incredibly fraught, but that obviously wasn't the case since ATC gave the call.

[Sir George Cayley]

2 questions.

Has the runway got white edge and centreline lights and were they on?

Has the taxiway got green centreline lights with blue edge lights at corners and were they on?

Sir George Cayley

[Green Guard]

How many times before someone has the bright idea of colouring the taxiways with red asphalt?



How many times you need to study the difference between the RWY and TWY edge lights or lamps ?
I am sure that "FireflyBob", even if alone in cockpit (2 eyes only) in the middle of the day should easily spot the difference.

The aircraft heavy or not does not matter, if TWY was the same length as RWY, as they usually are, the ONLY problem would be if other aircraft was using the same TWY...

PS
I guess this incident might have to do something with sushi and ooooo'sake

[The Ancient Geek]

Indeed.
Historically this is one of the recurrent incidents, often several per year.
From memory and picking at a few official reports the common themes seems to be poor signage, poor or missing lighting and work in progress.
Add an unfamiliar and complex airport at night and you have a powerful recipe for loss of situational awareness.
There is seldom a simple cause, just the proverbial holes in the swiss cheese lining up again. The official report will, as usual, make interesting reading.

The man who never made a mistrake never made anything.

[TDK mk2]

We might actually be in the presence of a bonefide skygod in Mr Dude. All those years flying and never made a mistake that could have led to the aircraft being endangered? Now that would be some claim and worthy of the above title. Perhaps, sir, you should read the report on the DAL crew who landed on the taxiway at their home base, Atlanta, last year. You might have roundly questioned their 'professionalism' as you say, but perhaps even you might even accept that there was a lot more to that incident (and likely this one) than lack of professionalism...

[DC-ATE]

TDK mk2 -
We might actually be in the presence of a bonefide skygod in Mr Dude. All those years flying and never made a mistake that could have led to the aircraft being endangered?

I venture to say that 999 out of 1000 pilots [ myself included ! ] could easily make the same claim. Perhaps even a greater percentage. Otherwise flying would REALLY be unsafe.

Edit: I only put in 30 years flying these things.

[bearfoil]

Dengue Dude

1977. KLM Chief Pilot launches on the Runway as Pan Am taxis opposing, same asphalt. Lots of experience, lots of ego, lots of FO fear. If anyone learns, how soon they forget, eh?

[grimmrad]

I am no PPL holder or can call me a pilot in any case (other than on my iPhone and rc helis, ha ha) - but I work in Medicine. Before we even attempt to do a procedure as simple as a contrast injection or a thyroid biopsy we have to do what is called a timeout - verify patients name, the procedure and the side. This has to be signed by the MD (me) and a witness and is a legal document. So, if we attempt to do the left nephrectomy of Ms Smitt we verify the side, procedure and the patient, so that Ms Smith and we have a chance to actually leave her with her kidney and better remove the appendix...

Now, YOU guys have 100+ pax behind you and are still able to take of from a taxiway (at least attempt to), fully loaded with fuel on a many ton multimillion dollar piece of equipmeni. Why is there no checklist point included into the pre takeoff CL verifying the actual runway? Last point - verify runway heading as given by clearance. It seems to me that these incidences are way too often to be just happening occasionally - and some are deadly. I remember a couple, adding to the DAL in Atlanta I believe there was a Continental in NWR landing on a taxiway...

[NigelOnDraft]

Link (http://www.pprune.org/fragrant-harbour/435313-another-attempt-takeoff-twy.html) Would appear they are not the first... including "locals", so instead of jumping to criticise, there appears to be something there making this rather "possible" :{

NoD

[Helmut Smokar]

Grimmrad

In all airlines there are procedures in place that would have the crew verify the runway/runway intersection, the performance has been calculated for that intersection etc. I believe a lot of threat and error management techniques in medicine were originally derived from aviation systems.

The problem happens when distraction or complacency interfere with the threat and error management model it leads to an incident. Much like in medicine where they still have cases of removing the wrong part. Aviation still has cases of taking off on the wrong runway.

[DA50driver]

We have a simple procedure that prior to entering the any runway the PF announces "Entering RWY XX", and PNF confirms it. In addition I always have the airport diagram with my little green GPS driven plane on one of the displays.

Hopefully this will prevent this kind of thing happening to us. (Knock wood).

[stepwilk]

"We might actually be in the presence of a bonefide skygod in Mr Dude."

I'd suggest actually in the presence of a competent captain. (And that would be "bonafide," unless you maybe mean "bone-fried.")

Surgeon says, "Oh, man, I just severed his spinal cord!" Should the rejoinder be, "Hey, it happens to all of us now and then. Deal with it." Hope not.

From following this thread and many others, it seems to me, a mere 3,000-hour light-twin and small-jets pilot, that we have increasingly few skygods and increasingly too many skydorks.

[grimmrad]

@ Helmut Smokar: Point well taken. No intention to say that we are perfect, you are not... And we have some more guys to pay attention as well (like the guy in the tower), thank god.
However, as apparantly some of you in your profession do as well, I have made it a habit to lean back and ask myself "OK, what did I miss" to raise vigilance. And not to be content if you have found one thing (I am a radiologist) but now to try if you find something else. E.g. don't be content if you found a tumor in the kidney - they often come in pairs...

[jackx123]

Helmut Smoker: and much of aviation rules are derived from shipping

grimmrad that makes you a sailor not an MD :}

[Cacophonix]

Midst the automated splendour that is the A340 there still seems to be a place for a Tom Tom with a worldwide database of airport layouts and a big symbol saying "you are here".

I suspect BearFoil has hit it bang on the button. Perhaps it is the van Zanten syndrome that stops people saying "Hey I am unsure where the hell we are, perhaps I'll ask the Tower for a bit of guidance here".

[AGNES]

NoD,

I can ensure that the lightings and signboards at VHHH are so clear that even a layman can identify which is the RWY, which is the TWY. Just ask yourself how do the RWY lights look like, what are the colours and the TWY vice versa?

Lack of situational awareness or lapse of concentration? I don't know.

Perhaps that corner of the airport is the Bermuda Triangle of VHHH - someones will get lost! Up to now, four carriers (three foreign and one local) had attempted to take off from TWY A.

While the case is being investigated, new instruction has been issued that no take off clearance can be issued until we "see" the aircraft is physically on the subject RWY.

[Arfur Dent]

Not sure which runway this incident happened on but 07L at night is a bit of a navex and if you go vai taxiway 'B' it does seem to take a long time to taxi North past 'A' and then on to the runway. The lack of any Cat 1 and 2/3 holding point signs and completely different lighting on a taxiway should be cues enough but we have a requirement to mention the signage when entering what we think/know is the runway.
I agree with the surgeon that to just sit back for a couple of seconds and regard what you're about to do with the detached 'common sense' of an amateur would save a lot of red faces (and maybe prevent a catastrophe). Leave your egos at home ladies and gents. This could be you...........

[AGNES]

Arfur,

No CAT II/III holding points on TWY A and B is because the GP is on the northern side of RWY 07L. I do agree with you that 07L is the "darkest" corner of the airport at night.

[Dualcouple]

While to err is definitely human, this still shouldn't happen. AY charts even have the 07L hotspot marked, but it's easy to overlook (assuming the T/O was from 07L). The report will make intresting reading, I fear the CVR will be overwritten though.

Not knowing the facts of course, but I wonder what the experience levels on the flight deck were. Rules were changed some time ago to permit co-pilots with as little as 2 years of airline experience to long haul ops and the skippers are not all very senior either anymore.

[kristofera]

I'm just SLF, but wouldn't it somehow have made sense to delay their departure for a quick breathalyzer check after a little snafu like that?

Not that Finns are known to be heavy drinkers or anything, but just as a precautionary measure..?

[nojwod]

Reading some of the posts on this thread confirms my suspicion that perfect pilots outnumber imperfect ones by a factor of at least two to one, but imperfect pilots tend to be flying and the perfect ones come on to forums and pontificate from their all-seeing perches.

I prefer to wonder what shortcomings in systems and procedures could be addressed to minimise the chances that the imperfect pilots who man most operating aircraft in the world suffer the indignity of not being perfect.

[Load Toad]

As a complete lay person, non pilot, pax only - why aren't taxi ways or runways given a specific colour? I know; lighting / metamerism, different weather conditions, at night &c but what is the reason why not?

[Loose rivets]

How wide was the taxiway?

[Joao da Silva]

It is a shame that the 'follow the green lights, stop at the red' taxiway system used at LHR is not implemented elsewhere.

While no system has complete safety, this one does seem to raise the bar.

[Airlift21]

It's only speculation, but it might be a case of tunnel vision by the flight crew. There have been cases where flight crew have been so preoccupied with departing on time, arriving on time, fuel management etc etc, coupled with being very familiar with the airport and a degree of complacency, that they have become almost blind to the surrounding enviroment leading to poor decision making and sometimes fatal consequences. I'm trying to remember an incident of this nature taking place a few years ago. For some reason, Singapore rings a bell where an aircraft tried taking off on a closed runway, with construction equipment cluttering it, in extreme weather conditions. The flight crew were trying to depart before the weather became even worse, which would have involved taxiing back to the stand and a serious overnight delay. Anybody remember this?
In the meantime, it would be very unfair to blame anyone without all the facts being available!

[stilton]

Grimmrad,


It's more than a little condescending to imply the medical profession has a better record than aviation with respect to human errors.



I see countless errors in medicine reported every day (removal of the wrong limb, organ, incorrect medicine prescribed etc, etc.



And these are just what are reported, the reports certainly don't include the cover ups, pay offs and 'settlements'



In fact, if aviation only had to meet what is accepted as a normal medical loss rate we would need another airframe manufacturer just to keep up with 'attrition'



Unlike Doctors we don't have the opportunity of burying our mistakes.

[sherburn2LA]

don't they train for this in the ATPL then ?

we would do it all the time in the UK when our runways were waterlogged

our preferred taxiway had a bend in it too

[His dudeness]

Reading some of the posts on this thread confirms my suspicion that perfect pilots outnumber imperfect ones by a factor of at least two to one, but imperfect pilots tend to be flying and the perfect ones come on to forums and pontificate from their all-seeing perches.

I prefer to wonder what shortcomings in systems and procedures could be addressed to minimise the chances that the imperfect pilots who man most operating aircraft in the world suffer the indignity of not being perfect.

+1

A very close relative of mine, who retired with accident free 44years of commercial flying/18000+hrs, told me when I started flying that if someone claims he does not make mistakes in the cockpit, he either is a liar or not a pilot.

I personally find signalling, lighting and local habits sometimes to be very confusing. But then, I only fly a Citation, what do I know...

[slast]

Perhaps GRIMMRAD should ask Santa Claus for a copy of this.....!

Amazon.com: The Checklist Manifesto: How to Get Things Right (9780805091748): Atul Gawande: Books (http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0805091742)

From what I have read, as a broad generalisation (always dangerous), in most hospitals generally surgery is in approximately the same situation as major airline flight operations in the 1960s, i.e. pre sophisticated checklists and pre any idea of Crew Resource Management. Which is not to say that aviation always gets it right, things slip through the cracks far too often!

[Carbon Bootprint]

Airlift21, you are referring to Singapore Airlines SQ006 at Taipei in 2000:

Singapore Airlines Flight 006 - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Singapore_Airlines_Flight_006)

[Checkboard]

Air traffic control intervened to halt the take-off and the aircraft taxied back to the correct departure point, from where it left without further incident, and arrived in Helsinki about 55min behind schedule.
Hong Kong controller halts Finnair A340 taxiway take-off (http://www.flightglobal.com/articles/2010/12/01/350396/hong-kong-controller-halts-finnair-a340-taxiway-take-off.html)

I am faintly surprised they weren't required to return to the terminal for investigation (i.e. breath testing) etc. after an incident such as this.

[Dengue_Dude]

Here's a hint from a 'skygod':

"Don't assume . . . check".

Many people have thought that with the advent of all glass cockpits, the level of monitoring has been affected. Humans are monitoring computers and not the other way around - potentially flawed as a concept.

I was also not aware that I said I never made a mistake, I stopped plenty and mine were never of this magnitude, and usually self-declared. Am I proud of that - damn right.

I think in those days we had more appreciation of size, inertia and plain old responsibility tempered with respect for hardware and liveware.

I maintain, that for this to happen there is NO excuse (notice I didn't say 'reasons'), the fare-paying public (or anyone else come to that) have a right to expect high (higher than normal) levels of professionalism in flightcrew.

OKAY guys - off you go again, I've got broad shoulders and spent quite a few years as a Flight Safety Officer and privy to the results of quite a few inquiries. Just call me cynical (perhaps one of the nicer things you're thinking). I can cope - the truth may even out.

[atakacs]

3 letters... GPS

As others have mentioned this could and should be solved by applying proven and cheap technology.

[MungoP]

It's unlikely that this crew would have elected to take-off from an intersection so whatever the technology present in the cockpit is it too much to ask that they look for the runway designators as they line up ?
Let's not abandon the basics.

[Lonewolf_50]

Question: is "map reading" as a skill dying off? If you have the airport diagram on your kneeboard/display, and orient yourself to the map and "drive" to the map position, you'll tend to arrive at your destination. Granted, this can be a real challenge at night when at an unfamiliar field, or a runway one hasn't been to previously. (Is calling for progressive taxi seen as a sign of weakness?)

I ask this due to something I saw during two different eras in flying instruction: pre GPS and post GPS, and in the era of the digital watch.

From discussing with instrument flight students who were having trouble entering and eaving holding patterns, or doing proper course reversals during procedure turn approaches, and teardrop approaches, I found that using the dial of a watch as a metaphor for compass card useful during the 80's in getting the light to come on, not so much after 2000. Simple map reading, or map to ground to situation conversion seemed to have degraded during the same period.

Looking at this flight crew: how often can the flight training branch in their airline assess their map to ground to situation skills or shortcomings? How would you know how well someone can visualize their position and how to get from A to B via the airport map/diagram?

In the GPS generation, I don't think it can be taken for granted.

I discovered this when I found out how differently my son and daughter understood directions, and which of them could better apply map to ground to situation. She did. This caused me to spend quite a bit more time with my son on maps and directions as he learned to drive.

It seems to be a learned skill, not an innate one.

Perhaps the opportunity to learn it is evaporating in the current day and age of tech, and the skill cannot be taken for granted, even among pilots.

Like reading a watch with a round face and 12 numbers.

[forget]

3 letters... GPS. ..... this could and should be solved by applying proven and cheap technology.

Or this. (http://www.axis-electronics.com/groundmarker/typicalinstallations.asp) Why rely on aircraft having GPS when you can modify the airfield - and get far more info to pilots.

[Cafe City]

While the case is being investigated, new instruction has been issued that no take off clearance can be issued until we "see" the aircraft is physically on the subject RWY.

Wasn't there already an instruction to that effect after the previous 3 incidents? Understand the guy was cleared to lineup and go contrary to that instruction.

BTW, what was the Tower North controller exactly doing at the time? Was it him/her that spotted it or someone else?? :oh:

Things are not always so clear cut as they seem.

[Antman]

Try again Grimmrad:ugh::ugh:

The JOURNAL of the AMERICAN MEDICAL ASSOCIATION (JAMA) Vol 284, No 4, July 26th 2000 article written by Dr Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health, shows that medical errors may be the third leading cause of death in the United States.

The report apparently shows there are 2,000 deaths/year from unnecessary surgery; 7000 deaths/year from medication errors in hospitals; 20,000 deaths/year from other errors in hospitals; 80,000 deaths/year from infections in hospitals; 106,000 deaths/year from non-error, adverse effects of medications - these total up to 225,000 deaths per year in the US from iatrogenic causes which ranks these deaths as the # 3 killer. Iatrogenic is a term used when a patient dies as a direct result of treatments by a physician.:sad::sad:

[HeadingSouth]

Independent of profession - there's folks who take their job with pride and prefer to check than to believe. And there's the others. Sometimes just working to feed the family. Not because they like what they're doing, but because they have to do something.

I therefore assume it's more a case of dedication to the job than actually the job itself.

Not sure how much training and other soft factors play a role to dedication. But if there's no dedication then there's certainly no culture, let alone safety culture, present.

Valid for all levels of employees (and employers). Valid for all professions - pilots and doctors, cleaners and CEO's.

[Cafe City]

there's folks who take their job with pride and prefer to check than to believe. And there's the others. Sometimes just working to feed the family. Not because they like what they're doing, but because they have to do something.

...

Not sure how much training and other soft factors play a role to dedication. But if there's no dedication then there's certainly no culture, let alone safety culture, present.


I think you just precisely stated why the Hong Kong CAD Runway controller DIDN"T spot it.

[Ops_Room_Junkie]

Sometimes (most times) reading PPRUNE forums are enlightening and thought provoking.:8

Other times reading through posts is like observing a tenis match style debate of oneupmanship, claim -v- counterclaim, and the ineviatble camps of :-
' I wouldn't have done that'
'they shouldn't have done that' -v-
'you may have done that'
'we all could end up doing that'
that add's nothing of substance to the debate - :rolleyes:

it doesn't change the fact 'it happened' and sadly ' will most likely happen again'.:sad:

[d105]

Guys are we seriously comparing aviation to complex medical operations such as surgery? I know we as pilots think a lot of ourselves but the average flight does not nearly require the same amount of skill and likewise doesn't bring with it the same probable dangers and complications as would say open heart surgery.

With regards to the A340 incident. The guys in front screwed up. It happens all the time, everybody does it and it is a risk inherent to any operation performed by a human.

Yesterday I performed a realignment on the IRS systems in my aircraft because the FMC kept complaining I had a IRS/nav position disagree error. Took me 10 minutes to figure out I accidentally entered the destination airport into the system as being the departure airport. 1200nm difference there...

Mistakes will happen regardless of how many safety procedures you put in force.

[grimmrad]

stilton, antman
please read my second post again. I quote myself here: "No intention to say that we are perfect, you are not..." Just saying if we screw up there is one (or max 2) dead people at onece, if you, well,...

slast:
I am aware of that book and the proposed content

[Dengue_Dude]

Grimrad:

Don't bother, your post made perfect sense, but what you're up against in professional (and I mean 'paid') aviation are supreme egos, a lot of very precious people and levels of arrogance that need to be seen to be believed. Not all by any means, just some. Quite often, their peers don't seem overly surprised by who is involved.

It's probably not too different from your peer group after all, because it's populated by humans.

I'll doubtless be harangued for that too, but I really don't care. I think after 40 years in aviation, that I'm entitled to my opinion. This is a place where we're allowed to do that . . .

With the benefit of a little maturity I've found that I don't have the inclination to be particularly politically correct these days, so can afford to call it as I see it, based on my own experience and observations.

I still think there's no excuse (probably just the classic error chain of one flavour or another).

[slast]

grimmrad,
as a matter of curiosity how well do you think that book is generally received in the medical profession?
Steve

[stepwilk]

For what it's worth, and I'm not a doctor, I do know that Gawande is a highly regarded MD himself, quite well-known, and I should think that his book--and his numerous other medical writings and books over the years--are pretty well-regarded by thinking docs.

[grimmrad]

As far as I remember there was even a NYT article about it and at least in certain areas like NICU, ICU there are more and more adopting that approach. Everybody has his own little checklist what to look for in his head as well.

[stepwilk]

Gawande is a frequent contributor to The New Yorker magazine.

[DC-ATE]

Why is it that flying airplanes is a PROFESSION whereas doctors PRACTICE their profession? That might explains some of the figures posted above.

[stepwilk]

Not sure I understand. Do pilots perhaps profess their profession? Commit their profession?? Undertake their profession???

[DC-ATE]

The medical 'profession' is called a PRACTICE.

[bearfoil]

Medicine itself is considered an ART. Professions are PRACTICED.

I think.

[DC-ATE]

They don't call what pilots do a "practice", but they DO call what doctors do a "practice".

[stepwilk]

Calm down. Take your meds, have a nap.

[Ndicho Moja]

The Singapore CAAS now, and has for some time, had a requirement for a positive runway identification by the pilots, verbalised, as the last item on the Before Take off Check List. Possibly a by product of the SQ TPE accident.

[de facto]

Maybe due to today's highly sophisticated airports(ie follow the green lights) and A too large reliance on ATC(ie mode S required on ground),pilots tend to reduce taxi routing(expected or standard routes) briefing leading to a possible lack of 'where to go next' knowledge.(actual and future position knowledge).
Identifying the runway by all means available(gps runway symbol),taxiway leading to runway entry point(including hot spots),runway threshold marking and touchdown marks(rubber marks from landings)are all signs that may avoid such potentially catastrophic situations.
It is even more so strange that these pilots must have loads of time in the flight deck prior to departure time.
Low vis isnt the only time when one should be extra cautious.
Incidents/accidents always happen with a mix of undetected or wrongly managed events,in that case well done to ATC,they saved the day.
Im sure these pilots have learned tbeir lessons and all of us along with them to make flying even safer on ground and inflight.

[MFALK]

A technical solution is already available from Airbus called OANS, which gives the pilots realtime aircraft position on an airport map displayed on the ND.

It obviously costs money but airlines have to put their money where their mouth is when they harp on about safety. I have seen it work and it is a great tool and authorities should start mandating this technology considering the big number of similar incidents that seem to be on the increase.

Onboard Airport Navigation System (OANS) - Thales (http://www.thalesgroup.com/Portfolio/Aerospace/Aerospace_Product_OANS/?pid=1568)

[firefish]

About the third pilot, was he on duty at the moment or just deadheading? If it was the cruise relief pilot, is he normally present on flight deck for t/o?

This looks like the type of blunder that sometimes happens in good weather (low vigilance) and in a non standard environment. While every case is unique I can't help comparing it to the Turkish (737?) crew that during approach kept yapping away with the colleague on the jump seat and thus failed to realize that the autothrottle was off and that speed was dropping fast (as did the aircraft).

[marsipulami]

The outfit I'm working for requires the ILS to be tuned in order to verify lined up on the correct runway for a departure when LVP in force. I must say I use it also when no LVP in force just to be sure to be lined up on the correct runway.

Complacency, too much reliance on the glass cockpit? Don't know, still too many possibilities for the holes in the cheese to line up.

Marsipulami.

[thehighlander959]

SLF here.... the 7 P,s come to mind.

Prior Preparation& Planning Prevents P-ss Poor Performance..

Thats all.

[oliver2002]

If the incident happened on 07L then the massive paved area may have been confusing, but still its not marked in any way to indicate you are on a runway:
hkg airport - Google Maps (http://local.google.com/maps?f=q&source=s_q&hl=de&geocode=&q=hkg+airport&sll=37.0625,-95.677068&sspn=51.443116,114.169922&ie=UTF8&hq=hkg+airport&hnear=&radius=15000&ll=22.30883,113.925927&spn=0.014809,0.027874&t=h&z=16)

[On the beach]

Oliver2002,

Wrong end, mate. That's 25L. The giveaway is the alphanumeric in rather large letters on the runway. Try scrolling left.

If you have a look at the correct end - 07L you'll notice a few giveaways that say it is a runway and not a taxiway.

1. The runway is a different coloured tarmac to the taxiway. By the way this applies to both runways.

2. There are big white markings on the runway but not on the taxiway.

3. There are an awful lot of tyre marks on the runway versus none on a taxiway.

4. Don't know if the incident was day or night, but if night, then I think you'll find that the runway lights are significantly different to those on the taxiways.

I suggest that all who fly into VHHH have a look next time you're there. It's very straight forward.

[Jetset320]

Just wondering whether, with today's available technology, it would be relatively simple to add a a new T/O config warning parameter, and address this issue.

Deviation sensed by GPS from the FMS's selected T/O runway centreline by more than a predetermined amount will trigger the horn, once T/O trust selected.

[Finn47]

Takeoff attempt was one hour after midnight local time, in excellent visibility (over 10 km, few clouds at 4500 feet) so yes, all the lights would have been on and visible from the cockpit.

[NigelOnDraft]

Jetset320...

Just wondering whether, with today's available technology, it would be relatively simple to add a a new T/O config warning parameter, and address this issueIts exists / coming in, called RAAS (?) or similar. See Link (http://www51.honeywell.com/aero/Products-Services/Avionics-Electronics/Egpws-Home3/raas.html?c=21)

NoD

[forget]

It would be interesting to know how RAAS could be configured for Gatwick; one main runway, one taxiway serving as a back-up runway. Anyone?

[His dudeness]

Gatwick shows 2 Runways (26L/08R and 26R/08L) on Honeywells RAAS database...so no Taxiway t/o warning if on the Runway 26R/08L, but a call approaching and when on the runway...

RAAS Runway Search Results (http://egpws.com/cgi-bin/raas_csv.pl?method=exact&search=gatwick)

[DC-ATE]

Back from my nap. Thanks, stepwilk, if you were referring to me back there.

Just wondering if the aircraft involved in this incident had any of this 'fancy' stuff you all are referring to; ie. GPS, RAAS, or whatever? We never had any of that stuff and ALWAYS managed to take off on a runway. All it required was to look out the front window to see where you were. If you weren't sure.....ASK someone. Plus, we carried airport diagrams along with all the approach plates. Impossible to get 'lost'.

Seems like the more 'gadgets' we put on these aircraft, the more problems we have.

[p7lot]

Maybe the PF was looking in for a moment calling fma's who knows.
I often do whilst taxiing to rw.
Still no excuse for mislaying runway imo
tut tut ....there but for the grace of god

[SKS777FLYER]

Shoot, I play golf sometimes in GPS equipped golf carts with the course layout in them. Purpose to speed play assisting golfers with info on distance to gren etc. On fairways carts not allowed on, the dang GPS warns you when it senses you are driving your cart off the cart path. I know, pilots too busy doing other stuff to pay attention to a GPS map, when the airport map is right under and in front of their nose. I know very well how difficult taxiway/runway identification is at many fields....it is what is it for the for the time being.
The OANS would be great, just have to get somebody to reliably monitor it.:uhoh:

[Dengue_Dude]

. . . err, that'll be 'Don't assume - check' then.

It might sound as if I'm just trying to be smart.

But this has been proven time and time and time again. Someone mentioned above about missing the basics.

The times I've heard that pilots (there are really only pilots left on the flightdeck these days) don't appear to be taught the basics anymore. There is a lot less mental effort required to keep up with (or better, one step ahead) of the aircraft.

Glass cockpits give so MUCH information, it's easy to get swamped by it or complacent because there's little need to think. Ergo, often people (pilots in this case) don't.

You HAVE to check, if you don't - then nobody WILL and we see it here. Fortunately nobody was physically injured here.

[firefish]

This is not a problem that can be solved by technology, or at least not with what we have available now or in the near future. Sure enough there are better aids out there to assist flight crews but I doubt that's what went wrong here.
Technology will fail you at some point, call it electronic hiccup or whatever, but it will happen inevitably.
There is still no substitute for proper training, task orientation, correct attitude and vigilance. If you look sharp enough you will see the holes in the cheese lining up. I've made my fair shares of mistakes and both attitude and vigilance (or lack thereof) took part in all of them. I hope that I'm wiser now...

[firefish]

And Dengue Dude - agreed. It's almost like a religion sometimes. "magenta, Magenta, MAGENTA!!!"

EFIS is really nice and a very good tool at times but sometimes I wonder if the old school wasn't better as then you really had to think and understand what went on behind the gages and not just follow the line that the GPS or INS or whatever told you to.

[NWSRG]

I'm only here as a PPL holder, but a couple of things come to mind.

First of all, pilots are not perfect, so we can't expect them never to make a mistake. As with the Turkish 737 at Schiphol, here three professional pilots managed to make the same mistake at the same time...so there must have been a set of circumstances that all added up to give three different people the same erroneous view of the world. And as most pilots probably think in the same way, you can see how that can happen.

In my industry, we had a fatality not so long ago where a highly experienced, highly proficient guy accessed the wrong piece of equipment. No reason could be identified. Procedure had been applied correctly, but it seems he simply suffered a moment of 'brain fade'. Without going into all the details, the HSE gave the company and procedures a clean bill of health. This poor guy had simply got something in his head that was incorrect.

Secondly, what about a GPS connection to the autothrust that would give a config warning (or even intervene) if take-off thrust was applied at a point not agreeing with the FMC departure runway? Surely that couldn't cost too much...

[The Ancient Geek]

There is still no substitute for proper training, task orientation, correct attitude and vigilance. If you look sharp enough you will see the holes in the cheese lining up. I've made my fair shares of mistakes and both attitude and vigilance (or lack thereof) took part in all of them. I hope that I'm wiser now...


At last - some reality.

Despite protestations by the perfect pilots of pprune we ALL make mistakes because we are human. I made some real doozies in my day but I learned from them. Picking up on your own errors takes vigilance and a finely tuned suspicion of that feeling that something is not quite right.
Assume nothing, check everything and then check again.

The second pilot is there for good reasons and one of the most important reasons is to monitor the PF. Two heads are better than one.

I often wonder how many of todays perfect pilots would have survived a ten year stint as a single pilot in the african bush. Fortunately the Twotter is a very forgiving big old pussycat..........

[Spendid Cruiser]

Picking up on your own errors takes vigilance and a finely tuned suspicion of that feeling that something is not quite right. Assume nothing, check everything and then check again.
Absolutely, who could argue with that? But is it possible to maintain such high standards of vigilance 4 sectors/day 5 days/week?

I suspect that not only is it not possible, but also with such concentrated schedules one even risks loosing control of when to apply said vigilance, especially when one conscientiously attempts to be perfect and make no mistakes. I have sometimes wondered the safest pilots allow themselves to reduce their concentration and accept small errors during relatively benign phases of flight to help ensure a sharp mind when it matters most. Would a training department find that acceptable though?

[MFALK]

NigelonDraft, RAAS was a good start but it is a reactionary tool much like the first generation GPWS.

On the other hand, airport navigation dislpays such as OANS give the pilots positional situational awareness all the way from the gate to the runway, not unlike how EGPWS TAD is a major enhancement to GPWS.

[firefish]

Off course it is hard to maintain vigilance for long hours, especially when nothing happens (out of the ordinary that is). But then again that's why some have what it takes to do this job and some don't. It's like excusing a waitress for being rude towards a customer because "it is hard being nice to people all day long". If you can't cope, do something else.
Understanding what is tough is one thing (makes for a good pilot), accepting it for a fact and then using it as an excuse for piss poor performance is another.
I make mistakes all the time but in my defense I seldom make them twice. And every time, every mistake, makes me pissed at myself because I should know better, be better. And as soon as I don't do my best at getting even better at what I do I might as well stop flying altogether since then I have become truly dangerous.
I've flown with colleagues, both left and right, that have had the attitude that "well it's hard so what can you expect - **** happens" and they are not fun to work with at best, although mostly much worse.

[DC-ATE]

On the other hand, airport navigation dislpays such as OANS give the pilots positional situational awareness all the way from the gate to the runway.....

Anyone that needs that stuff to find their way to the runway shouldn't be flying airplanes.

[The Ancient Geek]

Anyone that needs that stuff to find their way to the runway shouldn't be flying airplanes.


Another perfect pilot with attitude who is too conceited to ever make a mistake. Another accident looking for somewhere to happen.
Get a grip on reality before you end up as another statistic. :=

[DC-ATE]

The Ancient Geek -
Another perfect pilot with attitude who is too conceited to ever make a mistake. Another accident looking for somewhere to happen.
Get a grip on reality before you end up as another statistic.

Well, I flew everything from Piper Cubs to DC-8's for thirty years WITHOUT even a GPS and NEVER had trouble finding the runway to take off on. I fail to see how that makes me "conceited". It CAN be done; all you gotta do is pay attention to details and not rely on some gadget to do the job for you.

[Herod]

DC-ATE.

OK, let's remove TCAS, EGPWS, Rad Alt, Autopilot, ILS, VOR etc. Maybe even radios. "Anyone who needs that stuff shouldn't be flying aeroplanes". Hell, let's even get rid of that woosy enclosed cockpit: cold air will keep them awake.

[Dengue_Dude]

DC-ATE had a good point.

All the stuff Herod advocates removing (along with his teddy) makes life safer (and it does), but you forget the basics of respect, concentration and attention to detail at yours (and everybody's) peril.

I don't think anybody is actually trashing the new kit, but for years, we managed to do the job without it. For one, I was happy with EGPWS and TCAS particularly.

GPWS/TCAS have saved a lot of lives, but still, many aircraft have managed CFIT or collisions with it fitted.

Remember your last CRM course, the biggest part of the PI chart was Human Factors. Why is anyone who didn't make a monumental cock-up conceited or 'perfect' (this being a question from a demi-god)?

Too close to home or just plain unpalatable?

[grimmrad]

Do you guys have QC sessions? We have sessions were missed cases or wrong diagnoses are discussed. To learn from them. And everyone knows he is not free of mistakes also (but you always hope it is not one of the cases you read coming up that day)... So why not having meetings with airline pilots and even psychologist were they come clean and talk about their errors which maybe did not make it into the news and were they luckily could walk away from to talk about it so others and they themselves can learn and improve.

[DC-ATE]

Herod -

This whole discussion is about trying to take off on a taxiway vs a runway. I only said that all the fancy equipment is NOT needed to get you from the gate to the runway. I wasn't implying that it be removed for other flight purposes.

[Phantom Driver]

This whole discussion is about trying to take off on a taxiway vs a runway. I only said that all the fancy equipment is NOT needed to get you from the gate to the runway. I wasn't implying that it be removed for other flight purposes.

Absolutely. My current machine has a nice fancy moving map to navigate round the field, but from bitter experience in the early days, I still have good old 10-9 hardcopy out and ready. Good thing I still remember how to read it; just got back from a Chinese airport, where for some reason, the moving map for that particular airport was "Not in database". Lot of taxi "hotspots" on the chart as well, just to make life a little more interesting.

Dengue;
Don't assume, check.

One of my favorites, along with "complacency, the biggest killer", and
"Man has oft more need to be reminded than informed". We are forever reinventing the same old wheel, going over the same ground, making the same old mistakes, rather than learning from them.

I guess memories are short.

[Brian Abraham]

Over on "Fragrant Harbour" an ATCer makes the following observation
It amazes me that 07L is probably used for less than 5% of all night time departures here in HK, and yet there has been 4 serious "twy A attempted take-offs". To my knowledge, this has never happened on either 07R or 25L.That being the case does it not imply that the statistic is trying to tell us something? Certainly can't be that a good many pilots are dumbkofs surely. What is the systemic issue at work?

[Sciolistes]

Grimmrad
gDo you guys have QC sessions? We have sessions were missed cases or wrong diagnoses are discussed. To learn from them. And everyone knows he is not free of mistakes also (but you always hope it is not one of the cases you read coming up that day)... So why not having meetings with airline pilots and even psychologist were they come clean and talk about their errors which maybe did not make it into the news and were they luckily could walk away from to talk about it so others and they themselves can learn and improve.
We do sort of have such a system, but it depends from airline to airline. In my company we have an open reporting system, where we are encouraged to report any safety or security issues (and anything else we think is pertinant).

The problem is that it doesnt matter how often the company makes the point that reporting would never result in disciplinary action, many pilots dont. I have reported myself several times and results have been between nothing happens, to a phone call or a very positive chat. On one occasion I unwittingly identified a general weakness in procedure and memo was the result.

[Reeltime]

Idiotic Airbus procedures probably contributed to the loss of SA in this case.

To have a checklist (before T/O checklist below the line) that cannot be commenced until after a line up/take-off clearance is received, is a human factors nightmare. This part of the checklist may only contain four items, but the checklist is being read at a critical time, often whilst copying a sometimes complex clearance, checking there is no-one on short final and manoeuvering onto the rwy.

I'll take the Boeing philosophy any day, where everthing is done before line up, leaving the crew to concentrate only on the necessary things at this critical time.

[Hotel Tango]

Over on "Fragrant Harbour" an ATCer makes the following observation

Quote:
It amazes me that 07L is probably used for less than 5% of all night time departures here in HK, and yet there has been 4 serious "twy A attempted take-offs". To my knowledge, this has never happened on either 07R or 25L.

That being the case does it not imply that the statistic is trying to tell us something? Certainly can't be that a good many pilots are dumbkofs surely. What is the systemic issue at work?

Maybe there are more "dumbkof" pilots than we care to admit to then. I'm sorry, but I find it inconceivable for anyone but a dumbkof to mistake the taxyway for 7L - even more so on a clear and dry night.

[Dengue_Dude]

Last post on this subject (for me) and I don't want to go banging on about it but:

However many mitigating factors there are - bad design of airports, bad design of cockpits, non-ergonomic checklists and so on, it's the FUNDAMENTAL responsibility of the flightcrew - the skipper in particular, to ensure the safe conduct of the flight - taking off on the correct runway, in this particular case.

Or is that just me being 'perfect' again - slag me all you want - but the above is TRUE, absolute and unequivocal.

[aterpster]

Dengue Dude:

However many mitigating factors there are - bad design of airports, bad design of cockpits, non-ergonomic checklists and so on, it's the FUNDAMENTAL responsibility of the flightcrew - the skipper in particular, to ensure the safe conduct of the flight - taking off on the correct runway, in this particular case.

Or is that just me being 'perfect' again - slag me all you want - but the above is TRUE, absolute and unequivocal.

Correct, there are no excuses or mitigating factors for taking off on the wrong runway.

[Sir George Cayley]

Hot Spots have been introduced onto plates for points where there's an increased risk of a runway incursion. It should flag up to crews to focus and concentrate.

Maybe designating this area as a Hot Spot on the chart may help ensure crews sit up and take notice.

Btw does the Airbus system pick up Hot Spots?

Sir George Cayley

[merlinxx]

Tiz easy "TAXI WAY DO NOT ENTER FOR T/O RWxxx" illuminated, it's not hard:ugh: Murphy is a great leveler:D

[coffeezone]

Liked the idea of painting taxiways red. But many airports have a lot of taxiways. How about painting the runways red, entering a runway raises the caution level, more so if it was red. The paint could also be a nonslip type to enhance grip.

[MFALK]

Sir George, the beauty of OANS is that the flight crew can add red crosses or green flags as markers for example to indicate taxiways which are closed or not suitable for the aircraft type and also hotspots.

[cwatters]

Had they just changed runway in use or was it quiet so they wern't in a queue?

[iamhere]

had a russian (AFL) take off from the taxiway at liverpool in the early 1980s.
this was when the southern aerodrome was not visible from the tower which was located on the nothern airfiled.
situation different today, so hopefully, not likely to hapen.

[Finn47]

All lights were working and nothing was out of the ordinary, it says here in the prelim report:

http://www.cad.gov.hk/reports/Preliminary%20Report%20of%20Investigation_e.pdf

To prevent a similar event from recurring, ATC will from now on only give takeoff clearance after they have visually ascertained the aircraft has taxied completely cross taxiway A.

[Helen49]

Sorry, haven't had time to read all this thread but mistaking taxiways for runways????
Colour coded taxiway lights (at most airports), red stopbars, painted holding point markings, holding point designator signs, runway designator signs, wig-wags, painted runway designators on the taxiway surface, 'runway ahead' signs at many airports, runway markings different from taxiway markings. Goodness me chaps, how many more clues do you want??

Got to be an inexcusable error in my book!

H49

[crippen]

Murphy's law - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Murphy's_law)

[groundbum]

how about a police radar gun aligned down each taxiway and if it picks up more than 40knots it flashes an alarm in the tower, or announces something on the ground/tower frequency?

cue ryanair jokes...

G

[PantLoad]

Is it not SOP to, as you're taking the runway (or, you think you're taking the runway), to check runway alignment and heading on the ND?

Fly safe,

PantLoad

[forget]

........ check runway alignment and heading on the ND?

From Interim Report. The aircraft took the normal right turn at the end of Taxiway B towards Runway 07L but then took a premature right turn onto Taxiway A, a taxiway parallel to and in between the runway-in-use and Taxiway B.

[Green Guard]

but remember...
RWY HDG is a must
but not enough
How about looking the colour of the RWY/TWY lights
any difference there ?
even if eyes are tired from some special liquids...there is no excuse

[White Knight]

Is it not SOP to, as you're taking the runway (or, you think you're taking the runway), to check runway alignment and heading on the ND?

Fly safe,

PantLoad

Mmmm - no! It's not SOP at all. At least not in the FCOMS for 332/343/345. Nor is it in the company Ops Manual... EK's at least... Although we do check the ILS inbound course on a CAT 2/3 at 350' RA if that helps:ok:

Ah well:):)

[PantLoad]

Yes, it is the new Airbus SOP. Revision 43. Have a read.....

This came about, I believe, as a result of the RJ accident in LEX. (I think it was LEX...can't remember, for sure.)

As we take the runway, we're to check runway alignment and heading. With non-GPS, non-FMGC II, it'll be before you go to FLEX/TOGA to get the runway position update....but, the intent is to check, just the same.
(With GPS/FMGC II, there is no runway position update upon application of FLEX/TOGA....the aircraft position is valid already.)

Of course, runway lights, markings, etc., are important, as well. Everyone, here, has made a valid point.

What I, personally, find interesting is how, looking into the human brain, an entire crew could make this mistake. Again, this is not the first time something like this has happened. What causes a crew to make this mistake? Since this has happened many times before, I really don't see how we can simply write this off to the crew being a dumb-XXX. I'm not a PhD in Human Factors, but I think this is a case deserving some sort of study. Over the years, too many people have done this....the question is 'why?'


Fly safe,


PantLoad




Edited....Sorry, everyone, I just looked it up....It's not REV 43, but REV 42. My memory is bad. FCOM 3.03.11 P1 QFU/Threshold Confirm....just above the listing to stow the tray table prior to takeoff.

[Jay Arr]

There is something going on with this runway/taxiway intersection. I haven't taken off from 07L at night for a long time so cannot comment first-hand, but I was discussing this with a very experienced mate based in HKG flying Airbuses. He departed 07L recently at night, looked down A as they taxiied to the rwy and observed to his copilot that he "could understand how mistakes could be made, it just looks WEIRD..". As I said he is very experienced and it's his home base. He cannot put his finger on what illusionary effects are in play. Imagine the problem being faced by visitors to HKG.

It is ALREADY designated as a Hot Spot, Sir George Cayley, which came about after the previous incident. That's an official acknowledgement that something insidious is going on here. Whether it's a combination of lead-in lights, relative brightness of lights, the expanse of concrete, low vis., signage, whatever: the human factors of the situation must be revisited.

In the meantime, be careful out there.