LH E195 took off without clearance at BRU [Archive]

RAT 5

13th Oct 2016, 13:36

I am not saying this was the case, but it happened to me years ago at ORY. A similar runway layout. An Indian B747 freighter (I think) started to roll as I was short finals. The cause was a wrong change of frequency from ground to departure. They checked in on departure, who without confirmation of position, cleared them to an intermediate FL. So off they went rumbling down the runway. The human links in the chain are guaranteed at some point to prove weaker than required.

HEATHROW DIRECTOR

13th Oct 2016, 14:31

<<They checked in on departure, who without confirmation of position, cleared them to an intermediate FL.>>

Assuming it was a radar controller who cleared them to climb, he expects an aircraft to be airborne when it makes contact. I've seen it happen but I still find it unbelievable that an experienced pilot would do it.

costalpilot

13th Oct 2016, 17:12

yeah its unbelievable that an experienced pilot would make a simple if huge mistake. it hardly ever happens. i was a fo lined up on rwy 1 at msy back in the day when either the chief pilot of the airline or I ( i cant remember which) stopped the takeoff roll after power application with the simple question "do we have a clearance?" not a takeoff clearance, we had that. a clearance clearance. we didnt have that. im pretty sure he was experienced and i was in a dc 9 so i had at least three years experience. how did that happen? we both eventually completed successful, and happily uneventful, 30 plus year careers.

Lonewolf_50

13th Oct 2016, 20:33

There is no approach so smooth and so sweet that it can't be waved off, for whatever reason. Good job, A320 crew, and good job tower to see "something wrong" and call the wave off. How that other aircraft got this wrong, will hopefully come out in an incident report, and aren't we all glad that this did not become an accident report? I am.

EDIT: Corrected who spotted error, thank you what next, I obviously did not read with sufficient attention to detail.

Amadis of Gaul

13th Oct 2016, 20:47

costalpilot, was that in the middle of the night?

what next

13th Oct 2016, 20:48

Good job, A320 crew, to see "something wrong" and wave off.

They didn't see that something was wrong, but the tower controller (or rather his software) did and he told them to go around. Honor whom honor due!

EDDT

13th Oct 2016, 22:18

DaveReidUK

13th Oct 2016, 22:47

So all they have is a lufthansa callsign.

I think that was the point.

WHBM

13th Oct 2016, 23:11

Air Dolomiti wholly owned by Lufthansa, main base Munich.

costalpilot

13th Oct 2016, 23:43

nope

we didnt fly then

come to think of it, in my late 50's, flying in the middle of the night in SE asia, i dont remember any kind of mistake approaching that one, when i was in my early 30's, first flight of the day, flying with one of the great captains of my youth.

just goes to show, imo.

underfire

14th Oct 2016, 02:22

Amadis...

From the report:

OCCURENCE DATASET
Date: 2016-10-05 Time: 20:40
Location: EBBR BRU Brussels Airport
Country: Belgium
Flight phase: APR – Initial Approach (IFR), Final Approach, all Circuit Patterns, Missed Approach/Go-Around

ATC Watcher

14th Oct 2016, 08:51

:mad: happens. The " line up and wait" was introduced after Tenerife, but as we see here it does not solve 100% of the problems. The alarms on the Ground surface movements radars were generalized after Linate. Good to see the system worked here.
Also good professional handling by the TWR controller , if the R/T transcript provided in the jadec file is authentic and complete of course.

LimaFoxTango

14th Oct 2016, 22:53

I've always wondered why are airports designed with crisscrossing runways like this, especially when they are being used simultaneously. I know answers are going be to because of winds, space, maybe surrounding terrain etc., but this kind of set up seems to promote this kind of possible conflict. What procedures are in place to avoid such?

Check Airman

15th Oct 2016, 03:35

A few US airports have the runway ststus light system and FAROS. Is it in use in Europe? It's not bullet-proof, but I image it would help.

https://www.faa.gov/air_traffic/technology/rwsl/

http://rwsl.ll.mit.edu/pdf/FAROS_DFW_Pilots_Training_OpEval.pdf

PositiveClimbGearUp

15th Oct 2016, 04:03

A recording of the ATC has appeared on YouTube. Obviously, I can't confirm it is unedited.

http://youtu.be/rWR9ucU9eUg

ATC Watcher

15th Oct 2016, 07:32

A recording of the ATC has appeared on YouTube
Welcome to the 21st century.
That said, this recording makes more sense , but is different from the one published earlier. Just to point this out, especially when attempting to pass judgement on preliminary unofficial info.

Scuffers

15th Oct 2016, 07:56

Is that recoding typical of the audio quality of ATC?

If yes, then I can see how mistakes can happen, I'm amazed anybody can understand that real-time.

Bus Driver Man

15th Oct 2016, 08:17

IWhat procedures are in place to avoid such?
Not taking off without a clearance?
Listening to other traffic on the frequency?

A few US airports have the runway ststus light system and FAROS. Is it in use in Europe? It's not bullet-proof, but I image it would help.

https://www.faa.gov/air_traffic/technology/rwsl/

http://rwsl.ll.mit.edu/pdf/FAROS_DFW...ing_OpEval.pdf
(http://rwsl.ll.mit.edu/pdf/FAROS_DFW_Pilots_Training_OpEval.pdf)

(http://rwsl.ll.mit.edu/pdf/FAROS_DFW_Pilots_Training_OpEval.pdf)I have never seen this in Europe. But can't this create an additional threat by mistaking the red lights going out for a clearance? Obviously you shouldn't, but many pilots only fly to the US once in a while. Combine an unfamiliar lighting system with fatigue, and mistakes might happen.

RobShan

15th Oct 2016, 08:19

The youtube video cites LiveAtc.net as source; the audio will have been recorded from a volunteer's scanner in line of site of the airport.

It is reasonable to assume both pilots and the ATC would have had much better audio from equipment that is designed for ground aircraft communications.

ATC Watcher

15th Oct 2016, 08:40

Scuffers :I can see how mistakes can happen
No you don't.

, I'm amazed anybody can understand that real-time.
Well as said before , this is likely from a hand held scanner , the ATC real R/T quality is generally much better but not always ( thinking more HF) , no generally mistakes like this do not happen because of quality , if you have a doubt , we ask to " say again" . Here the instruction to line up and wait was repeated by the PNF, so understood. No complied with by PF is the issue here.
.

Hotel Tango

15th Oct 2016, 10:05

FZRA I thought that the term take-off should no longer be used outside that of an actual take-off clearance. Your example mentions "take-off" twice during a critical period. This is not as fail safe as you may think. Just a personal observation.

Check Airman

15th Oct 2016, 10:23

(http://rwsl.ll.mit.edu/pdf/FAROS_DFW_Pilots_Training_OpEval.pdf)I have never seen this in Europe. But can't this create an additional threat by mistaking the red lights going out for a clearance? Obviously you shouldn't, but many pilots only fly to the US once in a while. Combine an unfamiliar lighting system with fatigue, and mistakes might happen.

The airports with the system installed have dedicated Jepp pages explaining how it works. Those pages stress that the lights going out does NOT constitute a clearance. It isn't a panacea, but another pretty useful layer of safety.

Council Van

15th Oct 2016, 10:25

FZRA So if you do not want your colleague to slam the throttle forward and set off down the runway feeling dumb and happy how about

"Check list complete, line up only"

No need to mention Take off.

Check Airman

15th Oct 2016, 10:28

My company SOP is to mention the name of the checklist.

I do something similar on landing though.

"Landing checklist complete, cleared to land RW 33"

Chesty Morgan

15th Oct 2016, 11:00

No need to say anything at all. There is an SOP that is common to all aircraft once take off clearance has been received. If that SOP hasn't been actioned then you don't go or you double check your clearance.

By the by our SOPs require 3 mentions of "take off" during the line up process, which I think is stupid but They won't change it.

Scuffers

15th Oct 2016, 11:39

Scuffers :
Well as said before , this is likely from a hand held scanner , the ATC real R/T quality is generally much better but not always ( thinking more HF) , no generally mistakes like this do not happen because of quality , if you have a doubt , we ask to " say again" . Here the instruction to line up and wait was repeated by the PNF, so understood. No complied with by PF is the issue here.
.
Ah, OK, good to here.

I have heard better quality audio out of $50 CB rigs, kind of hope million dollar aircraft have something better...

Capn Bloggs

15th Oct 2016, 12:46

Snot a "Takeoff" checklist, it's a "Before Takeoff" checklist. Same Landing. :ok:

pilot1957

24th Oct 2016, 21:03

scifi

25th Oct 2016, 10:06

I thought the CAA approved buzzword was 'departure'. As in...
''G-ABCD ready for departure.''

Hotel Tango

25th Oct 2016, 11:31

I remember, not very long ago, when a particular German airline I flew with always used the term "take off" when making the announcement from the F/D, i.e. "cabin crew take your seats for take-off". I even commented on it here in PPRuNe. This was the standard call by all crew in that airline and it struck me as another potential hole in the cheese. Following a small reshuffle last year, the airline continued operating under a different guise and I noticed that "take off" had been replaced by "departure" in this announcement.

Uplinker

26th Oct 2016, 09:24

After saying "Before take-off checklist complete." I always say: "Line up only" in that situation - It is not SOP to do so, but it just seems safer to me.

I have heard better quality audio out of $50 CB rigs, kind of hope million dollar aircraft have something better...

They do, but the equipment is commonly misused. As an ex broadcasting engineer, the quality of aircraft and ATC VHF radio comms sometimes makes me despair. What also makes me despair though is when I say we should snag this box, your radio, your boom set, etc, and they don't understand or they say, "well it seems alright to me."

A lot of people seem to be of the opinion that "walkie talkie" transmissions or anything similar SHOULD sound distorted, so they don't think anything is wrong, but actually when properly set up and used, VHF RT comms can be very good.

Then you have the people whose first action is to take off the microphone windshield - "horrible things" they say; and spend the next 8-12 hours making breath distorted RT and interphone calls while their spit and germs fill up the bare microphone. This stops the noise cancelling from working and makes all their transmissions very noisy. "station calling?"

Phew, that's better. I'm off to have a quiet lie down...........!

(For best results, use a windshield and place the microphone a finger's width away from your lips, otherwise the noise cancelling won't work. Squeeze the windshield so you can feel the shape of the microphone - some are drum shaped, others flat - and rotate the microphone so you are speaking into its surface not its edge, otherwise - again - the noise cancelling won't work and your transmissions will be hard to understand. Speak slowly, and at normal speaking volume.)

Super VC-10

18th Jul 2017, 15:12

Final report is out.

https://mobilit.belgium.be/sites/default/files/downloads/accidents/2016-21_final_report.pdf

Doors to Automatic

18th Jul 2017, 15:57

Sidestick_n_Rudder

18th Jul 2017, 17:48

They do have a system like this in some places in Japan - e.g. Sapporo IIRC

Chronus

18th Jul 2017, 18:04

Is the proximity of the conflict yet known.

Centaurus

19th Jul 2017, 07:33

Welcome to the 21st century. Maybe time to go back to Aldis light signals aimed at the cockpit. Green for clear take off and red for don't take off. :E

parkfell

19th Jul 2017, 08:00

Swiss cheese at work again.

HEATHROW DIRECTOR

19th Jul 2017, 08:38

Centaurus... like to see that system works in LVPs!

RAT 5

19th Jul 2017, 09:14

Maybe time to go back to Aldis light signals aimed at the cockpit. Green for clear take off and red for don't take off.

Red stop bars on the runway at line up. ON = hold. Off = cleared to launch. Considering AC's incident at SFO, the green threshold lights of an active runway could be changed to red when the runway is closed, or it's not a runway at all.

MaydayMaydayMayday

19th Jul 2017, 09:55

It would make sense for "danger" runways (i.e. those with active intersections) to have a strip of bright lights a few hundred metres in that stay red and only turn green once clearance is given. This system already exists on taxiways so why not on runways?

They've got it at CDG. Particularly useful because of the two sets of parallel runways, so there's constantly landing traffic crossing over the takeoff runways. (They tend to land on the outer runways and take off from the inners)

atpcliff

19th Jul 2017, 18:05

Hence, when I'm PNF and reaching the end of the take-off checks, I normally say something along the lines of "Take-Off checks complete, we are not cleared to take-off yet" or words to that effect. Just to be sure that the PF is on the same page as me and doesn't slam the throttles forward as we finish the line-up. Does anyone else do this?

I would say, in the cockpit, "Take Off Checklist complete. Lineup and wait."...for the same safety reason you specified. Also, on taxi, if we need to cross a runway to get to the takeoff runway, but we are not cleared yet to cross, I will state "We will not cross any runways"...for safety reasons. Then, we we get clearance, I will repeat, in the cockpit, "Cleared to cross runway xxx".

parkfell

19th Jul 2017, 18:40

Speaking from bitter experience a number of years ago, as the ac commander,
I think putting the landing lights ON ( bar forward ) as the best way to mitigate this threat.

Best visual cue you have.......keeping it simple stupid 😎

simmple

20th Jul 2017, 16:17

Or never use the words take off until you are cleared to do so!

Uplinker

21st Jul 2017, 07:14

Quote:
Originally Posted by FZRA View Post
Hence, when I'm PNF and reaching the end of the take-off checks, I normally say something along the lines of "Take-Off checks complete, we are not cleared to take-off yet" or words to that effect. Just to be sure that the PF is on the same page as me and doesn't slam the throttles forward as we finish the line-up. Does anyone else do this?

.......I would say, in the cockpit, "Take Off Checklist complete. Lineup and wait."...for the same safety reason you specified.

These both contain those dangerous words: "take-off". In that situation I just say "Checks complete, line-up only."

(When seating the cabin crew, I never say "take-off" either; I say "Cabin crew, seats for departure please."

I avoid saying the phrase "take-off" until we are actually cleared by ATC to do so.

wiggy

21st Jul 2017, 18:13

Just an observation to stir further debate. For at least one current type Boeing makes the following comment in it's normal checklist handling instructions: For all checklists, the PM announces “___ CHECKLIST COMPLETE,” the PF visually confirms that the CHECKLIST COMPLETE indication is shown and.......
There is a " before take off checklist".

simmple

21st Jul 2017, 21:13

We used to have a before departure checklist but it is now a before take off checklist!
We ask for before takeoff checklist and the reply is before takeoff checklist complete....

tescoapp

22nd Jul 2017, 06:31

I have changed a couple of company checklists names to "line up checklist". Don't have an issue with departure checklist just as long as its anything but takeoff.

Must admit I can't even use "takeoff" in normal conversation with none pilots.

Klimax

24th Jul 2017, 15:21

Why do you put " LH " in the headline? It's not quite right.

It was an Air Dolomiti Embraer. That company is from Italy and flying wet-lease for Lufthansa City line.

So all they have is a lufthansa callsign.

What waz ze callsign again? If it's Lufthansa - then it's Ze Lufthansa. If Ze Lufthansa management has chosen to wet lease an operator to fly on it's behalf - it's a Lufthansa flight. End of ze story.

underfire

24th Jul 2017, 16:19

Combine an unfamiliar lighting system with fatigue, and mistakes might happen

fatique on DEP?

poldek77

25th Jul 2017, 10:38

Why not? It could be the fourth leg for them on that day.

Lissart

26th Jul 2017, 14:59

Two points to note from the final report:

1/. Limited traffic information/situational awareness given when delivering ATC clearances.

2/. Authorizing aircraft to line up on RWY 07R at a short distance from the intersection with RWY 01 without correlation with landing traffic on this latter.

Speaking as a controller, this confirms what I saw immediately on reading about the incident. Lining up on any crossing runway - and from an intersection so close to the runway with landing traffic - without giving traffic for SA, is something I would not do. (I would not do that where I work with 3 crossing rwys.) Especially when one considers the non-native language elements etc. Of course this does not condone taking off without a clearance but "Rwy xx, line-up and wait - landing traffic rwy yy" must be a sensible use of phraseology.

KriVa

27th Jul 2017, 13:09

....
"Rwy xx, line-up and wait - landing traffic rwy yy"
....

Practically the same phraseology has been suggested/implemented since the incident described and is used by most, if not all, controllers now.

Lissart

27th Jul 2017, 13:33

(For discussion only - only criticism of the controller implied or intended.)

Why not just leave the departure at the holding point, given that rwy configuration? The report states that traffic levels were not high, so no need to be super expeditious. Wait till the landing a/c has passed - which you have to do anyway obviously - then clear the departure for take-off from the holding point. Saves you one transmission and limits any risk of exactly what happened.

Further thought: it seems that there are two holding points adjacent to the landing rwy - from memory, C5 & C6. Seems that the latter might be way too close for comfort to the landing runway. Is there any possibility - and/or mitigations in place - that the pilots of departing a/c might inadvertently go to the wrong one? (Don't have the report open so that is from memory....) Anyone familiar with the procedures?

FlightDetent

27th Jul 2017, 16:58

Lissart: If memory is correct 07R have a special noise abatement take-off point. It is about 400 m down the runway from the threshold. Thus it make sense to allow the aircraft to line up, taxi forward and wait, saving about one and half precious minute, whilst the crossing traffic lands.

KriVa

28th Jul 2017, 11:08

C5 is not used for line-ups, only C6 is for intersection departures on 07R.
The stopbar for C6 is quite a ways away from the RWY, and the final part of the RWY entry is rather steeply uphill (relatively speaking). As such, line-up time is rather unpredictable, and lining up an aircraft only after the landing aircraft has passed leads to a very long time of nothing happening, and the next arrival only coming closer and closer.
Several runway holding positions are used (Hotel, 1 and 2, visible on charts in the AIP). Using runway configuration 01/07 results in a very busy environment for everybody involved, both on the flight deck and outside.
Mistakes happen, we're all human, key point is to learn from them, which seems to have happened.