Near Repeat Of Tenerife Disaster In Adelaide.

[Kal Niranjan]

Jetstar passengers came '30 seconds' from plane collision: report - World - NZ Herald News (http://www.nzherald.co.nz/world/news/article.cfm?c_id=2&objectid=11753702)

Excerpt from the report :

A Jetstar crew managed to avert a major disaster at Adelaide airport when the pilot of a second plane misheard instructions and crossed its path as it was coming in to land, a report reveals.

The Australian Safety Transport Bureau said an Alliance Airlines flight had landed at the airport with 53 people on board when its pilot taxied onto the tarmac and into the path of an incoming Jetstar A320, believed to be carrying more than 150 passengers.

The Jetstar plane was a mere 30 seconds from colliding with the Alliance Fokker 50 before its crew took evasive action. There were no injuries reported in the August 17 incident.

In its investigation, the bureau found miscommunication between the Alliance pilots and the airport's surface movement controller (SMC) contributed to the incident.

This is partly because words were "clipped" from the start of transmissions, a known problem air traffic controllers had become desensitised to, the bureau said.


It found Alliance pilots misheard instructions from air traffic control to "hold short" of the runway as the Jetstar plane approached.

They were told: "Hold short of runway 23, I've got you going to 50 golf".

But the Alliance crew heard: "Runway 23, I've got you going to 50 golf".

The SMC thought the word "hold" had been clipped when the Alliance crew repeated the instructions back, the bureau said.

Continued below.

[DaveReidUK]

Where did you get the Tenerife quote from? Unsurprisingly, it doesn't appear anywhere in the linked article.

The ATSB report makes interesting reading:

http://www.atsb.gov.au/media/5771829/ao-2016-102-final.pdf

[Capn Bloggs]

Putting your callsign last in a readback-transmission ain't that smart in some situations...

The captain was normally based in New Zealand and commented that to cross an active runway there, pilots are required to contact the ADC on the Tower frequency for a clearance.
A sound idea. It is a pity that the Airservices' trial of this procedure a couple of years back was such a shambles that everybody lost interest in it.

[Two's in]

The report highlights what can happen when assumptions are made and radio discipline is not applied by a group of experienced professionals.

[Jungmeister]

The full ATSB report (See link above) is certainly good reading.
I don't think this incident deserves the sensational reference to Tenerife.

[ClearedIGS]

A classic runway incursion. Seems that Airservices never read ICAO Doc. 9870, (Manual on the Prevention of Runway Incursions), where it says the following:

Doc. 9870 Para 4.2.6
All communications associated with the operation of each runway (vehicles, crossing aircraft, etc.) should be conducted on the same frequency as utilized for the take-off and landing of aircraft.

Doc. 9870 Appendix A Para 1.6.
To maintain high levels of situational awareness, it is also recommended that communications for all operations on a runway (landing, departing and crossing aircraft, vehicles crossing and runway inspections, etc.) take place on the VHF channel assigned for that runway.

Doc. 9870 Appendix C Para 4.3.
Communication with any aircraft related to the use of a runway for the purpose of taxiing should be transferred from the ground controller to the aerodrome controller prior to the aircraft entering or crossing a runway.

Standard Threat & Error Management principles dictate that an aircraft, (or a vehicle or tow) on a runway which is not on the same frequency as everyone else operating on that runway is a threat. How do you manage this THREAT? Everyone should be on the same frequency.

I worked ATC in Adelaide for 18 years and Hong Kong for 27 years on Tower and Approach. The simple fact of having all operational aircraft and vehicles on the same Tower frequency in Hong Kong, has saved many possible incidents from occurring over the years, because it adds to the situational awareness of everyone using the runway. Hong Kong has dozens of runway crossings every day by freighters, business jets and tows as the Cargo and Bizjet aprons (ramps) are South of the South runway. All are held short of the runway and call Tower South before being cleared to cross. It also does away with excessive coordination between the Tower Controller and Ground Controller and the timing of any cross can be more finely tuned.

You would think Airservices, (Civil Aviation Authority in those days), would have learned their lesson as far back as 1990 with a near collision between a departing Cathay 747 and a runway crossing tow. The report had a number of recommendations, the first being......

"1. The complete runway complex remain under the jurisdiction of the aerodrome controller (ADC) during SIMOPS and Multiple Runway operations;"

[Capn Bloggs]

IGS, as I mentioned earlier, that procedure was trialled at some places in Oz but was abandoned. The documentation and the introduction was a shambles, obvious at the time.

Perhaps it will be re-visited after this, with less-confusing procedures/documentation/education next time round...

[RobShan]

Tower frequency was trialled at Adelaide; my (SLF) observation was that this required what were rapid almost pointless frequency changes.

In the case of the F50 in this incident, the sequence would go like this. They come off the runway at D2 switch from tower to ground, ground tells them to hold short RWY 23 (less than 300m taxi, actually less by the time they make contact with ground) and contact tower. Now they go back to tower who clears them to cross RWY 23 and contact ground on the other side. Taxiway E2 exits only have about 200m before they had to hold short. This sequence led to the occasional "which genius" comments from pilots, even on the longer taxiway F exits.

A more common-sense approach at Adelaide, I believe, would be for E2 and D2 exits at least, for the aircraft to remain with tower until the RWY crossing is completed. This is what happens late at night when ground and tower are run by one controller who often tells aircraft to remain tower frequency for the taxi to the gate.

Adelaide chart to help make sense of my ramblings: http://www.airservicesaustralia.com/aip/current/dap/PADAD01-148.pdf

[RAT 5]

I've just made a quick trawl through the report and did not find the METAR. I assume it was VMC conditions. Is it only me, but if I step off the pavement into the danger area I look both ways twice; well at least once, even when there is a little green man.
Tower, you think, says Cross = little green man. Surely, groundmanship and self-preservation dictates you check there are no crocs about to bite your foot off before you put your toe in the water.
Or is that just me?

[peekay4]

The Captain (sitting on the left obviously) cleared left prior entering the runway. The FO, a Check Captain, spotted the A320 late, off the right window. By that time the F50 had entered the runway so he didn't say anything. The F50 was then told to expedite the crossing. Per the report the Captain never saw the A320 from his vantage point.

[ClearedIGS]

Totally agree with your observations re frequency changes RobShan. There are 2 methods of handling such a situation. The first is prior coordination. The ADC (Tower Controller), simply coordinates with the SMC (Ground), before the aircraft even lands and advises that they will keep the aircraft on Tower frequency until it has crossed Runway 23. When the aircraft has landed the controller simply says “XXX Vacate D2, Hold Short RWY 23, Remain this Frequency.” Same goes for taxying to 30 for departure. SMC taxis the aircraft to hold short of 23 on D1, transfers to the Tower, and the ADC crosses the aircraft. “XXX, cross RWY 23, Taxi D2, Holding Point 30, Report Ready.” (No further frequency change required.)

In Hong Kong we used to pre-coordinate this sort of thing all the time. For example, if I was crossing the South Runway with a Bizjet mid-field (25L/07R), once crossed, it is only a short taxi to the Business Aviation Centre. What is the use of changing an aircraft to Ground to taxi 300 Metres before the pilot changes again to the FBO frequency? It all depended on the circumstances. For example, if Ground had an aircraft taxying out, they would simply refuse the coordination and the aircraft would be directed to contact Ground as soon as they had crossed the runway.

The other way is to have a permanent procedure. That is, in the case of Adelaide, the whole of D2 belongs to the ADC, not the GMC. Again, we had such an arrangement in Hong Kong when using RWY 25R. (Generally, the North Parallel runway in Hong Kong is just used for landings). The Western half of the parallel taxiways ‘A’ & ‘B’ are retained by the ADC at all times. This is to avoid nose to nose conflicts with just landing aircraft about to vacate the runway with aircraft already landed by keeping all conflicting aircraft on the same frequency. Aircraft are only transferred to Ground when clear of all of these conflicts. There was also a permanent arrangement for landings 07L when the visibility was less than 1500 Metres to avoid nose-to-nose conflicts with aircraft taxying out of the North apron.

No aerodrome layout is perfect, even when built with a clean sheet design. The thing is to develop procedures to make the airport environment as safe as possible for all who operate there.

[Heathrow Harry]

"the weather at the time was benign" but the sun was right behind the A320 apparently

[DaveReidUK]

Though not cited by the ATSB as a contributing factor. The P2 saw the A320 regardless and the P1 couldn't reasonably have been expected to from the LH seat.

[Capn Bloggs]

The sun was behind the A320 on final approach to runway 23, which may have affected the check captain’s initial estimate, when they first entered taxiway D2, of how far away the A320 was. However, it was not a factor when FKV taxied onto the runway.
Had his initial estimate been more accurate...

Use the TCAS. If the target on final is at +200, he's at .7nm final.

[khorton]

Use the TCAS. If the target on final is at +200, he's at .7nm final.

Keep in mind that the resolution on that TCAS altitude display is only 100 ft (ie. ±50), and there could be up to 50 ft error in the baro altitude that feeds the TCAS on each aircraft. So, if it shows +200, with worst case stack up of errors the actual altitude difference could be as much +350, or as low as +50.

[RadioSaigon]

...and there could be up to 50 ft error in the baro altitude that feeds the TCAS on each aircraft...

Nope. TCAS ALT is from the Transponder ALT, which is PERMANENTLY set to 1013.2hPa, completely independent of and isolated from the Baro Altimeters on the panel.

[DaveReidUK]

Keep in mind that the resolution on that TCAS altitude display is only 100 ft (ie. ±50), and there could be up to 50 ft error in the baro altitude that feeds the TCAS on each aircraft. So, if it shows +200, with worst case stack up of errors the actual altitude difference could be as much +350, or as low as +50.

Not quite.

While your TCAS displays relative altitude in 100s of feet, that has been calculated from two transponders that are (nowadays) almost always sending altitude in 25 foot increments.

[Xshongololo]

30 seconds is a long time in aviation

[Ushuaia]

Huh? Radio frequencies? TCAS? Sun glare? Transmissions stepped on or clipped? Various procedures? You're all kidding, right?

The phrase "cleared to cross" was never issued and thus was never heard.

If ALL pilots on the flight deck have not heard and confirmed the phrase "cleared to cross", you don't cross. Period. The end.

Presumed, assumed, expected...... for heaven's sake.

What in hell ever happened to airmanship in this profession?

And a checkie in the right seat too......

[Una Due Tfc]

Use the TCAS. If the target on final is at +200, he's at .7nm final.

It's not that accurate unfortunately. It's a rough guide, like ADS (on the flight deck), it's not a separation tool. Be very careful and conservative with it would be my advice.

[peekay4]

If ALL pilots on the flight deck have not heard and confirmed the phrase "cleared to cross", you don't cross. Period. The end.

Presumed, assumed, expected...... for heaven's sake.

What in hell ever happened to airmanship in this profession?

Are you sure? According to Airservices Australia the standard phraseology there is still "CROSS RUNWAY XX" not "CLEARED TO CROSS RUNWAY XX".

[Ushuaia]

And there you have it. Pedanticism over airmanship. The gist of what I'm getting at completely overlooked....

You're right, I shouldn't have, in my haste, put the word "cleared" inside the inverted commas here on PPrune - yes, the word "cleared" is only verbalised in take-off and landing clearances. All other clearances we don't say the word "cleared". Naughty me, I should have cut & paste from the AIP when writing on PPrune after a cross continent red-eye.

But surely my point hasn't been lost? If you haven't been cleared to "CROSS", given the instruction to "CROSS", heard the word "CROSS"...... then you'd better not CROSS without clarifying?

God help us if instead of speaking up and clarifying, we decide its more important to go heads down into the AIP and begin a debate about whether that was standard phraseology? Airmanship and common sense, anybody?

[Heathrow Harry]

yes but it's also clear that people operating through Adeliade have got used to not hearing the full transmission due to the technical problems with the kit and have fallen into the habit of using their judgement (and that includes ATC) to infill the missing words

Right do do so - NO - but all to easy to do.................

[peekay4]

But surely my point hasn't been lost? If you haven't been cleared to "CROSS", given the instruction to "CROSS", heard the word "CROSS"...... then you'd better not CROSS without clarifying?

They DID try to clarify, by reading back what they thought they heard. From transcript:

FO: "CROSS Runway 23 to 50 Golf, Unity 3201"

Unfortunately ATC also misinterpreted the read back.