Close call in Japan
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I'm not quite sure how to pitch my comments here. I feel irritated by a lot of the previous comments, but I'll try to be analytical.
1. This is a newspaper report. We all know how unreliable they are.
2. We have no idea what really happened.
3. We have no idea of what was, or wasn't said in the cockpit.
4. We have no idea about the reporting that occurred internally in JAL.
5. We have no idea of what reporting occurred between JAL and JCAB.
6. We all know that humans make mistakes. People who live in glass houses etc etc.
7. The Japanese airlines are as good as the western airlines. In Asia they (along with the Hong Kong carriers) stand out as being in a class of their own.
8. This is presumably a first rate crew, in a first rate aircraft, in a first rate company, in a first rate country - and we do the following.
a. demand execution.
b. demean them racially and culturally.
c. fail to see that the real lesson from CRM is to recognise that we all could make the same mistake.
I conclude that I would more happily fly with JAL than the airlines represented here by shallow, vindictive, insular and racist gits.
1. This is a newspaper report. We all know how unreliable they are.
2. We have no idea what really happened.
3. We have no idea of what was, or wasn't said in the cockpit.
4. We have no idea about the reporting that occurred internally in JAL.
5. We have no idea of what reporting occurred between JAL and JCAB.
6. We all know that humans make mistakes. People who live in glass houses etc etc.
7. The Japanese airlines are as good as the western airlines. In Asia they (along with the Hong Kong carriers) stand out as being in a class of their own.
8. This is presumably a first rate crew, in a first rate aircraft, in a first rate company, in a first rate country - and we do the following.
a. demand execution.
b. demean them racially and culturally.
c. fail to see that the real lesson from CRM is to recognise that we all could make the same mistake.
I conclude that I would more happily fly with JAL than the airlines represented here by shallow, vindictive, insular and racist gits.
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Close call in Japan
At present there are about 300 foreign Captains and Co-Pilots in JAL Long haul, also there are 100+Flight Engineers who have all completed CRM. There would be no hesitation by any foreign crewman in bringing to the attention of any Japanese Captain if it was felt that a conflict was about to happen.
However there are no foreign crews working for JAL Domestic at this time apart from some on B737 With JAL Express.
The regime on aboard an all Japanese crewed flight deck is totally different to one with either all foreign crew or a combination of Japanese and foreign crew
However there are no foreign crews working for JAL Domestic at this time apart from some on B737 With JAL Express.
The regime on aboard an all Japanese crewed flight deck is totally different to one with either all foreign crew or a combination of Japanese and foreign crew
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Guys give the JAL Captain a break. There are 1,475 runway incursions in the US between 2000 and 2003, yet the vast majority of those incidents were never reported here. So why pick on him?
Don't forget that Japan has a history of incarcerating pilots so I guess he's very lucky to get away with it, just imagine how would you feel if you are doing jailtime for making an error like this? It was at night, there was snowfall, RVR was low, one runway closed, the crew are busy on the takeoff checks and probably worrying about icing.....it was a very stressful situation.
And IMO don't assume that the FO will always know better, because situational awareness usually comes from experience, something CRM can't always provide.
Don't forget that Japan has a history of incarcerating pilots so I guess he's very lucky to get away with it, just imagine how would you feel if you are doing jailtime for making an error like this? It was at night, there was snowfall, RVR was low, one runway closed, the crew are busy on the takeoff checks and probably worrying about icing.....it was a very stressful situation.
And IMO don't assume that the FO will always know better, because situational awareness usually comes from experience, something CRM can't always provide.
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Final 3 Green - yes, thanks, I did recognise you're remark as sarcastic.
I am often gob-smacked at how angry, self-righteous, holier-than-thou we become on this forum. In this case it was a simple human error. Which has been put into perspective by a subsequent post listing runway incursions in the USA.
I thought your quip nicely wrapped-up the metaphorical and literal 'baying for blood'.
When are we going to learn that the underlying benefit of CRM training is not just communication (speaking-up) and judgement and decision making and leadership and so on - but also learning from the humbling realisation that, "****, so help me god, I could have done that too..."
It's only through internalisation of mistakes that we can learn the lessons of time. The externalising of other people's mistakes - "silly bastard, I wouldn't have done that" - just goes to show how narrow, shallow, unreflective, stupid and dangerous many of us remain. Far from calling into question the CRM on board that 777, many of the posters on this thread should really take a long slow look at themselves.
Even worse is the reversion to cultural stereotypes, name calling and other racist crap. Sometimes, and this is one time, I am ashamed to be a white, western pilot.
I am often gob-smacked at how angry, self-righteous, holier-than-thou we become on this forum. In this case it was a simple human error. Which has been put into perspective by a subsequent post listing runway incursions in the USA.
I thought your quip nicely wrapped-up the metaphorical and literal 'baying for blood'.
When are we going to learn that the underlying benefit of CRM training is not just communication (speaking-up) and judgement and decision making and leadership and so on - but also learning from the humbling realisation that, "****, so help me god, I could have done that too..."
It's only through internalisation of mistakes that we can learn the lessons of time. The externalising of other people's mistakes - "silly bastard, I wouldn't have done that" - just goes to show how narrow, shallow, unreflective, stupid and dangerous many of us remain. Far from calling into question the CRM on board that 777, many of the posters on this thread should really take a long slow look at themselves.
Even worse is the reversion to cultural stereotypes, name calling and other racist crap. Sometimes, and this is one time, I am ashamed to be a white, western pilot.
Moderate, Modest & Mild.
In my opinion, "Yes", it could have happened, even with a mixed crew (Japanese & non-Japanese on the flight deck).
Regardless of the nationalities of crews, there is theoretically a greater degree of Safety on a multi-crew flight deck vs a single pilot operation, however this is only going to happen IF the multi-crew flight deck works as a team who check and cross check, and confirm with the other member.
In this case, full marks to the controller for being on the ball
as the holes in the Swiss cheese started to line up.
From the Japan times last week, referring to this incident,
"In connection with the incident, Japan Airlines Domestic Co. President Mitsuo Komatsubara, and Senior Managing Director Takenori Matsumoto will voluntarily return 10 percent of their executive remuneration."
(I wonder how "voluntary" that really is?!)
JAL got a BIG kick in the backside for failing to report the incident to the JCAB (Japan Civil Aviation Bureau) for "about a month", resulting in a reprimand from them a couple of days ago.
Regardless of the nationalities of crews, there is theoretically a greater degree of Safety on a multi-crew flight deck vs a single pilot operation, however this is only going to happen IF the multi-crew flight deck works as a team who check and cross check, and confirm with the other member.
In this case, full marks to the controller for being on the ball
as the holes in the Swiss cheese started to line up.From the Japan times last week, referring to this incident,
"In connection with the incident, Japan Airlines Domestic Co. President Mitsuo Komatsubara, and Senior Managing Director Takenori Matsumoto will voluntarily return 10 percent of their executive remuneration."
(I wonder how "voluntary" that really is?!)
JAL got a BIG kick in the backside for failing to report the incident to the JCAB (Japan Civil Aviation Bureau) for "about a month", resulting in a reprimand from them a couple of days ago.
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. . . . . Kaptin M....
JAL got a BIG kick in the backside for failing to report the incident to the JCAB (Japan Civil Aviation Bureau) for "about a month", resulting in a reprimand from them a couple of days ago.
Moderate, Modest & Mild.
You're obviously unaware of the power of the JCAB, GlueBall.
Imo, the return of 10% of the executive remuneration, by the 2 gents mentioned, is probably more likely to be because of the failure of JAL to submit their report to the JCAB - which would have been an internal investigation, and follow-up actions and recommendations for previous system weaknesses, and future preventive measures (rather than just a report of the actual incident) - than as a result of the incident itself.
This is pretty much standard procedure in most countries, following major breaches of the Safety net, but not least of all in Japan!
Imo, the return of 10% of the executive remuneration, by the 2 gents mentioned, is probably more likely to be because of the failure of JAL to submit their report to the JCAB - which would have been an internal investigation, and follow-up actions and recommendations for previous system weaknesses, and future preventive measures (rather than just a report of the actual incident) - than as a result of the incident itself.
This is pretty much standard procedure in most countries, following major breaches of the Safety net, but not least of all in Japan!
This is a typical journo wind-up. ...As if the working Air Traffic Controller and his supervisor Controller on duty (who work for the JCAB) all kept quiet about it and didn't file a required report of their own, eh...?
My mystical powers of deduction allowed me to propose the following:
Of course they did. Thats why JAL probably got fined, for not having filed their version as well.
Fine, so the execs return 10% of an already large salary.
Great, and the whole thing is still swept under the carpet.
While I take on some of the comments from previous posters, I disagree with others.
Pricincipally that there was no report supplied to the Japanese air ministry, and also no associated press report (from what I could see on the JAL website) that even references that incident, meanwhile other carriers have 22 odd pages within pprune on an IFSD.
So, meanwhile, a 'first rate crew', on a 'first rate airline' cause a runway incursion, (agreed by reasons still unknown), and until recently, unreported by the airline involved.
Whilst I am unaware of the level of runway incursions generally, how many of these are caused by experienced crews of established airlines, or for instance in-experienced GA traffic? (As an example)
I would not expect an 'experienced' captain and f/o of a 777 to make this kind of mistake, nor would I expect the airline involved to actively hide the fact that it happened.
I just hope that, when my family member left for her two JAL flights this weekend that she has had a f/o with the balls and empowerment to speak up, and ground controllers as observant and ready as the guy who managed to stop that previous accident.
And if being a concerned husband and normal run of the mill SLF makes me a racist bigot, then so be it.
JAL and their airline partners need to look at this, quickly, and don't pay lip service by buying off the public at large. Some of us are not convinced.
Great, and the whole thing is still swept under the carpet.
While I take on some of the comments from previous posters, I disagree with others.
Pricincipally that there was no report supplied to the Japanese air ministry, and also no associated press report (from what I could see on the JAL website) that even references that incident, meanwhile other carriers have 22 odd pages within pprune on an IFSD.
So, meanwhile, a 'first rate crew', on a 'first rate airline' cause a runway incursion, (agreed by reasons still unknown), and until recently, unreported by the airline involved.
Whilst I am unaware of the level of runway incursions generally, how many of these are caused by experienced crews of established airlines, or for instance in-experienced GA traffic? (As an example)
I would not expect an 'experienced' captain and f/o of a 777 to make this kind of mistake, nor would I expect the airline involved to actively hide the fact that it happened.
I just hope that, when my family member left for her two JAL flights this weekend that she has had a f/o with the balls and empowerment to speak up, and ground controllers as observant and ready as the guy who managed to stop that previous accident.
And if being a concerned husband and normal run of the mill SLF makes me a racist bigot, then so be it.
JAL and their airline partners need to look at this, quickly, and don't pay lip service by buying off the public at large. Some of us are not convinced.
Moderate, Modest & Mild.
Why is there the assumption, on the part of some contributors, that the F/O refrained from speaking up?
I feel certain that HAD he known about it, he would have. It may well have been the F/O who led the Captain to believe they had received a t/o clearance.
But ONE thing is certain, there was a breakdown in crew communications, inasmuch as they BOTH didn`t confirm with each other (and as is also usual here, to repeat to the Tower, "Clear for take-off.") that they had received the necessary clearance.
Another factor that might be considered is situational awareness, as they should have been listening for the Tower to advise the landing aircraft to contact Ground (control) - unfortunately, however, Japanese ATC'ers have a (bad) habit of advising aircraft to do this whilst still on the runway, and frequently during high speed during the landing roll.
Well the KLM/Pan Am accident certainly proved this CAN happen.
The "Hurry Up" syndrome is alive and well in many airlines, with some crew, and can often lead to costly, time-CONSUMING mistakes.
I feel certain that HAD he known about it, he would have. It may well have been the F/O who led the Captain to believe they had received a t/o clearance.
But ONE thing is certain, there was a breakdown in crew communications, inasmuch as they BOTH didn`t confirm with each other (and as is also usual here, to repeat to the Tower, "Clear for take-off.") that they had received the necessary clearance.
Another factor that might be considered is situational awareness, as they should have been listening for the Tower to advise the landing aircraft to contact Ground (control) - unfortunately, however, Japanese ATC'ers have a (bad) habit of advising aircraft to do this whilst still on the runway, and frequently during high speed during the landing roll.
I would not expect an 'experienced' captain and f/o of a 777 to make this kind of mistake, nor would I expect the airline involved to actively hide the fact that it happened.
The "Hurry Up" syndrome is alive and well in many airlines, with some crew, and can often lead to costly, time-CONSUMING mistakes.
At Cleveland, (CLE) Ohio, in the US, its main three runways are not only parallel, but are VERY close together. And sometimes you taxi across a runway, as in Atlanta (ATL), but the exit on the other side is at the opposite angle. This is not the point, just a warning. The CLE layout is almost unbelievable, not including the beginning of runway 28 on the airport's north side, with some very compressed space between yellow lines in that other area where multiple runways intersect. A narrow-body fanjet Captain mistakenly crossed one of the closely-spaced parallel runways instead of "holding short". The story I heard was that the FO failed to look outside when approaching the runway because he/she was more concerned with, for some reason, IMMEDiately doing the after landing "flow". There is nothing about an aircraft's ignition, APU master switch, airfoil anti-ice switches, altitude warning indicator or transponder which, after landing, has a serious influence on aircraft safety-especially trying to call airport operations (assuming that anyone is there...). Even if the Captain forgets to switch off the anti-skid. Nothing.
Luckily there was no very close call, and the visibility might have been good. When any runway intersection is close and in front of us, ALL pilots in the c0ckp1t MUST look, at least out their side windshields until the aircraft either stops in front of the red runway sign, or crosses (only if cleared!), before again looking inside for a while.
In the many thousands of two-pilot jets, not just turboprops and recip machines, the First Officer is always the Captain's, Flight Attendants' and passengers' ONLY back-up for safety, with or without automation, despite the fact that during taxi out and in, the hard-working FO must set almost all swiches and levers after the engines are started. The overwhelming reality that we have only TWO pairs of EYEballs up front is still easily forgotten after many hundreds of takeoffs/ landings, and thousands of hours. Pardon my crudeness, but these are the only balls that matter.
Luckily there was no very close call, and the visibility might have been good. When any runway intersection is close and in front of us, ALL pilots in the c0ckp1t MUST look, at least out their side windshields until the aircraft either stops in front of the red runway sign, or crosses (only if cleared!), before again looking inside for a while.
In the many thousands of two-pilot jets, not just turboprops and recip machines, the First Officer is always the Captain's, Flight Attendants' and passengers' ONLY back-up for safety, with or without automation, despite the fact that during taxi out and in, the hard-working FO must set almost all swiches and levers after the engines are started. The overwhelming reality that we have only TWO pairs of EYEballs up front is still easily forgotten after many hundreds of takeoffs/ landings, and thousands of hours. Pardon my crudeness, but these are the only balls that matter.
Last edited by Ignition Override; 15th Mar 2005 at 04:11.
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Good let's talk about the incident. It's an interesting thread on an interesting topic. I never meant to gag the subject or infer that SLF (anyone for that matter) shouldn't enter the topic. What I objected to was the 'heated', unrealistic, holier-than-thou and racist tones being used.
What seems to be coming out now is that, whilst this incident is frightening, it is not an isolated event. I think the thrust of this thread should be along the following lines:
1. It is a regrettable incident that should give ALL pilots, ATC, Regulators and Airline Management pause for thought. Rather than living in horrified denial - let's try to work out how to manage these events more effectively to try and ensure that Tenerife type accidents don't ever occur again. That's a task involving self-discipline and concentration on the part of pilots, concentration and rigorous observation on the part of ATC, and procedural and technical changes (to equipment and operating practices) on the part of regulatory authorities and airline managements.
2. It is wrong of the airline not to have immediately disclosed the event - for this they should be criticised and possibly even punished.
3. Congratulations and thanks to the ATC on duty. Commisserations to the crew for sadly, being humans and making a mistake. I can only imagine how I would feel if I had done a similar thing.
What seems to be coming out now is that, whilst this incident is frightening, it is not an isolated event. I think the thrust of this thread should be along the following lines:
1. It is a regrettable incident that should give ALL pilots, ATC, Regulators and Airline Management pause for thought. Rather than living in horrified denial - let's try to work out how to manage these events more effectively to try and ensure that Tenerife type accidents don't ever occur again. That's a task involving self-discipline and concentration on the part of pilots, concentration and rigorous observation on the part of ATC, and procedural and technical changes (to equipment and operating practices) on the part of regulatory authorities and airline managements.
2. It is wrong of the airline not to have immediately disclosed the event - for this they should be criticised and possibly even punished.
3. Congratulations and thanks to the ATC on duty. Commisserations to the crew for sadly, being humans and making a mistake. I can only imagine how I would feel if I had done a similar thing.
ex-Tanker
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Kaptin M's comments ring true throughout the thread, but then he knows how it works there.
Have you ever tried opening a door Kaptin, while in uniform and then waiting for the crew to walk through? The girls all stand around chatting and the FO suddenly has to tie his shoe lace - no-one wants to precede the captain.
Try doing a crew briefing without the hat on and watch the puzzled looks you get.
Nevertheless these are small ways to flatten the CRM slope in the Japanese / Far East cockpit.
As for the radio calls during roll out - Jet jockeys should ignore them until at at taxy speed. Likewise Japanese FO Jet jockeys, who tend to see controllers as some kind of Sensei and even give great priority to company communications at busy points in the flight.
They are lovely people but that Authority on a pedestal attitude needs to change - and that in a country of very long traditions and resistance to change.
Having said all that, the direct cause of this particular incident can only be speculated upon at this stage.
Have you ever tried opening a door Kaptin, while in uniform and then waiting for the crew to walk through? The girls all stand around chatting and the FO suddenly has to tie his shoe lace - no-one wants to precede the captain.
Try doing a crew briefing without the hat on and watch the puzzled looks you get.
Nevertheless these are small ways to flatten the CRM slope in the Japanese / Far East cockpit.
As for the radio calls during roll out - Jet jockeys should ignore them until at at taxy speed. Likewise Japanese FO Jet jockeys, who tend to see controllers as some kind of Sensei and even give great priority to company communications at busy points in the flight.
They are lovely people but that Authority on a pedestal attitude needs to change - and that in a country of very long traditions and resistance to change.
Having said all that, the direct cause of this particular incident can only be speculated upon at this stage.
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Aide-Memoire Required?
It's the easiest thing in the world to get a "line-up and wait" or "taxi into position and hold" then become distracted, forget your clearance limit and apply power. Pilots have sophisticated aide-memoires (altitude selects) to stop them busting cleared altitudes and now altitude busts are a rarity.
But then again a momentary excursion through a cleared altitude isn't anyways as significant or ominous or potentially catastrophic as rolling down a runway and attempting to take-off with a clearance. Why? Because there's probably only two reasons why you've not been cleared take-off (rather than line-up only) and they are:
a. Because Departures are trying to establish a gap with preceding traffic (wake turb or IFR separation)
OR
b. Because the runway is occupied by an aircraft or vehicle which, because of low vis (such as at Tenerife or for SQ006 in CKS Taipei) , you cannot see.
So the solution might well be another aide-memoire. Why not stick a glareshield panel edge-light (RED/AMBER/GREEN) in front of both pilots. When line-up clearance is received PNF punches his light and both lights change to amber. When he gets take-off clearance he punches it again and it's green. If they're cleared take-off approaching the holding-point then he double-taps it and it's green. Light would click off through WOW after rotate. The pre-roll litany then concludes "..... runway positively identified and it's GREEN for go". Sounds ridiculously simple but then again this mistake's been made before and such a system might save a few hundred lives one day.
But then again a momentary excursion through a cleared altitude isn't anyways as significant or ominous or potentially catastrophic as rolling down a runway and attempting to take-off with a clearance. Why? Because there's probably only two reasons why you've not been cleared take-off (rather than line-up only) and they are:
a. Because Departures are trying to establish a gap with preceding traffic (wake turb or IFR separation)
OR
b. Because the runway is occupied by an aircraft or vehicle which, because of low vis (such as at Tenerife or for SQ006 in CKS Taipei) , you cannot see.
So the solution might well be another aide-memoire. Why not stick a glareshield panel edge-light (RED/AMBER/GREEN) in front of both pilots. When line-up clearance is received PNF punches his light and both lights change to amber. When he gets take-off clearance he punches it again and it's green. If they're cleared take-off approaching the holding-point then he double-taps it and it's green. Light would click off through WOW after rotate. The pre-roll litany then concludes "..... runway positively identified and it's GREEN for go". Sounds ridiculously simple but then again this mistake's been made before and such a system might save a few hundred lives one day.
Moderate, Modest & Mild.
You're quite correct, UNCTUOUS - but again, the multi-crew system that is supposed to help keep a check on these things doesn't always, and in some (very rare) cases one crew member may well end up being the CAUSE of an increased workload for the other.
Few Cloudy has experienced the Japanese system, which is seemingly efficient to casual observers, however could do with some "tweaking" - except that "cultural differences" would get in the way.
From a westerner's point of view, it's well and good to say in theory, that "cultural differences" MUST be discarded in aviation, but in practice it simply is NOT always possible.
Unfortunately, some Japanese F/O's (and undoubtedly Captains) translate the CRM techniques of gaijin Captains as a weakness - something to try to "exploit" - at times. A subject that is a subject in itself, for the Far East Forum.
But back to the subject. HIALS states, "let's try to work out how to manage these events more effectively to try and ensure that Tenerife type accidents don't ever occur again. That's a task involving...procedural and technical changes (to equipment and operating practices)..", and UNCTUOUS suggests, "So the solution might well be another aide-memoire. Why not stick...".
The old (pre-1989 Dispute) Ansett (Airlines of Australia) for which I worked for many years had a VERY simple aide memoire for both Take-off and Landing clearances.
It was
****TAKE-OFF CLEARANCE****
and
****LANDING CLEARANCE****
as the very last items that had to be called and clicked, BEFORE the "XXXXX Check complete" call was allowed to be made.
Just as Flaps, Gear, stab trim, etc, was WRITTEN into the checklist, so was the final ATC Clearance.
If it is delivered out of sequence, then the OBVIOUS thing to do is to "confirm clear to take-off/land"" with ATC.
Sure we have a checklist to ensure that flaps are set, gear is down - but how many airlines actually incorporate ATC's final "clear to take off/land" as an integral part of their checklist?
The KISS system (Keep It Simple, stupid!!)
Few Cloudy has experienced the Japanese system, which is seemingly efficient to casual observers, however could do with some "tweaking" - except that "cultural differences" would get in the way.
From a westerner's point of view, it's well and good to say in theory, that "cultural differences" MUST be discarded in aviation, but in practice it simply is NOT always possible.
Unfortunately, some Japanese F/O's (and undoubtedly Captains) translate the CRM techniques of gaijin Captains as a weakness - something to try to "exploit" - at times. A subject that is a subject in itself, for the Far East Forum.
But back to the subject. HIALS states, "let's try to work out how to manage these events more effectively to try and ensure that Tenerife type accidents don't ever occur again. That's a task involving...procedural and technical changes (to equipment and operating practices)..", and UNCTUOUS suggests, "So the solution might well be another aide-memoire. Why not stick...".
The old (pre-1989 Dispute) Ansett (Airlines of Australia) for which I worked for many years had a VERY simple aide memoire for both Take-off and Landing clearances.
It was
****TAKE-OFF CLEARANCE****
and
****LANDING CLEARANCE****
as the very last items that had to be called and clicked, BEFORE the "XXXXX Check complete" call was allowed to be made.
Just as Flaps, Gear, stab trim, etc, was WRITTEN into the checklist, so was the final ATC Clearance.
If it is delivered out of sequence, then the OBVIOUS thing to do is to "confirm clear to take-off/land"" with ATC.
Sure we have a checklist to ensure that flaps are set, gear is down - but how many airlines actually incorporate ATC's final "clear to take off/land" as an integral part of their checklist?
The KISS system (Keep It Simple, stupid!!)
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Both good suggestions.
In the meantime - what about the procedure of turning on landing lights (or other lights) as, and only as, a consequential reaction to the "cleared to land/take-off" call from ATC?
I see some aircraft do it.
Mind you, it would be a non-SOP on the aircraft I fly.
Food for thought.
In the meantime - what about the procedure of turning on landing lights (or other lights) as, and only as, a consequential reaction to the "cleared to land/take-off" call from ATC?
I see some aircraft do it.
Mind you, it would be a non-SOP on the aircraft I fly.
Food for thought.
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Correct procedures aren't the answer to everything. Whose 'fault' was this. An oldie that, somehow, escaped press attention - at the time.
Note the separation - Horizontal, 300 Feet. Vertical, NIL
Summarised from ASRS Report Number 269000. Near Mid Air Collision.
Date/Local Time. 94/04. 18:01. Facility Cincinnati/Northern Kentucky Intl. OH
Weather Conditions: VMC. Daylight. Visual Range 5.00 Miles.
Flight Phase. Take-Off.
Aircraft. B737, MD-88.
Anomaly resolution: Avoidance, evasive action.
Primary problem area: Air Traffic Control ( Human Factors)
Horizontal Separation 300 Feet. Vertical Separation NIL
Narrative, Controller.
Aircraft X was told to taxi into position and hold on runway 27 for traffic departing on runway 18R. Aircraft Y was told to taxi into position and hold on runway 18R because of a previous departure on runway 18R. When the previous 18R departure was no longer a factor I told Y ‘At the MM turn right Hdg 210 Degs, runway 18R cleared for take-off’. I scanned the runway, looked at the previous departure to make sure the aircraft turned out on the noise track. I looked up at the Brite radar and looked back down to observe the 18R departure Y and re-scan the runway. I then wrote down my next 18R departure and looked back up to see Y and X departing simultaneously from intersecting runways. At this time there was nothing I could do to avoid the simultaneous departure. I used proper phraseology for crossing runways and I believe I heard only the read-back of Y off runway 18R. X was never issued a departure clearance nor did I hear X read back a clearance.
Narrative. Flight Crew X.
Aircraft X cleared by tower to ‘taxi into position and hold runway 27.’ I (PNF) acknowledged ‘X position and hold runway 27.’ As we completed the final items of the take-off checklist, the tower transmitted ‘X turn left Hdg 210, cleared for take-off.’ I responded ‘Hdg 210, X cleared for take-off runway 27.’ As we lifted off and passed the intersection of runways 18R/27 I observed a company MD-80 approaching the same intersection on runway 18R. The first half of runway 18R was not visible from our position. The initial 210 Hdg was unusual for a take-off on runway 27.
Aircraft X cleared to taxi into position and hold runway 27. The First Officer read back ‘Aircraft X position and hold runway 27’. About 30 seconds later we received take-off clearance, ‘Aircraft X fly Hdg 210, cleared for take-off.’ We acknowledged and commenced our take-off roll. At rotation we observed another jet approaching the intersection of our two runways (27 and 18R). We passed ahead of and above the oncoming aircraft and continued a normal take-off. Factors that contributed to the problem; We had somewhat similar call signs. We were not aware of another company jet departing 18R. The first portion of runway 18R is not visible from runway 27. If the controller had shared the information that he had two aircraft in position for take-off I don’t think this would have occurred.
Narrative, Pilot Y.
Aircraft Y was cleared into position and hold runway 18R. We read back ‘Cleared into position and hold runway 18R, aircraft Y’. After approximately 4 seconds CVG tower transmitted ‘Aircraft Y, fly Hdg 210 cleared for take-off runway 18R.’ My First Officer read-back ‘Hdg 210 cleared for take-off runway l8R, aircraft Y.’ At 145 knots during rotation, as our main wheels left the ground approximately 600 ft short of runway 18R/27 intersection, we noticed a company 737 rotating on runway 27 prior to the runway intersection. We deviated left behind his rotation. He passed approximately 300 ft just to the right of our nose. Company flight was aircraft X which is a similar sounding call sign. At no time did we hear tower and X communicate about position and hold or cleared for take-off. It is our assumption that aircraft X read back our clearance at the same time as us, mistaking our call sign.
Report Synopsis:
Multiple runway operation, intersecting runways, similar call signs.
Aircraft X unauthorized takeoff. Near Mid Air Collision with aircraft Y.
Note the separation - Horizontal, 300 Feet. Vertical, NIL
Summarised from ASRS Report Number 269000. Near Mid Air Collision.
Date/Local Time. 94/04. 18:01. Facility Cincinnati/Northern Kentucky Intl. OH
Weather Conditions: VMC. Daylight. Visual Range 5.00 Miles.
Flight Phase. Take-Off.
Aircraft. B737, MD-88.
Anomaly resolution: Avoidance, evasive action.
Primary problem area: Air Traffic Control ( Human Factors)
Horizontal Separation 300 Feet. Vertical Separation NIL
Narrative, Controller.
Aircraft X was told to taxi into position and hold on runway 27 for traffic departing on runway 18R. Aircraft Y was told to taxi into position and hold on runway 18R because of a previous departure on runway 18R. When the previous 18R departure was no longer a factor I told Y ‘At the MM turn right Hdg 210 Degs, runway 18R cleared for take-off’. I scanned the runway, looked at the previous departure to make sure the aircraft turned out on the noise track. I looked up at the Brite radar and looked back down to observe the 18R departure Y and re-scan the runway. I then wrote down my next 18R departure and looked back up to see Y and X departing simultaneously from intersecting runways. At this time there was nothing I could do to avoid the simultaneous departure. I used proper phraseology for crossing runways and I believe I heard only the read-back of Y off runway 18R. X was never issued a departure clearance nor did I hear X read back a clearance.
Narrative. Flight Crew X.
Aircraft X cleared by tower to ‘taxi into position and hold runway 27.’ I (PNF) acknowledged ‘X position and hold runway 27.’ As we completed the final items of the take-off checklist, the tower transmitted ‘X turn left Hdg 210, cleared for take-off.’ I responded ‘Hdg 210, X cleared for take-off runway 27.’ As we lifted off and passed the intersection of runways 18R/27 I observed a company MD-80 approaching the same intersection on runway 18R. The first half of runway 18R was not visible from our position. The initial 210 Hdg was unusual for a take-off on runway 27.
Aircraft X cleared to taxi into position and hold runway 27. The First Officer read back ‘Aircraft X position and hold runway 27’. About 30 seconds later we received take-off clearance, ‘Aircraft X fly Hdg 210, cleared for take-off.’ We acknowledged and commenced our take-off roll. At rotation we observed another jet approaching the intersection of our two runways (27 and 18R). We passed ahead of and above the oncoming aircraft and continued a normal take-off. Factors that contributed to the problem; We had somewhat similar call signs. We were not aware of another company jet departing 18R. The first portion of runway 18R is not visible from runway 27. If the controller had shared the information that he had two aircraft in position for take-off I don’t think this would have occurred.
Narrative, Pilot Y.
Aircraft Y was cleared into position and hold runway 18R. We read back ‘Cleared into position and hold runway 18R, aircraft Y’. After approximately 4 seconds CVG tower transmitted ‘Aircraft Y, fly Hdg 210 cleared for take-off runway 18R.’ My First Officer read-back ‘Hdg 210 cleared for take-off runway l8R, aircraft Y.’ At 145 knots during rotation, as our main wheels left the ground approximately 600 ft short of runway 18R/27 intersection, we noticed a company 737 rotating on runway 27 prior to the runway intersection. We deviated left behind his rotation. He passed approximately 300 ft just to the right of our nose. Company flight was aircraft X which is a similar sounding call sign. At no time did we hear tower and X communicate about position and hold or cleared for take-off. It is our assumption that aircraft X read back our clearance at the same time as us, mistaking our call sign.
Report Synopsis:
Multiple runway operation, intersecting runways, similar call signs.
Aircraft X unauthorized takeoff. Near Mid Air Collision with aircraft Y.
Moderate, Modest & Mild.
Yes HIALS, I personally use the landing lights as a queue (1 light only ON, on the "active" side, for line-up clearance only.....both lights ON, when cleared for take-off), however, SOP's here allow the co-pilot to configure the lights...although the SAME sop's also state that they are "Captain only" items in certain circumstances - so being pre-armed, SHOULD be pre-warned.
In a multi-crew environment, there MUST be one - and one ONLY - overall, designated authority.
That authority will ALWAYS be the company designated Captain/Commander............................regardless of ALL other perceived experience.
Understanding this goes a long way towards achieving a CO-ORDINATED, SAFE operation.
Speaking up at times might seem insignificant - but it may ultimately save hundreds of lives, and (save) your own career.
Deliberately withhholding info. from the other crew member in an attempt to try to FURTHER yourself (and your perceived career) at their expense is not only irresponsible, but dangerous
In a multi-crew environment, there MUST be one - and one ONLY - overall, designated authority.
That authority will ALWAYS be the company designated Captain/Commander............................regardless of ALL other perceived experience.
Understanding this goes a long way towards achieving a CO-ORDINATED, SAFE operation.
Speaking up at times might seem insignificant - but it may ultimately save hundreds of lives, and (save) your own career.
Deliberately withhholding info. from the other crew member in an attempt to try to FURTHER yourself (and your perceived career) at their expense is not only irresponsible, but dangerous
Last edited by Kaptin M; 7th Mar 2005 at 20:05.