Runway Collision Narrowly Averted at LAX
Some very good discussion of this incident. Thanks to all. 
You're right Astra driver, The comments made by the Gulfstream crewmember upon clearing runway 25R do appear to indicate that they believed they were cleared across 25R.
As DC-Mainliner points out, it could turn out that this was not the best thing to have said though.
For me, this incident serves as a reminder of how costly a simple error could be.
Best,
Westhawk
You're right Astra driver, The comments made by the Gulfstream crewmember upon clearing runway 25R do appear to indicate that they believed they were cleared across 25R.
As DC-Mainliner points out, it could turn out that this was not the best thing to have said though.
For me, this incident serves as a reminder of how costly a simple error could be.
Best,
Westhawk
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A voice can be heard in the background at this time, but I'm unable to tell if it was the other Gulfstream crewmember or perhaps something else.
In my opinion, it is the other gulfstream crew member and he says "I've just missed Alpha [Unintelligible]". It sounds like the last word is "golf" but its extremly hard to make out.
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In Hong Kong, we (the controller's) have developed a non standard practice of using the phrase "Cross inactive runway 07R" as part of a taxy instruction to freighters that are taxying at night from the cargo area to or from rwy 07L. This is when we are on single "North" or rwy 07L between midnight and 9am due to runway works. Admittedly, the departure does not have to cross the active runway again to get to the threshold holding point, so we don't have that risk. It seems to me listening to the tape a few times, that confussion could have been instilled in the crews mind on the Gulfstream. The clearance is shot out in fairly truncated and rapid fire manner. I like to work on the basis that if something is going to go wrong, then it will. However, I don't work at LA and I understand that they have a heap of aircraft crossing runways all the time, and I guess it is easy to keep things simple. And of course one extra word like "inactive" can slow things down a bit at times, but it sure helps to make things that little bit clearer as to the controller's intent. If that was me on ground in LA I would like to think that I would phrase the clearance "Via Golf, cross inactive rwy 25L and then hold short of rwy 25R". I have never worked in the States, but I have seen many incidents and close calls over the years caused often by the very phrases that are supposed to be in use. Ergo, I like to try and anticipate that I have bases covered. Please don't take this as any form of "opinion forming" on the part of how the guys in LA run their tower. I am merely saying how I do things.
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1. They were not cleared to cross 25R. They were cleared to hold short and they read that back verbatim twice. There was nothing unusual or "obscure" in the clearance from ground control. That type of clearance is standard and routine.
2. They crossed the active runway at one of the worlds busiest airports without contacting the tower. That is deplorable airmanship/common sense.
3. It appears that they did not look down the runway before crossing to check for conflicting traffic in the takeoff position and possibly already on the roll. Again deplorable airmanship.
I am a frequent user of LAX.
2. They crossed the active runway at one of the worlds busiest airports without contacting the tower. That is deplorable airmanship/common sense.
3. It appears that they did not look down the runway before crossing to check for conflicting traffic in the takeoff position and possibly already on the roll. Again deplorable airmanship.
I am a frequent user of LAX.
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Hi Tree
I don't think that I implied that they had not been told to cross 25R. What I am trying to say is that there were two aspects to the "Hold short 25R" that come into play, firstly the taxing out aspect, and secondly the holding at the departure holding point for 25R. I guess I was trying to say, that if confusion will raise it's head, then often it will. We all talk about the "chain of events" theory. I will leave it to you to suggest poor airmanship etc, and that I guess is open for others to form an opinion on. I work in an environment where a large percentage of the radio transmissions are made to at best, poor English speaking individuals. Airports can be very confusing and difficult places to get around, particularly for itinerant aircraft. I try to be very careful with what I say, and what is said back to me.
I don't think that I implied that they had not been told to cross 25R. What I am trying to say is that there were two aspects to the "Hold short 25R" that come into play, firstly the taxing out aspect, and secondly the holding at the departure holding point for 25R. I guess I was trying to say, that if confusion will raise it's head, then often it will. We all talk about the "chain of events" theory. I will leave it to you to suggest poor airmanship etc, and that I guess is open for others to form an opinion on. I work in an environment where a large percentage of the radio transmissions are made to at best, poor English speaking individuals. Airports can be very confusing and difficult places to get around, particularly for itinerant aircraft. I try to be very careful with what I say, and what is said back to me.
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Further to that Tree, I forgot to say. Imagine when 10 to 15 thousand VLJ's are supposedly let loose on the system. They are small, difficult to see, will often be manned by a single pilot (sometimes with minimal experience), down low to the ground, so very difficult for the crew to gain a visual perspective of the airport. I guess the proponents will say that they will be principally used only at minor airports. But I can't see it. I would think that they will be trying to operate from fairly large airports to small destinations. So should be interesting uhh!
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1. They were not cleared to cross 25R. They were cleared to hold short and they read that back verbatim twice. There was nothing unusual or "obscure" in the clearance from ground control. That type of clearance is standard and routine.
2. They crossed the active runway at one of the worlds busiest airports without contacting the tower. That is deplorable airmanship/common sense.
3. It appears that they did not look down the runway before crossing to check for conflicting traffic in the takeoff position and possibly already on the roll. Again deplorable airmanship.
I am a frequent user of LAX.
2. They crossed the active runway at one of the worlds busiest airports without contacting the tower. That is deplorable airmanship/common sense.
3. It appears that they did not look down the runway before crossing to check for conflicting traffic in the takeoff position and possibly already on the roll. Again deplorable airmanship.
I am a frequent user of LAX.
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http://www.pprune.org/forums/showpos...8&postcount=29
Last edited by Fokker28; 17th Oct 2006 at 19:12. Reason: added link to earlier discussion...
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http://abclocal.go.com/kabc/story?se...cal&id=4634099
Hi Fokker. I understand what you are saying, however I disagree, respectfully. Listen to Part II again. The pilot may have accentuated the phrase "25R" in the initial clearance, but he clearly followed that by the plain English phrase of "Hold Short 25R" in the read back. Air crews do not say they will hold short of a runway and then cross it 10 seconds later without an additional clearance to cross it. It just does not work this way.
Besides all this, the FAR/AIM clearly gives guidance on taxi clearance protocol, and even mails ATP's "Ground Safety" DVD's for their viewing pleasure and recurrent education on a voluntary basis. This action went against published and practiced protocols.
Tree is correct in that they were issued twice a clearance to hold short of an active runway and they read back the hold short clearance, twice. Innuendos and subtle pauses do not count in radio communication at a busy international airport, or anywhere, for that matter, but especially at LAX. Accurate, clear, concise and standard radio phrasology - and a clear understanding of the protocols there within, is the minimum standard a professional pilot must consistantly rise to or exceed.
Now, I agree, the subtle pause and vocal reinforcement of the "Runway 25R" is probably where we hear a sign of confusion while we all pick apart the nuances of this at our desktops and laptops in a warm room sipping coffee, but this does not pass for an acceptable excuse to a clear abrogation of the basics. It never hurts to clarify a clearance, I have seen it done and I have done it many times, and it is always a comfortable feeling knowing you have a darn good idea nothing has been left to chance, no matter how annoyed the controller may get at repeating themselves.
I say all this with the full knowledge that we are all fallable. I'd like to see this situation add to future aviation safety by the FAA/ICAO gleaning better ways to promote recurrent training in these situations and for better standardization the world over. This was a CRM brakdown. Excuses only taint the reality of it and the learning potential. We should learn from it rather than bury the crew and move on to the next incident that could involve you or me.
Hi Fokker. I understand what you are saying, however I disagree, respectfully. Listen to Part II again. The pilot may have accentuated the phrase "25R" in the initial clearance, but he clearly followed that by the plain English phrase of "Hold Short 25R" in the read back. Air crews do not say they will hold short of a runway and then cross it 10 seconds later without an additional clearance to cross it. It just does not work this way.
Besides all this, the FAR/AIM clearly gives guidance on taxi clearance protocol, and even mails ATP's "Ground Safety" DVD's for their viewing pleasure and recurrent education on a voluntary basis. This action went against published and practiced protocols.
Tree is correct in that they were issued twice a clearance to hold short of an active runway and they read back the hold short clearance, twice. Innuendos and subtle pauses do not count in radio communication at a busy international airport, or anywhere, for that matter, but especially at LAX. Accurate, clear, concise and standard radio phrasology - and a clear understanding of the protocols there within, is the minimum standard a professional pilot must consistantly rise to or exceed.
Now, I agree, the subtle pause and vocal reinforcement of the "Runway 25R" is probably where we hear a sign of confusion while we all pick apart the nuances of this at our desktops and laptops in a warm room sipping coffee, but this does not pass for an acceptable excuse to a clear abrogation of the basics. It never hurts to clarify a clearance, I have seen it done and I have done it many times, and it is always a comfortable feeling knowing you have a darn good idea nothing has been left to chance, no matter how annoyed the controller may get at repeating themselves.
I say all this with the full knowledge that we are all fallable. I'd like to see this situation add to future aviation safety by the FAA/ICAO gleaning better ways to promote recurrent training in these situations and for better standardization the world over. This was a CRM brakdown. Excuses only taint the reality of it and the learning potential. We should learn from it rather than bury the crew and move on to the next incident that could involve you or me.
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Did you even read my earlier post?
My point was simply that the bizjet driver swapped the order of the elements in the first clearance, which I think indicated his confusion right there. Not sure how you can 'disagree' with my pointing out that he didn't read back the clearance verbatim. It's a simple fact. Verbatim means EXACTLY the same terms, in the same order (obviously). The readback wasn't. Normally I wouldn't think it a big deal, but in this case I think it highlights the very cause of the confusion. I couldn't care less about 'subtle pauses' or whatever you said. That's not what I was talking about.
I don't think the crew should be 'buried', but I don't expect others to coddle me if I make a clearcut error on the job, either.
My point was simply that the bizjet driver swapped the order of the elements in the first clearance, which I think indicated his confusion right there. Not sure how you can 'disagree' with my pointing out that he didn't read back the clearance verbatim. It's a simple fact. Verbatim means EXACTLY the same terms, in the same order (obviously). The readback wasn't. Normally I wouldn't think it a big deal, but in this case I think it highlights the very cause of the confusion. I couldn't care less about 'subtle pauses' or whatever you said. That's not what I was talking about.
I don't think the crew should be 'buried', but I don't expect others to coddle me if I make a clearcut error on the job, either.
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This might be an appropriate time where some would like to visit another runway incident, but one with catastrophic results. I guess most people professionaly invloved in aviation are aware of the incident at Tenerife when 2 B747's collided. Whilst most of the basics vary a great deal from the LAX discussion that we are involved with here, I find it interesting to read the CVR tapes from both aircraft and ATC and note that on a number of occassions, actions taken by any of the three groups of people involved (ATC, KLM crew, PANAM crew) could have stopped the "chain of events" that preceded the disaster. Why did the Controller instruct the KLM 747 to backtrack the full length and to then line up on the runway in poor visibility when there was another aircraft (Clipper B747) also backtracking. Why did the Controller include the words "After Take-off..." in the ATC clearance. What was in the mind of the KLM captain to allow him to act in the way that he did, so that throttles were advanced to take-off power when he should have been sufficiently aware of the big picture, that this should never have happened. One can read the CVR transcripts at www.dnausers.d-n-a.net/dnetGOjg/270377.htm or if that doesn't work, google search to "B747 collision Tenerife" and then "CVR transcript KLM/PAA B747 Tenerife" should.
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Bedder believeit;
Hello and thanks for your comments.
Ground control cannot/does not issue clearances to "position and hold" or "line up and wait" (as the Euros say) on the active runway. That clearance is the domain of the tower. Therefore there is never a reason to believe/assume/etc. that Hold Short 25R (from gound control) means to hold short of the takeoff position, that instruction would only be heard after checking in with the tower controller. We all know you do not proceed beyond the takeoff hold line without tower clearance. Since there is no option there is no reason for ground control to issue it.
When ground control instructs you to Hold Short 25R it means just that, hold short of that runway the FIRST time you approach it at any location whether it be midfield, end, or whatever. If you are going to cross it a second time then you will be holding short again.
In addition, all "hold short" clearances are legally required to be read back by the pilot in the USA and Canada to eliminate errors.
Let's hope the G-V crew take advantage of some serious training opportunities before sharing space with the rest of us.
Hello and thanks for your comments.
Ground control cannot/does not issue clearances to "position and hold" or "line up and wait" (as the Euros say) on the active runway. That clearance is the domain of the tower. Therefore there is never a reason to believe/assume/etc. that Hold Short 25R (from gound control) means to hold short of the takeoff position, that instruction would only be heard after checking in with the tower controller. We all know you do not proceed beyond the takeoff hold line without tower clearance. Since there is no option there is no reason for ground control to issue it.
When ground control instructs you to Hold Short 25R it means just that, hold short of that runway the FIRST time you approach it at any location whether it be midfield, end, or whatever. If you are going to cross it a second time then you will be holding short again.
In addition, all "hold short" clearances are legally required to be read back by the pilot in the USA and Canada to eliminate errors.
Let's hope the G-V crew take advantage of some serious training opportunities before sharing space with the rest of us.
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Hi Fokker, I did not intend to make you feel like I was jumping all over everything you said. Yes, I read you post. I simply, and respectfully, believe when you boil this down to the facts, they speak for themselves. The fact is, they replied to a hold short clearance with a "hold short" reply, and they did not hold short.
The whole "verbatum" thing: The rest of the swapping orders, sublte pauses, et al - it is for the human factors guys to look at over time. I believed this was what you were talking about, so I brought up what was "different" between the controller instruction and the pilot readback to highlight that a verbatum readback was not required but the "difference" was a hint to what might have been the confusion. I was understanding your comment to mean they did not actually read back a hold short clearance. We are simply talking about "verbatum"
In that, I really have no beef.
Fly safe.
The whole "verbatum" thing: The rest of the swapping orders, sublte pauses, et al - it is for the human factors guys to look at over time. I believed this was what you were talking about, so I brought up what was "different" between the controller instruction and the pilot readback to highlight that a verbatum readback was not required but the "difference" was a hint to what might have been the confusion. I was understanding your comment to mean they did not actually read back a hold short clearance. We are simply talking about "verbatum"
In that, I really have no beef.Fly safe.
Last edited by DC-Mainliner; 18th Oct 2006 at 00:56.
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Further to that Tree, I forgot to say. Imagine when 10 to 15 thousand VLJ's are supposedly let loose on the system. They are small, difficult to see, will often be manned by a single pilot (sometimes with minimal experience), down low to the ground, so very difficult for the crew to gain a visual perspective of the airport. I guess the proponents will say that they will be principally used only at minor airports. But I can't see it. I would think that they will be trying to operate from fairly large airports to small destinations. So should be interesting uhh!
I know what you are thinking re the VLJ's and I fully agree.
Interesting-yes!
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Hi Tree
Thanks. Having been a tower instructor for more years than I care to remember, I am fully aware of who does what. I have just re-listened for the umpteenth time to the tapes, both Ground and Tower, and there is no doubt that the G5 was given and read back the appropriate instructions. However, it seems obvious to me that there was confussion in the exec jet cockpit, after all they missed "Golf", and it also appears that they assumed that the "Hold short of RWY 25R" related to the departure point. I could be wrong, but that is how I read it. As I said before, maybe part of the confussion stems from what the G5 people construed as a runway that needed a crossing clearance. Is a "closed runway" relevant to a clearance. To me it is. It is black and white to me (and obviously to you) that the initial clearance to cross 25L related to just that...RWY25L. However, I get the sneaking impression that this vital point was misinterpreted. They had already become lost once, and were probably a bit rattled because of that. It doesn't take much for the tree of confussion to take root. It would be interesting to be a fly on the wall when the G5 crew read these musings here, as I guess they do! Good luck. BB
Thanks. Having been a tower instructor for more years than I care to remember, I am fully aware of who does what. I have just re-listened for the umpteenth time to the tapes, both Ground and Tower, and there is no doubt that the G5 was given and read back the appropriate instructions. However, it seems obvious to me that there was confussion in the exec jet cockpit, after all they missed "Golf", and it also appears that they assumed that the "Hold short of RWY 25R" related to the departure point. I could be wrong, but that is how I read it. As I said before, maybe part of the confussion stems from what the G5 people construed as a runway that needed a crossing clearance. Is a "closed runway" relevant to a clearance. To me it is. It is black and white to me (and obviously to you) that the initial clearance to cross 25L related to just that...RWY25L. However, I get the sneaking impression that this vital point was misinterpreted. They had already become lost once, and were probably a bit rattled because of that. It doesn't take much for the tree of confussion to take root. It would be interesting to be a fly on the wall when the G5 crew read these musings here, as I guess they do! Good luck. BB
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For those familiar with LAX
Crossing 25R at golf, from left to right, is the departure end visible? Does 25R have significant slope?
Last edited by Smurfjet; 18th Oct 2006 at 16:58. Reason: Wrong rwy number used..thanks PT
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But yes, in VMC the 25R threshold is visible (as is the normal line of airplanes waiting on Bravo*) from Golf approaching the intersection. There is no slope.
* which had not been part of their clearance
Last edited by PaperTiger; 18th Oct 2006 at 20:22. Reason: Original wording ambiguous
