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BA pax tried to halt 777 take-off after taxiing error

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BA pax tried to halt 777 take-off after taxiing error

Old 2nd Sep 2010, 00:06
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BA pax tried to halt 777 take-off after taxiing error

Two passengers attempted to stop a British Airways Boeing 777-200 from taking off from a Caribbean airport last September, after realising the crew had lined up at the wrong runway intersection, but were too late to prevent the departure.

The pilots of the twin-jet, bound for Antigua, had intended to depart from the southwestern end of runway 07 - the 'A' intersection - at St Kitts' Bradshaw International Airport.

Despite specifically requesting a departure from 'A', the aircraft mistakenly taxied instead for the 'B' intersection, near the runway's midpoint, leaving available take-off distance of just 1,220m (4,000ft). The take-off performance calculations had been based on a distance of 1,915m.

The oversight escaped detection despite several references and queries in the communications between the crew and air traffic control.

In details of the event released today, the UK Air Accidents Investigation Branch reveals that the carrier's station engineer and airport duty manager were on board the 777 and realised the error as the aircraft lined up on the runway.

The engineer quickly moved from his seat to speak to a member of the cabin crew, telling her that he needed to contact the pilots immediately to warn them the aircraft was wrongly positioned.

In the cockpit the captain had specifically commented that the runway looked short. Neither pilot had been to the airport before and the lack of a tractor meant the crew had taxied the jet from the stand themselves. But, in spite of the captain's concerns, neither cross-checked the jet's location on the runway.

Instead the captain told the co-pilot to "stand on the brakes", says the AAIB, and apply a high thrust setting - some 55% of N1 level - before releasing the brakes for the take-off roll.

In the cabin behind, the station engineer realised that the aircraft was powering up for take-off and abandoned his bid to reach the crew. The 777 accelerated but reached the touchdown-zone markers for the reverse-direction runway 25 by the time it passed the crucial V1 decision speed, and lifted off about 300m from the end of the paved surface.

Taking off from the 'B' intersection reduces the available distance by 1,110m and the AAIB says that British Airways does not authorise 777 departures from this point on runway 07.

While the AAIB attributes the 26 September incident to simple lack of familiarity with the airport, combined with disorientation from poor signage, it also underlines the psychological factors which contributed to the failure to identify the error.

Bradshaw is a simple airport, and the crew did not conduct a taxi briefing. The AAIB says that the crew would probably have briefed the route at a larger, more complex airport.

It adds that the crew appears to have suffered from "confirmation bias", noticing only the evidence that backed their mistaken assumption of being at the correct intersection.

Crew resource management training should address this tendency in two ways, says the AAIB: by emphasising the need to "seek evidence that disproves assumptions whenever they are called into doubt" and by providing communications skills needed for "confident and clear discussion" of the problem.

BA passengers tried to halt 777 take-off after taxiing error
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Old 2nd Sep 2010, 01:00
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Fate is the Hunter

This could have easily been a far worse version of the Comair CRJ crash at Lexington. Just lucky. And probably a light load, assuming that full fueling was to happen in Antigua.

Does anyone know the time of day this occurred?
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Old 2nd Sep 2010, 02:41
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Does anyone know the time of day this occurred?
http://www.aaib.gov.uk/cms_resources...0%20G-VIIR.pdf
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Old 2nd Sep 2010, 07:15
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I feel another BA pilot saga unfolding here - P1 will be leaving 'voluntarily', P2 gone for re-training. P1 to write a book .......etc

I think there has to be a comparison here between BA038 and this incident. It looks like very close similarities in people incolved - same backrounds, age, experience etc

In this case I think that the actions at StKitts are bordering at the reckless end of the scale and that a criminal prosecution is warranted. You are paid to check / re-check - there was a complete and utter CRM failure with no attempt at anything. Swiss cheese etc again.

If there had been any failure before V1, then this particular 777 would be a pile of molten metal, down the 100ft ravine at the end of the 07 runway

When I consider what has unfolded for the BA038 crew, what is going to happen here?
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Old 2nd Sep 2010, 07:35
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That extraordinary dilemma. At what point does someone less qualified than the crew decide to intervene, based on perhaps little more than a feeling that something isn't right?

Even though these guys were local BA reps and might have known the restriction on the Bravo take-off, that's still a pretty big shout.
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Old 2nd Sep 2010, 07:45
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Herc708

I feel another BA pilot saga unfolding here - P1 will be leaving 'voluntarily', P2 gone for re-training. P1 to write a book .......etc
Wrong on most counts, I'm afraid. This took place nearly a year ago and was discussed/handled internally within our "positive safety culture" - we all learned some valuable lessons.
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Old 2nd Sep 2010, 07:49
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Wow.......................... Loads of contributory factors there. I was initially puzzled as to why the controller had detailed the 'parallel' nature of 'A' until I read 1.18.2.2.

As Herc says, thank the Lord they did not need to stop.
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Old 2nd Sep 2010, 08:10
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A test for whether someone else's incident occurred through idiocy or being unfortunate is whether you can see yourself making similar mistakes. Flying out of SKB knowing about this event, it wasn't going to happen to me but I did feel some 'but for the grace of...' The AAIB report focusses mainly on the non-technical aspects and is worth a read. Confirmation bias, faulty mental models, lack of advocacy from several parties... Interesting stuff which we have to deal with all the time as professional pilots. As Clint says: "A man's got to know his limitations".
That extraordinary dilemma. At what point does someone less qualified than the crew decide to intervene, based on perhaps little more than a feeling that something isn't right?
As most of the BA Caribbean shuttle destinations have no engineering cover, the hub engineers go out/back with the aeroplane. In this particular case he'd have been witness to dozens of approaches, takeoffs and landings at SKB - more than any pilot on the fleet.

I think he makes sure he's on the jumpseat now!
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Old 2nd Sep 2010, 08:19
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I have to say that as a pro BA guy this incident comes as a shock. People often question the qualifications and experience of LCC crews (for no good reason may I add) and then such an elementary error such as this happens to an experienced BA crew. Many lessons to be learned (yet again).
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Old 2nd Sep 2010, 08:54
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Proactive safety program

Interesting comparison.

Better outcome so far than the KAL 30 ton over weight departure from Chicago in a B777.

KAL sacked the national captain, messed over the FO, and ultimately got rid of the foreign pilot who reported the problem confidentially on the undertaking that the captain, aircraft, and airport would not be identified, due to the pathologically punitive culture. Apparently the reporters confidentiality was breached in about a week following the undertaking by the head of safety. Coming on top of KAL's deliberately overweight takeoff in an A330 out of Zurich by a similar amount... what the heck. The reporter of that event went west as well, (literally), as did of course the one person that stopped a B744 falling onto New York with no fuel on board some time back.

At some point airlines need to address their corporate risk issues openly to mitigate risk, or apparently not. BA should at least be respected for their actions if they truly have looked after the corporate risk matters, rather than acting expediently.

The balance between punitive responses and proactive response will continue to be perplexing. Does taking retribution on the crew for being human improve the program? Maybe it does, KAL at least hasn't left a blue bill board stuck in a hillside for quite a while, although not through the lack of trying.

For the same ticket price, I know who I would fly with.

Takeoff performance is an area of serious risks which have been poorly responded to by the industry. If you shoot the crew or messengers, and the same thing happens again, what did you accomplish, beyond retribution?

Remember Connies' B747 out of BRU? the one that went off the end into the rail lines? after the engine failure around Vr? Read the report again, and then check the data against the runway, and you may observe that the aircraft was nowhere near achieving a normal takeoff, irrespective of the engine failure. Like A340-300 takeoffs, rather "sporty" as they have been described by at least one person charged with the continuance of public safety.

"Sporty"... right. A new term in FAR/CS 25.107 etc... Just what the public pay for.

Humans err, but to get a major mess you need computers...


Wonder if they were derated?, definitely in the sporty category, shades of the IL76 happy snaps from CBR one would imagine.



Warm Springs.

Last edited by fdr; 2nd Sep 2010 at 08:58. Reason: lousy spelling
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Old 2nd Sep 2010, 10:05
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I have to say that as a pro BA guy this incident comes as a shock.
It shouldn't, and I'll tell you why.
First off, I've flown with BA First Officers that were secconded to the airline where I was at the time, so...I know the mind set.
Reasonable pilots all, good handling skills, pleasant folks.
Rather good decision makers, as well.
However....this absolute nonsence of having 'roll reversals' that BA espouse, is cr*p.
Note that this flight was a First Officer leg.
So far, so good.
However, with the nonsensical 'roll reversal' cr*p that BA uses, the First Officer is to taxi the airplane, the Commander then does...co-pilot duties.
Bad form.

To keep operations reasonable, the duties on the FD need to be standardized, and 'roll reversal' simply does not cut the mustard, in this respect.

I suspect...you can expect a few more of these BA fiascos, due largely for the reasons I have indicated, above.

In short, BA needs to reevaluate their FD procedures.
Urgently.

This very serious incident is just a case in point.
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Old 2nd Sep 2010, 10:18
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Role reversal

the First Officer is to taxi the airplane, the Commander then does...co-pilot duties
If the First Officer is taxiing the aircraft what should the Captain do? There is surely no roll (sic) reversal here as the Captain is always the Captain (unless incapacitated) regardless of who is pilot flying or non flying. By that I mean there might be a change in duties from one sector to the next, which I thought was pretty common in most airlines, but the Captain is the one who ultimately calls the shots.
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Old 2nd Sep 2010, 10:18
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Herc,
Your reference to BA038 puzzles me. On what basis is there any comparison? Am I being thick to-day?
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Old 2nd Sep 2010, 10:28
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There is surely no roll (sic) reversal here as the Captain is always the Captain (unless incapacitated) regardless of who is pilot flying or non flying.
Well, you need to visit the BA procedures, it can be an eye-opener, for sure.
I had one secconded BA First Officer say to me...'well, I taxi and I handle the throttles on takeoff'.
What rubbish.

Sadly, he was totally misinformed...here.

A co-pilot is a co-pilot...period.
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Old 2nd Sep 2010, 10:33
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'Roll reversal' happens at the stall and due to shockwave formation amongst other phenomena (added for the purists). I think 411 means role reversal.
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Old 2nd Sep 2010, 10:37
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Makes one wonder just how clever he is if he cannot differentiate between roll and role!
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Old 2nd Sep 2010, 10:39
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The roll reversal can be avoided by avoiding aileron use at high AOA.
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Old 2nd Sep 2010, 10:40
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I think 411 means role reversal.
Yes, and it is still BA cr*p.

And, it will continue to be a problem for BA, until...they change.
Don't hold your breath.
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Old 2nd Sep 2010, 11:02
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Speaking of role reversal could a BA 777 pilot answer this question...
Is it SOP for the PF to call for taxy instructions?
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Old 2nd Sep 2010, 11:07
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Is it SOP for the PF to call for taxy instructions?
Yes, once underway the PNF handles the R/T
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