One more illustration of calm, quick competence under pressure.
While pilots may not be required to read-back taxi clearances, they should, especially when complicated taxi routes are involved. Here, taxiway B involves numerous curved turns, and is then joined by taxiway P when it parallels runway 13R/31L. The intersection of the errant turn is where taxiways B (N.B., taxiway B continues on to parallel runway 04L/22R after a sharp left turn), A and J meet. And taxiway KD is nearby too. It seems sensible this should be highlighted in magenta as a taxiway "hot spot" regardless of whether or not there is a previous history incursions there. Also, this incident emphasizes the importance of a 2-person crew in large aircraft and the need for good old-fashioned CRM with particular attention to clear, concise and timely communications and a shared mental model. More specifically, there needs to be continued and perhaps increased emphasis on pilot monitoring duties and providing a progressive taxi instruction to the pilot flying (the Captain while taxing). Many more lessons will come.
The New York Times article on the incident (https://www.nytimes.com/2023/01/15/us/jfk-planes-delta-american-faa.html) noted another version of a near miss at San Francisco Airport in 2017 where a landing jet almost landed on a taxiway full of planes waiting to take off (https://www.ntsb.gov/investigations/accidentreports/reports/air1801.pdf). In that case the landing plane was supposed to land on the right runway of 2 parallel runways. However the left runway was closed and did not present its usual set of lights. So, the plane crew, missing many cues, took the taxiway to be the intended runway. Fortunately, the error was just recognized in time amd the plane pulled up to go around again. The executive summary of the report is a chilling read.
I'm finally finishing the PPL I started in the days before iPads, and have been amazed by the utility of position-referenced taxi diagrams on my knee. That said, I don't think I'll be trying to tackle a layout of KJFK's complexity anytime soon.
A key part of the training, of course, is learning to anticipate and fight expectation bias. We'll see what the investigation turns up, but particularly if 106 Heavy were on that counterclockwise route I have to imagine it played a role. Either way, it's a case I'll be discussing with my CFI and keeping in mind as a cautionary tale. Thanks for the writeup!
Speaking only for myself, as a pilot that has taxied on many a complicated airport, I would posit that while an egregious error, it is easy to see how once in a blue moon this can happen regardless of safeguards.
First, most airliners only have ground steering on the captains side through the use of a tiller. The captain sits on the left side. So imagine for a moment the captain is taxiing, as he approaches taxiway Juliet (on his left) he's looking left and hears cleared to cross runway 31. Looking left he sees a runway, a taxiway and has an instruction. He turns.
This is not uncommon for newer pilots learning the ropes and coping with the maze of airport signs all rather positioned IMHO in awkward places. I'm not excusing a two-man pro crew for this obvious slip up but I can see how it would happen. I'm glad for the safe outcome and quick actions by the Delta crew.
Is that intersection of taxiways flagged on the charts as a hot spot?
I was aboard DL1943 on Friday night.
I don't have much to add about my experience beyond the brief account I posted to Twitter (https://twitter.com/bhealyNYC/status/1614365814894854144) — but I do want to underscore the *utter* professionalism of our Delta pilot and crew, as I experienced it as a passenger. After a split second of frenzy following the activation of the brakes on the runway, the cabin was utterly *silent* — I'll never forget it. It took a few minutes for the captain to come on the PA with a brief update on the situation. I found his remarks helpful if a bit terse — and wished there was more communication in the next hour+, while we waited on the taxiway before returning to the gate and disembarking. Yet for all this time, silence, patience, and calm continued to obtain aboard the plane.
In retrospect, I am deeply grateful for the captain's need-to-know-basis communication style. The gravity of the situation only became clear to me in the day after the incident. (I opted to cancel my travel; I think — and hope! — that those who did continue Santo Domingo Saturday morning left before the facts started coming out on Twitter.) Can you imagine the adrenaline that was pumping through the captain's veins after this averted catastrophe, and as he had to "perform a few checklists" immediately after it? His coolness under pressure while communicating to the 150 passengers under his watch is remarkable. If he had expressed even a bit of what he must have been feeling, there would have been pandemonium in the cabin.
Late Friday night, after coming home 8 hours after I had set out, I was annoyed that I wasn't on my way to the Caribbean. Today, I am deeply grateful to be home in one piece. I read on another message board that Delta protocol requires captains to log off after an "RTO" (or "rejected take-off"). So I hope our captain is on a well-deserved vacation of his own.
PS: James, I'm a long-time reader, first-time subscriber. Thanks for all you've done to illuminate not just aviation but politics, China, communications... etc over the years!
Jan 15, 2023: " 14 years ago today, US Airways flight 1549 landed in the Hudson when it struck a flock of birds shortly after takeoff from LaGuardia, losing all engine power. 155 people on board were rescued by nearby boats, with only a few serious injuries." NYT
Also, Happy MLK Day to all!
" Hate can never be conquered by hate. Hate can only be conquered by love. This is a universal law." The Buddha
stay safe everyone! Thanks for the interesting analysis, JF!
Here are some interesting comments from aviation experts, twitter source:
"Long haul pilots tend to be the worst on ground. They get very little action on a per month basis and screw up a lot, especially at busy airports."
" That complex geometry there in the corner is ripe for runway incursions "
From recordings that included initial JFK ground clearance for taxi, seemed like the AAL106 First Officer missed runway assignment (instructed to taxi to 4L, did not repeat runway number in her reply, taxied across 4L toward 31L instead.)
: Kudos to the
controllers. Their quick actions most likely saved lives last night.
Were there simultaneous takeoffs on 31L? At peak times they’ll frequently have takeoffs both from 31L, starting from taxiway kilo alpha, and 4L
I just reviewed
. Departing 4L and arriving 4R. No other active runways were in use. All other aircraft were taxiing via Kilo for departure on 4L.
Ross Feinstein, Strategic communications professional. Previously
Previously @Teneo, @AmericanAir, @TSA, @ICEgov, @ODNIgov
So AA106 was supposed to turn left onto K to head for takeoff on 4L, yes?
I need to confirm the read back, but yes, all departures were departing via 4L. And they taxi via Kilo for 4L departures, as that is the only access for 4L.
might have more insight.
More of the audio is now available via @liveatc. @FAANews @JFKairport to American 106: "Cross Runway 31L at Kilo."
No other audio is heard before Delta 1943 was cleared for departure and American 106 crossed Runway 4L. twitter.com/RossFeinstein/…
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The American Airlines jet apparently did not have clearance to cross the runway. FAA has acknowledged the incident and investigating on it.
No, AA106 crossed *4L* while DL1943 was departing. You have a typo there.
David Burbach (@dburbach Mast/Post)
Prof of International Relations & National Security. Space, civil-military. Naval War College
Jan 15, 2023: 14 years ago today, US Airways flight 1549 landed in the Hudson when it struck a flock of birds shortly after takeoff from LaGuardia, losing all engine power. 155 people on board were rescued by nearby boats, with only a few serious injuries.
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That's a scary and puzzling incident. JFK has multiple systems designed to prevent such events, including Airport Surface Detection Equipment, Model X (ASDE-X); see https://www.faa.gov/air_traffic/technology/asde-x.
AA106 was never cleared to use taxiway Juliet. Ended up there instead of on taxiway Kilo where they were supposed to be.
On 31 March, 1985, there was the same situation at MSP when two Northwest Airlines 10's came very close to a dreadful collision involving 502 passengers. The pilot taking off ordered full power and then rotated at lower than usual speed when he concluded that was the only option. He estimated they cleared the other plane by 50 to 75 feet. This was a big story at the time in the Twin Cities, where I live.
Below is a UPI account of it and the investigation:
(There are several other accounts of the incident online. See also the Christian Science Monitor's broader article about the general problem at the time, as there were many near misses.
By FRANK T. CSONGOS
WASHINGTON -- The near collision last month of two Northwest Airlines jumbo jets carrying 502 people was caused by errors committed by two air traffic controllers, transcript of tower tapes showed Wednesday.
The National Transportation Safety Board, an independent federal investigative panel, released the tape transcript dealing with the March 31 near miss at Minneapolis-St. Paul International Airport. There were no injuries but the two DC-10s came within 75 feet of colliding.
The transcript of conversation between the air traffic controllers and crew members of the two planes showed one controller gave authorization for one of the planes to take off virtually at the same time when another controller told the other jumbo jet to begin taxiing on the same runway.
The near collision involved Northwest Flight No. 51, which was taking off for Seattle, Wash., on the southernmost runway. The other plane was Northwest Flight No. 65 to Phoenix, Ariz., which was taxiing across the runway when the mix-up occurred at 9:04p.m.
'Northwest, ah, 65 heavy (description of the jet), taxi across two nine left,' one controller advised Flight No. 65.
Just one second before, another controller in the tower told the second jumbo jet, 'Northwest 51 heavy, runway two nine left there's traffic crossing down field, fly the runway heading and cleared for takeoff.'
Six seconds later, the controller advised Flight 51, 'Runway heading cleared for takeoff.'
Shortly thereafter, Flight No. 51 was already in the air and an apparently puzzled crew member asked the tower, 'Was, ah, the 10 (DC-10) cleared to cross?'
'Northwest 51, yes sir, he was cleared to cross,' said the reply from the tower.
Don Nelson, the pilot of Flight No. 51, successfully pulled up the nose of the DC-10 much earlier than normal and managed to get the plane airborne and high enough to clear the other jet.
Flight No. 51 carried 235 passengers and a crew of 9. Flight 65 carried 247 passengers and a crew of 11. Safety board Chairman James Burnett said passengers on the two planes apparently did not realize what was happening.
Two air traffic controllers were suspended following the incident pending a full ilvestigation.
'The controllers made a mistake,' one safety board official said. 'Apparently, it was a mix-up in communication.'
Burnett said a storm that dumped 14.7 inches of snow on the Twin Cities, causing delays and congestion at the airport, appeared to have been a factor.
Nine hours before, there was a close call between an Eastern Airlines jet and a Republic jet on the same runway. That incident came to light during investigation of the Northwest near-miss, and a third air controller was suspended as the result.
Jim: As always, you do a great job of making complex aviation issues clear for folks. It's of enormous value.
May I quibble with one small, but I believe essential point? As you review the tapes, when the ground controller says (2nd paragraph) "106 Heavy, Kennedy Ground, Runway 4 left, Taxi Bravo, hold short of Kilo..." you comment that "the controller is saying that the plane should taxi TOWARD Runway 4 Left..." but I think it's more precise to say that instruction is for the airplane to taxi TO Runway 4 Left. In other words, the controller is telling the aircraft that's the runway they will be using and the taxi instructions will get them there, albeit with a hold along the way.
Note the American 1 pilot never did read back "Runway 4 Left". As you said, she was only required to read back the hold short instruction, but it seems clear she never mentally locked on to the fact that that was the assigned take off runway. If she had acknowledged that they were going to take off from 4L there is no likelihood they would have made the turn onto Kilo, since there is no path from there to the assigned departure runway.
As you note, they just lost situational awareness and I agree the controllers were on the ball.
I understand the AA flight, after about 30 minutes, did depart JFK for London. Is it the case that CVRs are still generally a two hour loop? If so, I guess we will have to rely on what the crew self-reports as their workload, actions during the taxi, wrong turn, etc.
I see there is an NTSB proposal (and in Europe, I think more like a rule-making, but only effective in new aircraft) for 25 hour CVRs.
I was on the edge of my seat reading this. Thanks for sharing.