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Author Topic: Really scary carelessness on ATC part  (Read 22098 times)
Saabeba
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« on: May 04, 2008, 10:29:42 PM »

If this has posted here before, sorry newbie here.

Providence near accident in thick fog -- I don't see how the ATC clear's a plane for take-off without having clear confirmation of where all planes are.


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lololepro
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« Reply #1 on: May 05, 2008, 01:25:05 AM »

Very scary clip!!! The controller sounds like she has no idea what she is doing... Notice at the end she clears 2998 for takeoff on the wrong runway (23L) before correcting it to 5R
Does anyone know if there was an investigation and what the outcome was? It seems obvious that 1448 made a big mistake but admitted it as soon as they realized something was wrong... But the controller sounded like she didn't care, she just ignored the comments about the "active runway"...
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ect76
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« Reply #2 on: May 05, 2008, 01:28:28 AM »

Agreed- And the fact she totally lost her cool and started shouting at everyone and anyone who'd listen over the radio didn't help. The scariest thing, I thought, was that she was still attempting to clear aircraft for takeoff when there was a plane out there with no idea where they were! Could've easily been disastrous!!

Edit - Sorry, just noticed Saabeba made more or less exactly the point I made about clearing for t/o...Makes my post seem kinda pointless now!!
« Last Edit: May 05, 2008, 01:30:33 AM by ect76 » Logged
Heading090
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« Reply #3 on: May 05, 2008, 05:00:11 AM »

FAA did not find any errors in controller's actions:

"Peters, the FAA spokesman, declined to identify the pilots or the controller last week. The controller's name, he said, "is not releasable" under federal law because the FAA did not find any errors in her instructions to the pilots.

Nonetheless, immediately after the incident, "The controller was decertified, meaning you can't handle live traffic, underwent retraining for a period of time, was recertified and returned to duty."

[Source: http://www.projo.com/news/nearmiss/]
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aevins
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« Reply #4 on: May 05, 2008, 10:06:33 AM »

FAA didn't but the NTSB did. She was de/recertified.
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Heading090
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« Reply #5 on: May 05, 2008, 10:17:11 AM »

Could you point me to the source of this information?
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aevins
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« Reply #6 on: May 05, 2008, 03:56:57 PM »

NTSB report on the incident, section on human factors
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cessna157
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« Reply #7 on: May 05, 2008, 04:13:27 PM »

This incident is used inmany training cases, as it involves exactly what to do in certain situations (stop the aircraft and sort out where you are in you're lost & if there's something odd going on, feel free to decline any clearance until it gets sorted out) and what not to do (obvious).

Interestingly enough, as we pointed out in a recent CRM class I had to take, there is a contradiction in the FAA's actions/findings.  They point out that the controller did nothing wrong operationally, but the controller was decertified, which happens when you have an operational error...... huh
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CRJ7/CRJ9 F/O, Travel Agent
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« Reply #8 on: May 05, 2008, 04:19:16 PM »

@aevins  I would like to look through this NTSB report - sounds like interesting reading.
Do you have a link or report number?
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Saabeba
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« Reply #9 on: May 05, 2008, 05:10:54 PM »

I don't see why, if you do not have visual sighting due to Fog and you do not have ground radar, why it is not a requirement in an airport that a plane holds before crossing any run/taxi way, confirms location with Tower, and then proceeds.  The same procedure when the plane is about to turn or pass a turn, hold first before and confirm.

Otherwise you are depending on Pilots navigating around an airport blind with just the map on their lap and their recollection of your instruction. huh

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aevins
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« Reply #10 on: May 05, 2008, 05:35:34 PM »

expert66 I'll look and see what I can find, but I learned of this incident in the way cessna157 mentioned, and awhile ago.

As for runway crossings, pilots must have a clearance from the controller to cross an active runway. Why aren't progressive taxi instructions used in very low visibility situations? Well, if the airport is fairly busy and there is only once controller working both the LC and GC positions, then that controller just does not have the time to issue progressive instructions to every aircraft. Since 1999, ASDE ("ground radar") has been installed at PVD, and I believe at most all higher level towers today possess some form of ground radar. AMASS prevents situations like this from happening.

Check out these links:

http://www.ntsb.gov/recs/letters/2000/A00_66_71.pdf

http://www.ntsb.gov/Events/2000/incursion/incur_video.htm
« Last Edit: May 05, 2008, 08:25:32 PM by aevins » Logged
Saabeba
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« Reply #11 on: May 05, 2008, 07:36:26 PM »

That is chilling.

I am in finance and IT, and you would not put a program or control place that you reasonably expect to fail.

In both of these examples, the onus is on the Pilot to execute instructions.

The ground radar seems like a resonable solution, but I now will think twice about flying out of or into smaller airports unless I know that it is in place.

I recall that a regional jet not long ago took off of the wrong runway, in Florida I believe.

For an industry involved in moving passengers at mortal speeds, I am surprised at risk allowed.  Are airports in other countries under tighter control (ground radar or progressive taxing)?
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aevins
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« Reply #12 on: May 05, 2008, 08:09:14 PM »

Welcome to the industry. Those recordings are all pre 2001. A lot had changed in the last 7-8 years. If you would like to learn about more current problems take a look at NextGen and the staffing crisis. Don Brown writes a great blog called "Get the Flick", gettheflick.blogspot.com, check it out.
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KSYR-pjr
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« Reply #13 on: May 05, 2008, 11:22:37 PM »

I recall that a regional jet not long ago took off of the wrong runway, in Florida I believe.

Lexington, Kentucky.  Accident report is here:  http://www.ntsb.gov/publictn/2007/AAR0705.htm
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Regards, Peter
ATC Feed:  Syracuse (KSYR), NY
Saabeba
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« Reply #14 on: May 06, 2008, 10:59:17 AM »

Really, great advert to avoid regional airports.
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RV1
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« Reply #15 on: May 06, 2008, 11:54:49 AM »

"Really, great advert to avoid regional airports"





Just remember to stay out of ANY water because two people were recently killed by sharks.

It is true that many smaller airports don't have ground radar, but you'd be mortified at how often the ground radar malfunctions, is in op or isn't set up to detect certain things that aren't specifically on the runways or taxiways. There is an incident where a cargo pilot flying a heavy turned off a runway and missed any taxiway, and got stuck in the grass/mud/snow. He didn't tell ground where he was but said he was off the runway(to be correct, only the front part of the plane was off!). The tower continued to clear a/c for takeoff(it was foggy or snowing, I don't recall). When an airport vehicle went out to check on the planes location, they closed the airport, a major airport. When the visibility finally improved, and controllers actually saw where he was, they realized how fortunate/lucky all had been. This airport HAS ground radar, but the parameters are set up so that it looks for traffic on the concrete, not in the grass.
The controller in the incident you mention was expecting the pilot to be in a certain spot and she was expecting to hear a certain thing. When neither of these occurred, she didn't allow the new info to become fact, she still considered the factual info wrong. Controllers and pilots both do this. It isn't good practise! When most people from the outside listen to controllers/pilots, they are amazed that either can understand the other. We explain that we are always listening for certain pieces of information, the rest is fluff. Problems enter when a pilot is expecting to hear one thing, say climb and maintain FL230, the requested altitude, but what was said was climb and maintain FL210. The controller is expecting to hear a readback of FL230 and doesn't catch the FL210. As the plane climbs through FL214, there becomes a problem! The controller will get pinched because he didn't catch the readback error, the pilot will get nothing.
Remember, part of the controller's mantra is that we are required to be right, all the time... 99.9% right isn't good enough if you're in a plane during the .1%.
« Last Edit: May 07, 2008, 01:06:29 AM by RV1 » Logged

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KSYR-pjr
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« Reply #16 on: May 06, 2008, 12:00:52 PM »

Just remember to stay out of ANY water because two people were recently killed by sharks.

Ha!  Was thinking something similar along the lines of "really good advert for staying at home with the doors locked and only eating food blended to a fine puree first," but then stopped short of clicking the REPLY button.
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Regards, Peter
ATC Feed:  Syracuse (KSYR), NY
Saabeba
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« Reply #17 on: May 06, 2008, 12:22:37 PM »

I am actually thinking about a plan for shark repellant next time I go ocean swimming in deeper water, lol.


It's only in cases where visibility is down to zero so hardly very often.

lol.
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mts
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« Reply #18 on: May 06, 2008, 04:13:18 PM »

What I do not understand about this is how come this aircraft got onto an active runway?

Pilot got lost? - ok, that happens sometimes...
Controller lost situational awareness? - ok, that happens sometimes as well ...
No ASMGCS or ground radar of any kind? - ok, this equipment is a luxury for many regional airports.

The real problem is none of the above however. The real problem is that the aircraft ENTERED THE ACTIVE RUNWAY. The real problem is not the mistake, but the consequence of it.

But how come there are no stop bars at this airfield? This is a simple and affordable equipment. If stopbars were present this aircraft wouldn't have entered the runway. Even if everybody is lost, a stopbar would have kept the aircraft out of the runway.

Most regional european airports do not have any equipment needed for the LVP, but they have simple procedures that are rather efficient. One is: without stopbars or ground radar - only one movement at a time. Another possibility is to work single runway configuration, with only two one-way taxiways - one  for getting departures form the apron to the runway, another getting arrivals from the runway to the apron.Both green lights equipped - just follow the greens - simple and safe. All other taxiways are phisically closed for the LVP periods with lights off . Thrid option is to cut down the movement rate to a reasonable minimum and have a follow me car for each movement so that unfamiliar pilots are supported by somebody local, who knows the airfield.

There are even more procedures that would have prevented this thing from happening, e.g. never issue a runway crossing together with a taxi clearance. (When a taxiing aircraft needs to cross a runway, initial taxi clearance limit shall always be the runway holding point)Especially in Low Visibility Procedures this is very important. Have them stop before the runway (active or not), check position then issue the runway crossing clearance separately.

You may argue that such  procedures are not very expeditious, but if there is fog and a controller sees nothing, and it is a small airfield that cannot afford the equipment, then  I think it is not a bad idea to slow down things a little bit.

I believe neither the controller, nor the pilot is to blame here. Humans will always make mistakes, this is invevitable. But the lack of appropriate procedures or basic equipment to support Low Vis operations is inexcusable.

The ones to blame are the guys who made the last safety audit of the airport and never found anything disturbing. The ones to blame are the ATC unit managers who let the airport operate in such conditions without providing the necessary procedural and technical support to operational people to do the job safely.

But of course management always gets away with it , a controller or a pilot takes the blame, gets fired ot recertified, and then recordings like this fill up the training presentations to scare young controllers . Of course it will happen again, because this is the human nature and you can't change humans  - they will always make mistakes. The problem is how to make sure that such mistakes do not lead to disastrous consequences and that's why u have all the prcedures, equipment and other stuff that I am unable to see at this airport. I hope that this incident has triggered some changes for good at this and other airfields.
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aevins
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« Reply #19 on: May 06, 2008, 06:07:52 PM »

Keep in mind, this incident occurred nearly a decade ago. A lot has changed since then, and this is a famous case that has been used in teaching both pilots and controllers. The controller did make a vital error in not listening to the aircraft when the flight crew informed her that they were on the (or an) active runway. Procedures have changed in the last 10 years, and there hasn't been a similar incident like this since. (Not referring to runway incursions of course, but to a low visibility situation that caused a controller to loose the picture, or an element of the picture, of the movement areas while ignoring the information she was receiving from the flight crew.)
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Saabeba
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« Reply #20 on: May 06, 2008, 10:13:37 PM »

Not to beat a dead horse,

but my conclusions closely echoed MTS line of view.

Why would a procedural system even be in place that would allow the possibility for such an accident to occur.

In other words,  I think the controller's initial taxiing instructions were wrong.  Not because she did anything wrong, but because the procedure itself was wrong for the conditions.  The controller appeared to follow procedure when giving the instruction; if tis was standard operating procedure until 10 years ago, it is an eye opener.

I know the history of airflight was about taking risk, so maybe it is part of the culture in the US.
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KSYR-pjr
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« Reply #21 on: May 06, 2008, 10:29:23 PM »

I know the history of airflight was about taking risk, so maybe it is part of the culture in the US.

Ummm.... no.    One word:  Actionable.

Protection from liability, not risk taking, is the culture in the US since at least the early '80s.
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Regards, Peter
ATC Feed:  Syracuse (KSYR), NY
moto400ex
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« Reply #22 on: May 07, 2008, 12:06:36 AM »

We listened to this clip in my ATC Tower class.   Lets just say my instructor had some choice words for this controller.  I had the opportunity to watch some higher level ATC students replay a similar scenario which was interesting to see what to do in a situation like this and compare what this controller should have done.  I guess this another reason why they invented ground radar and Safe Taxi.
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RV1
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« Reply #23 on: May 07, 2008, 01:17:29 AM »

We listened to this clip during a 'How to Manage an Air Traffic Facility' course in OKC. All in the room were cringing because it was evident what was taking place. The kneejerk reaction, however would be to start requiring a vehicle follow the leader for each airplane, limit runways in use, etc. It's during these times that all heads must be focused on the tasks at hand, whether it be controlling, flying or taxiing. It is also possible that the amount of traffic in the U.S. compared to the rest of the world would make limits unreasonable. Other countries may have less taxiways that cross runways than we do, but again you have to look at volume and logistics. Having better lighting and signage would help a lot. Having ASDE is also a step in the right direction. This is an area where satellite technology/gps would be a tremendous benefit.
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« Reply #24 on: May 17, 2008, 05:16:26 PM »

The controller didn't actually make any mistakes. If you listen to the clip, when the crew of 1448 realised that they were lost, twice they reported to be at the intersection of 16 and 23 RIGHT. You can see from the diagram that this is a runway that runs parallel to the terminal and as the controller states, is not an active runway at night or druing IFR

Admittedly, it was unwise for her to clear an aircraft for take-off when 1448 had obviously taken a wrong turn, but they reported twice that they were at 23R. The controller can't have lost situational awareness if she can't see the aircraft. She can only rely on the information that is being passed to her from the crew. Thank goodness the crew of the 2nd aircraft waiting to depart declined the clearance!
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