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Author Topic: Really scary carelessness on ATC part  (Read 15551 times)
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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RV1
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« Reply #25 on: May 18, 2008, 01:06:50 AM »

Totalbeginner

You may want to listen to the recording again. There were numerous times that the pilot, the female one, said that they were on 23L. The male said 23L and then 23R. She also said what she was looking at for signage and they gave a description of how they got to where they were. The controller was Expecting to hear one thing and didn't catch what they were actually saying. Towards the end, the pilots did NOT listen to control instructions very well and had to continually be given amended directions for taxi.

Major errors on both parts.

For all you pilots out there, especially those that fly the CRJs and E145s, here's a recent mind blower: E145 departs, climbing to 3000. Vfr traffic opposite direction @ 3500. Traffic is passed as follows: XXX145, zzz approach radar contact, traffic 12 o'clock, 6 miles, opposite direction cessna at 3500, maintain 3000. He states "traffic in sight". Told "Roger, maintain visual separation with cessna, climb and maintain 13 thousand." Cessna is told about tfc, he advises in sight. 30 seconds later, XXX145 says, "Hey approach! We just got an RA about that traffic!" Me "You mean the one you reported in sight and were told to maintain a visual with?!" Him" Yeah, he was coming right at us!" Me "That's pretty much what opposite direction means".



You can't make this stuff up...
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KSYR-pjr
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« Reply #26 on: May 18, 2008, 09:02:46 AM »

Cessna is told about tfc, he advises in sight. 30 seconds later, XXX145 says, "Hey approach! We just got an RA about that traffic!" Me "You mean the one you reported in sight and were told to maintain a visual with?!" Him" Yeah, he was coming right at us!" Me "That's pretty much what opposite direction means".

Something very similar happened just outside of Syracuse a few years ago and before I was good at making audio clips, otherwise I would have posted it in the Audio Clips board.  A Dash 8 was being vectored on a north downwind for an ILS intercept and there was a flight school Cessna 172 just north of the ILS approach at 2,000 practicing some VFR maneuvers.   

The controller told the Dash 8 about the Cessna and then gave the Cessna an "at or below 2,000 feet" restriction.  Moments later the Dash-8 reported traffic in sight.  The controller told the Dash-8 to maintain visual and descend to 2,500.   

About thirty seconds later the Dash-8 pilot announces that they are responding to an RA due to the Cessna.  The controller gets on and states that the Cessna is still showing 2,000 feet but the Dash-8 pilot begins to berate him about the "close call" and starts making comments about the Cessna pilots.  The controller was very professional and simply replied, "Sir, he was restricted to 2,000 and you were restricted to 2,500" and he let it go at that.   I was listening to this exchange thinking, hey, what about the fact that you (the Dash-8 pilot) called "Traffic in sight?"  That call doesn't give you the freedom to return to your duties inside the cockpit.

My guess was that the pilots called "traffic in sight" and then went back to both setting up the approach and running checklists, forgetting about the C172 until the TCAS alert.
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Regards, Peter
ATC Feed:  Syracuse (KSYR), NY
aviator_06
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« Reply #27 on: June 30, 2008, 04:24:11 PM »

Yea I saw this vid on youtube a while back.
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Crazyaviator06
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« Reply #28 on: October 01, 2008, 06:02:09 PM »

Just have to add.... Props to the pilots who declined the takeoff clearence... Thats who i want flying when i fly as a passenger.....
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drFinal
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« Reply #29 on: October 02, 2008, 04:23:41 PM »

I DID like the one pilot who refused his takeoff clearance 'until we figure out what's going on.'

I don't think the initial taxi instructions were incorrect. The pilot made a wrong turn and ended up back at the active. Both pilots reported in at different locations--on the R and L RY. The controller kept denying  that the plane wasn't where she thought it was and tried to keep running her operation.

The person that "broke the chain" of events that could lead to disaster is the pilot that refused his takeoff clearance.





« Last Edit: October 03, 2008, 02:57:07 PM by drFinal » Logged

Air traffic controllers tell pilots where to go.
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