FAA launches investigation after two planes nearly collide at JFK airport

[Half Fast]

Pilot error, but I wonder how they became confused. Anybody have any photos of the signage at the B-K and B-J intersections? I wonder if signs could have been in awkward spots, difficult to see, leading them to turn onto J rather than K.

Still, once there, they should have seen the 4L runway sign and realized it wasn't the one they'd been cleared to cross.

 

[4CornerFlyer]

I am curious why Delta 1943 returned to the terminal, unloaded all its passengers, and did not complete the scheduled flight until more than15 hours later. Anyone hear why they didn't take off when the runway was clear?
Jon

 

[FlightmechH3]

I am curious why Delta 1943 returned to the terminal, unloaded all its passengers, and did not complete the scheduled flight until more than15 hours later. Anyone hear why they didn't take off when the runway was clear?
Jon

They smoke checked the brakes....

 

[jordane93]

I am curious why Delta 1943 returned to the terminal, unloaded all its passengers, and did not complete the scheduled flight until more than15 hours later. Anyone hear why they didn't take off when the runway was clear?
Jon

Assuming it was a high speed abort (greater than 80kts, you need to check brake temps and you’ll need to get approval to continue from a chief pilot or duty pilot. Either way, you’re going back to the gate usually. Pilots also could have been tight on their duty limits so they may have had to find replacements. Also, this could have ended very badly. Usually after incidents, even if you have enough duty time, the chief pilot or duty pilot will remove you from the rest of your flights that day or remove the entire trip(at least that’s how it works at DL). Events like this can rattle someone and the last thing you want to do is fly when you may not be 100% mentally there.

 

[kayoh190]

Pilot error, but I wonder how they became confused. Anybody have any photos of the signage at the B-K and B-J intersections?

Don't have photos, but the signage is fine. Personally, I don't think they were confused about where they were on the airport. We'll find out for sure eventually of course, but the AA 777 had three JFK based pilots on that flight deck, and were given taxi instructions that are absolutely normal for JFK in that configuration. It sure does feel like expectation bias to me.

 

[jpskies]

This video has better animation and includes two controller's attempts to stop the AA106 from crossing 04L.
From the description, DAL1943 began to reject at about 100 knots ground speed. Wow!

 

[Jeff767]

I would be interesting to hear the entire ground calls from the time AAL called for taxi. Perhaps they were initially cleared for 31L but the cross 31L at Kilo instruction is pretty clear.

They were initially cleared to 4L when they called for taxi. The FO failed to properly read that back. I don’t know exactly how American does their weights ect.. but there has to be multiple failure levels. The runway configuration was one of the most common used at JFK with heavy and international departures off 4L and southbound domestic departures off 31L at KE. In the gate the ATIS would have stated that and all the international departures would expect 4L. They would put 4L in the FMS at the gate. When they loaded the weights if they put the numbers in for 31 the box would not load that unless they override it or change the departure runway. If they loaded 31L full length in the box at the gate you would think as they taxied right by 31L KE with a AA flight holding on the runway for departure they would have questioned their runway selection.
When they review what happened it will be interesting to see what runway they expected and briefed to depart from but a JFK based crew would expect 4L. They do run international flights off 31L on occasion but not while departing KE on 31. It’s possible with the winds they just assumed 31L and did load it in the box but a experienced JFK crew would know that winds are way down JFK’s priority list when setting runway configuration. If in fact that was the case the FO’s failure to properly read back the initial taxi clearance will become a key factor. ATC will be faulted also for failure to correct her and ask for a proper read back.

 

[Jeff767]

I am curious why Delta 1943 returned to the terminal, unloaded all its passengers, and did not complete the scheduled flight until more than15 hours later. Anyone hear why they didn't take off when the runway was clear?
Jon

Tire and brake inspection required and the crew timed out before it could be completed.

 

[Daleandee]

Events like this can rattle someone and the last thing you want to do is fly when you may not be 100% mentally there.

Or as uz southerners likes to say ... "had to go and change out them drawers!"

Seriously, I bet it takes a moment to decompress when, as a pilot, you realize just how close you were to a major disaster ...

Very, very, thankful that all ended well!

 

[Dave Theisen]

Or as uz southerners likes to say ... "had to go and change out them drawers!"

Seriously, I bet it takes a moment to decompress when, as a pilot, you realize just how close you were to a major disaster ...

Very, very, thankful that all ended well!

Which leads me to believe that the American crew had no idea as to the magnitude of what had happened since they just made a phone call and departed. My understanding is that they were replaced for the trip home.

 

[FPK1]

Excellent report on what happened and why by Juan Browne; video with ATC and FlightRadar overlays. Very well done as always!

 

[Hunter Handsfield]

Excellent report on what happened and why by Juan Browne; video with ATC and FlightRadar overlays. Very well done as always!

I agree about Juan Browne's excellent analysis. Looking back to the comments above about the delay in the Delta departure following the incident, it probably indeed was the need for brake service and possibly repair: Browne discusses braking with the rejected takeoff (RTO) brake setting. I was unfamiliar, having no heavy metal experience. Pretty dramatic.

HHH

 

[flyingron]

Pilot error, but I wonder how they became confused. Anybody have any photos of the signage at the B-K and B-J intersections? I wonder if signs could have been in awkward spots, difficult to see, leading them to turn onto J rather than K.

Still, once there, they should have seen the 4L runway sign and realized it wasn't the one they'd been cleared to cross.

They were supposed to cross 4L. It's the multiple 13L-31R indications they blew through.

Well there's a hold short line, two signs, and two big red 13L-31R signs on the entrance to the runway they crossed. About the only thing odd about where they is that the hold short line is bent at about a 135 degree angle well off to the left of the centerline. There are signs on the left that tell you Bravo is turning left and Juliet is going right and another one at the beginning of hwa tis properly Juliet telling you your on it. All this is well past where Kilo turns right (where they were supposed to run). The Kilo sign is there but perhaps not as prominent as the others.

Of course all this alpha/bravo nonense is because the FAA got rid of inner and outer as taxiway names.

 

[Flying Keys]

They were supposed to cross 4L. It's the multiple 13L-31R indications they blew through.

Well there's a hold short line, two signs, and two big red 13L-31R signs on the entrance to the runway they crossed. About the only thing odd about where they is that the hold short line is bent at about a 135 degree angle well off to the left of the centerline. There are signs on the left that tell you Bravo is turning left and Juliet is going right and another one at the beginning of hwa tis properly Juliet telling you your on it. All this is well past where Kilo turns right (where they were supposed to run). The Kilo sign is there but perhaps not as prominent as the others.

Of course all this alpha/bravo nonense is because the FAA got rid of inner and outer as taxiway names.

Couldn’t the airport rename them as one taxiway when it’s going in one general direction, then another after it turns? Most newer airports do it that way (though those ramps are more “squared off”). PDX, LAX, ATL, DFW, DEN, etc. Seems some standardization is in order.

 

[Greg Bockelman]

Tire and brake inspection required and the crew timed out before it could be completed.

Yeah, that. FAR 117 and brake cooling probably put them over duty limits.

 

[iamtheari]

Yeah, that. FAR 117 and brake cooling probably put them over doody limits.

FTFY. I know this came up in post #49 and possibly elsewhere, but I'm Bad Pun Guy and the ROC required me to do this.

 

[Larry in TN]

They were supposed to cross 4L. It's the multiple 13L-31R indications they blew through.

They were supposed to cross 31L at K. They crossed 4L, on which Delta was departing.

 

[Hunter Handsfield]

They were supposed to cross 4L. It's the multiple 13L-31R indications they blew through.

Well there's a hold short line, two signs, and two big red 13L-31R signs on the entrance to the runway they crossed. About the only thing odd about where they is that the hold short line is bent at about a 135 degree angle well off to the left of the centerline. There are signs on the left that tell you Bravo is turning left and Juliet is going right and another one at the beginning of hwa tis properly Juliet telling you your on it. All this is well past where Kilo turns right (where they were supposed to run). The Kilo sign is there but perhaps not as prominent as the others.

Of course all this alpha/bravo nonense is because the FAA got rid of inner and outer as taxiway names.

Maybe I don't understand: are you laying this on ATC, signage, the pilots, or some combination of them? Obviously you have direct and relevant experience, and of course runway and taxiway layout should be considered and be rational when designed, and signage and ATC communications must be as clear as possible. But it's probably impossible to be perfect, especially as size and complexity increase; and JFK appears to be at the far edge of complexity. Regardless, pilots have a responsibility to examine, understand and comply with signage and instructions, and to ask if anything isn't clear. The blancolirio (Juan Browne) summary implies that this wasn't done. Objective analysis (ATC, FAA, NTSB) will be required. When all is said and done, doesn't it seem probable that the American flight crew has the main responsibility?

HHH, MD

 

[Sluggo63]

A few weeks ago, American Airlines changed some pilot procedures and there were some news stories about how the pilots and their union weren't happy with the changes and how they were implemented.

https://www.usatoday.com/story/trav...-concerns-new-cockpit-procedures/10995941002/

The "training" came out to be basically a 100 page bulletin that fundamentally changed how cockpit procedures are done on all fleets. No simulator training, and just one month to implement the change. The union said that these rapid changes, and all done by bulletin, with no simulator training before line implementation would lead to an unsafe situation.

Then the JFK incursion happened.

https://www.forbes.com/sites/tedree...ask-at-departure-source-says/?sh=1dd4fb1567ac

 

[Lindberg]

A few weeks ago, American Airlines changed some pilot procedures and there were some news stories about how the pilots and their union weren't happy with the changes and how they were implemented.

https://www.usatoday.com/story/trav...-concerns-new-cockpit-procedures/10995941002/

The "training" came out to be basically a 100 page bulletin that fundamentally changed how cockpit procedures are done on all fleets. No simulator training, and just one month to implement the change. The union said that these rapid changes, and all done by bulletin, with no simulator training before line implementation would lead to an unsafe situation.

Then the JFK incursion happened.

https://www.forbes.com/sites/tedree...ask-at-departure-source-says/?sh=1dd4fb1567ac

What were the relevant changes? Is there a connection other than post hoc ergo propter hoc?

 

[luvflyin]

A few weeks ago, American Airlines changed some pilot procedures and there were some news stories about how the pilots and their union weren't happy with the changes and how they were implemented.

https://www.usatoday.com/story/trav...-concerns-new-cockpit-procedures/10995941002/

The "training" came out to be basically a 100 page bulletin that fundamentally changed how cockpit procedures are done on all fleets. No simulator training, and just one month to implement the change. The union said that these rapid changes, and all done by bulletin, with no simulator training before line implementation would lead to an unsafe situation.

Then the JFK incursion happened.

https://www.forbes.com/sites/tedree...ask-at-departure-source-says/?sh=1dd4fb1567ac

Pilot is certainly going to get probable cause. Tower should get a contributing for not confirming runway assignment on the read back of the Taxi Clearance. I wonder if this will become a contributing factor also.

 

[Sluggo63]

What were the relevant changes? Is there a connection other than post hoc ergo propter hoc?

I don't know. I don't fly for that airline (but I have a brother that does).

I think it lends a little more credence that the pilots and the union were saying this was unsafe and is going to cause an incident prior to the JFK runway incursion.

I understand that the crew is mostly to blame here. They were the ones that taxied across a runway they shouldn't have. I'm sure that's where most of the blame will lie.

But as far as a contributing factor, we'll see.

I know how new procedures can be distracting, especially if they are new during critical phases of flight like taxi, takeoff, landing and go-arounds. Usually the way these changes (should) happen is that you get notification that something is changing. For example, go-around procedures/call outs. Then, everyone gets to go to the simulator and practices the new procedures. Once everyone has seen it and practiced it, then it gets implemented on the line.

This doesn't look like that's what happened here. In fact, I just found another article (written before the JFK incident) which makes AA look even worse. They were disciplining pilots for delays caused by reviewing the new procedures.

https://www.forbes.com/sites/tedree...poses-new-cockpit-procedures/?sh=386a3f2c3a87

 

[hindsight2020]

This doesn't look like that's what happened here. In fact, I just found another article (written before the JFK incident) which makes AA look even worse. They were disciplining pilots for delays caused by reviewing the new procedures.

https://www.forbes.com/sites/tedree...poses-new-cockpit-procedures/?sh=386a3f2c3a87

Well, that one is gonna get dismissed as a labor dispute, especially during negotiations. It's a cynical take, but it's not news that airline pilots get pearl-clutchy around negotiation time. Management then argues it's illegal work actions, labor pushes back doubling down on the safety (canard if you're management, whistleblow if you're labor), and round and round we go. Reminds me of the Allegiant kerfuffle during the MD-80 phase outs, and the articles in the Tampa Bay times circa 2016. Big public relation bombshells were showcased, reputation of the airline as a mx death trap ensued. Then the pilot contract was ratified, and not a peep was ever heard about Allegiant being unsafe from the monkeys up front. Matter of fact, pilots engaged on a campaign of wagon circling internally to remove that stigma literally just previously stoked, internal to pro pilots (APC and other boards included). Cynical. Hard to believe johnny cry wolf going forward type of thing.

At any rate, sorry for the derail, now back to the topic of the thread.

 

[Hunter Handsfield]

I agree: This might be argued by the pilots and their union as a contributing factor but it's hard to imagine it absolves them of the main responsibility for the incident.

HHH

 

[PaulS]

Pilot is certainly going to get probable cause. Tower should get a contributing for not confirming runway assignment on the read back of the Taxi Clearance. I wonder if this will become a contributing factor also.

This, at the delta I fly out of, if you don't read back the runway assignment on taxi, they make you do it. I just automatically do it now.

 

[Palmpilot]

"Read back hold-short instructions and runway assignments" is a standard part of the ATIS at my home field. I'm not sure whether a crossing instruction is considered a runway assignment.

 

[Larry in TN]

"Read back hold-short instructions and runway assignments" is a standard part of the ATIS at my home field. I'm not sure whether a crossing instruction is considered a runway assignment.

They did read back the crossing instruction correctly.

 

[luvflyin]

"Read back hold-short instructions and runway assignments" is a standard part of the ATIS at my home field. I'm not sure whether a crossing instruction is considered a runway assignment.

It’s not, and yeah, getting read backs of hold short and crossing instructions is required by the Controller. Confirming runway assignment is also required. Runway 4L was in the Taxi Clearance. Pilot didn’t include that in the read back. The Controller didn’t confirm.

3−7−2. TAXI AND GROUND MOVEMENT OPERATIONS
Issue the route for the aircraft/vehicle to follow on the movement area in concise and easy to understand terms. The taxi clearance/route must include the specific route to follow. When a taxi clearance to a runway is issued to an aircraft, confirm the aircraft has the correct runway assignment.
NOTE−
1. A pilot’s read back of taxi instructions with the runway assignment can be considered confirmation of runway assignment.

 

[FoCoJayco]

NTSB preliminary report released: https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/106577/pdf…

Two interesting bits:

"Cockpit voice recorder data were both overwritten."

and

"NTSB attempted to interview the American Airlines flight crew three different times. American Airlines cleared the flight crew’s schedule to ensure their availability; however, the flight crew refused to be interviewed on the basis that their statements would be audio recorded for transcription."

 

[AKiss20]

How is it that CVDRs still require looping and overwrite audio so quickly? We can fit years of audio on a chip the size of a fingernail. I know most of this stuff was certified decades ago but still, you’d think we could update CVDRs no?

 

[Bell206]

How is it that CVDRs still require looping and overwrite audio so quickly?

Simply because the intended regulatory function of a CVR is to record the current flight with most digital versions only recording the previous 2 hours of operation until aircraft power is interrupted. The old rule was the previous 30 minutes. The CVR is strictly an accident tool and if it wasn't this way there would need to be a separate regulatory process to clear the memory when full.

 

[Daleandee]

Must be some lawyers in the mix ... "As a result of the flight crew’s repeated unwillingness to proceed with a recorded interview, subpoenas for their testimony have been issued."

 

[hindsight2020]

Apologies if a repost. Nah, it's worth a repost.

 

[sourdough44]

Not uncommon to have an infraction of ‘sterile cockpit’ while taxiing, though I’ll submit differences from sitting #8 in a straight line compared to night, low viz, unfamiliar with critical turns. Ref the overwritten CVR.

Yes I’ve seen the assortment of colored highlighters. I take it the inference is, a pretty color coded master flight plan & chart over minding the important task at hand of proper taxi for T/O?

 

[Kenny Phillips]

Must be some lawyers in the mix ... "As a result of the flight crew’s repeated unwillingness to proceed with a recorded interview, subpoenas for their testimony have been issued."

Interestingly, whilst the action may only be civil, the outcome (suspension, checkride, etc.) could be the same for speaking or not speaking.
Do they think it helps their careers to stay silent?

 

[Lindberg]

Interestingly, whilst the action may only be civil, the outcome (suspension, checkride, etc.) could be the same for speaking or not speaking.
Do they think it helps their careers to stay silent?

It would not be unreasonable to conclude they believe the outcome would be worse if they speak. In fact, it's near certain they believe that. But it's impossible to know if they're correct without knowing what they'd say.

 

[KSCessnaDriver]

Interestingly, whilst the action may only be civil, the outcome (suspension, checkride, etc.) could be the same for speaking or not speaking.
Do they think it helps their careers to stay silent?

I'm sure their lawyers (from the union) are running the show. They're not opposed to sitting down with the NTSB. They're against it being digitally recorded.

 

[flyingron]

You can bet that CVR got overwritten while they were parked after the incident waiting to taxi. Years ago a friend of mine managed to land an Airbus with the parking brake on. His FO decided they needed to erase the CVR for some reason and the way you do that in the airbus is to engage the parking brake and then push the erase button. Unfortunately, he forgot to release it and the captain didn't notice. He does have the flatspotted wheel in his garden as a souvenir. I guarantee that every crew knows how to erase the CVR.

As Bell206 says, it's intended to be a help when the plane has crashed badly enough that nobody is going to think about clearing it.

 

[kayoh190]

Guys, it's a 2 hour CVR and they flew to London. Nobody needed to 'erase' anything.

 

[Domenick]

Why do CVRs have such a short window? Memory is cheap. The audio need not be high-fidelity. Why not 24 hours or 48 hours?

 

[Larry in TN]

Why do CVRs have such a short window? Memory is cheap. The audio need not be high-fidelity. Why not 24 hours or 48 hours?

Because the applicable regulation requires two hours.