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6. Part 4 – Lessons
1. The Anatomy of a Close Call
X
2. Conclusion
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7. This document has been prepared
for training purposes only and sets
forth general principles and
guidance concerning good
operating procedures for avoiding
surface incidents and runway
incursions. It is neither mandatory
nor regulatory in nature.
X
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8. Can’t happen to you?
Think again!
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32. Is it carelessness when taxiing?
Neglecting ATC communication instructions?
Underestimating taxi speed?
Losing situational awareness?
X
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33. B 12L
The runway hold marking defines the
boundary of the runway safety area
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RUNWAY INCURSIONS CAN HAPPEN AT ANY TIME, ANY PLACE, ANYWHERE.
HIGH TIME OR LOW TIME PILOTS, RUNWAY INCURSIONS DO NOT DISCRIMINATE.
NORTH LAS VEGAS RUNWAY COLLOSION, NO FATALITIES, VFR WEATHER, SINGLE ENGINE AIRCRAFT
A/C 1 IS MD-80 HOLDING SHORT RUNWAY 12L
A/C 2 IS JET STREAM TURBO PROP TAXIING ON FOXTROT
THE MD-80 IS UP TOWER FREQUENCY, THE JET STREAM IS ON GROUND
JET STREAM IS TOLD TO HOLD SHORT RUNWAY 12L AT BRAVO AND ACKNOWLEDGES
WHEN THE MD-80 IS IN POSITION AND HOLD ON RUNWAY, JET STREAM IS ABOUT MIDWAY DOWN FOXTROT
WHEN MD-80 BEGINS TAKEOFF ROLL, JET STREAM IS JUST TURNING RIGHT ON BRAVO
INCURSION OCCURS 17 SECONDS FROM BRAKE RELEASE.
JET STREAM SEES MD-80 JUST PRIOR TO INCURSION POINT
MD-80 IS APPROACHING ROTATION SPEED, JET STREAM IS STOPPED.
POINT: HIGHLY EXPERIENCED ATC, HIGHLY EXPERIENCED MD-80 AND JET STREAM CREW, THE LATEST SURFACE RADAR TECHNOLOGY ON AIRPORT. THIS INCIDENT IS A GOOD EXAMPLE OF A FAIRLY BENIGN ENVIRONMENT TURNING SOUTH IS QUICK ORDER!
DIFFERENT FREQUENCIES
13 SECONDS FROM THE TIME THE MD 80 TAXIES ONTO THE RUNWAY
JET STREAM AT THIS POINT CAN’T SEE THE MD 80
CLOSEST POINT OF APPROACH.
THE JET STREAM IS AT RUNWAY EDGE
THE JET STREAM PILOT READ BACK THE HOLD SHORT INSTRUCTION!
WHERE ARE THE HOLD MARKINGS AND HOLD SIGN LOCATED AT THIS INTERSECTION?
NOTICE JET STREAM ACTUALLY BACKS UP FROM RUNWAY EDGE.
BUT IS STILL ACROSS THE RUNWAY HOLD MARKING
DOESN’T TAKE LONG TO GO FROM OPS NORMAL TO OPS CRITICAL.
17 SECONDS FROM MD-80 BRAKE RELEASE TO NEAR COLLISION
13 SECODS FROM THE TIME THE JET STREAM TAXIED ONTO BRAVO UNTIL NEAR COLLISION
LESS THAN 50 FEET. THE MD 80 CAPTAIN CLAIMS HE NEVER SAW THE JETSTREAM.
VIOLATING THE HOLD SIGN AND MARKING AND DISREGARDING HOLDING INSTRUCTIONS NEARLY RESULTED IN A FATAL ACCIDENT
IN THIS CASE, THE AIRPORT EQUIPMENT WAS STATE OF THE ART, BOTH AIRCREW WERE HIGHLY EXPERIENCED AS WERE THE ATC CONTROLLERS.
READ BACK HOLD SHORT INSTRUCTIONS AND LOOK BOTH DIRECTIONS.
YOU ARE NOT NORMALLY THE ONLY USER OF THE AIRPORT
FOR THE JET STREAM PILOT, WHERE DID HIS CAPABILITIES FALL BELOW THE TASK REQUIREMENTS LINE?
DON’T HESITATE TO ASK FOR HELP FROM ATC. IF NOTHING ELSE, IT WILL PUT THE CONTROLLERS EYES ON YOU.
AT END OF DAY FATIGUE SETS IN
‘GET HOMEITIS’
KNOW WHAT IS MEANS.
KNOW WHY IT IS THERE.
KNOW WHAT HAPPENS WHEN YOU DON’T COMPLY.
THE RUNWAY HOLD MARKING DEFINES THE RUNWAY SAFETY AREA
A RUNWAY HOLD SIGN WILL ALWAYS BE CO-LOCATED WITH THE MARKING AND ALWAYS LOCATED ON THE LEFT
MILAN ITALY, OCTOBER 2001
CITATION AND MD 80
122 FATALITIES
STL, NOVEMBER 1994.
LOSS OF SITUALIONAL AWARENESS
TWO FATALITIES
TWO AIRCRAFT OPERATING ON THE SAME RUNWAY AT THE SAME TIME..
DOYOU HAVE A QUESTION ABOUT THE MEANING OF THIS MARKING AND THE ASSOCIATED SIGN?
DO YOU NOW THE REQUIREMENTS AND EXPECTATIONS OF YOU AT A TOWERED AND NON TOWERED AIRPORT?
75% OF THE OPPORTUNITIES FOR LOSS OF LIFE CAN BE ELLIMINATED IF PILOTS UNDERSTAND AND COMPLY WITH THESE SIGNS AND MARKINGS.
DON’T LET YOUR GUARD DOWN DURING TAXI. LISTEN TO ATC INSTRUCTIONS, READBACK AND COMPLY.