Thursday, May 10, 2012

Look before you leap

As a one year CRJ Captain, about six years ago, I taxied the jet out of the Philadelphia regional jet ramp late one evening for Binghamton, New York.  This was the first trip with this particular First Officer, and we were getting along great together.  He had many good qualities, and you don’t always find well rounded FO’s (or Captains) on the line.  Many times one is able to determine (or hear on the line) that each pilot has a few areas which are their strengths, but there is one area where the other crewmembers would be wise to ‘cover them’ on.  It’s a wise and professional tactic to practice, and if you do it in the right way it does not disrespect the other crewmember at all; on the contrary it makes your ‘team’ stronger. 
Jay appeared to be strong in all areas; but there was still one corner in which I thought I might have to be careful in, and that was in taking his suggestions.  He was pretty assertive for a First Officer and a little cavalier (he had a lot of confidence which seemed to give him leeway), but he used the right tact and balance in communicating with me.  During our flights we had been conversing, mostly out of “sterile cockpit”, about all kinds of subjects – politics, company goings-on, our pilots union, and religion (and his lack of faith in my Jesus), and we had a pretty good time doing so, in spite of our differences on matters of faith.   
Really, we probably talked too much, in places where we shouldn’t have been.  I can’t recall how much the sterile cockpit rule was bent, but I’ve learned over the years that heated conversation during periods out of sterile cockpit can leave a pilots mind remain focused on the subject relatively long after sterile cockpit is entered again.  This is where discipline could and should come into play (not talking about subjects not pertaining to the flight at hand), and an area I try to focus on more these days.  I say ‘these days’ because as the years roll on, things happen, things that make you think twice about how disciplined you really are in your duties, and how you would like to be matches us with the reality.
It was late, a quarter till eleven, when we were given the “cross two-seven right, right turn on sierra, contact tower one one eight point five” clearance.  We continued south on taxiway Echo and followed the snaking, right left right path of taxiway Sierra, my left hand on the tiller steering the pointy end of the CRJ toward the rows of the orange lights of the UPS ramp nearby runway two-seven left. 
Whatever non-pertaining conversation there was (couldn’t have been much) stopped suddenly when Philly Tower gave our takeoff clearance, “cleared for takeoff runway two-seven left”.  My ‘strong in all areas’ first officer repeated the clearance back to the Tower, and I called out “Flaps eight before takeoff checklist”, which we quickly completed, leaving a two hundred yard straight section of taxiway Sierra, headed west, before a quick left and very short taxi segment on taxiway Sierra One (S1) to get on runway two-seven left, and then a sharp right turn to align with the runway for takeoff (see the airport diagram below).
Philadelphia International - Taxiway S1 and Runway 27L on center lower half, near control tower

We made the left turn and started to cross the hold short line for runway two-seven left.  I had made this turn many times, and only as a Captain.  Because S1 was a very short taxi segment before the hold short line, it was tricky to visually check the final approach of runway two-seven left for traffic before actually crossing the hold short line for the runway.  Not to worry, though, we had good men with good intentions looking out for us; the control tower was close enough that we could still see their silhouettes in the cab during the day.  Many times, but not always, before this evening I would delay making the turn until the last moment in order to make a sharper turn, which would give us more room to visually check that there is no traffic on the final approach course before the jet’s nose crossed the hold short line that marked the boundary between the taxiway and runway.  
“Tower are they going to get out of our way in time?”  The clearly and quickly spoken words by the female UPS pilot alerted us to a major problem, simultaneously as I got over my disbelief and did a triple take with my eyes, observing the multiple bright lights of a Boeing 757 on short final of our runway, and their runway also, two-seven left (27L).  My synapses snapped into overdrive, suddenly thinking as quickly as possible.  There was no time to wonder about why this was happening, no time to deny or delay the reality of the moment, no time to escape from the sudden pressure of the situation.  A huge airplane about a half mile to our left and about two hundred feet above the ground would be right where we were in less than fifteen seconds. 
The need for a pilot to check the final approach is a primary safety directive taught from a student’s first flight: always visually check that the final approach is clear before you take the runway for takeoff.  By this evening I had about six thousand hours of flight time, and I had never been in another aircraft’s way on the runway.
Fortunately I didn't freeze.  Because they were so close and we still weren’t aligned with the runway and wouldn’t have started the turn to do that for another ten seconds, there was absolutely no way we could have taken off and cleared the runway in time.  That was a no brainer, and postflight that made me think the UPS pilot’s words were a polite (and surprised) way of asking the control tower to make us clear the runway so that they did not have to abandon the approach and execute a go-around.   
Runway boundary constituted by 'holding positions markings' shown - FAA AIM

Because the nose and our cockpit was already past the hold short line and we were technically on the runway even though the plane wasn’t past the runway edge lines (see FAA AIM diagram above), I didn't let my feet ever touch the brakes.  I saw my escape across the runway to the other side of taxiway “Sierra One” and started to advance the thrust levers.  We could sort out the taxi back to the runway after we got out of the way.  With a stuttered surprise, the tower controller ordered urgently:  “Exit the runway at Sierra Two”.  He owed us that much at least, after clearing our aircraft to take off while having already cleared one to land, and creating a serious safety risk all at once. 
At that point I didn’t know if Sierra Two was straight ahead or where, I just wanted to ‘get away’ and have a snickers, so to speak.  “To the right, to the right!”  My First Officer urgently yelled and motioned in reply to my question regarding Sierra Two: “is that straight?”  I gunned the thrust levers halfway up, made a quick right turn down the runway halfway between the edge and the centerline, found Sierra Two (S2) and turned off clear of the runway, back eastbound, again on Sierra.  We watched the big, long 757 with cool customers driving it land just as we finished the turn on Sierra.  They braked normally and took the left turnoff from the runway at taxiway Yankee (Y) just like nothing had happened.  But something had just happened, something bad.  The control tower had cleared us for takeoff, directly conflicting with another aircraft they had already cleared to land.  We had just experienced a moment you do not want to have, ever, as a pilot.
The tower did not miss a beat, in spite of knowing their mistake.  I should say his mistake, although I don't know the staffing at that hour but I assumed the tower was minimally staffed with one controller for the tower and one for ground, and no manager backing either of them up.  He was businesslike as he stated to us “you are still cleared for takeoff, runway two-seven right”.  Still cleared for takeoff.  No takeoff clearance cancellation had been given, in spite of us severely cramping some big iron’s style on short final.  He should’ve cancelled our takeoff clearance, and I thought during our climbout that he didn’t because (1) he didn’t want that to be on the ATC tapes, and (2) he didn’t want to perform any possible paperwork required, (3) he didn’t have time to either.  He knew what he was doing, except for that one moment, and that’s all you need is a moment, unfortunately.
My First Officer and I talked a lot about this on the way up to Binghamton, New York, that night. 
How did that happen?  I didn’t visually clear the final approach path, and the tower probably had cleared the 757 to land before we had switched to the tower frequency.  Runway 27L is not usually used for landings, except by UPS at night when it provides them a short taxi to their nearby ramp.  I didn’t have my guard up for that possibility.  I have a theory that at some point the controller couldn’t see the 757 because the approach path position of the 757 made it to become blocked from view by the control tower cab roof, unless the controller gets up close to the windows.  The controller had a moment of inattention and permitted himself to be distracted.  Controller fatigue could have been a factor.  They could have had reduced staffing and fewer controllers to back each other up. 
I asked: should we report the controller’s mistake?  It would surely get him in trouble.  We wondered if they had an immunity program to write a report about their mistakes and be given protection from discipline or termination (they didn’t at that time).  Reporting him would force us to admit we didn’t clear the runway visually before entering it, and we wondered about what that meant for us.  We could call him when we arrived at Binghamton and asked for an explanation, he probably had a ready apology. 
What do you think I did, reader, at the end of the flight and end of the night?  What would you have done, and why?  Let’s start a little discussion. 
Learn from my lesson: always, always, always clear your runway before you cross the hold short line, control tower or not!  My favorite quote from Ronald Reagan applies here: “Trust but Verify”.
God bless you, and thanks for reading my blog!


aerofede said...

Hi Craig!

Thanks for a great post!

I talk from the controller point of view, as I am an ATCO myself in Italy.

Pilots are supposed to clear the final approach (and it works, I was in an A321 cockpit when the controller gave us 'Line up and a wait' with an A320 on very short final), but that should nevere substitute, but just complement, the ATCO judgment and awareness.

Cases like this, are considered runway incursions, and should be reported as such, even if without consequences, to permit a study of the event in order to avoid them in the future.

Best thing to do would be file an anonymous report, like the NASA ASRS or its equivalent, so as to notify the event without 'harming' the participants.

And a phone call to tower to discuss it in a totally relaxed and non-acrimonious way, so that everyone is able to know the counterpart point of view, and have a better knowledge on what goes on in this events and how to avoid them in first place.

A final note: nonm-essential conversations are a part also of ATCOs working life, especially in a light traffic condition, and could have the same detrimental effects that they have in cockpit, while at the same time could keep the ATCO a bit more alert.

Craig said...

Thanks for the comment!

You're right, yes, I should have at least called the control tower, which I didn't do. If it happened again I would.

Filing a NASA ASRS report is an excellent idea also, although I am not sure that it can be done anonymously by pilots or that the controller would not have been investigated, I should research that point.

Thanks for the insight from your view of things in the control tower!

Craig said...

Below are two accounts in the last three months wherein pilots at my airline were given incorrect clearances by the Control Tower at major airports we operate at. Both crews saw conflicting traffic, stopped, queried the controllers, and averted disaster. We had two major ATC failures where a catastrophic accident was avoided due to the professionalism and situational awareness of our flight crews. In both cases, ATC took full responsibility for the incident.
Unfortunately, we are all human, and in spite of all the safeguards in our system, mistakes still happen, on both sides. Operations on multiple, crossing runways continue to have the potential to be at a high collision risk. This underscores again the directive - LOOK BEFORE YOU LEAP. ALWAYS VISUALLY CLEAR YOUR PATH IN FRONT AND ON BOTH SIDES BEFORE YOU TAKE THE RUNWAY FOR TAKEOFF OR LANDING, OR CROSS AN ACTIVE RUNWAY. These are their stories:

“We were cleared onto 18L to line up and wait. As soon as the preceding aircraft had
lifted off, we were cleared for takeoff. At about the point I called set thrust and the F.O.
was proceeding to set the thrust, I noticed that an Eagle ERJ on taxiway Mike began to
cross our runway. It was around 40 knots or so that I called for the abort and stopped
the aircraft on the runway. The ERJ continued across to the other side of the runway. I
made a quick PA to the passengers to remain seated, and ATC cleared us to taxi off the
runway at C9. That required us to cross runway 23, and because we were not given a
crossing clearance, we elected to hold short. At that time I also noticed an aircraft on
final for 23. My F.O. queried tower about holding short and at that time they told us to
hold short. My F.O. also mentioned a concern to ATC as to whether or not we were
actually considered short of 23, because there was no hold short line that we could see.
In the interest of safety, tower called the go-around for the landing aircraft, then cleared
us to cross 23 and exit at C9. We got an amendment to our release, made sure that the
brakes were at an [acceptable] temp for takeoff, and were [re-sequenced] for an
uneventful takeoff. We were given a number to call in flight, and after arriving at OAJ, I
spoke with a representative from CLT ATC. He informed me that neither us nor the Eagle
ERJ crew were at fault, and it was an error on the part of ATC.”
PHL – June 21, 2012
“We landed on RWY 26 in PHL and exited the runway at the end. We were told by tower
to cross RWY 35 at taxiway G, and then proceed to the ramp. As he is saying this I am
thinking to myself “is this runway open or closed?” As I taxied the aircraft over the hold
short line at taxiway G, I looked both ways, up and down the runway, to check for traffic.
As I looked left, toward the beginning of RWY 35, I noticed the lights of a DASH-8. I at
first couldn’t tell if the aircraft was moving so I stopped immediately. Before I could tell
the FO to make a radio call, or even make one myself, I noticed the DASH was actually
moving so I started flashing all the landing and taxi lights to get the pilots’ attention. I
also had the NAV, beacon, strobe and logo lights on. The DASH then rotated and took off
right in front of us. If we would have crossed the runway as instructed, there is a really
good chance we would have been hit. I then got ATC’s attention. All I said at first was
our call sign to get him to respond. He then instructed us again to cross the runway. I
said wait, and asked if he realized what had just happened. He was very surprised. After checking both ways again, we proceeded across the runway (with clearance) and parked at the gate
with no further incident.”