May 2008 CLT Runway Incursion Update

surreal1221 said:
Unreal.

She lost SA on that one. Although, 9DR should have had the sense to at least look down the runway before taxing into position - hell - if only they had been listening they would have realized someone else was coming their way.

Controller's fault though.
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In the end, yes it was the controller's screw up, but I think it's a little unfair to say that "she" lost SA. Everybody's SA was gone. The PC12 crew should have heard the TO clearance, and the CRJ should have heard the PC12's clearance.

I'd also put a lot of blame on the PC12 pilot. All he said was "position and hold 9DR" If he had included the runway number, perhaps the CRJ would have caught it. That's why proper RT is so important. It's designed to save lives, but when people make up their own RT "standards" as they go along, we have things like this happen.

It seems she thought that the PC12 was at the threshold of 18L, as she advised them of traffic arriving on 23. IDK how the flight strips are set up. perhaps the PC12 was the next strip and it didn't indicate that they were holding short downfield?
 
Chief Captain said:
Scary indeed. I thought the proper phraseology was something like "N409DR, RW18L, taxi into position and hold via intersection A". Isn't that how it's done elsewhere?
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Yes. O'Hare uses a T10 intersection departure off 32L all the time, and they *never* give you position and hold without the intersection. Not hearing the taxiway would be a big red flag.
 
pfitmx15 said:
Hey guys I apologize if this is a stupid question but what happens after an event like this. It sounded as if she was sending the crew back to 18 (Holding short of 23) to take off again. Would you not cancel the flight and an investigation ensue? Or would you just collect yourself and go ahead and depart?
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Anytime we have a rejected takeoff, dispatch has to complete a FAIR (Flight and Airline Incident Report) with all the pertinent information. Who, what, where, when, how, why, etc ... I suppose it would be up to the crew as to whether or not they wanted to continue, but from dispatch's standpoint there is no reason to cancel the flight.
 
ozziecat35 said:
All 3 parties involved have their part to blame....9DR should have had better SA, 390 should have caught on when TWR cleared the Pilatus onto the same rwy...though she didn't mention they were an intersection departure. I totally agree the TWR controller was useless once the alarm went off.



Wow, scary stuff.
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I dunno that the CRJ crew should have caught on at that point in the takeoff roll. One guy has their head down for a second while setting thrust (or verifying thrust is set), checking the EICAS for abnormal anything, checking speed, scanning back out of the aircraft and then probably back down again for a second. All the while, they both hear somebody else go into position and hold, which is completely normal to hear as soon as you start rolling. As soon as we were cleared for takeoff almost anywhere, the next guy was getting lined up right behind us.

The Pilatus crew, on the other hand, should have realized that somebody else had just been cleared for takeoff on 18L, and even if they couldn't see them, something should have told them to step on the brakes before they got onto the runway.

In the end, it's the controllers fault without a doubt, but I wouldn't put any blame on the CRJ crew. Frankly I'm surprised they didn't go off the side of the runway. I'd generally take off roading in an RJ at 60 knots over hitting another airplane head on at 60 knots. The captain was probably just the right combo of lucky and good to miss that guy by 10 feet.
 
".....and prior to taxi clearance, sterile cockpit, and listen up for clearances for other aircraft."

"......clear left, clear right, final is clear, and we are crossing the line."

Always, with all my students! Here in Jeddah the students don't quite get why they should stop before the hold short line. They think that if they pull right up to the line it means they will get a clearance to depart sooner. I know it doesn't make a difference where they stop as long as they stop before the hold short line. But i figure if they have a healthy distance and respect for the hold short line then it might stay with them.

A few days ago a student and I taxied to rwy 34C, and got a "hold short rwy 34C" command and gave the readback. Student asks what is taking so long and could we just go. We are on the east side of 34C and I can see final so I ask him if he can think of any reason why we should not go. He says, in his most serious voice, "No." So I ask him to clear right and clear left. And with perfect timing a 777 roars by as he is turning to look left.

Slammed home a bit of ground training we had just done on listening to other clearances and SA prior to departure and cemented that lesson for me.

Not sure if that would have helped prevent this close call, but in my VERY short time it has kept my shorts clean since I started flying. I hope we can all be safe out there!!
 
pfitmx15 said:
Hey guys I apologize if this is a stupid question but what happens after an event like this. It sounded as if she was sending the crew back to 18 (Holding short of 23) to take off again. Would you not cancel the flight and an investigation ensue? Or would you just collect yourself and go ahead and depart?
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The flight wouldn't be cancelled, but would have been delayed. I'd definately be fililng out paperwork and calling the company, after parking the aircraft. Possibly on a remote ramp. Depending on weight, speed, and braking you may also need to consult your brake cooling charts. The last thing you would want is not enough braking ability for a second abort.
 
jtrain609 said:
I dunno that the CRJ crew should have caught on at that point in the takeoff roll. One guy has their head down for a second while setting thrust (or verifying thrust is set), checking the EICAS for abnormal anything, checking speed, scanning back out of the aircraft and then probably back down again for a second. All the while, they both hear somebody else go into position and hold, which is completely normal to hear as soon as you start rolling. As soon as we were cleared for takeoff almost anywhere, the next guy was getting lined up right behind us.
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When you're VMC especially in a Terminal Environment your head needs to be on a swivel. I don't care if you're flying a jet or a 172. I've never flown a jet so I know I'm going to catch crap on this but the CRJ crew is to blame also. They trusted the control 110% and left no doubt in her instructions. <-Bad.
 
As a controller I have seen this video previously and it scares the you know what out of me.

This is all my opinion and mine alone I don't know anything other than the video.

I am thinking the PC12 pilot was a little too focused on his instructions and not paying attention to anything else, the CRJ pilots for the most part did nothing wrong they were the ones who prevented this horrible tradgedy because the controller froze up, but IMO this has to fall on the controller. The excuse that maybe she didn't know is BS you can't put somebody on the runway without knowing where they are. From her transmission about the 23 traffic she obviously wasn't thinking intersection departure(23 is a non-factor for 18L at A). Only other thing I can think of is maybe ground never told Local about the intersection departure, that may mitigate her blame somewhat but not all the way.
 
jhugz said:
When you're VMC especially in a Terminal Environment your head needs to be on a swivel. I don't care if you're flying a jet or a 172. I've never flown a jet so I know I'm going to catch crap on this but the CRJ crew is to blame also. They trusted the control 110% and left no doubt in her instructions. <-Bad.
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Jhugz, there is no way you can fault the CRJ crew especially since the controller didn't even use the correct terminolgoy. I can't tell you how many times I have been cleared for take and hear during the take off roll Brand X 123 position and hold. It is not even a second thought as it is routine at the major airports. Once aircraft 1 is rolling aircraft 2 is put into position on the runway. The only way the CRJ crew would have had a chance is if the controller said 9DR position and hold runway 18L at intersection A. Then if the crew was familiar enough with airport they may have caught it. You can't exactly check a taxi chart as your flying down the runway.

Also in a jet there is a lot going on. The Pilot Flying is flying the aircraft and responding to the callouts while the PNF is making the call outs and setting the power for takeoff.

E.g.

Brand X 123 Cleared for Take 18L

Cleared for Takeoff 18L Brand X 123

(keep in mind that the PNF is also monitoring the engine insturments and checking to see that certains systems that are supposed to ARM during the takeoff roll ARMED)

PF: Advances Thrust Levers to 1.4 EPR and waits for them to stabilize onces stabilized and engine instrument agree (EPR, N1, N2, EGT, FF) the PF advances the power to near max thrust and calls set max thrust

PNF: Sets max thrust and calls max thrust set

PNF: now calls airspeed as the airspeed comes alive

PF: Checks his airspeed and responds checked

PNF: 80 knots

PF: checks airspeed again and responds checked

PNF: V1/VR

PF: Starts Rotates

PNF: V2

PNF: Positive Rate

PF: Gear up
 
I do not fault the CRJ crew at all. The controller did not state an intersection takeoff for the PC12 crew so there was not any indication to the CRJ crew of the conflict. I give the PC12 crew a very close second on the fault scale. I do not know how they did not catch they were taking a runway with an airplane on the way to hit them.

Brian
 
jhugz said:
When you're VMC especially in a Terminal Environment your head needs to be on a swivel. I don't care if you're flying a jet or a 172. I've never flown a jet so I know I'm going to catch crap on this but the CRJ crew is to blame also. They trusted the control 110% and left no doubt in her instructions. <-Bad.
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If the controller gives an aircraft after you position and hold on the same runway you're departing from, there's *no* indication there would be an airplane further on down the runway. They stopped as soon as they saw the conflict and saved a bunch of people....I fail to see the blame.
 
jhugz said:
When you're VMC especially in a Terminal Environment your head needs to be on a swivel. I don't care if you're flying a jet or a 172. I've never flown a jet so I know I'm going to catch crap on this but the CRJ crew is to blame also. They trusted the control 110% and left no doubt in her instructions. <-Bad.
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Why do you feel the need to say stuff like this? Do you have any self control?
 
Chief Captain said:
In the end, yes it was the controller's screw up, but I think it's a little unfair to say that "she" lost SA. Everybody's SA was gone. The PC12 crew should have heard the TO clearance, and the CRJ should have heard the PC12's clearance.

I'd also put a lot of blame on the PC12 pilot. All he said was "position and hold 9DR" If he had included the runway number, perhaps the CRJ would have caught it. That's why proper RT is so important. It's designed to save lives, but when people make up their own RT "standards" as they go along, we have things like this happen.

It seems she thought that the PC12 was at the threshold of 18L, as she advised them of traffic arriving on 23. IDK how the flight strips are set up. perhaps the PC12 was the next strip and it didn't indicate that they were holding short downfield?
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A readback of runway number and intersection would have probably also alerted the controller of her error. That is why I think its good practice to read back runway and intersection number if doing an intersection departure, even if the controler does not give the clearance with the intersection number.
 
Chief Captain said:
I'd also put a lot of blame on the PC12 pilot. All he said was "position and hold 9DR" If he had included the runway number, perhaps the CRJ would have caught it. That's why proper RT is so important. It's designed to save lives, but when people make up their own RT "standards" as they go along, we have things like this happen.
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:yeahthat:
 
jynxyjoe said:
Why do you feel the need to say stuff like this? Do you have any self control?
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I do have self control champ but since you don't drop me another PM and turn your epaulets back around.

I'm not trying to blame the RJ solely I just don't feel he is free of blame. He taxied past the traffic that would have positioned behind and I believe it was a Hawkeye(?) followed by a Corporate Jet.

If I'm taxing past the traffic that will be behind me and I don't see a PC-12 then I hope to hell I would realize what is going on if they get a call telling them to position and hold. 1+1=2. No PC-12 behind me so where the hell is it?

Any traffic holding short should be noted before the roll if possible and an eye should be kept on them. Which to their credit sounded like it happened and prevented a disaster. Just because their actions did prevent an accident doesn't mean they are free from critique. Just like I along w/ others made comments about the sterile through 10 on the Hudson Landing.
 
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