CLT runway incursion. It's okay to raise your voice.

[Pilot Fighter]

The controller made a mistake, but had the Pilatus pilot used standard phraseology, this would probably never have happened. She obviously thought the pc12 was full length. Had he responded properly (runway 18L at Alpha, position and hold) I'm willing to bet that somebody would have caught it.

It's the little things that can kill you...

I don't know if that's standard phraseology for an intersection takeoff, but it's certainly the call I'd make. Many are in the habit of echoing a controller instruction. My paranoia is apparent in my non-standard calls, as I try to leave less to chance. It probably pisses some controllers off, but I often mention potential conflicts in a response or make safety oriented requests. If aware, in response to my clearance I'd throw in, "understand Pilatus409 holding short of my 18L at alpha". If I am aware of a student pilot on a taxiway that could turn onto my active, I've asked for a full stop, before accepting takeoff clearance. I really don't care what anybody thinks of me.

 

[jeflies]

If I'm in the Pilatus, though, I'm thinking "wait a minute, didn't she just clear someone for takeoff on 18L?" ... but then, I don't fly big stuff, so I have a lot more time to myself to listen for such things. Regardless, kudos to both crews for not making a big mess.

-Fox

This is why I pay attention to my call sign as well as the others around me. It's all part of that situational awareness pie. Glad this wasn't any worse than it was.



Sent from my iPhone

 

[genot]

That one sits squarely on the controller. I could hear within the first 30 seconds of audio from local talking to AWE1989 the tell tale voice quiver that means "Oh yeah. She's down the tubes." I've never worked a tower so I don't have any insight as to how that happened. I have gathered from how many wrong squawks get airborne that ASDE-X isn't an extremely popular screen for the swivelheads to check out though.

I really appreciate pilots personally who speak up when there is a question like Pilot Fighter alluded to, within reason. If its what altitude was that again, what runway is the guy I have in sight going to, I welcome it. That doesn't piss us off at all.

The one thing I've noticed in that tape and at least one other (and in hearing my own emergency tapes) is when you hear shouting in the background and non standard phraseology is being used where it wasn't before, its not OPS normal. Being on my side of the radio I understand it, but every time I see it in an example like this it seems like it rarely registers with the pilots. Although I'm pretty sure 99% of the time it does and the 1% it doesn't we end up with something like this so these rare occasions appear more prevalent.

 

[BobDDuck]

I really appreciate pilots personally who speak up when there is a question like Pilot Fighter alluded to, within reason. If its what altitude was that again, what runway is the guy I have in sight going to, I welcome it. That doesn't piss us off at all.

Sometimes it does. We've all heard the tapes from PVD. The controller there got very annoyed with the AAA crew (correctly) questioning her clearance. I've been had Potomac get pretty frustrated with me before because despite questioning my clearance 3 times with DCA Tower (who finally just said "fly what I told you" I ended up going the wrong way.

That said, for every example I gave above I could probably give 20 more for times where the controller ended the conversation with "thanks for double checking".

 

[FM_Weasel]

I agree, it is clear to me as well. I just wonder if she was clear on what she was instructing the Pilatus to do. Usually (but not required??) the Position and Hold instruction is preceded by "taxi into" which I think she omitted. I wonder if she thought she was telling the Pilatus to Hold Short but used the wrong phraseology? In which case, if there is any doubt on my part or notice a conflict, your advice to confirm is spot on, especially at an intersection with landing and departing traffic.

It was proper phraseology. The evolution of Line Up and Wait verbiage changed over many years. It went:

Runway XX Taxi into Position and Hold >

Runway XX Position and Hold >

Runway XX Line Up And Wait

Her phraseology was appropriate for the time of this recording. It was exactly the right wording to place the Pilatus and Bluestreak in a very unsafe situation.

The aircraft being assigned an intersection by ground control would have been notated on a flight strip or verbally passed to local (tower) control. They were likely informed that this aircraft was going to an intersection but it was forgotten. Follow that with the pilot not checking in at an intersection, ATC not issuing an intersection "Position and Hold," and the pilot accepting the instruction without question (and without noticing that someone else had been cleared full length on that runway, assuming they were already on frequency.)

Bluestreak wouldn't have had any reason to think something had gone wrong. If they had heard the Position and Hold instruction without an intersection, their assumption would be that the airplane was taxiing into position behind them, not much farther down the runway.

 

[Pilot Fighter]

We weren't talking out the instruction change, we were talking about whether the PC-12 should have echoed the clearance or added his location, "18L at alpha". The controller screwed up, but I think I would have caught it if I was Bluestreak or the Pilatus. My ear is tuned to my call sign and any reference to my runway. I think that the words "full runway takeoff" and "intersection runway takeoff" should be used more. In the case of CLT, they had a bunch of safeguards in place to make intersection takeoffs safer, all ignored.

 

[A150K]

One of the many downsides of intersection takeoffs...

 

[bronco21016]

Terrifying.

I was recently (Decemberish?) line up and wait on 21R at DTW when an RJ was cleared for take off and while on the roll another RJ missed the turn at taxiway M and found his way out onto 21R in front of the rolling aircraft. Luckily the crew on the take-off roll and ATC both caught it and disaster was averted. Horrifying to see a close call like that then be cleared for take off right after they're clear of the runway.

I think a lot of guys who fly for a living in busy 121/135 environments get way to used to listening to everything ATC says and its easy to get complacent so they don't watch out the window to see what's going on. Keep your eyes and ears open out there!

 

[FM_Weasel]

We weren't talking out the instruction change, we were talking about whether the PC-12 should have echoed the clearance or added his location, "18L at alpha". The controller screwed up, but I think I would have caught it if I was Bluestreak or the Pilatus. My ear is tuned to my call sign and any reference to my runway. I think that the words "full runway takeoff" and "intersection runway takeoff" should be used more. In the case of CLT, they had a bunch of safeguards in place to make intersection takeoffs safer, all ignored.

cyas2003 was specifically talking about the omission of the words "taxi into." I even quoted their post.

Specification of the intersection in a takeoff clearance is mandatory. It wasn't issued because the controller mistook the pilatus for being at the runway end. Additionally, if someone is holding short at an intersection, the full length departure must be told "full length, cleared for takeoff." Still moot if the controller doesn't understand that someone's at the intersection to begin with.

 

[Chief Captain]

We weren't talking out the instruction change, we were talking about whether the PC-12 should have echoed the clearance or added his location, "18L at alpha". The controller screwed up, but I think I would have caught it if I was Bluestreak or the Pilatus. My ear is tuned to my call sign and any reference to my runway. I think that the words "full runway takeoff" and "intersection runway takeoff" should be used more. In the case of CLT, they had a bunch of safeguards in place to make intersection takeoffs safer, all ignored.

I just looked at the 7110, and it seems that I was incorrect. I don't see any specific requirement for the controller to say "runway 18L at Alpha". I've noticed that every time I do an intersection departure, the controller always uses that phraseology. Would this be a facility specific requirement?

 

[ppragman]

I don't think standard phraseology would have helped - a "18L at A" could have cued the Bluestreak crew, but more than likely they were busy doing their "below the line" or whatever. I think things would have been the same. Also, that's a hard angle to clear from the left seat of a PC-12 without really cranning your neck or having some of the passenger windows open and the seat un-occupied.

Relevant Youtube video:

 

[Pilot Fighter]

I just looked at the 7110, and it seems that I was incorrect. I don't see any specific requirement for the controller to say "runway 18L at Alpha". I've noticed that every time I do an intersection departure, the controller always uses that phraseology. Would this be a facility specific requirement?

I found an FAA training document that does use this verbiage, along with mention of full runway and intersection takeoff in clearances if intersection takeoffs are in-use.

I have noticed that some controllers randomly throw in "full runway" even in cases when there is no intersection takeoff, much to my dismay, forcing me to ask if there is a pending intersection takeoff on my runway.

I'm in a fancy 20 million dollar jet but if I'm confused, I will pull out my "explain it like I'm five" request.

 

[FM_Weasel]

I don't think standard phraseology would have helped - a "18L at A" could have cued the Bluestreak crew, but more than likely they were busy doing their "below the line" or whatever. I think things would have been the same. Also, that's a hard angle to clear from the left seat of a PC-12 without really cranning your neck or having some of the passenger windows open and the seat un-occupied.

Proper phraseology from the Pilatus may have helped. If the Pilatus had properly read back "18L at Alpha position and hold," it may have been caught.

I just looked at the 7110, and it seems that I was incorrect. I don't see any specific requirement for the controller to say "runway 18L at Alpha". I've noticed that every time I do an intersection departure, the controller always uses that phraseology. Would this be a facility specific requirement?

7110.65 3−9−9. TAKEOFF CLEARANCE

b. When clearing an aircraft for takeoff from an
intersection, state the runway intersection.

PHRASEOLOGY− RUNWAY (number) AT (taxiway designator) CLEARED FOR TAKEOFF.

c. When two or more aircraft call the tower ready
for departure, one or more at the full length of a
runway and one or more at an intersection, state the
location of the aircraft at the full length of the runway
when clearing that aircraft for takeoff.

PHRASEOLOGY− RUNWAY (number), FULL LENGTH, CLEARED FOR TAKEOFF.

7110.65 3−9−4. LINE UP AND WAIT (LUAW)

n. When authorizing an aircraft to line up and wait
at an intersection, state the runway intersection.

PHRASEOLOGY− RUNWAY (number) AT (taxiway designator), LINE UP AND WAIT.

o. When two or more aircraft call the tower ready
for departure, one or more at the full length of a
runway and one or more at an intersection, state the
location of the aircraft at the full length of the runway
when authorizing that aircraft to line up and wait.

PHRASEOLOGY− RUNWAY (number), FULL−LENGTH, LINE UP AND WAIT.

EDIT: multiple edits

 

[greg1016]

All this phraseology talk is moot. She demonstrated a lack of situational awareness when she cleared the pc-12 onto the runway. My guess is she thought it was a full length departure and didn't see the pilatus at the intersection. This may have been completely her fault or there may have been other contributing factors such as incomplete or erroneous coordination and visibility (think obstructions or time of day more than meteorological conditions. Not to make excuses because she definitely could have prevented it.

 

[TripSix]

All this phraseology talk is moot. She demonstrated a lack of situational awareness when she cleared the pc-12 onto the runway. My guess is she thought it was a full length departure and didn't see the pilatus at the intersection. This may have been completely her fault or there may have been other contributing factors such as incomplete or erroneous coordination and visibility (think obstructions or time of day more than meteorological conditions. Not to make excuses because she definitely could have prevented it.

The redundancies are built in for a reason. Often when investigating situations like these there are numerous contributing factors.

You know those pictures the agency likes to plaster all over the place with the slices of Swiss cheese lined up showing a line going through all of them? This is a perfect example of that concept.

Sometimes you can squarely shoulder the fault on a single act. This isn't one of those times. Attempting to do so results in those infamous "effective immediately" notices - that often do NOTHING to address an actual problem, but serve rather to contain one single result...

 

[jtsastre]

Does anyone know if the controller was subsequently fired for the event?

Jtsastre

 

[rd757]

Does anyone know if the controller was subsequently fired for the event?

Jtsastre

I doubt it. We had a controller who at our local Class D who had several OE's that resulted in losses of separation. They were recently transferred out of our facility and sent somewhere else, but not terminated.

 

[BobDDuck]

Does anyone know if the controller was subsequently fired for the event?

Jtsastre

She was back within a few weeks I think. I've had multiple issues with her issuing less than clear (non standard phraseology) instructions and both go arounds I did in the last year were because of her (and a 330 that wanted to roll all the way to the end). There are weaker controllers just like there are weaker pilots. I'd say she gets the job done, but certainly not as well as some of the other controllers in the facility.

 

[jtsastre]

I know they're allowed some leniency, just wasn't sure to what extent. This event is similar to the LAX accident with SkyWest and Airways, but obviously a different conclusion due to lives being lost.

Jtsastre

 

[greg1016]

She was back within a few weeks I think. I've had multiple issues with her issuing less than clear (non standard phraseology) instructions and both go arounds I did in the last year were because of her (and a 330 that wanted to roll all the way to the end). There are weaker controllers just like there are weaker pilots. I'd say she gets the job done, but certainly not as well as some of the other controllers in the facility.

When we are involved in deals where separation is lost we usually get up to 9 weeks (I think) of administrative leave, and I think psychological counselling. I don't know first hand. I say involved because in non-radar environment, you could have an error and not know it until 2 or 3 hours after the mistake was made.

Does anyone know if the controller was subsequently fired for the event?

Jtsastre

ATSAP was implemented before I was hired, in the past controllers were reprimanded, decertified and received re-training when they had deals. This lead to a lot of deals not being reported, but I don't believe one offence was cause for removal. Now, because of ATSAP, we are pretty much immune from termination because the agency is much more concerned with finding the cause of errors and determining ways to prevent them. This is the reason why you read about an increase in errors in the news, simply because more are being reported. Termination/Decertification only happens in cases of extreme negligence (or intentional acts). I have only heard of decertification happening once since ATSAP, and it was an unusual case.