DL 300, operating SXM-JFK, had just landed on 22L, and was told to hold short of 22R. Instead of reading back the (mandatory) hold short instruction, they only answered the controller's second question ("what is your gate number?"), and continued across 22R.

Another DL aircraft had been cleared for takeoff on 22R by the other tower controller, and was forced to execute an aborted takeoff.

As usual, VASAviation has put together a good summary.

https://www.youtube.com/watch?v=oI2rJhd ... e=youtu.be

We talk in training about the "swiss cheese model" of accidents, where it takes multiple failures (holes) all lining up perfectly to cause an accident. On this one, a combination of quick thinking by the local controller working departures (22R) and/or acute awareness by the crew of the departing DL aircraft, and VFR conditions were about the only things preventing a disastrous outcome here.

This should be a stark reminder to all aviators of every level to be extra diligent when plans call for runway crossings. There is a reason the FAA (and I assume aviation regulatory agencies all over the world) are focusing on runway incursions.

Really scary. Such a little thing, but with potentially terrible results. Tenerife all over again. That swiss cheese analogy sure fits, all the odd little random holes lining up perfectly and then disaster strikes. I know pilots are people too, they are human, but how on earth do you cross an active runway without clearance??? And what happened to the CRM? Surely the other pilot must have realized something was amiss, yet didn't speak up.

I do think the controller was a little bit lax, though, when DL didn't repeat back the instruction to hold; maybe she was busy, rushed, and didn't pick up on it.

Not quite all the holes lined up this time, thank the Lord.

I think the controller will share some of the blame on this because she didn't call the crew out on not reading back "hold short 22R" then clearing DL253 for takeoff.

JEEEEEEEEEEEEZZZZZZZZ!!! Co pilot or captain DID NOT LOOK RIGHT SIDE COCKPIT WINDOW LOOK the runway if there is any plane activation rolling taking off or landing look at landing LIGHTS so BRIGHT! DUH!!! WOW!

Q

Local TV news in NYC is playing it up with ATC recording. The ATC Controller was very excited about what happened, the PIC pretty much said 'oops, my bad'. I suspect that some re-education for both the ATC Controller and pilots of DL 300 will be in order.

This and the AVIANCA incident in Miami are very troubling too: https://www.youtube.com/watch?v=jmTb8wv828g&t=1s

The read-back portion has to be enforced I think more strictly.

ltbewr wrote:

Local TV news in NYC is playing it up with ATC recording. The ATC Controller was very excited about what happened, the PIC pretty much said 'oops, my bad'. I suspect that some re-education for both the ATC Controller and pilots of DL 300 will be in order.

ATC might get re-educated; the pilots will likely get more than that. This was a clear pilot deviation, and not only that but they lied about what they said in the exchange afterwards (they never read back "clear to cross" as they said). These are airline pilots; their company is probably going to ground them for a while.

spacecadet wrote:

ltbewr wrote:

Local TV news in NYC is playing it up with ATC recording. The ATC Controller was very excited about what happened, the PIC pretty much said 'oops, my bad'. I suspect that some re-education for both the ATC Controller and pilots of DL 300 will be in order.

ATC might get re-educated; the pilots will likely get more than that. This was a clear pilot deviation, and not only that but they lied about what they said in the exchange afterwards (they never read back "clear to cross" as they said). These are airline pilots; their company is probably going to ground them for a while.

We're assuming that LiveATC recorded everything audio wise. For all we know, the pilot of DL300 did actually say "clear to cross" and ATC did not catch it.

I am going to reserve judgement until the moment we have more facts.

From a ATC point of you, if a correct read back isn’t received, it’s like nothing was issued. She made a mistake not solitciting a read back of hold short instructions. I also fault the technique of issuing an important clearance like a hold short and in the same transmission adding another question like that.

Q wrote:

JEEEEEEEEEEEEZZZZZZZZ!!! Co pilot or captain DID NOT LOOK RIGHT SIDE COCKPIT WINDOW LOOK the runway if there is any plane activation rolling taking off or landing look at landing LIGHTS so BRIGHT! DUH!!! WOW!

Q

Often when you cross 22R there’s an aircraft holding in position with strobe and landing lights on. It wouldn’t be out of the ordinary to look right and see an aircraft with lights. It would be difficult to determine if it was on takeoff roll unless it was well on it way.

I’m not arguing that looking both ways isn’t a deterrent to a runway incursion but the crew was likely used to crossing 4L/22R with a lit up aircraft holding in position.

24Whiskey wrote:

Q wrote:

JEEEEEEEEEEEEZZZZZZZZ!!! Co pilot or captain DID NOT LOOK RIGHT SIDE COCKPIT WINDOW LOOK the runway if there is any plane activation rolling taking off or landing look at landing LIGHTS so BRIGHT! DUH!!! WOW!

Q

Often when you cross 22R there’s an aircraft holding in position with strobe and landing lights on. It wouldn’t be out of the ordinary to look right and see an aircraft with lights. It would be difficult to determine if it was on takeoff roll unless it was well on it way.

I’m not arguing that looking both ways isn’t a deterrent to a runway incursion but the crew was likely used to crossing 4L/22R with a lit up aircraft holding in position.

Huh. Years ago watching aircraft at DFW, I noticed that AA, at least, didn't activate the landing lights until they received the takeoff clearance. Into position and hold, landing lights off. In position with strobes on but not landing lights. Takeoff clearance issued, landing lights come on and engines spool up. Understood that once the landing a/c is crossing the intersection, the takeoff clearance can be issued so one might see the landing lights on as one is crossing, but still...

Do not issue an order and a query in the same question. Both the DL300 pilot and the ground controller erred here.

Listened to the tape. Bad practice by the controller and the crew.

We either slow down or we accept some sloppiness in the system for expedience. Some of our largest airports are absolutely wild wild west on the frequency and ground ops. ORD, JFK, EWR, BOS. Just wild and fast.

I think this controller yelled at me once for not getting off 31L quick enough after landing. But if you give me instructions when still at 100 knots and full reverse I'm going to ignore you no matter how much pressure you're under to keep the op moving.

Demand fewer jets. Nothing smaller than a 320. Lighten the load. Have pilots monitor the frequency or check in only with their call sign. Reiterate every aircraft must give callsign and full feedback. Get everyone on the same frequency. Get smarter technology.

"Get smarter technology"

Like automating both the pilot and the controller function. That's how it will be in 50 or 100 years. Computers don't make mistakes. The only question is the timing.

Whew, they got lucky this time. Bad look for both sides here.

Having landed in JFK many times, I think often the controllers add to the risk of mistakes happening as they sometimes have very little patience, especially with foreign sounding pilots, and may get irritated very easily.

AirPacific747 wrote:

Having landed in JFK many times, I think often the controllers add to the risk of mistakes happening as they sometimes have very little patience, especially with foreign sounding pilots, and may get irritated very easily.

What do you believe is the source of the lack of patience/frustration comes from?

Bradin wrote:

AirPacific747 wrote:

Having landed in JFK many times, I think often the controllers add to the risk of mistakes happening as they sometimes have very little patience, especially with foreign sounding pilots, and may get irritated very easily.

What do you believe is the source of the lack of patience/frustration comes from?

I think it’s a New Yorker thing. It’s not the same in LAX, SFO and other major US airports where many foreign pilots also operate in and out of.

AirPacific747 wrote:

Bradin wrote:

AirPacific747 wrote:

Having landed in JFK many times, I think often the controllers add to the risk of mistakes happening as they sometimes have very little patience, especially with foreign sounding pilots, and may get irritated very easily.

What do you believe is the source of the lack of patience/frustration comes from?

I think it’s a New Yorker thing. It’s not the same in LAX, SFO and other major US airports where many foreign pilots also operate in and out of.

I am super curious now if LGA, ISP, and EWR have similar demeanours.

Bradin wrote:

AirPacific747 wrote:

Bradin wrote:

What do you believe is the source of the lack of patience/frustration comes from?

I think it’s a New Yorker thing. It’s not the same in LAX, SFO and other major US airports where many foreign pilots also operate in and out of.

I am super curious now if LGA, ISP, and EWR have similar demeanours.

Only landed in EWR once but from memory, it seemed similar to JFK

wjcandee wrote:

24Whiskey wrote:

Q wrote:

JEEEEEEEEEEEEZZZZZZZZ!!! Co pilot or captain DID NOT LOOK RIGHT SIDE COCKPIT WINDOW LOOK the runway if there is any plane activation rolling taking off or landing look at landing LIGHTS so BRIGHT! DUH!!! WOW!

Q

Often when you cross 22R there’s an aircraft holding in position with strobe and landing lights on. It wouldn’t be out of the ordinary to look right and see an aircraft with lights. It would be difficult to determine if it was on takeoff roll unless it was well on it way.

I’m not arguing that looking both ways isn’t a deterrent to a runway incursion but the crew was likely used to crossing 4L/22R with a lit up aircraft holding in position.

Huh. Years ago watching aircraft at DFW, I noticed that AA, at least, didn't activate the landing lights until they received the takeoff clearance. Into position and hold, landing lights off. In position with strobes on but not landing lights. Takeoff clearance issued, landing lights come on and engines spool up. Understood that once the landing a/c is crossing the intersection, the takeoff clearance can be issued so one might see the landing lights on as one is crossing, but still...

That’s standard practice at my current and former airline as well. It rapidly identifies whether or not you’re “only” holding in position or actually cleared for takeoff. That’s the intent, though sometimes it may be difficult to discern in the heat of battle.

AirPacific747 wrote:

Having landed in JFK many times, I think often the controllers add to the risk of mistakes happening as they sometimes have very little patience, especially with foreign sounding pilots, and may get irritated very easily.

And they use skads of non-standard terminology. It's one of the most-challenging controller positions, and that's usually the excuse given for their impatience and authoritarian attitude, but the reality is they're just acting like New Yorkers, and that seems to be tolerated by management here. ATL is also a demanding position, and the controllers there in general seem to be able to do their jobs in a more-traditional manner, with much more standard nomenclature. If you listen to an average ATL arrival controller during a very-busy period, they get it all out in standard form, and they are relentless about demanding and correcting readbacks, a lot of which are surprisingly-sloppy.

JFK has had many colorful controllers over the years. Their rapid-fire, angry instructions using non-standard terminology to foreign pilots, particularly the ones that can barely speak English, obviously can and likely does lead to mistakes. I have even heard them essentially mock some of those pilots. OTOH, they on balance do an amazing job, and many pilots will defend them up and down for their competence, if not their attitude. The incident controller does not seem to be one of their stronger ones, and did not appear to react to the unfolding incident in the most-effective manner.

Ground movement control at JFK is a bit of a disaster waiting to happen. Apportioning blame won't help anyone, nor will punishments. A just safety culture shouldn't work that way. It's best to establish the facts and ensure prevention in the future.

Obviously mistakes were made; the mention above of not adding any other questions to a hold short instruction is vital. The Delta pilots may well have been fatigued, things get missed. This was obviously an incident with the Tower frequency but JFK could do with a split ground frequency, the RT congestion doesn't help.

I probably only go to JFK a handful of times a year but it's a much heightened workload level compared with other busy airports. Hopefully this incident will instigate some beneficial change rather than just a witch hunt of people wanting to punish someone that made a genuine mistake that could befall any of us.

The controller is a bit to fast at speaking and proceeded without ensuring that the pilots read back what she said, but also we don't have the pilots being told (or reading back) anything about being allowed to cross (unless that was earlier on).

There are 2 controllers working 2 frequencies here. One is landing aircraft on 22L and subsequently crossing them, another is departing 22R traffic. We miss a few transmissions on the audio because of the overlap as liveatc monitors both at the same time.

Acey559 wrote:

That’s standard practice at my current and former airline as well. It rapidly identifies whether or not you’re “only” holding in position or actually cleared for takeoff. That’s the intent, though sometimes it may be difficult to discern in the heat of battle.

Too bad Skywest can’t be bothered to follow the AIM’s guidance when it comes to light usage. They just taxi around with their landing lights on all day, confusing everyone on the airport about what their intention is...

BA777FO wrote:

Ground movement control at JFK is a bit of a disaster waiting to happen. Apportioning blame won't help anyone, nor will punishments. A just safety culture shouldn't work that way. It's best to establish the facts and ensure prevention in the future.

Obviously mistakes were made; the mention above of not adding any other questions to a hold short instruction is vital. The Delta pilots may well have been fatigued, things get missed. This was obviously an incident with the Tower frequency but JFK could do with a split ground frequency, the RT congestion doesn't help.

I probably only go to JFK a handful of times a year but it's a much heightened workload level compared with other busy airports. Hopefully this incident will instigate some beneficial change rather than just a witch hunt of people wanting to punish someone that made a genuine mistake that could befall any of us.

And you think that failing to hold people responsible for negligence will help? I hate to burst your dreamworld bubble, but the threat of consequences is the only thing that keeps some people in line.

I am glad that you don’t work for the NTSB.

N766UA wrote:

There are 2 controllers working 2 frequencies here. One is landing aircraft on 22L and subsequently crossing them, another is departing 22R traffic. We miss a few transmissions on the audio because of the overlap as liveatc monitors both at the same time.

Acey559 wrote:

That’s standard practice at my current and former airline as well. It rapidly identifies whether or not you’re “only” holding in position or actually cleared for takeoff. That’s the intent, though sometimes it may be difficult to discern in the heat of battle.

Too bad Skywest can’t be bothered to follow the AIM’s guidance when it comes to light usage. They just taxi around with their landing lights on all day, confusing everyone on the airport about what their intention is...

In SkyWests defense (which is hard to do because of the things they do to the industry), on a CR2, the taxi lights are garbage, which is where I’m sure that practice originated from at OO.

In ATC, the hearback is just as important as the readback.

The FAA is super focused on runway incursions, as they should be. I would not be surprised if there is a change in phraseology that states that a hold short instruction can not be combined with any other type of question or clearance (gate assignment, routing question etc.). I will not Monday morning quarterback this but I'm glad to see that with all of the back-ups in the system like ASDE-X alarms, other controllers in the cab looking out over the field as well as all of the pilots having their heads up and out the window, an accident did not happen. As long as humans are apart of the system there will be errors unfortunately.

N766UA wrote:

There are 2 controllers working 2 frequencies here. One is landing aircraft on 22L and subsequently crossing them, another is departing 22R traffic. We miss a few transmissions on the audio because of the overlap as liveatc monitors both at the same time.

Acey559 wrote:

That’s standard practice at my current and former airline as well. It rapidly identifies whether or not you’re “only” holding in position or actually cleared for takeoff. That’s the intent, though sometimes it may be difficult to discern in the heat of battle.

Too bad Skywest can’t be bothered to follow the AIM’s guidance when it comes to light usage. They just taxi around with their landing lights on all day, confusing everyone on the airport about what their intention is...

Ha I was on a deadhead in a window seat the other day and they were taxiing around with the landing lights on (it was a -175). I had a good laugh. They were serial offenders in broad daylight when I worked ramp back in college. Multiple times I just walked away until they figured it out. Then I’d finish marshaling them in.

Nomadd wrote:

BA777FO wrote:

Ground movement control at JFK is a bit of a disaster waiting to happen. Apportioning blame won't help anyone, nor will punishments. A just safety culture shouldn't work that way. It's best to establish the facts and ensure prevention in the future.

Obviously mistakes were made; the mention above of not adding any other questions to a hold short instruction is vital. The Delta pilots may well have been fatigued, things get missed. This was obviously an incident with the Tower frequency but JFK could do with a split ground frequency, the RT congestion doesn't help.

I probably only go to JFK a handful of times a year but it's a much heightened workload level compared with other busy airports. Hopefully this incident will instigate some beneficial change rather than just a witch hunt of people wanting to punish someone that made a genuine mistake that could befall any of us.

And you think that failing to hold people responsible for negligence will help? I hate to burst your dreamworld bubble, but the threat of consequences is the only thing that keeps some people in line.

I'm glad you're not responsible for aviation safety anywhere, although maybe some despotic regimes in the world could use your input.

Go google "just safety culture" and educate yourself. You hold people responsible for malicious intent, not for honest mistakes that could befall anyone, especially with the prevelance of fatigue these days. You encourage honest and open reporting in order to prevent future disasters, not make people cover things up for fear of reprisal. If you worked for any airline worth its salt you'd you know that though.

It’s interesting that controller instructed pilot to hold short of 22R and, when asked which gate he was heading to, he responded 22. Maybe controller thought she heard the hold 22R read back. I agree if things weren’t clear she should’ve asked for another read back and pilot shouldn’t have crossed without clearance.

IMO, the controller and pilots will keep their jobs, but I'd be surprised if a reprimand wasn't put in their personnel records. No merit or SSP increase on the ATC side. Don't know how DL HR would handle it.

Apparently, that video doesn't include a previous transmission of an initial instruction to DL, followed by a correct readback, that they are to hold short. Then, as DL approaches the departing runway, she again tells them to hold short and asks them the gate number. That's a little-different circumstance from what we understood.

The tape has two female controllers who sound similar, but enunciate differently. One is the departing runway controller, one is the arriving runway controller. As mentioned, because LiveATC is montoring two frequencies, we miss some simultaneous activity, including the departure controller cancelling takeoff clearance when she sees the incursion. The arriving runway controller just yelling out the flight number isn't particularly effective at anything. If you look at the video, the author actually identifies which controller is speaking by identifying the frequency that they're on.

The pilots will file an FSAP which is protected and the controller will file their equivalent which is protected. The FAA will respond to the FSAP and life will go on. There will be no retraining or grounding or letter of reprimand for the pilots......I can’t speak for the controller because I don’t know how their self reporting system works.

The worst the pilots will get is a letter of correction from the FAA which is the equivalent of them saying you know and We know you screwed up.

Dumb question, but aren't there some types of airfield lighting systems that are used in places as a visual indicator in addition to ground control clearances to visually give a go/no-go indicator to runway crossings. I can't remember which airports I've seen this system at but I know they exist. Why aren't they used more at airports that require crossing active runways?

JFK controllers are notorious for sloppy radios from every person I've talked to based there and the terrible design of the airport doesn't help at all. It seems like the entire airport is a gigantic hotspot for runway incursions.

Just from listening to the audio from this event, could the controller pick a worse time to ask about a gate? It seems like that info can wait until after the aircraft is on the other side of an active runway.

Does anyone know if the gate info is on the ACARS or if it is usually printed out? Being heads down looking for a gate number while hearing a controller say 22 makes it very possible to think you're heard cleared to cross 22R

We need Kennedy Steve back

PSU.DTW.SCE wrote:

Dumb question, but aren't there some types of airfield lighting systems that are used in places as a visual indicator in addition to ground control clearances to visually give a go/no-go indicator to runway crossings. I can't remember which airports I've seen this system at but I know they exist. Why aren't they used more at airports that require crossing active runways?

RWSL.

https://www.faa.gov/air_traffic/technology/rwsl/

Apparently installed in one place at JFK, but I'm assuming not where this incident took place, or that I'm misunderstanding the graphic.

https://www.faa.gov/air_traffic/technol ... ia/JFK.pdf

N766UA wrote:

There are 2 controllers working 2 frequencies here. One is landing aircraft on 22L and subsequently crossing them, another is departing 22R traffic. We miss a few transmissions on the audio because of the overlap as liveatc monitors both at the same time. ...

Is that standard practice at JFK, the 22L controller is the one issuing clearances to cross 22R, while the other controller is issuing takeoff clearances on 22R? With proper coordination it could work but it makes more sense to have each controller manage their own territory.

Not saying that is what caused the incursion, just trying to be objective.

At least here at BOS the controller that has the runway is the one issuing runway crossings for that runway. One exception I have heard is if someone is lined up 15R (non-standard runway) and traffic is taxiing to 22R, the ground controller may issue a crossing on N if the lined up aircraft isn’t close to departing due to landing traffic etc.

As mentioned the liveatc recording had both frequencies so something likely was missed.

ATCSuggester wrote:

The FAA is super focused on runway incursions, as they should be.

They should have stop bars then, and pilots only enter a runway when stop bars go out.

AirWorthy99 wrote:

The read-back portion has to be enforced I think more strictly.

Yeah, it seems we forget this is one of "must-do" readbacks. If it didn't happen in readback, it was not copied at all.

Blame on both, but still while pilot's the one to start the problems, it's controller to blame on this one, I'd say.

Cheers,
Adam

zeke wrote:

ATCSuggester wrote:

The FAA is super focused on runway incursions, as they should be.

They should have stop bars then, and pilots only enter a runway when stop bars go out.

What are stop bars? I'm thinking something like a stop light except on the taxiway.
Nm, I Googled it.

Yes, major airports like JFK, BOS, ORD, DFW, etc. should have these. I'm sure they are not cheap but it's got to be worth it, right? Even if they prevent one potential disaster.

zeke wrote:

ATCSuggester wrote:

The FAA is super focused on runway incursions, as they should be.

They should have stop bars then, and pilots only enter a runway when stop bars go out.

I would be surprised if JFK did not have them already.

I asked this question earlier - here is the response on RWSL

ryanov wrote:

PSU.DTW.SCE wrote:

Dumb question, but aren't there some types of airfield lighting systems that are used in places as a visual indicator in addition to ground control clearances to visually give a go/no-go indicator to runway crossings. I can't remember which airports I've seen this system at but I know they exist. Why aren't they used more at airports that require crossing active runways?

RWSL.

https://www.faa.gov/air_traffic/technology/rwsl/

Apparently installed in one place at JFK, but I'm assuming not where this incident took place, or that I'm misunderstanding the graphic.

https://www.faa.gov/air_traffic/technol ... ia/JFK.pdf

I also find it a bit coincidence after listening to the recording that they were instructed to hold short of 22R and also headed toward gate 22.

Also, according to the graphic, there should be RWSL at taxiway Juliet crossing 22R

RWSL is no panacea. Given that it's automatic, it's gonna depend on sensors and logic to work correctly, and I imagine that it needs testing and refinement before it works with the highest degree of reliability. If it is often wrong, it will clog up the operation with requests to ignore it. If it usually works correctly, people will start depending upon it despite what their actual clearance is.

N766UA wrote:

Too bad Skywest can’t be bothered to follow the AIM’s guidance when it comes to light usage. They just taxi around with their landing lights on all day, confusing everyone on the airport about what their intention is...

If the Skywest FOM says they’re required to taxi around with all the lights on, not doing so is a violation, AIM be damned.


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Agree that it's a coincidence with runway number being same as gate number "22". Maybe airports should not have gate numbers that are also runway numbers.