Lessons Learned...Or Not

[Clark]

I have been reviewing a few runway incursions recently and a few
recurring themes have popped up, and not the good kind.

1. In CLT, an RJ was cleared for takeoff on 18L and subsequently a
Pilatus was cleared to taxi into position on the same runway, further
down at an intersection. Fortunately CLT has the ASDE-X, which alerted
the Controller to the developing conflict. The RJ rejected the takeoff
at 143 knots and narrowly missed the Pilatus. 50 plus people could
have perished. While listening to the ATC tapes, there was a
disappointing lack of standard terminology. The controller and the
Pilatus pilot did not transmit the intersection involved for the
clearance, which was an important mental clue for all of the actors in
this event, especially the controller and RJ crew. CLT is a busy
airport, lots of things going on, very challenging for a controller
managing intersecting runways and mixing air carriers with GA
airplanes that can use shorter runways with intersection departures.
So a Lesson to Learn here is to be on our toes when we see airports
with runway layouts like this, and a mix of GA and Air Carrier
traffic, simultaneous intersecting runway departures and intersection
departures. Full readbacks and identification of your location on the
airport, especially a runway, is critical to survival. We lost some
folks in STL not too long ago and almost a full DC-9, at night, during
a frighteningly similar scenario.

Another Lesson Not Learned here is that the RJ had its forward facing
lights illuminated, as recommended by AC 91-73A Subject: PART 91 AND
PART 135 SINGLE-PILOT PROCEDURES DURING TAXI OPERATIONS as a signal
that it is taking off. Another aircraft took the runway in spite of
that, which tells me that this AC is not universally understood. Many
air lines have adopted the recommendations but many others have not
and who knows what the level of knowledge and adoption is in the GA
community.

AC 91-73A
9/26/03
10. USE OF EXTERIOR AIRCRAFT LIGHTS TO MAKE AIRCRAFT MORE
CONSPICUOUS.
a. General.
(1) Exterior aircraft lights may be used to make an aircraft operating
on the airport surface more conspicuous. Pilots may use various
combinations of exterior lights to convey their location and intent to
other pilots. Certain exterior lights may also be used in various
combinations to signal whether the aircraft is on a taxiway or on a
runway, in position on the runway but holding for takeoff clearance,
crossing an active runway, or moving down the runway for takeoff.
(2) Because adherence to the guidelines in this AC are voluntary and
aircraft equipment varies, pilots are cautioned not to rely solely on
the status of an aircraft’s lights to determine the intentions of the
pilot(s) of the other aircraft. Additionally, pilots must remember to
comply with operating limitations on the aircraft’s lighting systems.
b. Exterior Lights. To the extent possible and consistent with
aircraft equipage, operating limitations, and pilot procedures, pilots
should illuminate exterior lights as follows:
(1) Engines Running. Turn on the rotating beacon whenever an engine is
running.
(2) Taxiing. Prior to commencing taxi, turn on navigation, position,
anti-collision, and logo lights, if available. To signal intent to
other pilots, consider turning on the taxi light when the aircraft is
moving or intending to move on the ground, and turning it off when
stopped, yielding, or as a consideration to other pilots or ground
personnel. Strobe lights should not be illuminated during taxi if they
will adversely affect the vision of other pilots or ground personnel.
(3) Crossing a Runway. All exterior lights should be illuminated when
crossing a
runway.
CAUTION: Pilots should consider any adverse effects to safety that
illuminating the forward facing lights will have on the vision of
other pilots or ground personnel during runway crossings.
(4) Entering the Departure Runway for Takeoff. When entering a runway
after being cleared for takeoff, or when taxiing into position and
hold, pilots should make their aircraft more conspicuous to aircraft
on final behind them and to ATC by turning on lights (except landing
lights) that highlight the aircraft’s silhouette. Strobe lights should
not be illuminated if they will adversely affect the vision of other
pilots.
NOTE: The SOP of turning on landing lights when takeoff clearance is
received is a signal to other pilots, ATC, and ground personnel that
the aircraft is moving down the runway for takeoff.

(5) Takeoff. Landing lights should be turned on when takeoff clearance
is received, or when commencing takeoff roll at an airport without an
operating control tower.

So don't be afraid to use those lights. Use of the landing light
during the day in the pattern is another good way to get folks to see
you. And use of a landing light at an uncontrolled field on the ground
helps other pilots pick us out from the clutter, right Neil? :)

2. In Boston a construction truck crosses an active runway in front of
a US Airways jet, which narrowly misses it. The driver thought the
runway was "closed", and had no radio. I'm sorry, but this falls into
the "ya gotta be kidding" category. Vehicles on the airport in BOS
without escort or radio? And there is no such thing in my book as a
"closed" runway; every runway requires a clearance to cross, period.
People forget, and it is a bad practice to clear someone to take off
from or cross a runway when they are nowhere near that runway, like
Lexington and our next subject, CLE...

3. In CLE, after some creative taxi routings for several different
aircraft crafted by Ground and Tower, one airplane is cleared to
takeoff and another is cleared to "Position and Hold" in preparation
for its departure. But through a lack of shared mental model and non-
standard terminology, the 2nd airplane taxis into position at an
intersection IN FRONT OF the departing aircraft. Luckily the cleared
aircraft had just begun its takeoff roll, it was a clear day and the
big orange 737 in front of it was easy to spot. No paint was swapped ,
metal bent or lives destroyed. But this could have been prevented by
NOT clearing one airplane to takeoff while it was still far away from
the end of the runway, that throws off timing in our heads. And
another defense was breached by lack of proper terminology and
assumptions about where a runway is to be entered.

SOAPBOX TIME: The FAA discontinued the use of Taxi Into Position and
Hold clearances several years ago as a runway safety initiative, then
immediately granted waivers to airports to ignore the protective
measure. Time to reevaluate.

Wrap Up: There is a lot for everyone to learn here. Listen up, use
proper terminology to keep EVERYONE in the loop, use lights so folks
can see you, question any clearances onto a runway when someone else
is on it, do NOT cross a "closed" runway without a positive clearance,
and slow down. We all fought to get into the pilot and controllers
seats, let's take time to enjoy them.

Fly Smart,
Kent

[Walker, Dale J]

Outstanding comments...as always, you are right on target. There is a
reason that correct phraseology is specified, and there is also a reason
that it is not always used. Call it lack of attention to detail, poor
personal techniques, lack of accountability, whatever fits.

Dale Walker
Lead Operations Supervisor
Lockheed Martin Flight Services
Fort Worth, TX Hub
Office: (817) 541-3431
Cell: (940) 765-1100