All the usual authorities are investigating an unusually close call at JFK on Jan. 13. The crew of a Delta 737 had to reject a takeoff at 104 knots when an American 777 crossed the runway in front of them. As the animation by Real ATC above shows, a controller spotted the incipient conflict and canceled the Delta takeoff clearance. The planes were only about 1,000 feet apart when they stopped. The American crew took a wrong turn in an area of multiple intersections where Runway 4L and Runway 31L cross each other.
The American crew got initial taxi instructions after pushback. They were supposed to cross 31L and take a parallel taxiway to line up on 4L behind the Delta plane. Instead, they missed the correct taxiway and crossed 4L just after the Delta flight had received its takeoff clearance.
An earlier version of this story mixed up the runways and chronology of the taxi instructions. We’ve also substituted a clearer version of the tower tape. Sorry for the mixup.
From the information available, this seems like an egregious error by the American crew, and I’m sure the investigation will find multiple broken links in the safety chain. How did they get the taxiway route wrong after reading it back correctly — and how did BOTH pilots manage to get it wrong? Isn’t it SOP to look both ways before crossing a runway, and wouldn’t they have seen a brightly-lit plane lined up or on the roll on the runway they were about to cross? Weren’t there flashing red lights at the runway intersection?
I read somewhere that the crew was getting close to their deadline to get off the ground or have to return to the gate because they’d be exceeding their duty limits, and I certainly hope that pressure did not induce them to rush through briefings and hurry to the runway. I also read an allegation that no safety briefing was given to passengers, which, if true, also might indicate that they were rushing. I think most of us know that “in a hurry” and “safety” are not great partners.
I think the system worked here — an attentive controller saw the incursion and was able to stop the Delta takeoff and avoid what would have been a catastrophe. Kudos to the Delta crew for reacting immediately. I hope that there can be some lessons learned and changes implemented/training reinforced to reduce the odds of this happening again.
Makes me think that a new rule should be considered that entering ANY runway should require a change to TWR for the crossing ?
Respectfully, I don’t believe that adding another layer of complexity for the crew would help. I’d suggest that every runway crossing have an “eyes on it” controller assigned. This sounds like catching the conflict was almost accidental, itself.
Alternately, there needs to be soft limits on flight/duty time limitations, with any excursion getting automatic extension on the other end. IOW, if you clock out late, you get to come back correspondingly late, so that there’s no concern about any reduction in your time off. Framkly, the minimum 8 hrs time off is inadequate, anyway, unless that’s changed since I’ve been out of it. You still have to get home, shower, sleep, dress, eat again, and get back to the ‘drome. If anybody can get more than 5 or 6 hours of sleep in that sked, it’s a miracle!
Forgot to add, after several days of 5-6 hrs sleep, just how sharp would *you* be? Me, not so much! Was this crew on the backside of that power curve?
As AA was crossing a runway they weren’t supposed to cross, an “eyes on it” controller wouldn’t have been looking at them. I don’t think checking with TWR before entering any runway would be complicated. GC doesn’t pay any attention to runways.
Switching to tower for any crossing and then back to ground for more taxiing is over complicating the situation for the pilots. How about a system where the taxi instructions are relayed to the aircraft via a datalink and then automatically displayed on one of the displays. An internal system could alarm if a deviation occurs.
You are suggesting MapsMe/Waze for aircraft on the ground. Not a bad idea as while looking at Airport diagram it isn’t possible to look out the window.
100% agree, CPDLC is available on most aircraft, the pilots could review the clearance as required, also need moving map required in the cockpit with alerts.
As an FO, I once landed on the outboard runway (forgive me, I don’t remember which airport, 30+years ago) and tower cleared us to cross the inboard runway and then call GC. Looking back down the inboard runway I saw an aircraft on short final. I told the tower we would hold short for the landing aircraft. He apologized and concurred. Don’t trust anyone, verify.
I think GC telling AA to “turn right on Kilo…” would have helped, instead of “take Kilo to 4L cross 31L.”
One last thing, it sounds like the controller saved the day telling Delta to “cancel TO clearance.” First, I think forceful “ABORT” would be called for here. And second, I would think Delta seeing a 777 crossing the runway in front of them (most pilots do look outside on TO) would have already started their reject.
American flight later cleared for TO…perhaps the right CRM policy answer would have been to return to a gate for a crew swap, ala “equipment” failure.
Realize that would be a logistical nightmare for all involved, difficult to assess in near real time (and union, dispatch/company, pax advocates would probably all have different views of impact/implied fault), but “stand by to copy a phone#” of a potential deviation of this magnitude is an additional distractor to a crew apparently not at their best.
I agree. It should have been “return to gate”.
Yes, this would be a great time to return them to the gate to check the crew out. Not have them fly across the ocean to England.
??? Cross 31L to depart 4L… and taxi down Kilo.. CORRECT?
That’s what I hear on the tape too. Russ’ text above is incorrect.
Looks like Russ made the exact same mistake as American…
Whew as the Delta pilot said. I think your description is not quite correct. You say “They were supposed to cross 4L and take a parallel taxiway to line up on 31L behind the Delta plane. Instead, they missed the correct taxiway and crossed 31L just after the Delta flight had received its takeoff clearance.” It looks to me that you should say “They were supposed to cross 31L and take a parallel taxiway to line up on 4L behind the Delta plane. Instead, they missed the correct taxiway and crossed 4L just after the Delta flight had received its takeoff clearance.” Everyone is confused on this and it goes to show that we are indeed all equal; women can screw up just as badly as men (Not politically correct.)
I see this has already been addressed by Ken A and Peter G, but I’ll add this: if reporter Russ Niles, sitting at a desk with full benefit of time and editing can get the clearance wrong, then I imagine pilots in a dark cockpit in a dynamic situation heading out on a complex international flight might as well. One can never know what else was occurring on the flight deck when clearance was received, but often there are other issues vying for the pilot’s attention. And, if it were an OE flight, the LCA would have their hands full. Human error is an unfortunately reliable presence in all human endeavors. Reporters make mistakes, pilots make mistakes. Only one is usually deadly.
Flight crew of 2 (some say 3) entering wrong runway in front of an aircraft approaching with bright landing lights verges on criminal. Looks like they thought they were heading for 4R and had forgotten they were cleared to cross 31L and not 4L. Good point is that they will never do that again.
A trans Atlantic flight is not complex. Normally the clearance is received prior to the taxi clearance and not while taxiing. All the pilots had to do was follow taxi clearances including changes they might be receiving. Taxiways are clearly marked with lit signs so a crew of 3? crossing a runway on taxiway J when cleared to cross on taxiway K suggests a big problem.
Taxiing to a runway is very a basic flying skill. You’re making excuses for what is supposed to be a professional crew. Sit down and study the 10-9 plate. Listen to ATIS for active runways. Articulate the threats, and taxi at a complex airport certainly is worth a detailed briefing.
Distractions during busy phases of operation are common, and pilots get paid the big bucks to “trap” them by a variety of means. They could see aircraft taxiing to and taking off on 4L. They have moving maps, heading indicators, and probably three crew members in the cockpit for an international flight. Stop the aircraft, ask for a clarification, never assume. If there is any doubt, then there is no doubt.
Not the first such and certainly not the last. Humans and their creations are both imperfect – with the exception of the occasional web commentor, of course.
We watch our little icon navigate the ground environment on our GPS, which does make it sound tempting to launch into some sort of downloaded taxi clearance project, but adding complexity isn’t always a great idea. Often it just moves the source of error somewhere else while simultaneously adding more failure modes.
Agree that in general more complexity doesn’t help, but the challenge of translating verbal taxi instructions into a mental image of where to go is one has been tripping up pilots for a long time. Just brainstorming a little here, a simple additional data transmission of the path for a plane to follow – just a sequence of taxiway waypoints – sent over ADSB and displayed in the cockpit in whatever way the avionics were able (if at all) would help avoid this. This could be added in a backward-compatible way, with software-only changes.
If a flight crew of 3 can’t taxi properly, the shouldn’t be a flight crew.
Yep.
Absolutely correct. The INS on Air New Zealand 901 to Mt. Erebus showed the flight crew that they were correctly on course but it didn’t tell them that it wasn’t the course they thought they were on.
Always ask if you are cleared to cross ANY RWY on your taxi route before crossing, even if you are previously cleared.
Russ, you need to amend your reporting of taxi clearance instructions! ;^)
But seriously, kudos to the tower controller for being on the ball and avoiding what could have been a disaster. As has already been stated, I bet that American flight crew will not make that mistake again.
cockpit p. January 16, 2023 At 11:05 am
“Always ask if you are cleared to cross ANY RWY on your taxi route before crossing, even if you are previously cleared.”
Reply
cockpit p. – you got that right!!
JFK layout must be simple because there are zero hot spots published (I say rhetorically).
…..Delta1493… You need time to clean your shorts?
…..Delta1943… You need time to clean your shorts?
Perhaps a physical illuminated pop up gate controlled by the tower at the hold short line.
They do have lights embedded in the taxiways that turn green or red. But, they don’t work well during the day and an Airbus driver will just run over gates.
Russ, I think you got the clearance wrong too. They were told to go to 04L for departure and later told to cross 31L at Kilo. Instead they continued on to Juliet, apparently thinking they were supposed to depart on 31L, and that’s when they crossed 04L as Delta started to roll. And in all the recordings that I have been able to listen to I never heard American acknowledge their assigned departure runway was 04L and I never heard ground confirm the runway assignment with them.
God. Sorry you guys. I think I’ve fixed it all and substituted a better version of the tower tape.
Seem like we have a tape from Midway with the same runway configuration !!
Looks like the Muppets in the balcony are paying attention to details. Good thing!!
We are old and angry… but still pay attention.
and still flying a Lake amphibian in Alaska.
Define old.
I flew for 3 airlines a total of 20 years and spent 18 of those years in the right seat as an First Officer. I was never taught, nor did I ever see a good way to quickly write down a clearance that could incorporate hold short instructions as well as how to handle when you are later cleared beyond the hold short point. My background is an accounting degree & a law degree. So, I came up with a method that assisted many captains on thousands of flights, saved us from confusion on hundreds of flights, & stopped a deviation on several flights.
The taxi clearance was given rather fast and I am unable to replay the audio, but I think the clearance was “4 Left via Bravo, hold short Kilo.” Here is how I would have quickly written it down:
4L B K(with an X over the K to signify hold short but I cannot type an X over the K.)
This means I am assigned and headed to runway 4 Left, taxi via taxiway Bravo, and hold short of Kilo. When the taxi clearance was later ammended by the controller stating “Cross 31 Left at Kilo” I would have circled the previously written K that has a X through it, signifying the hold short clearance has been overridden and written “31L K.”
So our complete taxi instructions would have appeared simply as:
4L B K 31L K (the first K would have an X through it and be circled after final taxi instructions.)
I am now retired but I hope this helps some active pilots. Stay safe.
This incident is a perfect example of how complicated it can be getting, and carrying out taxi instructions at larger and busier airports with irregular layouts. Add to that the distraction of controllers reading out clearances fast, one after another, and other lines of traffic and even the best and most experienced crews or controllers can have an uh-oh! Good job for the tower controller catching the taxiing crossing error. In the end I think maybe slowing things down just a little will go a long way toward maintaining safe operations at JFK.
Agreed!!
If there had been just one pilot on board, with a computer doing the navigating, this might have never happened.
Actually… ForeFlight does have a taxi map that can be programmed as the taxi clearance is given. I still stop and look both ways when crossing a street. I don’t like the idea of being hit by a bus… especially an Airbus.
I disagree. I think having only one pilot on the FD would dramatically increase the likelyhood of such errors. I saw (and lived) several situations where the 2nd or 3rd pilot saved the day by calling out the error before it metastasized into a fiasco. I also think that “more technology” wouldn’t solve the problem; it would just cause the errors to morph into new and creative forms. There is no substitute for “eyes on the flight deck” with SA ensured by prebriefing and crosschecking. Drones crash, too.
I keep seeing the article and comments referring to Delta and American, but the planes on the tape are Delta 1328 and Southwest 3828!
Wrong tape as it is a different incident at Midway resulting from two aircraft with similar call signs and both thinking the TO clearance was for them. Another Gremlin for this discussion.
Not sure how that happened. I reset the video and it seems fine now.
On a long taxi to get to crossing runway, I always confirm a crossing, especially when I look both ways crossing and see an aircraft with landing lights pointing at me.
At one airport I fly out of, the controllers give me multi runway crossing if I’m air taxiing across the airport. I’ll always stop in an hover and confirm the multi runway crossing, just because I know it is an unusual and technically not legal instruction.
I don’t want to fly too high and create rotor down wash vortex that can knock a small aircraft out of the air. So air taxiing low seems safer, but does creat the air taxi multi runway crossing situation.
Flying is dangerous… always look out the window and reconfirm a runway crossing when there is a plane positioned on a runway with landing lights on.
I would say that flying is not inherently dangerous but screwing things up when operating an aircraft can be.
Simply put, human error by the American pilots was a factor in this situation. It is ironic that the original version of this article was also subject to human error when “An earlier version of this story mixed up the runways and chronology of the taxi instructions.”
The American pilots reached a junction. One way leads to crossing Runway 4L; the other direction leads to crossing runway 31L. Their taxi instructions were to taxi to runway 4L and to cross runway 31L. Instead, they crossed 4L and taxied to runway 31L. This seems like a mistake that is easy to make. Fortunately, this mistake did not lead to catastrophe…this time.
It is my sincere expectation that this investigation will result in a change at JFK, be it taxiway signage, procedure, or other methods to ensure a human error like this one is much harder to make in the future. I suspect changes may also be integrated into the American Airlines’ SOP based on this investigation. Bottom line: no one was hurt, and we can all take a deliberate look back on what precipitated this error and find ways to avoid this error ourselves as controllers, pilots, and operators.
Progressive Taxi Instructions for unfamiliar or bewildered pilots would have helped.
Professional pilots with onboard taxi maps for a U.S. based crew…this is professional aviation not a hand holding event. If the crew is/was unfamiliar they should have spoke up if that were the case. Sadly, it’s likely boiled down to a distracted crew with poor CRM.
ASDE-X is in place for events like this and Im sure it was going off loudly in the tower replacing the “eyes on it” suggestion.
I’m curious why Delta had to return to the gate and deplane the passengers, while American was able to proceed to London (and potentially overwrote the cockpit recording in the process). Is there a standard procedure at Delta that after a critical incident, the crew parks the plane and stands down, or is this related to potential damage from a heavy-braking rejected takeoff at high weight? It seems to me that a flight that begins with a possible pilot deviation notice automatically has a possible safety problem as the pilots will be distracted about potential repercussions. I think American should also have returned to the gate. Interested in others thoughts on this.