Verify, Verify, Verify.

November 19, 2008 by Bruce Landsberg

NTSB is just finishing a preliminary investigation on what has to be the closest call we’ve had between a GA aircraft and an airliner in years. On September 19, 2008, at 1938 local time, a runway incursion resulted in a near-collision on Runway 6 at the Lehigh Valley International Airport, Allentown, Pennsylvania. Mesa Air Shuttle flight 7138, a Canadair CRJ aborted takeoff at 120 knots skidding around a Cessna R172K that had just landed and was still taxiing on the runway. The RJ crew estimated the distance between the two aircraft at 10 feet.

Click here for an interactive recreation of the incident, provided by the FAA.

The conditions were night VMC. The Cessna had just landed on Runway 6 and the tower cleared the RJ into position and hold. Tower then discussed with the Cessna pilot where he wanted to park, and cleared him to exit the runway at A-4 taxiway. You will note from the airport taxi diagram that A-4 is the first turnoff and unless the Cessna touched down right at the end, and was moving slowly, making the first turnoff might be difficult. Some 35 seconds later, the tower, assuming the Cessna was off the runway cleared the RJ for takeoff. 23 seconds after the RJ was cleared, the Cessna pilot advised the tower that he’d missed A-4 and would like to exit on Bravo taxiway.

Allentown Runway IncursionThe skid marks speak for themselves!

There are multiple factors in this incident which both pilots and ATC should consider:

1. ATC apparently did not visually scan the runway prior to clearing the RJ and assumed the Cessna had cleared. It might also have been prudent to give the Cessna pilot more runway to get the aircraft slowed to taxi speed.
2. RJ crew apparently did not visually scan the runway prior to accepting the takeoff clearance- assumed the Cessna had cleared. It’s always good to verify that the runway is clear and if you can’t see for yourself, ask the tower.
3. The Cessna pilot should have notified the tower that he’d missed A-4 taxiway quite a bit sooner in my opinion. AIM section 4-4-1 and FAR 91.123 make it clear that you don’t have to roll it up in a ball to stop at the next taxiway if that cannot be done safely but you DO have to let the tower know, on a timely basis, that an amended clearance is needed. It would also be smart to SPEAK UP immediately if tower clears another aircraft to takeoff while you’re still on the runway.

Everyone was lucky – this time. Remember that no matter how routine something may seem, it can turn ugly faster than a speeding RJ can leapfrog a slow-clearing Cessna.

For more information on runway safety, take our Runway Safety Online Course and Runway Safety Quiz.

Bruce Landsberg
Senior Safety Advisor, Air Safety Institute

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83 Responses to “Verify, Verify, Verify.”

  1. Lawrence Ryan Says:

    I was taught that a pilot “owned” the runway until he/she reported being clear of it. The controller should take most of the blame on this. The RJ pilot should not have accepted the clearance to take off until the other aircraft was clear. The only thing the landing pilot may be guilty of is being slow.

  2. Jerry Megna Says:

    Lawrence Ryan is dead wrong. A clearance requires compliance unless amended or emergency dictates other action. It doesn’t sound like he frequents busy airports where turn off requests are common and controllers get testy when you don’t advise of inability to comply especially when there is following traffic .

  3. Richard Jacobs Says:

    I had a “first cousin” to the event described by Bruce when was landing at Boston’s Logan Airport in my Bonanza when flying an Angel Flight: I had enquired whether any particular speed was needed on the landing, which was in VFR conditions, and was advised that no one was behind me, but that I should plan to take the first turn out. I slowed the aircraft down with that in mind, but just before crossing the threshold, the tower instructed me “expedite, expedite”. I did not respond, since I was busy “flying the plane” low and slow. I pulled off at the first turnout. I think that (1) I should have responded to the instruction to take the first turn off with “Angel Flight …will slow it down and do its best to make the first turn off” and (2) my decision to focus on landing, when on very short final and to NOT respond to the last minute “expedite, expedite” with something like “unable to expedite and make the first turnoff” was correct.

  4. Don McClain Says:

    I was taught that a Landing aircraft has the right away on the runway until it’s clear of it. HOLD SHORT. The controller is the blame on this. The RJ pilot should not have started the take off until the other aircraft was clear. The only thing the landing pilot may be guilty of is being at the wrong airport with RJ pilots in the area. This is ATC just trying to blame the pilots for their mistakes because they don’t make any. This goes on ever day at MDW where ATC clears a aircraft for Take off when your coming over the FENCE on the ILS approach. The tower claims you should have KNOWN to switch runways. Switch runway and your still mistaken.Typical GOVT that wants TOTAL control and NO responsbilty for their actions. DEAD PILOT’S don’t get to tell what HAPPENED.

  5. Daniel D. Connor Says:

    The real moral of the story here is that communication is critical to every endeavor on, in, or around any airport. If we all know what all the other parties are doing and where they are, situations like this would never occur.

  6. Sam Beale Says:

    Lawrence Ryan is not dead wrong. It is true that the pilot of the 172 should have spoken up sooner, but controllers do not assume an aircraft is clear of the runway; they can, and should, easily look. In night VMC conditions, aircraft lights show up real well. If the pilot was new to the airport (didn’t say, but sounds like he may have been) he probably did not have all the taxiway locations memorized, so would not have known A4 until he came to it, or passed it in this case. When I go to a strange airport, I memorize all the runway locations, which side the taxiways are on, and about where the FBO is, but cannot recite all the taxiway designations and locations.

    Besides, a VFR only pilot would (or should) not be expected to be aware that an instruction to turn off at a particular taxiway constituted a “clearance” that must be complied with unless amended or other action is dictated by an emergency.

    I would not consider an aircraft in position and holding to be “following traffic”.

    I give 75% responsibility to the tower controller, and the Cessna pilot should get 15% and the Canadair pilot the remaining 10%. Since the Canadair was behind the 172, maybe the lights did not show up as well as they would have to the tower. But the Canadair guy (or gal) gets Kudos for his (or her) quick reaction and avoidance manuever.

    I wonder if the “testy” controllers Jerry speaks of might be at CLT. I landed there once in a 172RG on 36R, made the first high speed turnoff, and was treated to a lengthy tirade for slowing down too much before turning off. I successfully resisted the urge to violate radio decorum.

  7. Dick Branick Says:

    No comments, just a question: did the NTSB and the FAA get involved in this incident? If so, what was their conclusion?

  8. Don Eck Says:

    I have long taught pilots that “cleared for takeoff (land, position-and-hold, etc), is like a green light at a traffic intersection: it DOESN’T mean “go”. It only means you’re approved to go IF there’s nothing in your way. The situation the RJ pilots encountered is a scenario that is routinely applied in FAR Part 121 recurrent training, because, as this event and many others like it have shown, it does and will occur in the “real world”. While the greatest error was ATC’s, the jet crew was the one with the most vested interest in the outcome of this event. While there are things the Cessna pilot could have done to have improved the situation, he/she wasn’t busy with the radio because they were dealing with the more critical “aviate and navigate”.

  9. Captain Jim Carney Says:

    The controller is what I would call, over controlling, trying to rush rush!!!. You would think,especially at night, you would ask the landing aircraft to report CLEAR of the runway before you clear someone for takeoff on the same runway. A4 isn’t very far down RW 06 so it sounds like the controllers were talking to him in the landing flare or still rolling out above taxi speed. The RJ crew should have been paying more attention to their departure runway. It is hard to be a Monday Quarterback without having more info but Jerry Megna post is not factual. Sounds like he lets the controllers fly his airplane. Saftey first and ZESTY Controllers last!! It makes no difference if I’m flying my Baron or a 747-400, above all, FLY THE PLANE FIRST!! I have landed at busy airports around the world.

  10. Ken Novak Says:

    Sure the tower is responsible but the captain of the RJ is responsible too. If I was in that situation and holding for the cessna to clear, I would not takeoff or allow my first officer to until I verified the runway was clear. There are not a lot of runways where you can’t see enough to be safe.

    Having just taken a load of people to ABE last night, I can attest the visibility is sufficient to verify the runway is clear. And if it is low visibility, ask the tower to verify it is clear (they get paid for that sort of thing – safety, you know).

    There is no reason to endanger the lives of those passengers who have blindly put their trust in you. And there is no reason to endanger your own life by not doing all that you can to enhance safety. As former President Reagan said, “Trust, but verify.”

  11. Mike Howell Says:

    172 pilots, please remove the bighplane-littleplane chip from your collective shoulders. Yes, the controller was mainly at fault here but if the 172 driver had just communicated his inability to make A4 then this whole scenario would not have happened. He had already had a conversation with the tower about where to park so there was no excuse for not saying he couldn’t make A4. Forget what AIM says or what vfr pilots should or should not know about flying, use common sense and COMMUNICATE your intentions. There have been too many of these scenarios like this in the past where there was a lack of communication, planes actually collided and the vfr pilot was right but, unfortunately, dead right. Speak up please. (Also, it is unclear if the 172 and the RJ were on the same frequency but if they were then the 172 should have responded when the RJ was cleared to depart on the runway that he was still on.) COMMUNICATE PLEASE.

  12. Lawrence Ryan Says:

    I’d rather be dead wrong than dead. I don’t fly into busy airports these days, but the decision process is the same for all airports. Make sure the runway is clear before accepting a clearance! Safety takes precedence over efficiency. Having been involved in product and plant (refineries, nuclear, etc.) safety for over 40 years and a pilot for about the same time I have done a lot of thinking about risks and safety.

  13. Zach Heineman Says:

    Bruce calls out the conditions as “night VMC”, but if the incident occurred at 1938 local this would have only been 7 minutes after the end of civil twilight. I imagine the light at that point would have been contingent on atmospheric conditions, but it seems possible that it might have been bright enough that lights would have been difficult to see, but also dark enough that the aircraft itself might have been discernible. My question regards the proper use of strobes. I was taught that one should not taxi with them on in order to preserve the night vision of other pilots. But what about on landing? I assume that if the plane were equipped with them, the pilot would have used them; if this is the case, would it have been proper to keep them on until he or she was clear of the runway?

  14. Flyboy Says:

    Good grief. For all of you blaming the RJ crew–do you really think they were dumb enough to begin a takeoff roll if they could see that there was a Cessna more than halfway down the runway? They too, assumed the Cessna was clear. It was night conditions, and they were unable to make out the lights of the Cessna for all of the blinking lights associated with construction past the departure end of the runway. It’s amazing that the RJ crew not only realized the Cessna was still on the runway in time to abort the takeoff, but was able to swerve an 80,000lb RJ around the Cessna at 120 knots. The RJ crew is totally without fault, and have been commended for their extraordinary actions that possibly saved many lives.

    While the cause of the incident is being referred to as “operational error” ie– controller error, the Cessna pilot shares some blame. The AIM states that you should clear the runway at the first available taxiway or as instructed by ATC. The pilot of the Cessna did neither, but fortunately spoke up and admitted he was lost in time for the RJ crew to hear that they were on the runway. The controller should have ordered the RJ to abort at this time, but did not, fortunately the crew exhibited excellent situational awareness and initiated an abort of their own volition. Had the Cessna pilot had similar SA, they could have advised on tower frequency that they were not clear of the runway when they heard a takeoff clearance being issued to a jet behind them.

  15. Flyboy Says:

    In response to Heineman: I do not know if the cessna pilot used strobes or not, but at least in the airlines, we leave all lights on until we’re clear of the runway.

  16. George Horn Says:

    I see many attitudes here that are neither conducive to safety nor correct, in my opinion.
    Firstly, Assigning “percentage” points in fault-finding is not helpful. If any “percentage” is to be assigned, I belive 100% belongs to ATC.
    Why? Because this is not a runway “incursion”. This is an ATC error!
    The Cessna 172 OWNED that runway until it exited. It makes no difference
    that the 172 failed to exit at the assigned taxiway. ATC cannot “order” an airplane to exit a runway at any specified point prior to lanidng. (LAHSO might be underway, but that does not require a runway EXIT. It only requies landing/holding within a specified distance. It does NOT requre exiting the runway.
    Secondly, The CL crew complied with ATC’s clearance, AND they complied with their obligation to “see and avoid”, despite the fact that ATC had supposedly already “cleared” the runway for them. There is no guarantee that a windshield-post, compass, or glare, or other vision anomaly might not have prevented their seeing the 172 still occupying the runway. THAT was ATC’s obligation, and it’s very fortunate that the CL crew saw and avoided the 172.
    Lastly, the C-172 was under NO obligation to comply with ATC’s exit
    clearance. ATC cannot assume that a brake/wheel failure or some other event might not allow such compliance. The ONLY failure I see in this incident is ATC’s, and the cause of that failure is yet to be determined, but I’ll be willing to bet that trainee specialists without adequate supervision is found to be at the epicenter.
    FAA has delayed and distracted from settling controller contract issues, and although many will not see it, that failure to conclude a fair and equitable labor contract that also addresses hiring and training and manning issues are at the heart of this sort of incident. We should all demand that this matter be concluded, even if it means we have to pay more for a safe ATC.

  17. Jim Thompson Says:

    I was taught by my primary instructor to ALWAYS report “Clear of the runway” even when not asked. This is at both controlled and non-controlled airports. If this was a common and REQUIRED PRACTICE, this situation would most likely not have developed.

    Something that may have made it difficult, if not impossible for the CRJ pilot to see the Cessna is a rise in the middle of the runway. If the CRJ is at one end of a runway with even a rise in the middle and the Cessna at the other end, that rise can make it appear the runway is clear.

  18. Cary Alburn Says:

    Without pointing fingers (fault-finding), the real issue is, how can this circumstance be avoided in the future? The easy answer is that ATC should not clear anyone for take-off unless ATC is sure that the runway is clear. Next, anyone cleared for take-off should not assume that the runway is clear. And finally, anyone still on the runway who hears a takeoff clearance for the same runway should speak up immediately.

    Applying these 3 steps to this situation, ATC should not have cleared the jet for takeoff without first determining if the 172 had cleared, either by seeing that it had or by asking its pilot if it was clear. Assuming that the jet’s pilots had observed the 172 land and had heard the radio conversation between ATC and the 172 pilot, when they were cleared for takeoff but had not heard the 172’s pilot clear the runway or could not see that it had cleared, they should have asked rather than rolled. And finally, when the 172 pilot heard the takeoff clearance given to the jet, he should have spoken up immediately to advise both ATC and the jet that he was still on the runway.

    There’s enough fault to go around here, so let’s don’t call it fault–all had a duty to do something that they didn’t do. Whether that duty was created by rule or by common sense, fortunately no one was hurt when they all breached that duty. Assuming that others will do their duty without doing one’s own duty is dangerous.


  19. Jean Schwarzkopf Says:

    Jerry Megna is dead wrong. The tower controler can ask me to depart the runway at any taxi way of his choosing but untill I am clear, I own the runway. I may have had reverser failure or a failure of auto brakes or auto slats that caused my landing roll to be longer than normal. Controling the aircraft comes first and chatting on the radio comes second.

    Taxiway A4 is 1500 feet from the end of the runway. That’s 500 feet from the Aim Point. Not impossible in a 172, but not reasonable.

  20. John Dassoulas Says:

    NEVER, EVER! Make Assumptions. J.

  21. Lawrence Ryan Says:


  22. Keith Carbine Says:

    It seems to me that the Cessna pilot has very little culpability here. The pilot might not have been aware of the exact location of the A4 taxiway, and likely his first choice for exit was Rwy 13/31. The first priority for the pilot still on the runway is to slow the aircraft to a safe speed on centerline and then to exit the runway as practical.

    ATC is to blame here, with secondary blame going to the RJ crew, which has as an SOP to “check left”, “check right”.

  23. avi weiss Says:

    Its unfortunate that “fault assessment”, “responsibility” and “what can be learned” are somewhat orthogonal discussion points. Since there seems to be a lot of conjecture and opinion on all fronts, perhaps some facts might be in order.

    * As for “fault”, meaning some form of procedural failure as stated by either regulations and / or adopted procedures, that has to lie with the local controller and the RJ pilot. The local controllers PRIMARY job is to ensure the “runway environment” is clear for each landing and departing aircraft. Everything else that the controller provides (traffic sequencing, callouts, ball scores, etc) is on a “as able” basis. The RJ crew needed to VISUALLY ensure that the runway was clear before commencing their takeoff roll. Can’t see? unsure? you got a thumb and mouth? use them to ORALLY ensure the runway is clear. The Cessna pilot could and should have been more proactive about announcing his continued presence on the runway, especially once he knew he would pass A4, but it was not his RESPONSIBILITY to do so prior to the controller issuing a takeoff clearance, AND/OR the RJ rolling; only that he do so “in a TIMELY fashion, when safety permits”. It should be noted that “fault” should not and does not mean that either the RJ crew or the controller acted negligently or willfully, only that they had fault based on regulated responsibilities.

    As for “ultimate responsibility”, while generally speaking everyone has a moral responsibility to act as safely as possible, there is usually ONE person as “ultimately responsible” in a given aviation situation, REGARDLESS of who or what is involved, and in this particular situation, that person would have to be the local controller. As per Order JO 7110.65S Air Traffic Control section 3-1-3: “The local controller has primary responsibility for operations conducted on the active runway and must control the use of those runways. Positive coordination and control is required as follows…”

    As for “learning from mistakes”, the lessons I’ve gleaned are:

    * Controllers shouldn’t ever ASSUME the position of an aircraft if that aircraft’s position predicates another aircraft’s movement, and must VERIFY the location either visually (hey thats why they have a huge tower with windows) or orally.
    * Pilots need to maintain “the flick” and be aware of pending aircraft movement around them, and what that movement means to them, and speak up as soon as possible if they realize something the controller does not.
    * Pilots should not assume that the controller is precisely aware of the exact state and location of everything they are controlling, and how all those things relate to one another positionally, and need to VERIFY that the area around them is truly clear to operate in.
    * “Position and Hold” is far more trouble than it is worth. It has caused more loss of life and damage than all the possible time it will EVER save for the infinite future

    Hope that helps.


  24. tom connor Says:

    Missing from this discussion is lighting, specifically how conspicuous was the C-172? Did the aircraft have any lights on or was it dark? How was the ambient lighting, airport lighting etc? My point is that well-lit aircraft sometimes disappear into a sea of runway and surrounding lights, especially if there is no relative motion. A poorly or unlit airplane is essentially invisible. IMHO this scenario begs for a rear-facing strobe such as the Whelen A500 that you just turn on and leave on day or night. It is intended to alert fast movers who are overtaking slow movers in flight. It probably works on the ground too.

  25. DAB Says:

    While taxiway A4 is makeable, particularly for a 172 (I have used it many times in as an instructor in 172s, Archers and Arrows), it usually requires aiming at some point short of the PAPI aim point. Since it was getting dark, most pilots would use the PAPIs and then A4 becomes problematical.

    Though I routinely used TWY A4 when able, I have only been assigned that taxiway to exit when it was obvious I was slow enough to do so. Probably only a dozen times in 10 years of instructing at LVIA (KABE). Typically tower would clear me to exit at Rwy 13/31 or TWY B when flying a small plane.

    There is no runway hump that would have hidden the 172 from the RJ. However, as for the 172’s lights being visible to the RJ crew, that too is problematical. Since Airport Road was re-routed a number of years ago, traffic headed south on Airport Road looks like it is coming southwest on TWY A. More than once I have thought an airliner from the terminal was taxiing toward me while I was northeast bound on TWY A. Traffic headlights are also a problem on RWY 6, though not quite as bad as on the parallel taxiway. Also, there is a set of traffic lights on Airport road that can add bright red lights to the situation. In short, automobile headlights and traffic lights can make it very difficult, if not impossible, to see a small aircraft on the runway headed away from you at night.

    I heard through the grapevine at one time that the airport was going to put up some sort of fencing to alleviate the headlight problem, but I don’t know if it was a fact. At any rate, it was never done.

    The controller obviously made a mistake. The 172 pilot should definitely have spoken up when he heard the RJ being cleared for takeoff. The RJ pilots very possibly could not see the 172, and incorrectly assumed he was clear, but made a very good save of a bad situation.

  26. Leo H. LeBoeuf Says:

    This is an interesting situation of an accident chain. Many links were coming together. The CL crew managed to break the chain just in time. I once almost had a Bonanza land on top of me at night.

    I was landing from right traffic on 17R since it was my last landing, I requested 17L. The controller gave me a cleared to land. I repeated cleared 17 Left. He then cleared a Bonanza to land 17L. I didn’t see the Bo as it was probably abeam and above my C172. I decided to do a short landing and as I started to flare the Bo landed over me on the fixed distance markers. The Bo pilot never saw me, even though my aircraft had strobes, wing tip lights, and logo lights on the tail.

    The controller sited me for landing on the wrong runway. A review of the tapes showed that he was in error. This controller was not the strongest of the bunch at that tower.

    Here was another situation where the chain almost came together. Luck was on our side that evening, however luck must not be part of any pilot’s safety plan.

  27. Rick Simmers Says:

    Avi Weiss’s comments are very well taken. I’ve been flying out of ABE for over 10 years, the layout at that end of the airport is of course very open and clear enough for everyone to see and be seen. Everyone involved had resposibilities as mentioned in others comments . It would seem that it was a combination of events that led to a mishap, I think we’ve heard that before. Not to throw percentages of blame around but I believe the controller had the ultimate responsibilityfor making sure the active runway was clear of traffic before clearing the rj for take off, whether it was visually or by radio conformation. After all , this is more than common sense or even safety this is job requirement.The 172 should have radioed back to tower that he or she missed the taxiway well before, infact AS he was missing it so as to take timely recourse. I would think the rj would have been listening to the tower/172 call to hear the situation . Even so , when I’m cleared for take off I still look all around to verify what the controller says, It’s my life out there, not to mention 30 innocent people under my care. Also, I don’t see how a moving 172 aircraft position lights and probably flashing strobe lights can blend into or be mistaken for runway or taxiway lights, especially with 2 pair of eyes looking. I personally do not like “position and hold”, I see no advantage or benifit to it, and it is an uncomfortable and unsafe position to be in. Because no one was killed or injured here should not lessen the importance of an incident like this if only to serve as having pilots be aware and learn from someone elses mistakes or potential accidents.

  28. Ken Novak Says:

    No more blame here – just one comment about lights. On the MD-80, we keep the position light switch in the strobe position all the time. The strobes only start flashing when the aircraft breaks ground (gound shift mechanism). So while it is a good idea to have strobes on whenever you are on the runway (we used to in the CRJ), it isn’t always possible.

  29. Frank Loeffler Says:

    Regarding your report on the very close call at Allentown(gave me chills), as usual, there certainly was a chain of events. However, one of the things that continues to bug me about incursion reports is that, unlike today’s auto insurance companies, there never seems to be an attempt to proportion responsibility when such events occur. In this case, it is quite clear to me that the tower local controller was primarily(maybe 85%) at fault., with the RJ crew being minimally at fault and the GA pilot could have broken the chain.

    I’ve been to that airport/runway and my recollection is that the site line down rwy 6 on the ground from the numbers is minimal. It is quite likely that the RJ crew could not see the Cessna and especially at night given the low height of an RJ cockpit. Seems to me there was probably close to zero complacency with the crew. We depend upon controllers to do their jobs and questioning every clearance would not be particularly efficient. The GA pilot might not have even realized he was beyond the A4 taxiway untill he crossed the other runway during rollout. He could have prevented the near collision by immediately reporting the erroneous takeoff clearance and that’s about it.

    I’ll bet this never would have happened if it was an uncontrolled field, and kudos to the RJ crew for everting trajedy.

    Frank R. Loeffler, Jr.

  30. jnicola Says:

    this reminds me of the joke “what is it that a pilot and an air traffic controller have in common? When a pilot makes a mistake, the pilot dies, when an air traffic controller makes a mistake, the pilot dies.” That being said the idea of having clearance and it being safe are not allways the same. look before you leap

  31. Brian Wilkins ATP Says:

    The clearance is exactly that. It is a clearance. The RJ was cleared to go and did. Who’s fault,well there are mitigating factors, but simply stated it was ATC’s fault. To expect an RJ crew who is busy with checklists in prep for the roll to hear whether a Cessna has exited a runway is absurd. The Cessna was told to contact ground when exiting. This is clear to the RJ crew that they have exited. All of you armchair quarterbacks expect the RJ to monitor ground to hear if the Cessna has made it? Stick to your day job.In addition if you expect to see an C-172 a mile and a half away at night out of the front of an RJ when it is sitting 10 feet below your cockpit-Good Luck. The bottom line is that all GA pilots need to understand WTF they are doing, over. If they are not familiar with an airport then familiarize yourself ahead of time. Actually do some planning! It might just save your life. As far as the performance of ATC, enough said. The real heroes are the crew of that RJ.

  32. Brian Wilkins ATP Says:

    Sounds like Rick needs to ride up front in a turbo-fan powered aircraft. In a a/c like the RJ you have about 15 seconds before you hit V1-V2. Take about half of that if you want to actually get the thing stopped on the same runway. The crew is glued to engine instruments and airspeed. Sure,it would be nice to gaze outside at the perty lights like the good ole days of piston powered flight but,there is just a little more involved than you obviously think.

  33. Bob H. Says:

    I’d say that this has to to the scariest almost-event since Delta missed United at Fort Lauderdale. Frankly, there is enough blame here to go around and the real lesson is what can happen when situational awareness is not maintained.

    Was the Cessna pilot aware of exactly where A-4 was before landing? Had he already anticipated what exit he might get, and/or which one he might prefer before crossing the threshold?

    How did the RJ crew lose sight of the Cessna? They had 45 seconds from TIPH to CTO, which should have been a fair amount of time to look straight down the runway.

    The tower was overly fixated on traffic in the pattern. In fact, in the 20 seconds after clearing the RJ for takeoff, there is no break in the comms between tower and landing traffic. Some of the time used there was for instructions that were superfluous. Once the comm gap is there, the incident Cessna calls back for amended instructions.

    The facts available support the loss of SA by all parties involved. The RJ crew did a commendable job, but should have been able to see (and avoid) an aircraft on the runway less than 3000 feet ahead (fact check 1) before they ever started the takeoff roll.

    Fact check 2: The recording clearly indicates to exit and “…remain this frequency”

    All pilots (equipped with turbo-fans or not) need to look out the window, over.

  34. JF Says:

    For the most part, this discussion is educational. One post is eerily illustrative.

    I am a ~250hr GA pilot (PP ASEL, no additional ratings other than a high-performance endorsement, although with more varied experience than typical flying mountains and not-sunny England) who hasn’t flown for a few years due to inability to qualify for a medical. I recognize my lack of standing to project any ‘expertise’ into a turbofan cockpit, but I find Brian Wilkins’ comments, specifically “To expect an RJ crew who is busy with checklists in prep for the roll to hear whether a Cessna has exited a runway is absurd” disturbing.

    Of the several flight instructors I’ve had, all but one (who was an ineffective instructor when I started ab initio with him, and now that I know a little, I know also was not a safe pilot) expected a student pilot to keep up with tower, to maintain traffic SA both visually and via radio, use checklists properly, and operate the airplane before they would sign off on a student pilot. Granted, that’s not a terribly full bag at many airports, but I suspect that several of the fields at which I’ve trained and gotten club initial and proficiency checkrides (KCOS, EGUN, EGUL, KPNS) are as challenging as KABE, or possibly moreso. Flying out of KCOS with FAA trainees in the tower and a fairly large fleet of Air Force flying club T-41s having similar callsigns homed there made for a lot of clearance mixups. Student pilots were expected to communicate and fly simultaneously before going to stage check prior to their private pilot checkrides, and specifically to verify clearances before accepting any clearance coming over as ambiguous or which didn’t fit into the operational environment. Maybe the peculiarities of KCOS made instructors particularly attentive to clearance issues, but my instructors would have expected me to query tower before commencing takeoff roll if an aircraft had been cleared to land and hadn’t reported clear of the intersecting runway on tower frequency. I’m not sure what to make of an ATP finding “absurd” skills that were expected of student pilots nearing the end of the private pilot syllabus at Peterson AFB’s flying club.

    In my observation of professional pilots, a small portion have given me the impression that they are more interested in what’s going on inside versus outside the cockpit. One example leading me to this impression was crossing KOKC’s Class C inbound from the west approaching KOUN in 2001. Oke City approach made a traffic call to a 737 departing KOKC to the south reporting me when I was 2500′ above and 1.5 miles south of the 737. The 737 never saw me despite highly favorable (about an hour before sunset) light conditions, but never ceased his monologue to approach about his TCAS. The 737 was beginning to sound a little stressed by the time we passed; since then I’ve thought that he could have easily observed our passing with 1500′ vertical separation had he used the two upward-looking cockpit windows provided by Boeing. Another example was from the passenger compartment of (interestingly enough) the same carrier’s 737 landing at KDTW in 2007. While the 737 in which I was a passenger was on ~3/4-mile final, the plainly-visible RJ on the diagonally-intersecting runway commenced its takeoff roll, and the 737 continued the approach to land with what apparently was a LAHSO clearance. Although the view from a passenger window didn’t allow watching the geometry play out all the way to the runway intersection, the few seconds I could watch gave the impression that should the 737 fail to stop, the two aircraft would be competing for the same acreage on the field. While exiting the aircraft, I asked the FO how separation was to be assured in case the departing aircraft had fouled the 737’s overrun past the hold short, or in the case of the 737 going around. (I figure if he’s standing at the door to meet-and-greet, he’s fair game.) His answer was to the effect that ‘we were cleared to land and tower would not have issued clearance if adequate separation wasn’t to be maintained’ led me to believe that he also hadn’t been using the cockpit windows provided by Boeing, and put in-cockpit information (a clearance delivered by radio) ahead of outside-cockpit information (the visual picture) in forming his SA mental picture. (Never mind the capacity-over-margin-for-error decision inherent in continuing an approach into LAHSO with a plainly visible aircraft moving so as to put it just on the far side of the hold short point at the same time a long landing or failure to stop would put him there.) I certainly agree with Bob H. that turbofans don’t relieve any pilot of his responsibility to see and avoid.

    Another part of Brian Wilkins’ post – “The crew is glued to engine instruments and airspeed. Sure,it would be nice to gaze outside…” – makes it appear that Mr. Wilkins is sorting himself into that small portion of professional pilots who appear to process the in-cockpit information in preference to processing externally-sourced information. I haven’t gotten to the point in flying to be exposed to mandatory CRM, but what I’ve read and picked up hangar flying is that one out of two-man crew flies and the other monitors, runs checklists, and makes call-outs during critical phases of flight. If I’ve gotten that wrong, I’d appreciate some wisdom from those with experience greater than mine.

    Additionally, “The bottom line is that all GA pilots need to understand WTF they are doing, over.” gives the impression that this ATP (whom I assume has his pocketbook filled, rather than drained, with each revolution of the Hobbs) doesn’t care for coexisting in public airspace with those not flying for air carriers. It seems to me that safety (and several other things) would be better served if aviators interacted with other aviators based upon their actions, rather than upon their employment status.

  35. Brian Wilkins ATP Says:

    To Bob H. “How did the RJ crew lose sight of the Cessna? They had 45 seconds from TIPH to CTO, which should have been a fair amount of time to look straight down the runway.”

    Fact check-runway is 7600 feet Not 3000.

    You are assuming the RJ crew saw the Cessna over one and half miles away initially. The Cessna lands in the first thousand to two thousand feet and taxis down the runway. You try looking downrange at a mile an tell anyone if an aircraft is 30 feet to the left on a taxiway taxiing towards you or on the runway with everything going on in the cockpit and you are accelerating to 135 mph. Think fast! Your 15 seconds is almost up.

  36. Brian Wilkins ATP Says:

    I can understand your point of you view because I fly GA all the time. I also instruct in my spare time and fly people around for a living so I guess since why you can’t understand certain parts of us “professional pilot’s” is about the only thing that you stated that actually rings true.

    First of all I can see where you are coming from. I always loved students like you that “, and now that I know a little, ” seem to know everything about flying except that 250 hours is the first mark in flight time where you get that B.S. confidence. It’s one of those things we learned in our fundamentals of instruction about ego. Now you know more than your instructor. I am here to tell you that even the newest flight instructor knows more than you ever will with that attitude.

    You need to re-read and get your facts straight. How do you expect a aircraft on a tower frequency that has just been cleared to listen to ground frequency to verify the Cessna has cleared. Since you dont get this point I will give you a free instruction lesson.

    Aircraft lands and is told to exit on taxiway xyz and call ground on 121.xy
    So that is the last thing you will ever hear if you are on tower frequency. You wont hear him call clear on tower. You call clear on ground for taxi instructions. Different frequencies get it? End of free lesson.

    The incident you wrote about the 737 rings true. Here is where and why I mentioned the word “turbo-fan” not as an insult but to enlighten GA pilots that things are moving at a faster pace and you can not always see things like you can in a Cessna. Just a fact. I dont care how big his windows are.

    I can answer your hangar flying question since I qualify. I never said that a crew doesn’t look outside. There is a lot of information to process in a very short amount of time. This crew did exactly what you would expect them to do. The in cockpit information is as critical as the external cockpit information when you only have a short amount of time to react-not think.

    Last but not least. I am an AOPA member as well as a flight instructor. I love promoting general aviation. However from time to time there are bumps in the road like you. So the next time you are riding in the back of that 73 or that RJ and you see something you dont like, why dont you just go up front and tell that crew about your flight experience and opinion and let us know how it worked out.
    So Long

  37. J. Small Says:

    I’ll chime in as a low time GA pilot with several thousand hours of non-pilot time in naval aircraft. Blame doesn’t matter. What’s required by the regulations and associated procedures inevitably becomes crystal clear in the aftermath of such things. In real time, one enhances everybody’s safety if you maintain situational awareness until the aircraft is parked. I won’t address what the tower controller or ATP crew should have done. I will say that:
    1. I would have advised tower “Unable A4″ as soon as I could, and if still necessary,
    2. I would have still been up on the tower freq and would have been loud, and unambiguous regarding my location when I heard tower clear the RJ for takeoff. I am reasonably confident that the RJ crew would have stopped their TO roll upon hearing that.
    Please understand that I’m not blaming the 172 pilot for anything. Rather I’m pointing out that we retain some measure of influence on our destinies in most situations, ATC & big iron notwithstanding.

  38. Ohio Dave Says:

    I was taught you owned the runway until you exited it. Aircraft landing has the right of way. If following an airplane while landing do not land if plane is not clear of runway. All the rules point to the runway realistate being owned by the landing airplane.

    Why blame the Cessna driver? Had this ended in an accident the Cessna driver would have been blamed as everyone in todays society points the finger at anyone but them selfs. The news papers would have damned the GA driver no matter how blameless he or she was.

    Overall this had a good ending and I learned more about flying with controllers. Listen and then make your own decisions after evaluating the situation. He or she might be wrong.

    Ohio Dave – not bold but just old

  39. Bob H. Says:

    The RJ lined up at the threshold of 6, which the cessna crossed. I hope they saw that before accepting the TIPH, because they had been given a hold short instruction for landing traffic. The Cessna eventually exited at Bravo – that’s 2900-3100 feet.

    There’s two sets of eyes in that cockpit – I stand by my assertion that they lost the SA and should have been able to see and avoid the incident long before the thrust levers moved forward. Everybody has to do their part, and this includes pilots having our own mental ASDE-X display image.

    For an example of the system and its capabilities, this is a snippet on how that works:

    “However, the tower controller cleared Flight 2998 to take off on the same runway to which the disoriented B-757 crew had returned. Capt. Tilly and F/O Redmond politely but pointedly refused to accept the takeoff clearance until the actual location of the “lost” B-757 was confirmed—and the airplane was safely at the gate.

    “Without the precautions that both Capt. Tilly and F/O Redmond took, an enormous disaster could have occurred on the runway,” Capt. Woerth asserted. They earned the ALPA Presidential Citations, he said, for “demonstrating exceptional situational awareness and judgment in avoiding a potentially catastrophic runway collision at Providence.” –Air Line Pilot, November/December 2001, p. 16 By Jan W. Steenblik, Technical Editor

  40. Bert Staehling Says:

    Dear Bruce,

    As an Air Traffic Controller(since 1982) and 35 years as a plilot (CFI for 25 years) I have a suggestion that might help.

    If we were to rewrite the FAR requiring all pilots to become familiar with all runways at intended destination airports with the addition that all pilots shall become familiar with all TAXIWAYS at destination airports, it may help overcome some of the confusion about where and when to exit the runway in accordance with the controller’s instructions.

  41. Jim McCord Says:

    EVERYONE makes mistakes – controllers, pilots, you, me, etc. No regulation or legislation will EVER fix this. Every pilot and controller should have an attitude that mistakes will be made and if there is ANY question, a question should be asked. This approach will go a long way toward improving safety. There were at least 4 people (Cessna pilot, controller, 2 pilots in the RJ) that could have piped up to clarify the situation.

  42. Andres Says:

    The main responsibility of ATC is aircraft seperation. I agree that mistakes can not be avoided 100%. Which is why communication is essential. I would like to hear the cockpit voice recorder of the RJ to see at which point the pilots reacted.

    In my opinion the Cessna pilot bears some of the responsibility for this incident and ATC the rest.

  43. Tom Werner Says:

    It is a shame that Mr. Lansberg wrote an article epsousing to be factual, accurate, and non-biased; yet is none of the three. He would be the first to say don’t believe what you read in the media, but his article is nothng but a dramatization of these. Perhpas since there may be some controller blame, he is anvious to believe what he has read.
    We are the curators of our industry, and it does no good for anyone to place any blame when they no few, if any, of the facts. It would behoove all of us to first investigate the conditions, including local lighting, frequency congestion,and workloads both in the tower and in the cockpits before getting on our high horses. A complete investigation must be done to establish what events lead up to this incident. Then, with the help of airport operators, the FAA, aircraft operators, pilots, etc., come up with workable solutions, not “put a tack in the wall with a sledge hammer”.
    Fly safe

  44. Sam Beale Says:

    Speaking of fact checks, had the 172 been “over one and half miles away”, I would like to think that those big turbo fans would have had the RJ quite high in the air by that time, not skidding around the 172. Looks like a lot of runway exists beyond the skid marks, so perhaps the 172 was not sitting on the big 24 at the other end as has been assumed by some.

    Another fact check (question, not statement), was the 172 pilot definitely told to contact ground on a different frequency? At least one account (Bob H.) indicates that the pilot was told to “remain this frequency”, which is not an uncommon instruction at night when both traffic and the controller staff are reduced, at least not uncommon at PDK, which is probably as busy as most GA airports.

    Bottom line, as with most accidents and near accidents, a simultaneous occurrence of error in some degree on the part of two or more parties is a (the?) major factor here. The fact that the regulations might allow one party (the controller) to be assigned all the blame does not mean that no one else contributed to the near miss.

    Again, kudos to the RJ crew for their skill in avoiding the collision when all other safeguards in the system had not been effective.

  45. Rich Nasser Says:

    Aren’t we taught to TRUST but VERIFY ATC? This is for a reason. The blame game doesn’t work and shouldn’t even be a topic for discussion – the event already happened and you can’t change it.

    Also, kudos to the ASF for making the real cool flash simulation of the event with the original radio calls – it is almost as if you were there that evening! Great learning tool.

    That could have been any one of us in the Cessna or the RJ.

    Thank heavens no one was hurt!

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  73. George Horn Says:

    JF… Good comments. Disregard the self-impressed, arrogant Brian Wilkins, ATP. It’s folks with his attitudes that cause most of the problems.

    Your query to the 737 FO were appropriate, and his response (“His answer was to the effect that ‘we were cleared to land and tower would not have issued clearance if adequate separation wasn’t to be maintained’) … demonstrates his own misunderstanding of the system.

    ATC cannot guarantee seperation in a LAHSO operation. The pilots, once they accept such a landing clearance, are the ones who are then responsible for seperation. Therefore the 737 FO who thinks that just because ATC issued such landing clearance, that such clearance is automatically safe, clearly should go back to school. I hope you wrote the Chief Pilot of that airline and related your experience.

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  82. Bob Yarmey Says:

    Very weak situational awarness by all players.
    Majority blame on ATC.
    CRJ crew – poor listening watch on tower freq.
    Cessna crew – ” ”

    Also Cessna crew should have quiered tower on landing distance available and advised. I treat specific requests by tower to depart at a specific taxiway like a LAHSO situation. When in doubt as to distance available and aircraft capability, do not hesitate to advise tower – even if slight doubt exists.

    I agree that until CONFIRMED clear of runway, it did indeed belong to the Cessna. Also from the 6 oclock position at night, it can be VERY DIFFICULT to ensure nothing lies ahead.

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