Pilots warned to stay alert for Toronto incursion risks

[altiplano]

I can't believe I've never noticed illuminated red stop bar lights embedded in the taxiway... I guess I was always too busy paying attention and holding short...

Anyway Merry Christmas. To more awareness and safe flying and taxiing in 2018.

[Cliff Jumper]

I can't believe I've never noticed illuminated red stop bar lights embedded in the taxiway... I guess I was always too busy paying attention and holding short...

That's good info... you never noticed them, and I'm assuming neither did the crews that crossed them. It's not just some foolish distracted crews, it's you too (no insult intended, we're all human).

If the hold line is a few metres (not 25-50m) closer than expected, there is still no excuse for not seeing the lit bar.

The D6 exit from 24L is shorter than the others so that line can creep up on you but since it 8000' down a 9000' runway, you're not going in there at 50kt.

Google Earth shows all the lines are exactly 115m from the centerline, with the exception of D6, which is ~140m. They are 25m-50m further from the runway compared to normal.

But, it's not about making excuses. Everyone seems to get wrapped up in that idea. I'm sure none of the crews who went over the line felt that 'it was someone else's fault'; and, I don't think the solution to make everything safer is to get those crews to just admit they screwed the pooch. How would that help? Should those crews just be fired, and then problem solved?

In contrast however, understanding why those crews made that mistake, might actually lead to improvement.

[Rockie]

The stop bars between 24L and 24R are immediately after the turn from the high speed and are not visible until late. As Pelmet alluded to before getting fixated on AC’s procedures, a line of red taxiway centreline lights leading up to the corner would go a long way towards reinforcing to the crew as they clear the landing runway that they need to stop.

Everything about flying and the operational side of airports has evolved over the years to accommodate human factors. This is no different.

[pelmet]

As Pelmet alluded to before getting fixated on AC’s procedures,

Or lack thereof.....

[Rockie]

What do you base this fantasy on Pelmet besides a dislike of me? You are publicly suggesting a serious deficiency in a large company’s procedures based on what exactly?

[pelmet]

The stop bars between 24L and 24R are immediately after the turn from the high speed and are not visible until late. As Pelmet alluded to before getting fixated on AC’s procedures, a line of red taxiway centreline lights leading up to the corner would go a long way towards reinforcing to the crew as they clear the landing runway that they need to stop.

Actually, this is incorrect. One will just as likely have to stop(hold short) even if the red lights are not illuminated. It has nothing to do with a clearance/ATC instruction to hold short of a runway and its greatest potential benefit comes into play when one has a clearance to cross a runway.

You do understand how RWSL works don't you?

[Rockie]

Well I’m pretty new at this but let’s see if I can suss it out. Red lights mean stop...is that right Pelmet? Do I have that wrong?

[pelmet]

Well I’m pretty new at this this but let’s see if I can suss it out. Red lights mean stop...is that right Pelmet?

Good cover. Anyways, bottom line......as mentioned earlier, no distracting stuff until clear of both runways. I know it sounds basic but this earlier quote says it all...

"All the controllers here have had aircraft call 121.9 while between the runways even though no frequency change was given. We've heard calls to company frequency on guard from an aircraft in between the runways, sometimes while the aircraft is still moving. Really! You have to make that call right now?"

Somebody wanted answers as to why this keeps on happening. Now you know why and it has nothing to do with markings.

[Rockie]

Can you cite an investigation that shows that as the reason these events happened? And while you’re at it maybe you can show us definitive proof that runway and taxiway markings are ineffective at informing crews about what’s ahead of them.

[altiplano]

There is obviously more to it for "pelmet"...

Good luck...

[pelmet]

Can you cite an investigation that shows that as the reason these events happened? And while you’re at it maybe you can show us definitive proof that runway and taxiway markings are ineffective at informing crews about what’s ahead of them.

Actually, the markings are effective in YYZ if you pay attention and don't do unnecessary things at critical times. Of course there will be no TSB report for these incursions(although you might post the internal AC report for us and SFO ones as well, for safety reasons of course), but.....

As a general investigation not directly related to but similar to YYZ events....pretty much the top recommendation is...

"Recommendations
The SCRI recommends that:

Transport Canada focus on developing preventive strategies for runway incursions that result from pilot deviations. Immediate action should be taken to disseminate, on a recurring basis, information to pilots about human performance vulnerability to error due to workload, and potential distractions associated with the performance of cockpit tasks."

https://www.tc.gc.ca/eng/civilaviation/ ... u-1947.htm

[Rockie]

Distractions happen Pelmet, you may just be the very last person to realize that. The challenge is negating those distractions, and procedures are only one of the methods of doing that. Since no operator to my knowledge encourages crews to ignore ATC instructions, and yet these incidents still happen, other methods of keeping crews cognizant of hold short requirements need to also be employed. You even acknowledged that before embarking on this mission to expose AC’s imaginary deficient procedures.

Anyway, as stated before have a good Christmas. We’ll continue the pointless arguments in the new year.

[pelmet]

You are a strange man Rockie. I have been creating this thread to try do my very small part to prevent a major disaster.

I have mentioned that distractions are a big part of the problem and have given some detailed thoughts on what someone can do to prevent this sort of situation from happening.

Concerning distractions, you asked me

Can you cite an investigation that shows that as the reason these events happened?

I post a link to major investigation showing that distractions are a major problem and you seem to only be able to write condescending remarks in reply.

Distractions happen Pelmet, you may just be the very last person to realize that.

You seem to be quite a distasteful character. If you can't add to the safety ideas of preventing future accidents(and I don't remember any useful advice that you have given so far that wasn't a repeat of what I already said) then please refrain from posting.

Due to your tenacious defence of AC's procedures, I will assume that you are correct and hope that you and your insults disappear with that acknowledgement in hand.

[altiplano]

Pot calling the kettle black?

[pelmet]

Pot calling the kettle black?

Once again....after having made several suggestions myself on how to prevent a disaster tomorrow based on the current markings, I challenge you to show me one useful suggestion that you have made on this thread for the pilot landing in YYZ, or SFO, or LAX tomorrow to prevent the same.
Or better yet, try making a first safety suggestion tonight.

That would be appreciated as potshots don't save lives

[altiplano]

Have you?

In fact you made assumptions about one airline's SOP that you admittedly know nothing about... and are wrong about. That leads to a pissing match that solves nothing.

Put the hold line in a standard position. That's my suggestion. I'm speculating that guys are so far back from the runaway they think the line is further up. Cossack said the incursions are less than an aircraft length and at slow speed.

[pelmet]

Put the hold line in a standard position. That's my suggestion. I'm speculating that guys are so far back from the runaway they think the line is further up. Cossack said the incursions are less than an aircraft length and at slow speed.

Once again, your suggestion for the pilot flying to Toronto tomorrow is completely useless for the pilot on the line and it is likely that the people in charge of moving makings are not on this forum.

A check of Google earth shows that the hold short line is fairly close to the runway. But lets assume that the markings are further than they should be.

So once again, as an experienced pilot, do you have any suggestions for pilots flying into Toronto on what they can to prevent this from happening, regardless of where the hold short markings are as I have been doing? We have to deal with what we've got and there is little doubt that we as pilots will encounter some differences in markings at various airports.

You keep saying that the incursion is less than an aircraft length as if it is not significant and that the incursion is at slow speed suggesting that it is not significant, yet plenty of slow taxiing aircraft have no doubt improperly entered runways over the years. The fact that the incursion distances supposedly ended as they did would be expected when, according to others on this thread, there is an alarm, an ATC watcher and an alerted controller yelling at the crew to stop.

Do you have any prevention ideas for the average pilot out there.

[pelmet]

Once again....after having made several suggestions myself on how to prevent a disaster tomorrow based on the current markings, I challenge you to show me one useful suggestion that you have made on this thread for the pilot landing in YYZ, or SFO, or LAX tomorrow to prevent the same.

Have you?

It surprises me that you seem unaware of that I have....repeatedly and I will repeat them here including an example of why an incursion happened and a willingness to put safety above the secrecy of an operations manual to actually prove that there is something written to try to prevent incursions. And finally after having seen your cohort somehow believe and insist that only an investigation can reveal answers as to why incursions are happening, I have provided a study proving that cockpit distractions are a major cause, only to be insulted directly by that unprofessional for that.

And once again, after a review of this thread, I haven't seen one useful post on what you feel one of us can do in the cockpit to prevent an incident like this. I now realize that neither of you two are likely to assist in providing any direct preventative advice for pilots and that your only goal is to insist without evidence that your company has the proper procedures in place. So thanks for your participation and hopefully someone else can help.

I must say that it is odd at best that this is the reaction of professional pilots to a huge safety issue being discussed but it is what it is...disappointing. However, I will continue to try to come up with information, hopefully in a collaborative manner with others on various aspects of flying to improve safety.

One should mention during the approach briefing to hold short of the parallel and it can quickly be stated after a runway change if that is the case.

Is there a written procedure at your company stating that the after landing flow/checklist can only be done such as after receiving a clearance to taxi in from ground? This is how it is done where I work. I hope you answer this question in the name of safety as this could be a cause factor worth looking into.
Even if you decide not to let us know, I suggest to everyone that this procedure be applied. It may not be 100% effective but it is designed to keep pilots looking outside at potentially critical moments.

Keeping the lights on, flaps and speed brakes extended, and both pilots looking outside the cockpit window seems likely to reduce the chances of accidentally crossing a hold short line and passing by/over hold short lights.

Like most companies, we have an ops manual. As well, there are memos on certain procedures the company wants us to follow. Part of the statement on vacating runways in the manual states..."No switch or lever shall be repositioned after landing until clear of the active runway unless necessary for the safe control of the aircraft." After a incident similar to what has been posted on this thread involving close parallel runways with a hold short clearance which was caused by the captain becoming distracted by the copilot operating the landing lights, a memo was produced about including close parallel runways being included in this practice. Therefore in my experience we always have a taxi clearance prior to the after landing flow. It is just the way it always works out.

[altiplano]

Re: Have you?

Again all you are doing is making guesses that people are being careless... and then demanding proof about one operation's procedure...

Do you know that is not being done? Vigilance is always important.

I think the reason the incursions are slow and of a short amount is because guys don't have the right picture being so far back. It's a familiarity thing too.

They cross the line at slow speed because they are so far back from the other runway they think it's not the right line to stop at and they are moving forward with the expectation of holding short at a line further ahead, you know, where the line would usually be another half a football field ahead...

FWIW I always brief hotspots and crossing runways - always. Delay after landing flows until either clear or brake set and waiting. Pretty sure that's all SOP too.

[pelmet]

Re: Have you?

Again all you are doing is making guesses that people are being careless.

Do you know that is not being done?

As frustrating as it is to have to repeatedly say the same thing, please look at the study that I provided a link to on the last page and go to the conclusions area.

I admit that this can feel like talking to a brick wall and while it is tempting for me to give up when you refuse to believe anything I say despite it being obviously correct, in the name of safety and saving lives, I will continue....

https://www.atsb.gov.au/media/36244/dis ... report.pdf

"In a subsequent study, Monan (1992) examined 140 Aviation Safety Reporting System (ASRS) reports to determine the causes of runway incursions. The examination revealed that 23 incidents involved a breakdown of attention management by the pilot due to distraction. Often the distraction was caused by a flight attendant entering the cockpit or a head-down task associated with programming the Flight Management System (FMS). The sources of distraction were ranked in order of most to least distracting as follows:
1. Checklists 2. Passenger announcements 3. Company radio calls 4. Miscellaneous (system malfunction, putting away manuals, etc) 5. Flight attendant entering the cockpit 6. Conversation 7. FMS programming.

A specific example was given...

" In one incident, cognitive distraction contributed to a runway incursion at Sydney airport. According to the investigation report:
During discussions with the crew of the Metro, it became apparent that, after landing, the pilot under training had been concerned with his performance during the practice ILS approach, and had initiated a brief discussion with the training captain at about the time the aircraft had been taxiing along taxiway Juliet. "


I suspect that there are many out there who do not want to hurt feelings by admitting that someone was careless. In this politically correct era, some seem more concerned about preventing hurt feelings than preventing accidents with harsh analysis and therefore blame the personless airport authority for where they located the hold short line(and enhanced taxiway line and the lights across the taxiway, and the flashing wig-wags). But the harsh truth shows the reality. It is not difficult to hold short of a runway at YYZ, but if you are careless, it will happen...to you or to me. Make it a specific point to ignore the distractions that inevitably come up at inopportune times and as well, don't create your own distractions.