China Airlines’ Takeoff Shows Breakdown in Situational Awareness

Crew followed green taxiway centerline lights for night takeoff in wrong direction

The nighttime takeoff on a taxiway of a China Airlines (CAL) jet with 252 passengers and crew shows that the answer to latent pitfalls is an enforced double-check.

In the case of the January 2002 takeoff at Anchorage, Alaska, takeoff power was applied as the crew turned onto what they thought was the runway, but no one made a double-check to verify they were on the assigned runway, rather than the broad taxiway leading to it.

In a May 30 decision, the National Transportation Safety Board (NTSB) said the incident was the result of inadequate crew coordination, including the absence of a checklist requirement “to verbalize and verify the runway in use prior to takeoff.” China Airlines has since modified its procedures, calling for such a verbal check.

The taxiway takeoff at Alaska’s Ted Stevens Anchorage International Airport (PANC) underscores the continuing concern about the safety of airport operations and the abiding risk of catastrophe. At a meeting with reporters last week, NTSB Chairman Ellen Engleman said, “We are looking for simple solutions” to improve the safety of airport operations. Moving map displays in cockpits to help pilots know their location on the airport are fine, she said, but these technologies are years from deployment.

Meanwhile, Honeywell International Inc. [NYSE: HON], a major avionics manufacturer, is developing a technology – actually a relatively low cost adjunct to its enhanced ground proximity warning system (EGPWS) – that will provide pilots with an aural advisory of the runway to which they are taxiing, and on which they are lined up for takeoff. Honeywell’s runway awareness and advisory system (RAAS) also will sound a caution should a crew attempt takeoff on a taxiway. Honeywell officials hope to attain supplemental type certification from the Federal Aviation Administration (FAA) by this fall. Deployment in the form of a software upgrade could follow in short order.

Had RAAS been available earlier, the China Airlines takeoff on a taxiway and the deadly crash of a Singapore Airlines (SIA) B747 attempting takeoff on a closed runway at Taipei in October 2000 might have been avoided (see ASW, March 5, 2001, and May 6, 2002). Both the CAL and the SIA cases have a number of elements in common.

The crew of the CAL A340-300 was lucky. Without the full length of a runway, they were able to get airborne from a much shorter taxiway, leaving tire impressions in the low bank of ploughed snow at the end of the tarmac. As they heard the sound of takeoff thrust and saw the airplane still on the taxiway, the horrified observers in the control tower thought for sure a crash was imminent. The crew had been cleared for takeoff on runway 32, which is 10,500 feet long. For the long flight to Taipei, the A340’s calculated takeoff distance was 7,700 feet. When the crew turned onto taxiway Kilo and the captain advanced the throttles, an estimated 6,500 feet of tarmac was available. In this situation, the first officer was the pilot flying, but the captain retained control of the throttles, according to the investigative documents.

The reserve captain was in the cockpit jump seat at the time.

With the earlier attempted takeoff on a closed runway of the SIA jet and this case in mind, ASW contributing editor John Sampson offered this analysis:

“To a certain extent, crews nowadays are less focused on their external environment, particularly at night, because of:

a. The cocooning effect of a warm brightly lit cockpit on a dark night, and

b. All the checklist action being in the cockpit, so that’s where the crew’s collective primary focus lies.

“From the illuminated cockpit of a modern airliner, the external environment is a sea of lights (and windscreen reflections and rain-spattered distortions), largely devoid of any real discriminating or attention-getting detail. There is an unsubtle difference between lighting and the visibility afforded by illumination. With only cockpit lights – and not the judicious use of landing lights to avoid ‘night wandering’ – the mind is required to formulate its own lucid interpretations of what it might be seeing. The mind actually becomes prone to pellucid imperceptions. If the aircraft just happens to stop on a heading that aligns itself with, and between, a couple of parallel lines that lead seductively off into the night, the mind is apt to later skip a step – after the checklist’s complete – and leap easily to the conclusion that the vista ahead is the launch direction.

“If it looks convincing enough – and it must have been for the CAL crew, because they weren’t suicidal – then the ATC take-off clearance would have been almost subliminal confirmation for them that they were properly poised to punch off in that direction. Then, power being applied authoritatively by the captain, at that nominal point of no return, everyone is too busy and too dependent and trusting of each other to entertain, let alone enunciate, lingering doubts. Attention is then wholly upon the rapidly developing sequence of events and call-outs of a typical take-off. Concentration is on systems operation and awareness becomes very insular.

“The CAL incident compares well, on the crew resource management (CRM) scale of grand failures, with the KLM flight engineer in Tenerife who at least had the gumption in that tragic 1977 accident to vocalize his misgivings – but than gave up because the captain quickly counter-claimed to have the plot (576 people were killed when the KLM B747 on takeoff in heavy fog collided with a Pan Am B747 taxiing down the runway).”

With respect to the CAL incident at Anchorage, Sampson used a rugby metaphor: “Sometime it’s possible, amidst all the scrimmaging, for the ball to depart the scrum and nobody notice.” The ball here is awareness of the airplane’s location on the airport.

Sampson seconded the enforced double-check put in place since. For added back-up, he endorsed “an attitude of healthy cynicism and querulous outspoken and insistent inquiry by subordinates.” That attitude, of course, is the essence of effective CRM. And in this respect, perhaps there is another CRM issue at work: that of the captain “handing over” the airplane to the pilot flying while applying takeoff power. It is more customary for the pilot flying to apply power himself. There may be a blurring of delegated responsibilities here that may have contributed to the second and third officers being loathe to say any words out of place to the man in the left seat – who never totally relinquished control.

There are related issues. The combination of blue, green, white and other colors in airport surface markings and signage is unnecessarily confusing, according to some sources. Airports lack the simplicity and standardization of highway markings and signs, an example which the aviation industry might emulate. To be sure, if the desire were to seduce someone into mistaking a taxiway for a runway, one would make the markings look similar and just subtly change the colors of the centerline lights – from white to green. To minimize the potential for a mistake, it might be preferable to make every other or every third taxiway light yellowish (as an example). That would be distinctive enough for the contrast definitely to register in the conscious mind – whereas the fact that a light is bright green when it should be white does not provide enough of a difference, as the pilot’s remarks in this case plainly attest.

As a final note to the case, the Anchorage airport diagram contains this interesting note: “CAUTION: Avoid landing on twy K.” In other words, it’s possible for a pilot to mistake Kilo for the runway on landing as well. Kilo runs parallel to Runway 06R. In this situation, if the pilots were descending to land on the taxiway, they would not hear the RAAS call out, “Approaching 06 Right.” A flight crew used to the RAAS advisories “would be expecting to hear that,” said a Honeywell official. A second-generation system (RAAS II), with more refined terrain data, may well include a specific in-air advisory to a crew inadvertently descending to land on a taxiway. (Note: See also Qantas B717 incident May 29 in table).

What the Pilots Had to Say for Themselves

Capt. Yao Hsiao Hung, pilot not flying (PNF): The take-off roll was normal, but I observed the length and light of the remaining runway was shorter than normal. Due to the speed had already reach Vr at that time, I decided to call for rotate. The mistakes were made due to: 1. Ask checklist too fast which leave limited time for CM2 (first officer) and CM3 (relief pilot) to verify take off runway, 2. I did not check runway heading before takeoff and therefore made this mistake to take off from taxiway ‘K.(ASW note: comments as written in signed statement.)

First Officer Hsieh Wei-Ting, pilot flying (PF): Prior to enter ‘K’ taxiway, the take off clearance was given by ANC [Anchorage] Ground Control (same frequency for ground and tower). CM1 (the captain, who taxis the airplane per China Airlines procedures) turned onto taxiway ‘K’ and ordered me for before takeoff checklist. CM1 then handed over the control to me and call out ‘you have control.’ The take off was initiated after that.

Capt. Fong Yen Lung, reserve captain and also a check airman: The crew was not very familiar with ANC airport in general. According to our duty assignment, the CM3’s responsibility is to assist other crewmembers and check the signage. Prior to enter taxiway ‘K,’ the takeoff clearance was given by ANC tower. While CM1 turned onto taxiway ‘K,’ he ordered CM2 to perform ‘before takeoff checklist.’

At that time, I was concentrating on monitoring CM2 performing before take off procedures. When CM2 completing his checklist, I looked up and found airplane was already aligned with bright and clear centerline lights. It was not until V1 when I noticed that this might be the incorrect runway and was too late to abort. Source: NTSB. Officials from Taiwan’s Aviation Safety Council conducted crew interviews.

‘This is going to be ugly’

China Airlines takeoff on a taxiway Air traffic control transcripts (extracts)

Time (local)& Speaker: Content

02:32:32 Anchorage local control (LC): Dynasty zero one one heavy taxi runway three two at kilo taxi via mike romeo kilo.

02:32:40 China Air Flight 011: Dynasty zero one one heavy (unintelligible) for kilo mike romeo kilo dynasty zero one one heavy.

02:40:06 LC: Dynasty zero one one heavy wind three six zero at seven runway three two at kilo cleared for takeoff.

02:40:13 CAL011: Cleared for takeoff three two kilo dynasty zero one one heavy.

02:42:45 LC: No, he’s going the wrong – (ASW note: instead of being amazed and bemused, another more alert controller might have called an abort).

02:42:47 Anchorage TRACON (NR) : He’s on a taxiway.

02:42:48 LC: He’s on a taxiway.

02:42:49 NR: This is gonna be ugly.

02:42:50 LC: This is gonna be seriously ugly. Call the crash phone and make it an alert three [airplane has crashed].

02:42:54 NY: Yeah, geez.

02:43:21 LC: He’s airborne.

02:46:38 NR: Did he hit anything out there?

02:46:39 LC: We’re still checking.

02:46:40 NR: Huh, he’s not climbing real good.

02:46:43 LC: No, he wasn’t taxiing very well.

02:47:22 CAL001: Anchorage departure dynasty zero one one request uh normal speed for climbing.

02:47:28 NR: Dynasty zero one one heavy your discretion.

02:48:21 NR: He departed on a taxiway and – it wasn’t a very long taxiway.

02:48:26 Anchorage ARTCC (ZAN) : Okay.

02:48:27 NR: And the airport’s checking things right now.

02:48:28 ZAN: All right.

02:48:29 NR: Um, if there’s pieces of his airplane somewhere we’ll have to let him know about it.

Source: NTSB