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|
Attributes | |
ACN | 236994 |
Time | |
Date | 199303 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : ewr |
State Reference | NJ |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : ewr |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | ground : holding ground other : taxi |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | descent : approach landing other |
Route In Use | approach : visual approach : straight in enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 200 flight time total : 13000 flight time type : 3000 |
ASRS Report | 236994 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 150 flight time total : 6000 flight time type : 3500 |
ASRS Report | 236987 |
Events | |
Anomaly | conflict : ground critical incursion : landing without clearance non adherence : published procedure non adherence : far non adherence : required legal separation other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : investigated faa : reviewed incident with flight crew |
Miss Distance | vertical : 150 |
Supplementary | |
Primary Problem | Ambiguous |
Air Traffic Incident | Pilot Deviation Operational Error |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
Our flight, air carrier Y, was cleared to taxi from our company ramp at ewr to runway 4L. We were instructed to taxi into position on 4L and hold. As we were taxiing into position on 4L, ewr tower instructed air carrier X that he was cleared to land on 4R, that there would be a departure prior to his arrival. After holding in position for 1 1/2 to 2 mins, air carrier X flew right over the top of us and landed on 4L. We asked ewr tower if they were aware of what had happened. They said that they were and they would investigate. We saved our cockpit voice recorder. This incident turned into a full scale NTSB investigation. Here are some possible contributing factors: 1) ewr ATIS information, H plus 50Z had runway 4R closed. 2) ewr ATIS information H plus 1 plus 50Z had departures on 4L and arrs on runway 4R. The incident took place at H plus 2 plus 28Z. The crew of air carrier X may have only gotten information west and were thinking that 4R was closed. 3) I have no way of knowing which runway ewr approach told air carrier X to expect or what type of approach they were cleared for or to which runway. 4) we had our navigation lights, rotating beacon (red), and the taxi light illuminated as per company directives and ICAO procedures. Corrective actions: 1) I see having a common frequency for parallel runways to be a potential hazard. 2) here we are, 2-3 yrs after the air carrier Z disaster at lax, and standard procedures do not call for pilots to turn on landing and strobe lights until cleared for takeoff. In other words, ICAO procedures call for us to taxi into position and hold and try to be as inconspicuous as possible. I do not know whether air carrier X ever saw us. Supplemental information from acn 236987: tower cleared us to taxi into position and hold on runway 4L (4L has an overrun at the end of the approach end of the runway). I looked out the right window for possible landing traffic on runway 4R. We observed an aircraft fly over us (still on the overrun) and then land on runway 4L. After that aircraft cleared the runway, our captain asked tower if they were aware of what just happened. They answered that they were and would investigate. The cockpit voice recorder was pulled after climbing through 10000 ft. Our being in position on the overrun probably caused our aircraft lighting to blend in the approach lighting, while at the same time, allowing the aircraft to fly about 100 ft above us. Supplemental information from acn 237004: we were cleared visual 4L contact the tower. Tower cleared us to land on 4L at about 200 to 300 ft AGL, the first officer mentioned a blinking light that appeared to be in the runway displaced threshold. Just over the threshold the first officer said 'it's an airplane!' it did not appear to be fully on the threshold. I asked the first officer to reconfirm landing clearance. Tower replied 'air carrier X' and did not complete statement. At this point, I was already in the flare, reducing power, and I judged it prudent to land. All 3 crew members agreed clearance to land was for 4L. None of us heard any transmission between tower and other aircraft. I would strongly suggest aircraft entering an active runway put all lights on, even if told position and hold. Callback conversation with reporter (acn 237005) revealed the following information: there was an NTSB hearing a few days after this incident involving only this crew. There was a separate hearing for the controllers involved and another for the other crew. Rumor has it, according to the first officer of the landing aircraft, that 3 controllers were downgraded. 1 controller was a trainee with no supervisor in the cabin attendant. The reporter has not heard from the FAA, but it is only 3 weeks since the incident. The landing aircraft was not told of the opening of runway 4R, nor were they told of the change in ATIS. This reporter has not heard the tower tape, but he has seen the transcript which shows that the landing aircraft was cleared to land on runway 4R vice 4L. The tape shows that the landing aircraft did not acknowledge the change in runway from the previous clearance to land on 4L. The air carrier line checked both crews and found them to be up to standard. The crews are still talking to each other. The aircraft in position on the runway has a purple top paint job against a black runway. Its position on the runway was in a displaced threshold among a series of runway approach lights. There was plenty of landing gear to tail fin clearance as the displaced threshold is 700 ft from the end of the runway. Callback conversation with reporter (acn 236987) revealed the following information: the first officer of the aircraft on the runway reports that his crew had a telephone interview with an NTSB representative and the other crew had a separate interview. The captain had a line check shortly after this incident. The first officer has not heard from the FAA yet.
Original NASA ASRS Text
Title: AN ACR LGT FREIGHTER CREW LANDED OVER THE TOP OF ANOTHER ACR LGT FREIGHTER THAT WAS IN POS ON THE RWY BUT HOLDING IN APCH LIGHTS ON AN OVERRUN. USED FOR TKOF ONLY.
Narrative: OUR FLT, ACR Y, WAS CLRED TO TAXI FROM OUR COMPANY RAMP AT EWR TO RWY 4L. WE WERE INSTRUCTED TO TAXI INTO POS ON 4L AND HOLD. AS WE WERE TAXIING INTO POS ON 4L, EWR TWR INSTRUCTED ACR X THAT HE WAS CLRED TO LAND ON 4R, THAT THERE WOULD BE A DEP PRIOR TO HIS ARR. AFTER HOLDING IN POS FOR 1 1/2 TO 2 MINS, ACR X FLEW R OVER THE TOP OF US AND LANDED ON 4L. WE ASKED EWR TWR IF THEY WERE AWARE OF WHAT HAD HAPPENED. THEY SAID THAT THEY WERE AND THEY WOULD INVESTIGATE. WE SAVED OUR COCKPIT VOICE RECORDER. THIS INCIDENT TURNED INTO A FULL SCALE NTSB INVESTIGATION. HERE ARE SOME POSSIBLE CONTRIBUTING FACTORS: 1) EWR ATIS INFO, H PLUS 50Z HAD RWY 4R CLOSED. 2) EWR ATIS INFO H PLUS 1 PLUS 50Z HAD DEPS ON 4L AND ARRS ON RWY 4R. THE INCIDENT TOOK PLACE AT H PLUS 2 PLUS 28Z. THE CREW OF ACR X MAY HAVE ONLY GOTTEN INFO W AND WERE THINKING THAT 4R WAS CLOSED. 3) I HAVE NO WAY OF KNOWING WHICH RWY EWR APCH TOLD ACR X TO EXPECT OR WHAT TYPE OF APCH THEY WERE CLRED FOR OR TO WHICH RWY. 4) WE HAD OUR NAV LIGHTS, ROTATING BEACON (RED), AND THE TAXI LIGHT ILLUMINATED AS PER COMPANY DIRECTIVES AND ICAO PROCS. CORRECTIVE ACTIONS: 1) I SEE HAVING A COMMON FREQ FOR PARALLEL RWYS TO BE A POTENTIAL HAZARD. 2) HERE WE ARE, 2-3 YRS AFTER THE ACR Z DISASTER AT LAX, AND STANDARD PROCS DO NOT CALL FOR PLTS TO TURN ON LNDG AND STROBE LIGHTS UNTIL CLRED FOR TKOF. IN OTHER WORDS, ICAO PROCS CALL FOR US TO TAXI INTO POS AND HOLD AND TRY TO BE AS INCONSPICUOUS AS POSSIBLE. I DO NOT KNOW WHETHER ACR X EVER SAW US. SUPPLEMENTAL INFO FROM ACN 236987: TWR CLRED US TO TAXI INTO POS AND HOLD ON RWY 4L (4L HAS AN OVERRUN AT THE END OF THE APCH END OF THE RWY). I LOOKED OUT THE R WINDOW FOR POSSIBLE LNDG TFC ON RWY 4R. WE OBSERVED AN ACFT FLY OVER US (STILL ON THE OVERRUN) AND THEN LAND ON RWY 4L. AFTER THAT ACFT CLRED THE RWY, OUR CAPT ASKED TWR IF THEY WERE AWARE OF WHAT JUST HAPPENED. THEY ANSWERED THAT THEY WERE AND WOULD INVESTIGATE. THE COCKPIT VOICE RECORDER WAS PULLED AFTER CLBING THROUGH 10000 FT. OUR BEING IN POS ON THE OVERRUN PROBABLY CAUSED OUR ACFT LIGHTING TO BLEND IN THE APCH LIGHTING, WHILE AT THE SAME TIME, ALLOWING THE ACFT TO FLY ABOUT 100 FT ABOVE US. SUPPLEMENTAL INFO FROM ACN 237004: WE WERE CLRED VISUAL 4L CONTACT THE TWR. TWR CLRED US TO LAND ON 4L AT ABOUT 200 TO 300 FT AGL, THE FO MENTIONED A BLINKING LIGHT THAT APPEARED TO BE IN THE RWY DISPLACED THRESHOLD. JUST OVER THE THRESHOLD THE FO SAID 'IT'S AN AIRPLANE!' IT DID NOT APPEAR TO BE FULLY ON THE THRESHOLD. I ASKED THE FO TO RECONFIRM LNDG CLRNC. TWR REPLIED 'ACR X' AND DID NOT COMPLETE STATEMENT. AT THIS POINT, I WAS ALREADY IN THE FLARE, REDUCING PWR, AND I JUDGED IT PRUDENT TO LAND. ALL 3 CREW MEMBERS AGREED CLRNC TO LAND WAS FOR 4L. NONE OF US HEARD ANY XMISSION BTWN TWR AND OTHER ACFT. I WOULD STRONGLY SUGGEST ACFT ENTERING AN ACTIVE RWY PUT ALL LIGHTS ON, EVEN IF TOLD POS AND HOLD. CALLBACK CONVERSATION WITH RPTR (ACN 237005) REVEALED THE FOLLOWING INFO: THERE WAS AN NTSB HEARING A FEW DAYS AFTER THIS INCIDENT INVOLVING ONLY THIS CREW. THERE WAS A SEPARATE HEARING FOR THE CTLRS INVOLVED AND ANOTHER FOR THE OTHER CREW. RUMOR HAS IT, ACCORDING TO THE FO OF THE LNDG ACFT, THAT 3 CTLRS WERE DOWNGRADED. 1 CTLR WAS A TRAINEE WITH NO SUPVR IN THE CAB. THE RPTR HAS NOT HEARD FROM THE FAA, BUT IT IS ONLY 3 WKS SINCE THE INCIDENT. THE LNDG ACFT WAS NOT TOLD OF THE OPENING OF RWY 4R, NOR WERE THEY TOLD OF THE CHANGE IN ATIS. THIS RPTR HAS NOT HEARD THE TWR TAPE, BUT HE HAS SEEN THE TRANSCRIPT WHICH SHOWS THAT THE LNDG ACFT WAS CLRED TO LAND ON RWY 4R VICE 4L. THE TAPE SHOWS THAT THE LNDG ACFT DID NOT ACKNOWLEDGE THE CHANGE IN RWY FROM THE PREVIOUS CLRNC TO LAND ON 4L. THE ACR LINE CHKED BOTH CREWS AND FOUND THEM TO BE UP TO STANDARD. THE CREWS ARE STILL TALKING TO EACH OTHER. THE ACFT IN POS ON THE RWY HAS A PURPLE TOP PAINT JOB AGAINST A BLACK RWY. ITS POS ON THE RWY WAS IN A DISPLACED THRESHOLD AMONG A SERIES OF RWY APCH LIGHTS. THERE WAS PLENTY OF LNDG GEAR TO TAIL FIN CLRNC AS THE DISPLACED THRESHOLD IS 700 FT FROM THE END OF THE RWY. CALLBACK CONVERSATION WITH RPTR (ACN 236987) REVEALED THE FOLLOWING INFO: THE FO OF THE ACFT ON THE RWY RPTS THAT HIS CREW HAD A TELEPHONE INTERVIEW WITH AN NTSB REPRESENTATIVE AND THE OTHER CREW HAD A SEPARATE INTERVIEW. THE CAPT HAD A LINE CHK SHORTLY AFTER THIS INCIDENT. THE FO HAS NOT HEARD FROM THE FAA YET.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.