Agree, “rushing” or “hurrying” is the enemy. I fly B-777s for a major cargo airline. Getting the freight there on time or early used to be deeply engrained in our company culture. Everyone was always in a hurry. 250 knots to the marker, then idle/boards/configure on schedule was the norm. Then we wrecked a few airplanes. CRM, ORM, FOQA, and a Safety Management System showed what we were doing was stupid. It took a couple of decades, but the culture has changed. During my pre-departure brief to the crew, I tell the them "No rushing. We’ll taxi or takeoff when the airplane is ready and we are ready. If we need more time, we’ll set the parking brake or hold. As far as I’m concerned, we were ‘on time’ when we showed up for work.
I hear folks blame the “crew” but only the Captain taxies and only the Captain sets the tone for how rushed he/she permits their flight deck to be.
I’m not one to look to technology to fill the gap of poor airmanship, but Foreflight has aural warnings of entering runways and taxiways. This incident and the one recently in MDW likely could have been prevented by incorporating the Foreflight warning system.
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- *“The crew mistook the surface for the nearby runway,” an airline statement said.. What does that mean exactly?
One cannot ignore the fact that this was both a pilots and ATC error. The plane got to 70 knots before ATC noticed what was going on. I can’t imagine that ATC wasn’t aware of the potential for this type of error given the taxiway setup. However, cudos to ATC for catching it before the pilots did.
Anyone who has much experience flying knows that these types of mistakes happen all the time especially with GA pilots and that the FAA has been fighting this kind of problem for years (The FAA Runway Incursion Program).
I think that there is a much increased awareness of pilot and ATC mistakes now thanks to the internet. But we are still just seeing the tip of the iceberg. There were over 106,000 reports filed with the NASA Aviation Safety Reporting System in 2024. It is estimated that over 1100 reports are filed annually with the Aviation Safety Action Program each year. We don’t know how many reports are filed annually with the Flight Operation Quality Assurance program (FOQA), the Mandatory Occurrence Report (MOR) system, or the Air Safety Report (ASR) system annually because these are not in the public domain but I suspect they are in the tens of thousands. The UK had over 46,000 MOR reports filed in 2023 and their traffic volume is 1/8th of ours.
The solution is not to just starting firing pilots and air traffic controllers every time they make a mistake. Experience shows that just creates an environment where the mistakes are covered up and not reported. To ere is to be human. What needs to be done is to pay attention to the reports and develop mitigation strategies to eliminate them. Juan Browne did an excellent video on this just recently. We have the technology and science to solve this problem. Let’s use it.
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The difference is military training. The structure, quality, and intensity is very important for core training. Civilians who embark on an aviation career path outside of the military, don’t have that much money and time to devote exclusively at that level of training, very unfortunately. As you mentioned, there is no excuse, especially with more than one professional in the cockpit. And if and when signage is not clear enough, that should be addressed, too.
I assume ORL, but punching Orlando into my EFB returns four airports, so maybe providing the airport ID would be a good idea. Would be also useful to know time of day and WX conditions.
That said, in today’s day and age where even your smart watch can tell the difference between taxiway and runway, and a crew of two - that mistake is very hard to justify.
Human factors. CRM.
Tunnel vision
If both suffered from TV at the same time, the result was inevitable.
I’m confident the crew members are in total disbelief as well.
KMCO.
Orlando International.
Rafael,
I think we both agree that the ground incident - lining up on the taxiway and commencing the t/o roll is - simply pilot error.
Again, I feel for both these pilots, but I have wonder how they mistook a 75’ wide taxiway, with a YELLOW line down the middle, with BLUE lenses on the light standards and taxiway signs around as the assigned runway. The sheer narrowness of the taxiway and the missing “picket fences” and runway number should have been a clear indication that they weren’t on the runway.
So, the question is this - how did two (2) commercial pilots, line certified make this blundering mistake? It’s almost incomprehensible.
Regarding CRM, I was in Navy advanced flight training in 1975 flying the TS-2F Tracker, a Grumman multi-engine aircraft that performed ASW and landed on the carrier. It was the Navy’s multi-engine trainer. Having gone from the single seat T-28 B/C to the TS-2F’s two (2) pilot cockpit, I was introduced to the Navy’s version of CRM – Cockpit Coordination and Execution (CCE). Frankly, the Navy was doing CRM before the air carriers fully adopted it in the mid 1980’s.
In fact, in 1983 was Fleet Replacement Squadron instructor in the P-3B/C and we were invited by American Airlines to demonstrate our CEE training so they could further develop CRM for their crews using some of our techniques and practices.
For multi-piloted aircraft, I firmly believe the concepts, practices, procedures and techniques embedded in CRM are incredibly important and critically essential in today’s aviation environment. I have numerous former squadron mates who had very successful airline careers and have repeatedly told me how CRM was the key to successfully flying a sweep wing commercial jet.
However, if you simply break this incident down to determine a primary and perhaps secondary causal factor, it would be a lack of situational awareness.
As you know, the captain of a commercial aircraft handles the movement of the aircraft (nose wheel steering/tiller) until such time he or she turns the acft over to the F/O for take-off, Even then, the captain is advancing the throttles as the F/O is transitioning to controlling the acft.
So, the captain is the one who positioned the acft on the taxiway and evidently, the F/O didn’t say anything. It’s clear they both lacked situational awareness and a visual understanding of where they were regarding the acft movement areas.
To say the least, I’m perplexed by how this happened. As I said, it’s an incredible blunder and one that you have to question. I led numerous mishap/incident investigations in the Navy, and the two (2) most common primary casual factors were poor situational awareness and acute spatial disorientation.
This incident is a clear case of poor situational awareness.
Mark, I respect your insights, and I’ll keep your points about discipline and situational awareness in mind. Thank you.
Rafael,
One last last comment.
You know, there are three (3) primary areas where most accidents or incidents are centered – mechanical failure, computer or technical system failure and lastly, human failure.
In most cases, human factors are the most likely to be associated with an event relative to CRM, basic airwork, situational awareness, spatial disorientation, practices, procedures, techniques, habit patterns and lastly, headwork. As we all know, all of these are engaged by human functions and factors.
In the case of the incident we’ve both exchanged comments about, the human factors element is the center piece.
Mark, I appreciate that, and you are right, human factors are almost always at the core of aviation incidents. Mechanical and system failures do happen, but it is the human side, judgment, awareness, communication, and habits, that often determines whether those issues are managed well or spiral into something worse.
Thanks again for the exchange. I have genuinely appreciated your input, and I will carry your observations forward, as they reflect the kind of high standards we should all continue to aim for.
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