[SystemSafety] Chicago controller halts Delta jet's near-miss on takeoff: '1328, stop, stop stop!'

[Les Chambers]

It seems to me that the ATC - Pilot voice protocol is missing a step.
Basic principles: 
1. The ATC must be made aware of the pilot's intention to roll his aircraft.

2. The Pilot must not act on this intent without explicit approval from the
ATC.

In concept, a safer protocol might look like this:
ATC: You are cleared for takeoff
Pilot: My understanding is that I am cleared for takeoff
ATC: Your understanding is correct

A high-level design might look like this:

[aircraft state: positioned for takeoff]
	|
	|Message 1. ATC : Southwest 3828 cleared for takeoff
	|
	V
[aircraft state: takeoff enabled]
	|
	|Message 2. Southwest 3828 Pilot:  Southwest 3828 clearance to roll 
	|
	V
[aircraft state: pending approval] 
	|
	|Message 3. ATC : Southwest 3828 cleared to roll 
	|
	V
[aircraft state: taking off]

The Southwest pilot would have to misunderstand two ATC clearances for this
to fail.

I could not find the exact text of the conversation between ATO and pilot in
the Chicago case study so, in search of ATC/Pilot voice protocols in common
use, I reviewed Sully Sullenberger's book: Highest Duty: My search for what
really matters, which has the NTSB cockpit voice recorder transcript in an
appendix. This transcript is now available at:
http://www.tailstrike.com/150109.htm

To summarise:
{15:24:54}ATC: Cactus 1549 runway four clear for takeoff.
{15:24:56.7}Sullenberger: Cactus 1549 clear for takeoff
.
.
{Take off Dialogue between pilot and copilot}
.
.
{15:25:45}ACT: Cactus 1549 contact New York departure, good day.
{15:25:48}Sullenberger: good day.

In this dialogue, the lack of a third exchange as per message 3 above seems
remarkable. I note also that Sullenberger did not repeat the authorised
runway ID in his acknowledgement (refer Bonus material two below). This
seems a tad dangerous.
Am I missing something?

Cheers
Les

PS bonus material:

Bonus material one:
I draw your attention to --> http://www.tailstrike.com/150109.htm, refer to
the following timestamps :
{15:27:10.4} Sullenberger: birds.
{15:27:11} Copilot: whoa.
{15:27:11.4} Cockpit area microphone: [sound of thump/thud(s) followed by
shuddering sound]
{15:27:12} Copilot:  oh #.
{15:27:13} Sullenberger: oh yeah.
{15:27:13} Cockpit area microphone: [sound similar to decrease in engine
noise/frequency begins]
{15:27:14} Copilot:  uh oh.

"{15:27:12} Copilot:  oh #."  Really???  These men are heroes, gods almost.
Surely their every word, including explicatives,  which must have been
sublime, are worthy of inclusion in the Canon of heroic deeds.

Bonus material two:
On August 27, 2006, a Bombardier Canadair Regional Jet 100ER crashed while
attempting to take off from Blue Grass Airport in Fayette County, Kentucky.
The aircraft was assigned the airport's runway 22 for the takeoff, but used
runway 26 instead. Runway 26 was too short for a safe takeoff, causing the
aircraft to overrun the end of the runway before it could become airborne.
It crashed just past the end of the runway, killing all 47 passengers and
two of the three crew.

In 1993, a commercial jet at Blue Grass Airport was cleared for takeoff on
Runway 22 but mistakenly took Runway 26 instead. Tower personnel noticed the
mistake and canceled the aircraft's takeoff clearance just as the crew
realized their error. The aircraft subsequently made a safe departure from
Runway 22.[49]

In January 2007, a Learjet was cleared to take off at Blue Grass Airport on
runway 22, but mistakenly turned onto runway 26. Takeoff clearance was
canceled by the local controller prior to the start of the takeoff roll.[50]

On October 31, 2000, the crew of Singapore Airlines Flight 006 mistakenly
used a closed runway for departure from Chiang Kai-shek International
Airport, Taipei. The Boeing 747-400 collided with construction equipment
during the takeoff roll, resulting in the deaths of 83 of the 179 passengers
and crew on board.



-----Original Message-----
From: systemsafety-bounces at lists.techfak.uni-bielefeld.de
[mailto:systemsafety-bounces at lists.techfak.uni-bielefeld.de] On Behalf Of
Peter Bernard Ladkin
Sent: Friday, June 19, 2015 3:52 PM
To: Simon Whiteley
Cc: systemsafety at lists.techfak.uni-bielefeld.de
Subject: Re: [SystemSafety] Chicago controller halts Delta jet's near-miss
on takeoff: '1328, stop, stop stop!'



Prof. Peter Bernard Ladkin, University of Bielefeld and Causalis Limited

> On 18 Jun 2015, at 19:37, Peter Bernard Ladkin
<ladkin at rvs.uni-bielefeld.de> wrote:
> 
> A known problem. Quasi-ambiguous call signs.

As Chris says, not particularly rare.

Steven Cushing's Fatal Words, a book published by U. Chicago Press nearly
two decades ago on safety problems in civil aviation caused through
linguistic  factors, has a chapter on it, I recall (I am away from my
library).

Contributing factors are moderately clear. One is similar call signs.
Another is transmissions being "stepped on" (partially obscured by a
concurrent transmission from another). The third is cognitive confusion of
some sort - someone gets the airplanes mixed up as a result of the first
two. It is surprising that the issue persists after decades of attention
from smart people.

PBL
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