Narrative:

On the time and date indicated, I was captain of air carrier flight xx with scheduled departure from hnl at xa hst. Kona winds existed at the time and the assigned runway for takeoff was 22L. The flight was part 91 with no passenger, destination the island of molokai, thence to maui. Air carrier xx was cleared to takeoff on runway 22L and I repeated the clearance, 'air carrier xx rolling on 22L.' during the takeoff roll I noticed a widebody transport ahead and to the right approaching 22L on taxiway delta, almost at right angles to 22L. They had proceeded across 22R and passed the hold line at the taxiway entrance to 22L. I had just rotated and become airborne and estimate I had about 10-20' of altitude as I passed in front of the widebody transport. Because of the climb angle, right wing and wing tank visibility obstruction, I cannot estimate the minimum sep. I heard the widebody transport captain immediately query the tower, something to the effect, 'we were cleared across 22L, weren't we?' the tower responded in the affirmative. The widebody transport replied, 'we almost hit him.' then the tower operator said, 'my mistake.' the following day (mon) I talked with the hnl tower manager and told him essentially the above. He called me back later in the morning, said they had listened to the tapes and were proceeding with an investigation based on controller error that would go beyond that facility. He thanked me for taking the time to discuss the situation with him. I asked if the previous day's shift supervisor or controller had noted the incident in their logs and he replied, 'no, they did not.' my analysis of what caused the controller's error is as follows: with the prevailing tradewinds, runways 4R and 4L are used much more frequently than 22L or 22R. I think the controller's habit patterns betrayed him and after he cleared air carrier xx for takeoff on 22L he got a handoff from the ground controller for controling the widebody transport as he taxied across active runways to the reef runway. In talking with the widebody transport (and the control tower's physical location near the approach end of runway 4L and 4L is a factor here) he looked at 4R at foxtrot, which is the usual spot with tradewinds for air carrier xx to start takeoffs, seeing no one there he automatically cleared the widebody transport across, what to him at that point was 4L and 4R. Habits and familiarity lead to complacency and carelessness. I suggest that everybody, pilots as well as controllers, take extra precautions when conditions require us to change behaviors at variance with routine and firmly established habit patterns.

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Original NASA ASRS Text

Title: A NEAR COLLISION OCCURRED WHEN A WDB WITH CLRNC TO CROSS TAXIED ONTO THE ACTIVE RWY AND INTO THE PATH OF A DEPARTING SMT.

Narrative: ON THE TIME AND DATE INDICATED, I WAS CAPT OF ACR FLT XX WITH SCHEDULED DEP FROM HNL AT XA HST. KONA WINDS EXISTED AT THE TIME AND THE ASSIGNED RWY FOR TKOF WAS 22L. THE FLT WAS PART 91 WITH NO PAX, DEST THE ISLAND OF MOLOKAI, THENCE TO MAUI. ACR XX WAS CLRED TO TKOF ON RWY 22L AND I REPEATED THE CLRNC, 'ACR XX ROLLING ON 22L.' DURING THE TKOF ROLL I NOTICED A WDB AHEAD AND TO THE RIGHT APCHING 22L ON TXWY DELTA, ALMOST AT RIGHT ANGLES TO 22L. THEY HAD PROCEEDED ACROSS 22R AND PASSED THE HOLD LINE AT THE TXWY ENTRANCE TO 22L. I HAD JUST ROTATED AND BECOME AIRBORNE AND ESTIMATE I HAD ABOUT 10-20' OF ALT AS I PASSED IN FRONT OF THE WDB. BECAUSE OF THE CLB ANGLE, RIGHT WING AND WING TANK VIS OBSTRUCTION, I CANNOT ESTIMATE THE MINIMUM SEP. I HEARD THE WDB CAPT IMMEDIATELY QUERY THE TWR, SOMETHING TO THE EFFECT, 'WE WERE CLRED ACROSS 22L, WEREN'T WE?' THE TWR RESPONDED IN THE AFFIRMATIVE. THE WDB REPLIED, 'WE ALMOST HIT HIM.' THEN THE TWR OPERATOR SAID, 'MY MISTAKE.' THE FOLLOWING DAY (MON) I TALKED WITH THE HNL TWR MGR AND TOLD HIM ESSENTIALLY THE ABOVE. HE CALLED ME BACK LATER IN THE MORNING, SAID THEY HAD LISTENED TO THE TAPES AND WERE PROCEEDING WITH AN INVESTIGATION BASED ON CTLR ERROR THAT WOULD GO BEYOND THAT FAC. HE THANKED ME FOR TAKING THE TIME TO DISCUSS THE SITUATION WITH HIM. I ASKED IF THE PREVIOUS DAY'S SHIFT SUPVR OR CTLR HAD NOTED THE INCIDENT IN THEIR LOGS AND HE REPLIED, 'NO, THEY DID NOT.' MY ANALYSIS OF WHAT CAUSED THE CTLR'S ERROR IS AS FOLLOWS: WITH THE PREVAILING TRADEWINDS, RWYS 4R AND 4L ARE USED MUCH MORE FREQUENTLY THAN 22L OR 22R. I THINK THE CTLR'S HABIT PATTERNS BETRAYED HIM AND AFTER HE CLRED ACR XX FOR TKOF ON 22L HE GOT A HDOF FROM THE GND CTLR FOR CTLING THE WDB AS HE TAXIED ACROSS ACTIVE RWYS TO THE REEF RWY. IN TALKING WITH THE WDB (AND THE CTL TWR'S PHYSICAL LOCATION NEAR THE APCH END OF RWY 4L AND 4L IS A FACTOR HERE) HE LOOKED AT 4R AT FOXTROT, WHICH IS THE USUAL SPOT WITH TRADEWINDS FOR ACR XX TO START TKOFS, SEEING NO ONE THERE HE AUTOMATICALLY CLRED THE WDB ACROSS, WHAT TO HIM AT THAT POINT WAS 4L AND 4R. HABITS AND FAMILIARITY LEAD TO COMPLACENCY AND CARELESSNESS. I SUGGEST THAT EVERYBODY, PLTS AS WELL AS CTLRS, TAKE EXTRA PRECAUTIONS WHEN CONDITIONS REQUIRE US TO CHANGE BEHAVIORS AT VARIANCE WITH ROUTINE AND FIRMLY ESTABLISHED HABIT PATTERNS.

Data retrieved from NASA's ASRS site as of August 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.