Narrative:

As the captain taxied out for our 1ST leg of the day, the 1ST 2 legs on this 4TH day of a 4-DAY trip had been cancelled, we completed the appropriate checklists. I briefly discussed a small airplane we both had flown. As we approached the runway we were cleared to tower frequency and then told to hold short. The next clearance from tower was being transmitted as the captain turned the aircraft over to me and took over the radio. I reminded him to seat the F/a's. I went through the final items of the before takeoff checklist. I pulled onto the runway and advanced takeoff thrust. As the captain called 'V1' the tower very deliberately and nicely cleared us for takeoff. Our immediate reaction was to look at each other in disbelief and comment that we thought we had been cleared for takeoff. Then the tower called and told us not to cut out the aircraft ahead of us ont he same departure procedure. It took a few moments to get through to departure and clarify whether or not we should start our turn. By this time we were 1 mi past where we should have turned and both of us were still pretty confused. It took a conscious effort for me to put my error and confusion behind and concentrate on the task at hand. Quite frankly, I have no recollection of the actual clearance but it obviously was to taxi into position and hold. I was relinquishing the radio to the captain and taking control of the aircraft as the tower was issuing the clearance and I expect that I just tuned them out in favor of taxiing, seating the F/a's and finishing the checklist. There was no reason for me to be in such a hurry and even when hurrying, one should only do one item at a time and those should be done in proper sequence. In other words, I should not have tuned out the clearance by starting something else while it was being issued. Human performance factors - fatigue: last day of a 4-DAY trip. I had 3 nights of poor rest. One night I was awakened by a wake-up call 3 hours early, one night I just couldn't seem to get to sleep, and one night sleep was good but only 5 hours. Long. I was with a brand new captain which requires a lot more concentration for a first officer. 4 day trips with 20 lndgs are tiring. Preoccupation: stress. My marriage has been in trouble and we are in counseling. I had been thinking almost exclusively on this just prior to our departure. (But I thought I had put it aside.) I also have a son who I have been taking to a therapist. There have also been some major financial changes for me in the last few weeks (damn 'B scale'). Distrs: the captain and I had been discussing another aircraft during taxi. Although illegal, during a long taxi, this shouldn't have been a factor but in retrospect, it may have been just enough of a change that when combined with all other factors, it was enough to push us over the edge. Being in a hurry is also a distraction. Solutions: I had cautioned myself the trip before about my problems and complacency. I am going to have to do that daily instead of weekly. I am going to write down each takeoff and landing clearance now in addition to clrncs with restrictions that I already record. I think that whenever control of the aircraft changes hands, the pilots should each restate the previous clearance. What really bothers me most about this incident is I allowed it to happen in spite of being very aware of the human factors that can affect my performance. I have always made a conscious effort to control them and to not allow them to interfere with my professionalism. It just shows how subtle and insidious complacency can be.

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Original NASA ASRS Text

Title: ACR MLG DEPARTS SJC WITHOUT TKOF CLRNC WHICH IS SUBSEQUENTLY ISSUED TO THEM AS THEY ROLL.

Narrative: AS THE CAPT TAXIED OUT FOR OUR 1ST LEG OF THE DAY, THE 1ST 2 LEGS ON THIS 4TH DAY OF A 4-DAY TRIP HAD BEEN CANCELLED, WE COMPLETED THE APPROPRIATE CHECKLISTS. I BRIEFLY DISCUSSED A SMALL AIRPLANE WE BOTH HAD FLOWN. AS WE APCHED THE RWY WE WERE CLRED TO TWR FREQ AND THEN TOLD TO HOLD SHORT. THE NEXT CLRNC FROM TWR WAS BEING TRANSMITTED AS THE CAPT TURNED THE ACFT OVER TO ME AND TOOK OVER THE RADIO. I REMINDED HIM TO SEAT THE F/A'S. I WENT THROUGH THE FINAL ITEMS OF THE BEFORE TKOF CHECKLIST. I PULLED ONTO THE RWY AND ADVANCED TKOF THRUST. AS THE CAPT CALLED 'V1' THE TWR VERY DELIBERATELY AND NICELY CLRED US FOR TKOF. OUR IMMEDIATE REACTION WAS TO LOOK AT EACH OTHER IN DISBELIEF AND COMMENT THAT WE THOUGHT WE HAD BEEN CLRED FOR TKOF. THEN THE TWR CALLED AND TOLD US NOT TO CUT OUT THE ACFT AHEAD OF US ONT HE SAME DEP PROC. IT TOOK A FEW MOMENTS TO GET THROUGH TO DEP AND CLARIFY WHETHER OR NOT WE SHOULD START OUR TURN. BY THIS TIME WE WERE 1 MI PAST WHERE WE SHOULD HAVE TURNED AND BOTH OF US WERE STILL PRETTY CONFUSED. IT TOOK A CONSCIOUS EFFORT FOR ME TO PUT MY ERROR AND CONFUSION BEHIND AND CONCENTRATE ON THE TASK AT HAND. QUITE FRANKLY, I HAVE NO RECOLLECTION OF THE ACTUAL CLRNC BUT IT OBVIOUSLY WAS TO TAXI INTO POSITION AND HOLD. I WAS RELINQUISHING THE RADIO TO THE CAPT AND TAKING CONTROL OF THE ACFT AS THE TWR WAS ISSUING THE CLRNC AND I EXPECT THAT I JUST TUNED THEM OUT IN FAVOR OF TAXIING, SEATING THE F/A'S AND FINISHING THE CHECKLIST. THERE WAS NO REASON FOR ME TO BE IN SUCH A HURRY AND EVEN WHEN HURRYING, ONE SHOULD ONLY DO ONE ITEM AT A TIME AND THOSE SHOULD BE DONE IN PROPER SEQUENCE. IN OTHER WORDS, I SHOULD NOT HAVE TUNED OUT THE CLRNC BY STARTING SOMETHING ELSE WHILE IT WAS BEING ISSUED. HUMAN PERFORMANCE FACTORS - FATIGUE: LAST DAY OF A 4-DAY TRIP. I HAD 3 NIGHTS OF POOR REST. ONE NIGHT I WAS AWAKENED BY A WAKE-UP CALL 3 HRS EARLY, ONE NIGHT I JUST COULDN'T SEEM TO GET TO SLEEP, AND ONE NIGHT SLEEP WAS GOOD BUT ONLY 5 HRS. LONG. I WAS WITH A BRAND NEW CAPT WHICH REQUIRES A LOT MORE CONCENTRATION FOR A F/O. 4 DAY TRIPS WITH 20 LNDGS ARE TIRING. PREOCCUPATION: STRESS. MY MARRIAGE HAS BEEN IN TROUBLE AND WE ARE IN COUNSELING. I HAD BEEN THINKING ALMOST EXCLUSIVELY ON THIS JUST PRIOR TO OUR DEP. (BUT I THOUGHT I HAD PUT IT ASIDE.) I ALSO HAVE A SON WHO I HAVE BEEN TAKING TO A THERAPIST. THERE HAVE ALSO BEEN SOME MAJOR FINANCIAL CHANGES FOR ME IN THE LAST FEW WEEKS (DAMN 'B SCALE'). DISTRS: THE CAPT AND I HAD BEEN DISCUSSING ANOTHER ACFT DURING TAXI. ALTHOUGH ILLEGAL, DURING A LONG TAXI, THIS SHOULDN'T HAVE BEEN A FACTOR BUT IN RETROSPECT, IT MAY HAVE BEEN JUST ENOUGH OF A CHANGE THAT WHEN COMBINED WITH ALL OTHER FACTORS, IT WAS ENOUGH TO PUSH US OVER THE EDGE. BEING IN A HURRY IS ALSO A DISTR. SOLUTIONS: I HAD CAUTIONED MYSELF THE TRIP BEFORE ABOUT MY PROBLEMS AND COMPLACENCY. I AM GOING TO HAVE TO DO THAT DAILY INSTEAD OF WEEKLY. I AM GOING TO WRITE DOWN EACH TKOF AND LNDG CLRNC NOW IN ADDITION TO CLRNCS WITH RESTRICTIONS THAT I ALREADY RECORD. I THINK THAT WHENEVER CONTROL OF THE ACFT CHANGES HANDS, THE PLTS SHOULD EACH RESTATE THE PREVIOUS CLRNC. WHAT REALLY BOTHERS ME MOST ABOUT THIS INCIDENT IS I ALLOWED IT TO HAPPEN IN SPITE OF BEING VERY AWARE OF THE HUMAN FACTORS THAT CAN AFFECT MY PERFORMANCE. I HAVE ALWAYS MADE A CONSCIOUS EFFORT TO CONTROL THEM AND TO NOT ALLOW THEM TO INTERFERE WITH MY PROFESSIONALISM. IT JUST SHOWS HOW SUBTLE AND INSIDIOUS COMPLACENCY CAN BE.

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.