37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 135674 |
Time | |
Date | 199002 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : bos |
State Reference | MA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : sfo |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | climbout : takeoff ground : holding other |
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 : missed approach landing : go around |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp pilot : commercial |
Experience | flight time last 90 days : 200 flight time total : 18000 flight time type : 550 |
ASRS Report | 135674 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : cfi pilot : commercial |
Experience | flight time last 90 days : 235 flight time total : 10000 flight time type : 1450 |
ASRS Report | 135974 |
Events | |
Anomaly | conflict : ground less severe incursion : runway non adherence : clearance |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance other other |
Consequence | faa : investigated faa : reviewed incident with flight crew |
Miss Distance | horizontal : 500 vertical : 150 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Large transport a departed gate at XX33. Poor visibility, blowing and drifting snowstorm, 23 degrees C. Deiced aircraft, taxiway and engine heat on, briefed crew to taxi with flaps up. Approaching runway 9, a leading edge ambler light came on forward panel. Lower flaps 2, 5 and 15 degrees, takeoff position. Everything normal, however this caused a distraction so close to takeoff runway. Completed taxiway checklist and sent flight engineer aft to inspect wing and control surfaces. Tower cleared lga onto runway 9 for takeoff. Flight engineer absent. First officer responded to tower 'need 2 mins.' tower responded with 'position and hold.' first officer acknowledged. Flight engineer returned with wings clear report as we positioned on runway 9. Called for takeoff checklist down to lights on, told first officer 'your brakes,' as he was to make takeoff. Spooled engines up to comply with anti-ice procedures, asked flight engineer to confirm wing heat off. To my best recollection, received takeoff clearance. During all this, and because first officer was going to fly, I turned lights on and responded to tower for the first time: 'large transport a is cleared for takeoff.' advanced power toward takeoff thrust. First officer released brakes. Aircraft moved with slow forward movement, no airspeed ever was indicated on airspeed gauge. Then received transmission from tower. Do not recall exact terminology, however message was clear to discontinue takeoff. I stopped aircraft, runway 9 departure crossed runway 4R approach end. Sometime during this sequence of events an aircraft reported a go around on approach to runway 4R to bos tower. I never saw the aircraft on his go around. Shortly thereafter, a commuter type aircraft landed on 4R. We were then cleared to taxi left turn on 4R, then next left taxiway echo and eventually repos back to runway 9 for departure. Departed bos for ny during climb-out bos departure asked me to call tower control. Called from ny and was informed that the tower controller claimed not to have given us takeoff clearance, thus the large transport B that mad a go around initiated go around when he heard 'large transport a's cleared for takeoff.' it was also stated that the tapes were being reviewed for further action. In conclusion, to that point I never doubted our takeoff clearance. The copilot never indicated we did not have clearance. We were busy, occupied with de-ice surfaces, WX, obscured txwys, slippery conditions, holding flaps until near departure runway in order to prevent ice and snow buildup on control surfaces, wing heat, engine heat and coordinating communications with ground and tower control. The tapes will tell who made the error. As a fairly new captain, the incident has created a great deal of self-doubt. The circumstances surrounding this particular departure were the most stress-filled experience that I can remember during my career. Callback conversation with reporter revealed the following: captain says that tapes indicate he was not cleared for takeoff. He did not pull cockpit cvr circuit breaker, so can only assume that tower was correct. Reporter understands that air carrier that had to make a go around would be upset, as WX was poor and he never saw that aircraft. Crew was trying to get aircraft out shortly after deicing and was apparently too centered on that task. Appears that neither first officer nor so can verify one way or the other on the takeoff clearance. Reporter new captain and is very concerned that such a mistake could happen. Had to be deiced twice before flight finally got underway. Supplemental information from acn 135774: our flight, large transport B, was cleared for ILS approach to runway 4R at bos approximately 15 mi on final. We were changed over to tower controller at approximately 9 mi final. Tower cleared us to continue the approach, and requested preceding aircraft to call clear of the runway after landing. That was complied with by the preceding aircraft. Tower then cleared large transport a for takeoff. Large transport a replied that they were not ready for takeoff. Tower then cleared large transport a into position and hold and cancelled takeoff clearance. Large transport a acknowledged. Tower then cleared large transport B to land 4R. We acknowledged. Tower reconfirmed with large transport a that their takeoff clearance was cancelled. We broke out and had the runway in sight at approximately 2 mi. At approximately 150' AGL a detected aircraft had begun a takeoff roll and had moved approximately 500' on runway 9. I immediately initiated go around and descended no further. Go around and subsequent landing normal. Time of incident: xxpm local. All landing, turnoff and taxi lights on large transport B were in the on position.
Original NASA ASRS Text
Title: ACR FLT CREW IN POSITION AND HOLD RWY 9, STARTED TO TKOF WITHOUT CLRNC. TWR INTERVENED AND ACR ON FINAL RWY 4R HAD MISSED APCH.
Narrative: LGT A DEPARTED GATE AT XX33. POOR VISIBILITY, BLOWING AND DRIFTING SNOWSTORM, 23 DEGS C. DEICED ACFT, TXWY AND ENG HEAT ON, BRIEFED CREW TO TAXI WITH FLAPS UP. APCHING RWY 9, A LEADING EDGE AMBLER LIGHT CAME ON FORWARD PANEL. LOWER FLAPS 2, 5 AND 15 DEGS, TKOF POS. EVERYTHING NORMAL, HOWEVER THIS CAUSED A DISTR SO CLOSE TO TKOF RWY. COMPLETED TXWY CHKLIST AND SENT FE AFT TO INSPECT WING AND CTL SURFACES. TWR CLRED LGA ONTO RWY 9 FOR TKOF. FE ABSENT. FO RESPONDED TO TWR 'NEED 2 MINS.' TWR RESPONDED WITH 'POS AND HOLD.' FO ACKNOWLEDGED. FE RETURNED WITH WINGS CLEAR RPT AS WE POSITIONED ON RWY 9. CALLED FOR TKOF CHKLIST DOWN TO LIGHTS ON, TOLD FO 'YOUR BRAKES,' AS HE WAS TO MAKE TKOF. SPOOLED ENGS UP TO COMPLY WITH ANTI-ICE PROCS, ASKED FE TO CONFIRM WING HEAT OFF. TO MY BEST RECOLLECTION, RECEIVED TKOF CLRNC. DURING ALL THIS, AND BECAUSE FO WAS GOING TO FLY, I TURNED LIGHTS ON AND RESPONDED TO TWR FOR THE FIRST TIME: 'LGT A IS CLRED FOR TKOF.' ADVANCED PWR TOWARD TKOF THRUST. FO RELEASED BRAKES. ACFT MOVED WITH SLOW FORWARD MOVEMENT, NO AIRSPD EVER WAS INDICATED ON AIRSPD GAUGE. THEN RECEIVED XMISSION FROM TWR. DO NOT RECALL EXACT TERMINOLOGY, HOWEVER MESSAGE WAS CLEAR TO DISCONTINUE TKOF. I STOPPED ACFT, RWY 9 DEP CROSSED RWY 4R APCH END. SOMETIME DURING THIS SEQUENCE OF EVENTS AN ACFT RPTED A GAR ON APCH TO RWY 4R TO BOS TWR. I NEVER SAW THE ACFT ON HIS GAR. SHORTLY THEREAFTER, A COMMUTER TYPE ACFT LANDED ON 4R. WE WERE THEN CLRED TO TAXI LEFT TURN ON 4R, THEN NEXT LEFT TXWY ECHO AND EVENTUALLY REPOS BACK TO RWY 9 FOR DEP. DEPARTED BOS FOR NY DURING CLB-OUT BOS DEP ASKED ME TO CALL TWR CTL. CALLED FROM NY AND WAS INFORMED THAT THE TWR CTLR CLAIMED NOT TO HAVE GIVEN US TKOF CLRNC, THUS THE LGT B THAT MAD A GAR INITIATED GAR WHEN HE HEARD 'LGT A'S CLRED FOR TKOF.' IT WAS ALSO STATED THAT THE TAPES WERE BEING REVIEWED FOR FURTHER ACTION. IN CONCLUSION, TO THAT POINT I NEVER DOUBTED OUR TKOF CLRNC. THE COPLT NEVER INDICATED WE DID NOT HAVE CLRNC. WE WERE BUSY, OCCUPIED WITH DE-ICE SURFACES, WX, OBSCURED TXWYS, SLIPPERY CONDITIONS, HOLDING FLAPS UNTIL NEAR DEP RWY IN ORDER TO PREVENT ICE AND SNOW BUILDUP ON CONTROL SURFACES, WING HEAT, ENG HEAT AND COORDINATING COMS WITH GND AND TWR CTL. THE TAPES WILL TELL WHO MADE THE ERROR. AS A FAIRLY NEW CAPT, THE INCIDENT HAS CREATED A GREAT DEAL OF SELF-DOUBT. THE CIRCUMSTANCES SURROUNDING THIS PARTICULAR DEP WERE THE MOST STRESS-FILLED EXPERIENCE THAT I CAN REMEMBER DURING MY CAREER. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: CAPT SAYS THAT TAPES INDICATE HE WAS NOT CLRED FOR TKOF. HE DID NOT PULL COCKPIT CVR CB, SO CAN ONLY ASSUME THAT TWR WAS CORRECT. RPTR UNDERSTANDS THAT ACR THAT HAD TO MAKE A GAR WOULD BE UPSET, AS WX WAS POOR AND HE NEVER SAW THAT ACFT. CREW WAS TRYING TO GET ACFT OUT SHORTLY AFTER DEICING AND WAS APPARENTLY TOO CTRED ON THAT TASK. APPEARS THAT NEITHER FO NOR SO CAN VERIFY ONE WAY OR THE OTHER ON THE TKOF CLRNC. RPTR NEW CAPT AND IS VERY CONCERNED THAT SUCH A MISTAKE COULD HAPPEN. HAD TO BE DEICED TWICE BEFORE FLT FINALLY GOT UNDERWAY. SUPPLEMENTAL INFO FROM ACN 135774: OUR FLT, LGT B, WAS CLRED FOR ILS APCH TO RWY 4R AT BOS APPROX 15 MI ON FINAL. WE WERE CHANGED OVER TO TWR CTLR AT APPROX 9 MI FINAL. TWR CLRED US TO CONTINUE THE APCH, AND REQUESTED PRECEDING ACFT TO CALL CLR OF THE RWY AFTER LNDG. THAT WAS COMPLIED WITH BY THE PRECEDING ACFT. TWR THEN CLRED LGT A FOR TKOF. LGT A REPLIED THAT THEY WERE NOT READY FOR TKOF. TWR THEN CLRED LGT A INTO POS AND HOLD AND CANCELLED TKOF CLRNC. LGT A ACKNOWLEDGED. TWR THEN CLRED LGT B TO LAND 4R. WE ACKNOWLEDGED. TWR RECONFIRMED WITH LGT A THAT THEIR TKOF CLRNC WAS CANCELLED. WE BROKE OUT AND HAD THE RWY IN SIGHT AT APPROX 2 MI. AT APPROX 150' AGL A DETECTED ACFT HAD BEGUN A TKOF ROLL AND HAD MOVED APPROX 500' ON RWY 9. I IMMEDIATELY INITIATED GAR AND DSNDED NO FURTHER. GAR AND SUBSEQUENT LNDG NORMAL. TIME OF INCIDENT: XXPM LCL. ALL LNDG, TURNOFF AND TAXI LIGHTS ON LGT B WERE IN THE ON POS.
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.