37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 155573 |
Time | |
Date | 199008 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : jfk |
State Reference | NY |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air taxi |
Make Model Name | Small Transport, Low Wing, 2 Recip Eng |
Flight Phase | climbout : takeoff ground : holding ground other : taxi |
Flight Plan | VFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 150 flight time total : 3100 flight time type : 200 |
ASRS Report | 155573 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : less severe incursion : runway non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The 15 min flight from isp to jfk had been uneventful. My copilot and I were to pick up 2 passenger there. When they arrived and we all approached the aircraft however, we noticed a small puddle of oil under the right engine and found that 2 qts of oil had been lost. We cancelled the flight, making other arrangements for the passenger and contacted our director of maintenance for instructions. He was certain the oil loss was from a new vacuum pump that had been installed the day before and he advised us to bring the oil level back up to normal and return to home base (isp). Some more oil would be lost, but the amount would again not be excessive on this 15 min flight. Ground issued a taxi clearance for an intersection takeoff on runway 31L. We complied with the taxi instructions assisted by an airport diagram and continually monitored the right engine INS for any abnormalities. Approaching the intersection, ground instructed us to monitor tower. Upon switching frequencys, we found tower already calling us and clearing us for an immediate takeoff. Sensing some urgency in his voice, we completed the final checklist items as we taxied into position and began our takeoff roll. Particular attention was paid to the right engine INS indications, which were normal. A couple hundred ft in the air, tower informed us that we had just taken off on the reciprocal runway (13R). Astounded that my copilot and I had both missed this, we continued on to isp west/O further problem. I believe this incident was the result of several factors: a large airport with many txwys (concrete as far as the eye can see) helped to disorient us with respect to direction; a rushed takeoff leaving little time to analyze and double check; a preoccupation with the right engine, to ensure that its INS indications remained normal; and finally, a quick glance at our heading on the HSI (no runway #south to see as this was an intersection takeoff) showed us what we expected to see as we began our takeoff roll--the digits 3 and 1. Of course, we were distracted from noting that they were reversed (13 vs 31). Any of these factors alone and we would probably have caught the mistake we were about to make. Together, however, they added up to just enough distrs to let us do something dumb. I doubt if this exact combination of items could ever happen again, but in the future I know that I will be alert for a similar conspiracy of circumstances and be doubly careful when I perceive the potential for overlooking something important exists.
Original NASA ASRS Text
Title: ATX ACFT FLT CREW DEPARTS RIGHT RWY WRONG DIRECTION AT JFK.
Narrative: THE 15 MIN FLT FROM ISP TO JFK HAD BEEN UNEVENTFUL. MY COPLT AND I WERE TO PICK UP 2 PAX THERE. WHEN THEY ARRIVED AND WE ALL APCHED THE ACFT HOWEVER, WE NOTICED A SMALL PUDDLE OF OIL UNDER THE RIGHT ENG AND FOUND THAT 2 QTS OF OIL HAD BEEN LOST. WE CANCELLED THE FLT, MAKING OTHER ARRANGEMENTS FOR THE PAX AND CONTACTED OUR DIRECTOR OF MAINT FOR INSTRUCTIONS. HE WAS CERTAIN THE OIL LOSS WAS FROM A NEW VACUUM PUMP THAT HAD BEEN INSTALLED THE DAY BEFORE AND HE ADVISED US TO BRING THE OIL LEVEL BACK UP TO NORMAL AND RETURN TO HOME BASE (ISP). SOME MORE OIL WOULD BE LOST, BUT THE AMOUNT WOULD AGAIN NOT BE EXCESSIVE ON THIS 15 MIN FLT. GND ISSUED A TAXI CLRNC FOR AN INTXN TKOF ON RWY 31L. WE COMPLIED WITH THE TAXI INSTRUCTIONS ASSISTED BY AN ARPT DIAGRAM AND CONTINUALLY MONITORED THE RIGHT ENG INS FOR ANY ABNORMALITIES. APCHING THE INTXN, GND INSTRUCTED US TO MONITOR TWR. UPON SWITCHING FREQS, WE FOUND TWR ALREADY CALLING US AND CLRING US FOR AN IMMEDIATE TKOF. SENSING SOME URGENCY IN HIS VOICE, WE COMPLETED THE FINAL CHKLIST ITEMS AS WE TAXIED INTO POS AND BEGAN OUR TKOF ROLL. PARTICULAR ATTN WAS PAID TO THE RIGHT ENG INS INDICATIONS, WHICH WERE NORMAL. A COUPLE HUNDRED FT IN THE AIR, TWR INFORMED US THAT WE HAD JUST TAKEN OFF ON THE RECIPROCAL RWY (13R). ASTOUNDED THAT MY COPLT AND I HAD BOTH MISSED THIS, WE CONTINUED ON TO ISP W/O FURTHER PROB. I BELIEVE THIS INCIDENT WAS THE RESULT OF SEVERAL FACTORS: A LARGE ARPT WITH MANY TXWYS (CONCRETE AS FAR AS THE EYE CAN SEE) HELPED TO DISORIENT US WITH RESPECT TO DIRECTION; A RUSHED TKOF LEAVING LITTLE TIME TO ANALYZE AND DOUBLE CHK; A PREOCCUPATION WITH THE RIGHT ENG, TO ENSURE THAT ITS INS INDICATIONS REMAINED NORMAL; AND FINALLY, A QUICK GLANCE AT OUR HDG ON THE HSI (NO RWY #S TO SEE AS THIS WAS AN INTXN TKOF) SHOWED US WHAT WE EXPECTED TO SEE AS WE BEGAN OUR TKOF ROLL--THE DIGITS 3 AND 1. OF COURSE, WE WERE DISTRACTED FROM NOTING THAT THEY WERE REVERSED (13 VS 31). ANY OF THESE FACTORS ALONE AND WE WOULD PROBABLY HAVE CAUGHT THE MISTAKE WE WERE ABOUT TO MAKE. TOGETHER, HOWEVER, THEY ADDED UP TO JUST ENOUGH DISTRS TO LET US DO SOMETHING DUMB. I DOUBT IF THIS EXACT COMBINATION OF ITEMS COULD EVER HAPPEN AGAIN, BUT IN THE FUTURE I KNOW THAT I WILL BE ALERT FOR A SIMILAR CONSPIRACY OF CIRCUMSTANCES AND BE DOUBLY CAREFUL WHEN I PERCEIVE THE POTENTIAL FOR OVERLOOKING SOMETHING IMPORTANT EXISTS.
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.