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|
Attributes | |
ACN | 157564 |
Time | |
Date | 199009 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : ftw |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport |
Flight Phase | climbout : takeoff other |
Flight Plan | IFR |
Aircraft 2 | |
Operator | general aviation : corporate |
Make Model Name | Small Transport, Low Wing, 2 Recip Eng |
Flight Phase | landing other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : developmental |
Experience | controller military : 4 |
ASRS Report | 157564 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : non radar |
Events | |
Anomaly | conflict : ground less severe non adherence : required legal separation non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : rejected takeoff |
Consequence | faa : investigated |
Miss Distance | horizontal : 2500 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
I was training on the local control position. An medium large transport X was holding in position runway 1R. Traffic on final was an medium large transport for runway 28R and an small transport Z about 1/4 mi in trail for runway 28L. When the first arrival crossed the intersection for runway 1R I had forgotten about the small transport Z and cleared medium large transport X for takeoff. I scanned to the west of the airport, and when I looked back the small transport Z was entering the intersection of runway 1R. The medium large transport X was coming up on intersection golf and had aborted takeoff. Possible factors affecting the quality of human performance where I had not trained on local control position for 2 weeks due to annual leave, coverage and sick leave, and I was still congested from a cold I had for approximately 1 week. I believe 2 factors were primary in forgetting about the small transport Z. First, visibility on final was adversely affected by haze making it difficult to see the small transport Z on final and at T/D. Second, and most importantly, almost 4 mins had elapsed from landing clearance to the small transport Z to takeoff clearance to the medium large transport X. During this 4 mins, there was no other contact with the small transport Z. This is not unusual at sfo ATCT. To prevent a recurrence of this situation, I believe it would be beneficial to have small, slow aircraft report 2 mi final for landing clearance. This would serve as an additional reminder to local control of difficult to see aircraft on final.
Original NASA ASRS Text
Title: MLG X ABORTED TKOF WHEN HE NOTICED THE SMT WHO WAS LNDG ON AN INTERSECTING WAS NOT CLEAR OF HIS DEP PATH.
Narrative: I WAS TRNING ON THE LCL CTL POS. AN MLG X WAS HOLDING IN POS RWY 1R. TFC ON FINAL WAS AN MLG FOR RWY 28R AND AN SMT Z ABOUT 1/4 MI IN TRAIL FOR RWY 28L. WHEN THE FIRST ARR CROSSED THE INTXN FOR RWY 1R I HAD FORGOTTEN ABOUT THE SMT Z AND CLRED MLG X FOR TKOF. I SCANNED TO THE W OF THE ARPT, AND WHEN I LOOKED BACK THE SMT Z WAS ENTERING THE INTXN OF RWY 1R. THE MLG X WAS COMING UP ON INTXN GOLF AND HAD ABORTED TKOF. POSSIBLE FACTORS AFFECTING THE QUALITY OF HUMAN PERFORMANCE WHERE I HAD NOT TRAINED ON LCL CTL POS FOR 2 WKS DUE TO ANNUAL LEAVE, COVERAGE AND SICK LEAVE, AND I WAS STILL CONGESTED FROM A COLD I HAD FOR APPROX 1 WK. I BELIEVE 2 FACTORS WERE PRIMARY IN FORGETTING ABOUT THE SMT Z. FIRST, VISIBILITY ON FINAL WAS ADVERSELY AFFECTED BY HAZE MAKING IT DIFFICULT TO SEE THE SMT Z ON FINAL AND AT T/D. SECOND, AND MOST IMPORTANTLY, ALMOST 4 MINS HAD ELAPSED FROM LNDG CLRNC TO THE SMT Z TO TKOF CLRNC TO THE MLG X. DURING THIS 4 MINS, THERE WAS NO OTHER CONTACT WITH THE SMT Z. THIS IS NOT UNUSUAL AT SFO ATCT. TO PREVENT A RECURRENCE OF THIS SITUATION, I BELIEVE IT WOULD BE BENEFICIAL TO HAVE SMALL, SLOW ACFT RPT 2 MI FINAL FOR LNDG CLRNC. THIS WOULD SERVE AS AN ADDITIONAL REMINDER TO LCL CTL OF DIFFICULT TO SEE ACFT ON FINAL.
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.