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|
Attributes | |
ACN | 157890 |
Time | |
Date | 199009 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lns |
State Reference | PA |
Altitude | agl bound lower : 0 agl bound upper : 50 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zlc |
Operator | general aviation : personal |
Make Model Name | Small Aircraft |
Flight Phase | climbout : takeoff climbout : initial |
Route In Use | departure other |
Flight Plan | VFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Transport, High Wing, 2 Turboprop Eng |
Flight Phase | ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : non radar |
ASRS Report | 157890 |
Person 2 | |
Affiliation | government : faa |
Function | controller : ground |
Qualification | controller : non radar |
ASRS Report | 158307 |
Events | |
Anomaly | conflict : ground critical non adherence : published procedure non adherence : required legal separation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : took evasive action |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 100 vertical : 50 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Inter Facility Coordination Failure |
Narrative:
I was working local control on a west operation, runway 31 and 26, traffic was moderate, no restrictions to visibility, VFR and IFR mix of traffic. I was on position for just over one hour. Ground control requested runway 31 crossing at bravo taxiway, which I approved. At ths time a single engine small aircraft was already for takeoff roll just passing the intersection at bravo, which is 1000' down the runway, the next VFR departure on runway 31 was taxied into position hold, for the runway crossing and for the required runway sep with the small aircraft departure. The aircraft was small aircraft X, a bi-plane. I then began to move to other duties that needed to be resolved, sequence traffic pattern, there were numerous arrs into the pattern, an opp direction low approach to runway 8, and traffic advisories between departures and arrs. I then observed the small aircraft departure over the departure end of runway 31. I back scanned the runway from departure end to the arrival end and then to the final, I didn't see any traffic on the runway, nor did I see the aircraft on bravo taxiway. At that point, I had either forgotten about the runway crossing or thought it was completed. Small aircraft X was issued takeoff clearance. I started to put the next aircraft into position hold when I observed air carrier Y entering the runway environment at bravo. Small aircraft X lifted off the runway and over flew air carrier Y by some 10-15'. Evasive action was required of small aircraft X. About an hour later small aircraft X pilot came to the control tower, in taking with him, he saw air carrier Y on bravo taxiway off to his left side, he thought air carrier Y was holding short. Small aircraft X is a tail dragger, and the pilot sits in an open cockpit in the back of the plane, he couldn't see in front of his aircraft, he realized something was wrong when my next transmission to the next aircraft for departure was interrupted with desperation to bring the situation to his attention, he looked left and saw air carrier Y was entering the runway and started his climb out. In looking back at how this could have been avoided, I should have scanned the runway with more conviction especially if traffic was at a moderate level. When I taxied small aircraft X into position and hold, I should have told him why, this would have alerted him that an aircraft was crossing, and may not have started his takeoff roll. It also may have stuck in my head that a crossing was in the process, regardless if the runway was clear. Supplemental information from acn 158307. I advised air carrier Y traffic holding, cross runway 31. At that time another aircraft called and my attention was diverted. When I checked back to see how air carrier Y was progressing, I saw small aircraft X in a steep climb over air carrier Y. (The intersection is only about 800' from the beginning of the runway). Supplemental information from acn 157275. We were given clearance from ground control to taxi (from the terminal) to bravo hold short of runway 31. As we came upon the bravo hold line, ground control issued us clearance to cross runway 31 and taxi to runway 26. There was a tailwheel airplane (small aircraft X) holding in position on runway 31. As we began to cross the runway the captain noticed the propeller of small aircraft X spinning up. By this time small aircraft X was rolling towards us as we were now in the middle of the runway. Small aircraft X rotated and just missed our tail. The captain talked on the phone with the supervisor of the tower to discuss the situation. From what I understand, small aircraft X was given takeoff clearance right about the time we were crossing the runway. The controller admitted there was a communications error in the tower between 2 controllers. My feelings are there must be an increased awareness of better communication skills needed to prevent a situation such as this that could have been a serious accident.
Original NASA ASRS Text
Title: ACFT WAS CLEARED ACROSS RWY WHILE ANOTHER ACFT WAS CLEARED FOR TKOF. DEP ACFT FLEW OVER CROSSING ACFT.
Narrative: I WAS WORKING LCL CTL ON A W OPERATION, RWY 31 AND 26, TFC WAS MODERATE, NO RESTRICTIONS TO VISIBILITY, VFR AND IFR MIX OF TFC. I WAS ON POS FOR JUST OVER ONE HR. GND CTL REQUESTED RWY 31 XING AT BRAVO TXWY, WHICH I APPROVED. AT THS TIME A SINGLE ENG SMA WAS ALREADY FOR TKOF ROLL JUST PASSING THE INTXN AT BRAVO, WHICH IS 1000' DOWN THE RWY, THE NEXT VFR DEP ON RWY 31 WAS TAXIED INTO POS HOLD, FOR THE RWY XING AND FOR THE REQUIRED RWY SEP WITH THE SMA DEP. THE ACFT WAS SMA X, A BI-PLANE. I THEN BEGAN TO MOVE TO OTHER DUTIES THAT NEEDED TO BE RESOLVED, SEQUENCE TFC PATTERN, THERE WERE NUMEROUS ARRS INTO THE PATTERN, AN OPP DIRECTION LOW APCH TO RWY 8, AND TFC ADVISORIES BTWN DEPS AND ARRS. I THEN OBSERVED THE SMA DEP OVER THE DEP END OF RWY 31. I BACK SCANNED THE RWY FROM DEP END TO THE ARR END AND THEN TO THE FINAL, I DIDN'T SEE ANY TFC ON THE RWY, NOR DID I SEE THE ACFT ON BRAVO TXWY. AT THAT POINT, I HAD EITHER FORGOTTEN ABOUT THE RWY XING OR THOUGHT IT WAS COMPLETED. SMA X WAS ISSUED TKOF CLRNC. I STARTED TO PUT THE NEXT ACFT INTO POS HOLD WHEN I OBSERVED ACR Y ENTERING THE RWY ENVIRONMENT AT BRAVO. SMA X LIFTED OFF THE RWY AND OVER FLEW ACR Y BY SOME 10-15'. EVASIVE ACTION WAS REQUIRED OF SMA X. ABOUT AN HR LATER SMA X PLT CAME TO THE CTL TWR, IN TAKING WITH HIM, HE SAW ACR Y ON BRAVO TXWY OFF TO HIS L SIDE, HE THOUGHT ACR Y WAS HOLDING SHORT. SMA X IS A TAIL DRAGGER, AND THE PLT SITS IN AN OPEN COCKPIT IN THE BACK OF THE PLANE, HE COULDN'T SEE IN FRONT OF HIS ACFT, HE REALIZED SOMETHING WAS WRONG WHEN MY NEXT XMISSION TO THE NEXT ACFT FOR DEP WAS INTERRUPTED WITH DESPERATION TO BRING THE SITUATION TO HIS ATTN, HE LOOKED L AND SAW ACR Y WAS ENTERING THE RWY AND STARTED HIS CLB OUT. IN LOOKING BACK AT HOW THIS COULD HAVE BEEN AVOIDED, I SHOULD HAVE SCANNED THE RWY WITH MORE CONVICTION ESPECIALLY IF TFC WAS AT A MODERATE LEVEL. WHEN I TAXIED SMA X INTO POS AND HOLD, I SHOULD HAVE TOLD HIM WHY, THIS WOULD HAVE ALERTED HIM THAT AN ACFT WAS XING, AND MAY NOT HAVE STARTED HIS TKOF ROLL. IT ALSO MAY HAVE STUCK IN MY HEAD THAT A XING WAS IN THE PROCESS, REGARDLESS IF THE RWY WAS CLR. SUPPLEMENTAL INFO FROM ACN 158307. I ADVISED ACR Y TFC HOLDING, CROSS RWY 31. AT THAT TIME ANOTHER ACFT CALLED AND MY ATTN WAS DIVERTED. WHEN I CHKED BACK TO SEE HOW ACR Y WAS PROGRESSING, I SAW SMA X IN A STEEP CLB OVER ACR Y. (THE INTXN IS ONLY ABOUT 800' FROM THE BEGINNING OF THE RWY). SUPPLEMENTAL INFO FROM ACN 157275. WE WERE GIVEN CLRNC FROM GND CTL TO TAXI (FROM THE TERMINAL) TO BRAVO HOLD SHORT OF RWY 31. AS WE CAME UPON THE BRAVO HOLD LINE, GND CTL ISSUED US CLRNC TO CROSS RWY 31 AND TAXI TO RWY 26. THERE WAS A TAILWHEEL AIRPLANE (SMA X) HOLDING IN POS ON RWY 31. AS WE BEGAN TO CROSS THE RWY THE CAPT NOTICED THE PROP OF SMA X SPINNING UP. BY THIS TIME SMA X WAS ROLLING TOWARDS US AS WE WERE NOW IN THE MIDDLE OF THE RWY. SMA X ROTATED AND JUST MISSED OUR TAIL. THE CAPT TALKED ON THE PHONE WITH THE SUPVR OF THE TWR TO DISCUSS THE SITUATION. FROM WHAT I UNDERSTAND, SMA X WAS GIVEN TKOF CLRNC RIGHT ABOUT THE TIME WE WERE XING THE RWY. THE CTLR ADMITTED THERE WAS A COMS ERROR IN THE TWR BTWN 2 CTLRS. MY FEELINGS ARE THERE MUST BE AN INCREASED AWARENESS OF BETTER COM SKILLS NEEDED TO PREVENT A SITUATION SUCH AS THIS THAT COULD HAVE BEEN A SERIOUS ACCIDENT.
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.