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|
Attributes | |
ACN | 1740103 |
Time | |
Date | 202004 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | DFW.Airport |
State Reference | TX |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 91 |
Flight Phase | Takeoff |
Route In Use | None |
Flight Plan | IFR |
Person 1 | |
Function | Local Ground |
Qualification | Air Traffic Control Fully Certified |
Experience | Air Traffic Control Time Certified In Pos 1 (yrs) 6 |
Events | |
Anomaly | ATC Issue All Types Deviation - Procedural Clearance Ground Incursion Runway |
Narrative:
I was working local control combined up with all positions at the airport except controller in charge. It was xa:25 and still dark out when the incident occurred. The airport had just switched from a north flow to a south flow. Wind was calm. I was still trying to configure my radar; keyboards and position set up for the flow change but I was having trouble with the stars. My 2 co-workers in the tower were chipping in and helping me but they were busy doing other duties as well. I only had a few aircraft on frequency at the time but the things happening at the time were all odd situations. One aircraft didn't have their numbers holding short. I had a closure at taxiways that made it difficult to taxi aircraft from west to east and visa versa. So I had to taxi them reverse taxi to make it all work smoothly. I had a helicopter just off the departure end of the runway on a scene and maybe one arrival tagged (just guessing on that one). As I taxied aircraft X to the runway from the west side of the airport. I noticed he wasn't tagging up on the asde-X and he was just a primary target only moving across the airport. So it was easy to lose him in the darkness. As aircraft X approached the runway I started the release process. I couldn't obtain a release with TRACON using the F13/rundown list function due to the stars keyboards not configuring correctly. So I coordinated manually with TRACON and when I did; I coordinated with the wrong position. I realized it during the coordination and corrected it and got the release from the appropriate controller for me. I scanned the runway and then cleared aircraft X for takeoff at a taxiway which is non standard intersection. Its usually the taxiway which is right next to it. I issued aircraft X a right turn to 240. Then I was trying to configure my keyboards and trouble shoot the issue again. I was head down just for a moment during this. I looked up to check aircraft X and he still wasn't tagged but I barely noticed him rolling the wrong way in the dark. I also saw his primary target moving north on the asde-X. He was departing the wrong direction from the taxiway. There is right about 2;000 ft. Of runway that direction. I immediately keyed up and with urgency and I told aircraft X to stop. I then told him he was departing the wrong direction. He quickly stopped his aircraft and turned around. We exchanged a few words then I cleared him for take off again. He then departed without issue and went on his way. I didn't issue a pilot deviation because I know the pilot was very shaken as was I. I didn't want to add to his stress of what just happened while he was flying to his destination.not sure if any recommendations would prevent this. The whole swiss cheese thing was in effect here. There were many distractions; odd situations; aircraft not tagging on the asde-X; aircraft with no numbers; taxing aircraft; helicopter; miscommunication and coordination with TRACON on my part; darkness; equipment issues etc etc. I felt the situation starting to 'spiral' very early and asked for help. My two co-workers jumped in to help soon as I asked with what they could. I became hyper vigilant and relied on experience. I would have never thought a pilot would try and depart the wrong way on a runway being so close to the end of it. This scenario has crossed my mind before in my 'what if's' I run through my head daily. Well; 'what if' happened and I got extremely lucky I caught it. I'm not sure if aircraft X had enough runway to get airborne or not. He appeared to be going around 40 to 50 kts. When I stopped him. Scanning was the key here to prevent an incident/accident. I think if the lighting in the tower was better to read the cheat sheets would have helped me and I may have been less distracted. I think if there was a way to trouble shoot keyboard/stars configuration issues it would make it safer and streamline it all to reconfigure. You have to guess and figure out what is wrong when they keyboards don't configure. Its most likely operator error but it doesn't help you figure out what the error is to correct it quickly. I had trouble configuring from the moment I stepped in the tower this morning.
Original NASA ASRS Text
Title: A Tower Local Controller reported that an aircraft attempted to depart in the wrong direction from an intersection takeoff.
Narrative: I was working Local Control combined up with all positions at the airport except Controller in Charge. It was XA:25 and still dark out when the incident occurred. The airport had just switched from a north flow to a south flow. Wind was calm. I was still trying to configure my radar; keyboards and position set up for the flow change but I was having trouble with the STARS. My 2 co-workers in the tower were chipping in and helping me but they were busy doing other duties as well. I only had a few aircraft on frequency at the time but the things happening at the time were all odd situations. One aircraft didn't have their numbers holding short. I had a closure at taxiways that made it difficult to taxi aircraft from west to east and visa versa. So I had to taxi them reverse taxi to make it all work smoothly. I had a helicopter just off the departure end of the runway on a scene and maybe one arrival tagged (just guessing on that one). As I taxied Aircraft X to the runway from the west side of the airport. I noticed he wasn't tagging up on the ASDE-X and he was just a primary target only moving across the airport. So it was easy to lose him in the darkness. As Aircraft X approached the runway I started the release process. I couldn't obtain a release with TRACON using the F13/rundown list function due to the STARS keyboards not configuring correctly. So I coordinated manually with TRACON and when I did; I coordinated with the wrong position. I realized it during the coordination and corrected it and got the release from the appropriate controller for me. I scanned the runway and then cleared Aircraft X for takeoff at a taxiway which is non standard intersection. Its usually the taxiway which is right next to it. I issued Aircraft X a right turn to 240. Then I was trying to configure my keyboards and trouble shoot the issue again. I was head down just for a moment during this. I looked up to check Aircraft X and he still wasn't tagged but I barely noticed him rolling the wrong way in the dark. I also saw his primary target moving north on the ASDE-X. He was departing the wrong direction from the taxiway. There is right about 2;000 ft. of runway that direction. I immediately keyed up and with urgency and I told Aircraft X to stop. I then told him he was departing the wrong direction. He quickly stopped his aircraft and turned around. We exchanged a few words then I cleared him for take off again. He then departed without issue and went on his way. I didn't issue a pilot deviation because I know the pilot was very shaken as was I. I didn't want to add to his stress of what just happened while he was flying to his destination.Not sure if any recommendations would prevent this. The whole swiss cheese thing was in effect here. There were many distractions; odd situations; aircraft not tagging on the ASDE-X; aircraft with no numbers; taxing aircraft; helicopter; miscommunication and coordination with TRACON on my part; darkness; equipment issues etc etc. I felt the situation starting to 'spiral' very early and asked for help. My two co-workers jumped in to help soon as I asked with what they could. I became hyper vigilant and relied on experience. I would have never thought a pilot would try and depart the wrong way on a runway being so close to the end of it. This scenario has crossed my mind before in my 'what if's' I run through my head daily. Well; 'What if' happened and I got extremely lucky I caught it. I'm not sure if Aircraft X had enough runway to get airborne or not. He appeared to be going around 40 to 50 kts. when I stopped him. Scanning was the key here to prevent an incident/accident. I think if the lighting in the tower was better to read the cheat sheets would have helped me and I may have been less distracted. I think If there was a way to trouble shoot keyboard/stars configuration issues it would make it safer and streamline it all to reconfigure. You have to guess and figure out what is wrong when they keyboards don't configure. Its most likely operator error but It doesn't help you figure out what the error is to correct it quickly. I had trouble configuring from the moment I stepped in the tower this morning.
Data retrieved from NASA's ASRS site 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.