37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 175902 |
Time | |
Date | 199104 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : mdw |
State Reference | IL |
Altitude | agl bound lower : 0 agl bound upper : 150 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : ewr |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff |
Flight Plan | IFR |
Aircraft 2 | |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, High Wing, 1 Eng, Fixed Gear |
Flight Phase | ground : holding |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 218 flight time total : 11500 flight time type : 8000 |
ASRS Report | 175902 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 13330 flight time type : 9900 |
ASRS Report | 175910 |
Events | |
Anomaly | conflict : ground critical non adherence : published procedure non adherence : required legal separation |
Independent Detector | other flight crewa |
Resolutory Action | none taken : insufficient time |
Consequence | faa : investigated |
Miss Distance | horizontal : 0 vertical : 150 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
Normal takeoffs and lndgs were on runway 4R. When air carrier X called for taxi, ground asked if we could use runway 31C for takeoff. After advising that we could, we received clearance to taxi to runway 31C. At the hold short line advised tower air carrier X was ready for takeoff runway 31C. Tower was landing an aircraft on runway 4R, then advised air carrier Y to position and hold 4R. Next he advised air carrier X position and hold 31C crossing traffic. After landing aircraft passed through the intersection of runway 31C, tower said, 'air carrier X, cleared for takeoff, turn right heading 130 degrees.' at that point we turned on landing lights, advanced power and began the takeoff roll. At approximately 80-100 KTS white centerline paints looked unusual. At about 100 KTS recognized small aircraft Y on centerline of runway 31C. Air carrier X was very light, 85000 pounds, and we were at takeoff speeds, so we rotated and safely cleared small aircraft Y on runway. Normal flight continued (acceleration was very fast flying prior to crossing runway 4R). Human factors: 1) after talking to tower supervisor, clearance was, 'air carrier X, cleared for takeoff runway 4R, right turn heading 130 degrees.' we never heard '4R,' and our readback was, 'air carrier X cleared for takeoff, right turn heading 130 degrees.' (possible confusion: 'cleared 4 takeoff 4 right right turn'--same words, very close together.) 2) white small aircraft Y parked on white centerline looked like part of centerline markings until air carrier X was almost 100 KTS. Our medium large transport is very overpwred at light takeoff weights and acceleration is very quick. Possible view downfield was more on line-up than obstructions, but the white small aircraft Y on centerline was easily mistaken as centerline. The wings did not show up. 3) if tower had instructed us to position and hold, 'aircraft on runway,' maybe we would have been able to make out small aircraft Y instead of centerline markings. At least we would have known an aircraft was on the runway. In this incident, tower had actually intended for company, similar # to takeoff on runway 4R, but he gave the clearance for air carrier X to takeoff. Fortunately, we were light loaded and overpwred and an accident was avoided. Company aircraft did not accept the takeoff clearance. Small aircraft Y did not recognize the conflict till he saw our aircraft proceeding down the runway. No other radio communications were made till air carrier X was flying. Supplemental information from acn 175910: to me, everything was normal until the first officer (flying left seat and making takeoff) announced, 'there's an aircraft on the runway,' shortly after initiating rotation. Sure enough, looking over the nose, there was a white small aircraft on the runway. It was white and right on centerline, blending in with the centerline stripes and ILS runway markings at the far end of the runway. After takeoff roll was initiated, my focus was primarily on instruments for callouts. The first officer said (after the fact) that he recognized 'the stripe' became something 'not right' at about 80-100 KTS, and that it was, in fact, an aircraft at vr! Aborting would never have been a consideration at the time the problem was recognized. Company management was notified at destination. Tapes are being sent to the company for review. A call was placed by me to the tower supervisor, and he said that we were, 'cleared for takeoff on 4R, turn to heading 130 degrees for vector.' I acknowledged the clearance for takeoff and the turn, but neither myself nor my cockpit-mate recalled the one thing that might have told us (as we knew it) that something was wrong. The controller evidently used the wrong call sign in attempting to clear company aircraft, holding on runway 4R, for takeoff. I was unaware of company holding on runway 4R for takeoff. When we were cleared into position and hold on 31C, we were cleared to hold 'for crossing traffic,' not for 'aircraft on the runway,' which might have alerted us. I am not clear on tower's exact terminology, but if he said, 'cleared for takeoff 4R, turn right heading 130 degrees for vectors,' our minds focused on the right (as in turn) instead of the right as in 4. My acknowledgement did not include a runway, only a clearance to roll, a heading to fly, because I did not understand or comprehend his runway statement!
Original NASA ASRS Text
Title: ACR X TKOF ON OCCUPIED RWY HAD LESS THAN STANDARD SEPARATION FROM SMA Y. SYSTEM ERROR. LCL CTLR CLEARED WRONG ACFT FOR TKOF. SIMILAR ACFT CALL SIGN.
Narrative: NORMAL TKOFS AND LNDGS WERE ON RWY 4R. WHEN ACR X CALLED FOR TAXI, GND ASKED IF WE COULD USE RWY 31C FOR TKOF. AFTER ADVISING THAT WE COULD, WE RECEIVED CLRNC TO TAXI TO RWY 31C. AT THE HOLD SHORT LINE ADVISED TWR ACR X WAS READY FOR TKOF RWY 31C. TWR WAS LNDG AN ACFT ON RWY 4R, THEN ADVISED ACR Y TO POS AND HOLD 4R. NEXT HE ADVISED ACR X POS AND HOLD 31C XING TFC. AFTER LNDG ACFT PASSED THROUGH THE INTXN OF RWY 31C, TWR SAID, 'ACR X, CLRED FOR TKOF, TURN RIGHT HDG 130 DEGS.' AT THAT POINT WE TURNED ON LNDG LIGHTS, ADVANCED PWR AND BEGAN THE TKOF ROLL. AT APPROX 80-100 KTS WHITE CENTERLINE PAINTS LOOKED UNUSUAL. AT ABOUT 100 KTS RECOGNIZED SMA Y ON CENTERLINE OF RWY 31C. ACR X WAS VERY LIGHT, 85000 LBS, AND WE WERE AT TKOF SPDS, SO WE ROTATED AND SAFELY CLRED SMA Y ON RWY. NORMAL FLT CONTINUED (ACCELERATION WAS VERY FAST FLYING PRIOR TO XING RWY 4R). HUMAN FACTORS: 1) AFTER TALKING TO TWR SUPVR, CLRNC WAS, 'ACR X, CLRED FOR TKOF RWY 4R, RIGHT TURN HDG 130 DEGS.' WE NEVER HEARD '4R,' AND OUR READBACK WAS, 'ACR X CLRED FOR TKOF, RIGHT TURN HDG 130 DEGS.' (POSSIBLE CONFUSION: 'CLRED 4 TKOF 4 RIGHT RIGHT TURN'--SAME WORDS, VERY CLOSE TOGETHER.) 2) WHITE SMA Y PARKED ON WHITE CENTERLINE LOOKED LIKE PART OF CENTERLINE MARKINGS UNTIL ACR X WAS ALMOST 100 KTS. OUR MLG IS VERY OVERPWRED AT LIGHT TKOF WTS AND ACCELERATION IS VERY QUICK. POSSIBLE VIEW DOWNFIELD WAS MORE ON LINE-UP THAN OBSTRUCTIONS, BUT THE WHITE SMA Y ON CENTERLINE WAS EASILY MISTAKEN AS CENTERLINE. THE WINGS DID NOT SHOW UP. 3) IF TWR HAD INSTRUCTED US TO POS AND HOLD, 'ACFT ON RWY,' MAYBE WE WOULD HAVE BEEN ABLE TO MAKE OUT SMA Y INSTEAD OF CENTERLINE MARKINGS. AT LEAST WE WOULD HAVE KNOWN AN ACFT WAS ON THE RWY. IN THIS INCIDENT, TWR HAD ACTUALLY INTENDED FOR COMPANY, SIMILAR # TO TKOF ON RWY 4R, BUT HE GAVE THE CLRNC FOR ACR X TO TKOF. FORTUNATELY, WE WERE LIGHT LOADED AND OVERPWRED AND AN ACCIDENT WAS AVOIDED. COMPANY ACFT DID NOT ACCEPT THE TKOF CLRNC. SMA Y DID NOT RECOGNIZE THE CONFLICT TILL HE SAW OUR ACFT PROCEEDING DOWN THE RWY. NO OTHER RADIO COMS WERE MADE TILL ACR X WAS FLYING. SUPPLEMENTAL INFO FROM ACN 175910: TO ME, EVERYTHING WAS NORMAL UNTIL THE F/O (FLYING LEFT SEAT AND MAKING TKOF) ANNOUNCED, 'THERE'S AN ACFT ON THE RWY,' SHORTLY AFTER INITIATING ROTATION. SURE ENOUGH, LOOKING OVER THE NOSE, THERE WAS A WHITE SMA ON THE RWY. IT WAS WHITE AND RIGHT ON CENTERLINE, BLENDING IN WITH THE CENTERLINE STRIPES AND ILS RWY MARKINGS AT THE FAR END OF THE RWY. AFTER TKOF ROLL WAS INITIATED, MY FOCUS WAS PRIMARILY ON INSTRUMENTS FOR CALLOUTS. THE F/O SAID (AFTER THE FACT) THAT HE RECOGNIZED 'THE STRIPE' BECAME SOMETHING 'NOT RIGHT' AT ABOUT 80-100 KTS, AND THAT IT WAS, IN FACT, AN ACFT AT VR! ABORTING WOULD NEVER HAVE BEEN A CONSIDERATION AT THE TIME THE PROB WAS RECOGNIZED. COMPANY MGMNT WAS NOTIFIED AT DEST. TAPES ARE BEING SENT TO THE COMPANY FOR REVIEW. A CALL WAS PLACED BY ME TO THE TWR SUPVR, AND HE SAID THAT WE WERE, 'CLRED FOR TKOF ON 4R, TURN TO HDG 130 DEGS FOR VECTOR.' I ACKNOWLEDGED THE CLRNC FOR TKOF AND THE TURN, BUT NEITHER MYSELF NOR MY COCKPIT-MATE RECALLED THE ONE THING THAT MIGHT HAVE TOLD US (AS WE KNEW IT) THAT SOMETHING WAS WRONG. THE CTLR EVIDENTLY USED THE WRONG CALL SIGN IN ATTEMPTING TO CLR COMPANY ACFT, HOLDING ON RWY 4R, FOR TKOF. I WAS UNAWARE OF COMPANY HOLDING ON RWY 4R FOR TKOF. WHEN WE WERE CLRED INTO POS AND HOLD ON 31C, WE WERE CLRED TO HOLD 'FOR XING TFC,' NOT FOR 'ACFT ON THE RWY,' WHICH MIGHT HAVE ALERTED US. I AM NOT CLR ON TWR'S EXACT TERMINOLOGY, BUT IF HE SAID, 'CLRED FOR TKOF 4R, TURN RIGHT HDG 130 DEGS FOR VECTORS,' OUR MINDS FOCUSED ON THE RIGHT (AS IN TURN) INSTEAD OF THE RIGHT AS IN 4. MY ACKNOWLEDGEMENT DID NOT INCLUDE A RWY, ONLY A CLRNC TO ROLL, A HDG TO FLY, BECAUSE I DID NOT UNDERSTAND OR COMPREHEND HIS RWY STATEMENT!
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.