Narrative:

This was our first flight of the day. A xa am departure at a familiar airport. Both the captain and I had not slept especially well at the hotel, so we were both probably still mildly fatigued. This was day 3 of a 3 day trip. The WX and aircraft both preflted well, and we departed the gate on time. 100 ft prior to the hold line, we stopped to perform the propeller overspd and automatic feather tests. We noted that the left propeller was sluggishly moving to feather and retested it twice. We were both convinced that the automatic feather was adequate, but we would ask maintenance to check it out at our home base destination. I told tower that we were ready, and were cleared 'position and hold'. As we taxied toward the runway, the captain commented that should we have an actual left engine failure, and the automatic feather failed or was sluggish, we would need to quickly feather the propeller manually. This was a good observation, and I concurred. The captain called for 'runway items', and we completed the challenge and response checklist as we turned onto the centerline. After I advanced the condition levers (the last checklist item), the captain smoothly advanced the power levers and we began the takeoff roll. As we rolled down the runway, we could see an air carrier medium large transport climbing out from left to right across our projected flight path. This aircraft just departed runway 31. Seeing this, the captain asked, 'we were cleared for takeoff, weren't we?' I responded 'yeah, I think so'. This was near rotation speed, so we continued normally. About the time that the landing gear came up, the tower cleared us for takeoff. We had taken off with only a position and hold clearance! Tower then gave us a frequency change to departure control and the warning 'the next time you're told 'position and hold' -- do so!' both the captain and I are experienced, senior pilots, who work well together. We enjoy flying together and employ excellent CRM procedures and philosophy. I could even go so far as to say that this is probably one of the most professional, safety conscious capts in our company. We were shocked and embarrassed that this 'unthinkable' incident could happen to us. I believe that we were both so mentally distracted by the automatic feather test problem that we went into our normal takeoff routine without leaving the 'run-up' mind set. Both the captain and I normally use a mental procedure which regularly requires us to stop and look at the big picture, analyze, then proceed. This is especially important when changing phases of flight (such as taxi to takeoff phase). This might be seen as a curtain falling between the acts of a play. Why did we both fail to use this safeguard? It seems that possibly when we discussed the emergency procedure as we rolled to the runway, our thought processes jumped from the 'here and now' to the 'what if?' mode. I believe that we executed the takeoff in a mental autoplt state that is the result of innumerable behavior repetitions. Literally we could do it with our eyes closed. Our groggy early morning fatigue, made us ripe for an accident. Possibly we will be able to prevent this in the future by verbally exclaiming 'position and hold!' or 'cleared for takeoff!' when crossing the hold line on taxi out. This sort of mnemonic device may help us to mentally 'draw the curtain' on the last act. This is one story that neither of us wants to see repeated.

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Original NASA ASRS Text

Title: UNAUTHORIZED TKOF.

Narrative: THIS WAS OUR FIRST FLT OF THE DAY. A XA AM DEP AT A FAMILIAR ARPT. BOTH THE CAPT AND I HAD NOT SLEPT ESPECIALLY WELL AT THE HOTEL, SO WE WERE BOTH PROBABLY STILL MILDLY FATIGUED. THIS WAS DAY 3 OF A 3 DAY TRIP. THE WX AND ACFT BOTH PREFLTED WELL, AND WE DEPARTED THE GATE ON TIME. 100 FT PRIOR TO THE HOLD LINE, WE STOPPED TO PERFORM THE PROP OVERSPD AND AUTO FEATHER TESTS. WE NOTED THAT THE L PROP WAS SLUGGISHLY MOVING TO FEATHER AND RETESTED IT TWICE. WE WERE BOTH CONVINCED THAT THE AUTO FEATHER WAS ADEQUATE, BUT WE WOULD ASK MAINT TO CHK IT OUT AT OUR HOME BASE DEST. I TOLD TWR THAT WE WERE READY, AND WERE CLRED 'POS AND HOLD'. AS WE TAXIED TOWARD THE RWY, THE CAPT COMMENTED THAT SHOULD WE HAVE AN ACTUAL L ENG FAILURE, AND THE AUTO FEATHER FAILED OR WAS SLUGGISH, WE WOULD NEED TO QUICKLY FEATHER THE PROP MANUALLY. THIS WAS A GOOD OBSERVATION, AND I CONCURRED. THE CAPT CALLED FOR 'RWY ITEMS', AND WE COMPLETED THE CHALLENGE AND RESPONSE CHKLIST AS WE TURNED ONTO THE CENTERLINE. AFTER I ADVANCED THE CONDITION LEVERS (THE LAST CHKLIST ITEM), THE CAPT SMOOTHLY ADVANCED THE PWR LEVERS AND WE BEGAN THE TKOF ROLL. AS WE ROLLED DOWN THE RWY, WE COULD SEE AN ACR MLG CLBING OUT FROM L TO R ACROSS OUR PROJECTED FLT PATH. THIS ACFT JUST DEPARTED RWY 31. SEEING THIS, THE CAPT ASKED, 'WE WERE CLRED FOR TKOF, WEREN'T WE?' I RESPONDED 'YEAH, I THINK SO'. THIS WAS NEAR ROTATION SPD, SO WE CONTINUED NORMALLY. ABOUT THE TIME THAT THE LNDG GEAR CAME UP, THE TWR CLRED US FOR TKOF. WE HAD TAKEN OFF WITH ONLY A POS AND HOLD CLRNC! TWR THEN GAVE US A FREQ CHANGE TO DEP CTL AND THE WARNING 'THE NEXT TIME YOU'RE TOLD 'POS AND HOLD' -- DO SO!' BOTH THE CAPT AND I ARE EXPERIENCED, SENIOR PLTS, WHO WORK WELL TOGETHER. WE ENJOY FLYING TOGETHER AND EMPLOY EXCELLENT CRM PROCS AND PHILOSOPHY. I COULD EVEN GO SO FAR AS TO SAY THAT THIS IS PROBABLY ONE OF THE MOST PROFESSIONAL, SAFETY CONSCIOUS CAPTS IN OUR COMPANY. WE WERE SHOCKED AND EMBARRASSED THAT THIS 'UNTHINKABLE' INCIDENT COULD HAPPEN TO US. I BELIEVE THAT WE WERE BOTH SO MENTALLY DISTRACTED BY THE AUTO FEATHER TEST PROBLEM THAT WE WENT INTO OUR NORMAL TKOF ROUTINE WITHOUT LEAVING THE 'RUN-UP' MIND SET. BOTH THE CAPT AND I NORMALLY USE A MENTAL PROC WHICH REGULARLY REQUIRES US TO STOP AND LOOK AT THE BIG PICTURE, ANALYZE, THEN PROCEED. THIS IS ESPECIALLY IMPORTANT WHEN CHANGING PHASES OF FLT (SUCH AS TAXI TO TKOF PHASE). THIS MIGHT BE SEEN AS A CURTAIN FALLING BTWN THE ACTS OF A PLAY. WHY DID WE BOTH FAIL TO USE THIS SAFEGUARD? IT SEEMS THAT POSSIBLY WHEN WE DISCUSSED THE EMER PROC AS WE ROLLED TO THE RWY, OUR THOUGHT PROCESSES JUMPED FROM THE 'HERE AND NOW' TO THE 'WHAT IF?' MODE. I BELIEVE THAT WE EXECUTED THE TKOF IN A MENTAL AUTOPLT STATE THAT IS THE RESULT OF INNUMERABLE BEHAVIOR REPETITIONS. LITERALLY WE COULD DO IT WITH OUR EYES CLOSED. OUR GROGGY EARLY MORNING FATIGUE, MADE US RIPE FOR AN ACCIDENT. POSSIBLY WE WILL BE ABLE TO PREVENT THIS IN THE FUTURE BY VERBALLY EXCLAIMING 'POS AND HOLD!' OR 'CLRED FOR TKOF!' WHEN XING THE HOLD LINE ON TAXI OUT. THIS SORT OF MNEMONIC DEVICE MAY HELP US TO MENTALLY 'DRAW THE CURTAIN' ON THE LAST ACT. THIS IS ONE STORY THAT NEITHER OF US WANTS TO SEE REPEATED.

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.