Narrative:

We were delayed leaving the gate at pbi due to an ATC hold for WX at our arrival airport. We received clearance to go on shorter notice than expected and we quickly called our passenger and ground crew so that we could push. The checklist was completed and we started our taxi on 1 engine to speed our departure and save fuel. As we neared the hold short line, I switched to tower and was asked by the controller if we were ready to takeoff. I responded that we needed a little more time and that we would hold short. Meanwhile, we rapidly worked on starting the other 2 engines and completing the checklists. Very shortly following my hold short transmission the captain instructed me to tell tower that we were ready as we rushed through our final preparations. The tower then gave us another clearance which we understood to be 'to takeoff.' the aircraft (which never stopped rolling during the entire taxi and takeoff) was fully configured with checklists complete as the captain came forward on the throttles. With power set and the aircraft on centerline, I gave a quick 'X is rolling' call to the tower. Shortly after liftoff the tower controller called and asked what heading we had been given. I thought briefly and saw that both of our heading bugs were on runway heading, and responded with 'runway heading.' he then stated that we had been told position and hold, but now we were cleared for takeoff with a left turn out, switch to departure. There was no traffic conflict stated nor none noticed by us. Needless to say, that hit us like a ton of bricks. We were all 3 shocked and angered to have made such an important yet elemental mistake. We proceeded with the job at hand and made a normal approach and landing in fll. Contributing factors: fatigue -- this was our second leg of our fourth consecutive day of flying on a trip that seemed 2 weeks long. None of us can say for certain that we heard either 'cleared for takeoff' or 'position and hold.' in a rush -- the entire chain of events was needlessly compressed into a short period of time. There's never a need to rush in a case like this -- I hate to think that this lesson had to be learned over again. Economics -- this captain normally taxies on the min number of engines and starts the remaining one or ones at the last moment to save fuel. This practice requires a lot of actions and checklists to be completed in the final moments before takeoff. Summary: each pilot involved is a highly trained and an experienced professional. Our apparent misunderstanding of the clearance was an exceptionally rare unintentional event that could have been very serious. The controller although apparently correct could have more diplomatically addressed the situation by suggesting we call him upon arrival in fll. Supplemental information from acn 191798: the captain interrupted the taxi checklist to tell the first officer to tell tower we were ready. Tower cleared us on to hold. The taxi checklist continued as we took the runway and was completed as we lined up on centerline. Due to the inputs from the captain the checklist interruption and the fact that we were behind on the checklist set up a bad situation. I believe that the first officer response to tower when 'cleared on to hold' was 'roger, cleared for takeoff' with no comeback from tower. At this point I am busy with the engineer's panel making a PA and also trying to get the before takeoff checks complete when the captain pushed up the throttles and started to roll. The before takeoff checklist was completed by the time we accelerated to 50 KTS. Rushing through checklists and trying to save an infinite amount of time and fuel were contributing factors to this situation. Although this incident did not cause a problem it very well could have and could have been prevented by any one of the aircraft crew or the tower controller had he listened for the first officer's readback. Lessons learned: 1) don't let captain rush you, and say stop, or not ready, at some point. 2) don't be intimidated by the captain. 3) debriefed among crew. Callback conversation with reporter revealed the following information: reporter participated in structured callback for runway incursion study. Reporter stressed the fatigue factor as this was fourth day of tough trips. Thinks in this case the PIC should have ordered engine starts sooner as it was going to be a short and quick taxi. The cockpit workload and noise was too much. Reporter says he apparently misunderstood tower controller to say 'cleared for takeoff' when the clearance was actually 'position and hold.' he thinks that maybe this clearance was partially blocked by other conversations between crew members as they were rushing through engine start and checklists. Evidently tower did not hear reporter broadcast that they were rolling.

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Original NASA ASRS Text

Title: ACR TKOF WITHOUT CLRNC.

Narrative: WE WERE DELAYED LEAVING THE GATE AT PBI DUE TO AN ATC HOLD FOR WX AT OUR ARR ARPT. WE RECEIVED CLRNC TO GO ON SHORTER NOTICE THAN EXPECTED AND WE QUICKLY CALLED OUR PAX AND GND CREW SO THAT WE COULD PUSH. THE CHKLIST WAS COMPLETED AND WE STARTED OUR TAXI ON 1 ENG TO SPD OUR DEP AND SAVE FUEL. AS WE NEARED THE HOLD SHORT LINE, I SWITCHED TO TWR AND WAS ASKED BY THE CTLR IF WE WERE READY TO TKOF. I RESPONDED THAT WE NEEDED A LITTLE MORE TIME AND THAT WE WOULD HOLD SHORT. MEANWHILE, WE RAPIDLY WORKED ON STARTING THE OTHER 2 ENGS AND COMPLETING THE CHKLISTS. VERY SHORTLY FOLLOWING MY HOLD SHORT XMISSION THE CAPT INSTRUCTED ME TO TELL TWR THAT WE WERE READY AS WE RUSHED THROUGH OUR FINAL PREPARATIONS. THE TWR THEN GAVE US ANOTHER CLRNC WHICH WE UNDERSTOOD TO BE 'TO TKOF.' THE ACFT (WHICH NEVER STOPPED ROLLING DURING THE ENTIRE TAXI AND TKOF) WAS FULLY CONFIGURED WITH CHKLISTS COMPLETE AS THE CAPT CAME FORWARD ON THE THROTTLES. WITH PWR SET AND THE ACFT ON CENTERLINE, I GAVE A QUICK 'X IS ROLLING' CALL TO THE TWR. SHORTLY AFTER LIFTOFF THE TWR CTLR CALLED AND ASKED WHAT HDG WE HAD BEEN GIVEN. I THOUGHT BRIEFLY AND SAW THAT BOTH OF OUR HDG BUGS WERE ON RWY HDG, AND RESPONDED WITH 'RWY HDG.' HE THEN STATED THAT WE HAD BEEN TOLD POS AND HOLD, BUT NOW WE WERE CLRED FOR TKOF WITH A L TURN OUT, SWITCH TO DEP. THERE WAS NO TFC CONFLICT STATED NOR NONE NOTICED BY US. NEEDLESS TO SAY, THAT HIT US LIKE A TON OF BRICKS. WE WERE ALL 3 SHOCKED AND ANGERED TO HAVE MADE SUCH AN IMPORTANT YET ELEMENTAL MISTAKE. WE PROCEEDED WITH THE JOB AT HAND AND MADE A NORMAL APCH AND LNDG IN FLL. CONTRIBUTING FACTORS: FATIGUE -- THIS WAS OUR SECOND LEG OF OUR FOURTH CONSECUTIVE DAY OF FLYING ON A TRIP THAT SEEMED 2 WKS LONG. NONE OF US CAN SAY FOR CERTAIN THAT WE HEARD EITHER 'CLRED FOR TKOF' OR 'POS AND HOLD.' IN A RUSH -- THE ENTIRE CHAIN OF EVENTS WAS NEEDLESSLY COMPRESSED INTO A SHORT PERIOD OF TIME. THERE'S NEVER A NEED TO RUSH IN A CASE LIKE THIS -- I HATE TO THINK THAT THIS LESSON HAD TO BE LEARNED OVER AGAIN. ECONOMICS -- THIS CAPT NORMALLY TAXIES ON THE MIN NUMBER OF ENGS AND STARTS THE REMAINING ONE OR ONES AT THE LAST MOMENT TO SAVE FUEL. THIS PRACTICE REQUIRES A LOT OF ACTIONS AND CHKLISTS TO BE COMPLETED IN THE FINAL MOMENTS BEFORE TKOF. SUMMARY: EACH PLT INVOLVED IS A HIGHLY TRAINED AND AN EXPERIENCED PROFESSIONAL. OUR APPARENT MISUNDERSTANDING OF THE CLRNC WAS AN EXCEPTIONALLY RARE UNINTENTIONAL EVENT THAT COULD HAVE BEEN VERY SERIOUS. THE CTLR ALTHOUGH APPARENTLY CORRECT COULD HAVE MORE DIPLOMATICALLY ADDRESSED THE SITUATION BY SUGGESTING WE CALL HIM UPON ARR IN FLL. SUPPLEMENTAL INFO FROM ACN 191798: THE CAPT INTERRUPTED THE TAXI CHKLIST TO TELL THE FO TO TELL TWR WE WERE READY. TWR CLRED US ON TO HOLD. THE TAXI CHKLIST CONTINUED AS WE TOOK THE RWY AND WAS COMPLETED AS WE LINED UP ON CENTERLINE. DUE TO THE INPUTS FROM THE CAPT THE CHKLIST INTERRUPTION AND THE FACT THAT WE WERE BEHIND ON THE CHKLIST SET UP A BAD SITUATION. I BELIEVE THAT THE FO RESPONSE TO TWR WHEN 'CLRED ON TO HOLD' WAS 'ROGER, CLRED FOR TKOF' WITH NO COMEBACK FROM TWR. AT THIS POINT I AM BUSY WITH THE ENGINEER'S PANEL MAKING A PA AND ALSO TRYING TO GET THE BEFORE TKOF CHKS COMPLETE WHEN THE CAPT PUSHED UP THE THROTTLES AND STARTED TO ROLL. THE BEFORE TKOF CHKLIST WAS COMPLETED BY THE TIME WE ACCELERATED TO 50 KTS. RUSHING THROUGH CHKLISTS AND TRYING TO SAVE AN INFINITE AMOUNT OF TIME AND FUEL WERE CONTRIBUTING FACTORS TO THIS SITUATION. ALTHOUGH THIS INCIDENT DID NOT CAUSE A PROBLEM IT VERY WELL COULD HAVE AND COULD HAVE BEEN PREVENTED BY ANY ONE OF THE ACFT CREW OR THE TWR CTLR HAD HE LISTENED FOR THE FO'S READBACK. LESSONS LEARNED: 1) DON'T LET CAPT RUSH YOU, AND SAY STOP, OR NOT READY, AT SOME POINT. 2) DON'T BE INTIMIDATED BY THE CAPT. 3) DEBRIEFED AMONG CREW. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR PARTICIPATED IN STRUCTURED CALLBACK FOR RWY INCURSION STUDY. RPTR STRESSED THE FATIGUE FACTOR AS THIS WAS FOURTH DAY OF TOUGH TRIPS. THINKS IN THIS CASE THE PIC SHOULD HAVE ORDERED ENG STARTS SOONER AS IT WAS GOING TO BE A SHORT AND QUICK TAXI. THE COCKPIT WORKLOAD AND NOISE WAS TOO MUCH. RPTR SAYS HE APPARENTLY MISUNDERSTOOD TWR CTLR TO SAY 'CLRED FOR TKOF' WHEN THE CLRNC WAS ACTUALLY 'POS AND HOLD.' HE THINKS THAT MAYBE THIS CLRNC WAS PARTIALLY BLOCKED BY OTHER CONVERSATIONS BTWN CREW MEMBERS AS THEY WERE RUSHING THROUGH ENG START AND CHKLISTS. EVIDENTLY TWR DID NOT HEAR RPTR BROADCAST THAT THEY WERE ROLLING.

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.