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Attributes | |
ACN | 194565 |
Time | |
Date | 199111 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : sfo |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 315 flight time total : 14500 flight time type : 3800 |
ASRS Report | 194565 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 8000 flight time type : 2200 |
ASRS Report | 194456 |
Events | |
Anomaly | non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Air carrier X departed air carrier gate and contacted sfo ground control approaching taxiway. We were instructed to taxi to runway 28 via the inner (a) to F (see accompanying diagram) to cross runways 5L/right. As we approached D taxiway, ground control instructed us to join the outer at D behind a widebody transport exiting at east going to the international terminal. As we approached east taxiway moved to the outside (northeast) part of the east taxiway to clear the widebody transport. At this point we continued to follow the green taxiway centerline lights. At the spot marked by the X on accompanying diagram, was told to 'hold our position, you are on taxiway J.' we stopped abruptly. We were then cleared to taxi onto runway 28L followed by a right turn onto runway 19R to F then left on F to the 28 runways. Not until cleared, did we taxi onto runway 28L. There were no aircraft on 28L as we taxied onto J. The cause of this incident is attributed to the confusion in clearing the rear of the widebody transport and then continuing to following the green taxiway centerline lighting to the incorrect taxiway. Both captain and first officer unaware of taxiway deviation until called by ground control. Suggest area of taxiways a and B at east be examined to improve painting of markings and lighting in this area. This crew was unaware of the deviation. Supplemental information from acn 194456: we were cleared via the inner to foxtrot and cleared to cross runways 1L and 1R and to taxi to 28. On the way out we were given instructions to transition to the outer at echo and follow a widebody transport. We made the transition and then made the next left turn which was juliet, the high speed exit off of runway 28L. Before reaching the runway ground called for us to stop immediately because we were on runway 28. We did not actually go onto the runway . We were about 30 yards from the edge of the runway. I believe however that had the controller not called us we might have continued onto the runway. Neither one of us felt we were in the wrong place, but we were. I feel contributing factors were us watching the widebody transport taxi in front of us and then becoming a little confused on where we were. We both had the airport diagrams out but did not look at them because we both knew where foxtrot was. We just got confused. Also the green taxiway center line lights on the highspeed led us to believe we were on the correct taxiway. Myself as the copilot was probably not concerned enough with watching the captain and double checking our position as often as I should have. I will be more vigilant in the future.
Original NASA ASRS Text
Title: ACR X POTENTIAL UNAUTHORIZED RWY ENTRY NON ADHERENCE TO ATC CLRNC (USED WRONG TAXIWAY). PLTDEV.
Narrative: ACR X DEPARTED ACR GATE AND CONTACTED SFO GND CTL APCHING TAXIWAY. WE WERE INSTRUCTED TO TAXI TO RWY 28 VIA THE INNER (A) TO F (SEE ACCOMPANYING DIAGRAM) TO CROSS RWYS 5L/R. AS WE APCHED D TAXIWAY, GND CTL INSTRUCTED US TO JOIN THE OUTER AT D BEHIND A WDB EXITING AT E GOING TO THE INTL TERMINAL. AS WE APCHED E TAXIWAY MOVED TO THE OUTSIDE (NE) PART OF THE E TAXIWAY TO CLR THE WDB. AT THIS POINT WE CONTINUED TO FOLLOW THE GREEN TAXIWAY CENTERLINE LIGHTS. AT THE SPOT MARKED BY THE X ON ACCOMPANYING DIAGRAM, WAS TOLD TO 'HOLD OUR POS, YOU ARE ON TAXIWAY J.' WE STOPPED ABRUPTLY. WE WERE THEN CLRED TO TAXI ONTO RWY 28L FOLLOWED BY A R TURN ONTO RWY 19R TO F THEN L ON F TO THE 28 RWYS. NOT UNTIL CLRED, DID WE TAXI ONTO RWY 28L. THERE WERE NO ACFT ON 28L AS WE TAXIED ONTO J. THE CAUSE OF THIS INCIDENT IS ATTRIBUTED TO THE CONFUSION IN CLRING THE REAR OF THE WDB AND THEN CONTINUING TO FOLLOWING THE GREEN TAXIWAY CENTERLINE LIGHTING TO THE INCORRECT TAXIWAY. BOTH CAPT AND FO UNAWARE OF TAXIWAY DEV UNTIL CALLED BY GND CTL. SUGGEST AREA OF TAXIWAYS A AND B AT E BE EXAMINED TO IMPROVE PAINTING OF MARKINGS AND LIGHTING IN THIS AREA. THIS CREW WAS UNAWARE OF THE DEV. SUPPLEMENTAL INFO FROM ACN 194456: WE WERE CLRED VIA THE INNER TO FOXTROT AND CLRED TO CROSS RWYS 1L AND 1R AND TO TAXI TO 28. ON THE WAY OUT WE WERE GIVEN INSTRUCTIONS TO TRANSITION TO THE OUTER AT ECHO AND FOLLOW A WDB. WE MADE THE TRANSITION AND THEN MADE THE NEXT LEFT TURN WHICH WAS JULIET, THE HIGH SPEED EXIT OFF OF RWY 28L. BEFORE REACHING THE RWY GND CALLED FOR US TO STOP IMMEDIATELY BECAUSE WE WERE ON RWY 28. WE DID NOT ACTUALLY GO ONTO THE RWY . WE WERE ABOUT 30 YARDS FROM THE EDGE OF THE RWY. I BELIEVE HOWEVER THAT HAD THE CTLR NOT CALLED US WE MIGHT HAVE CONTINUED ONTO THE RWY. NEITHER ONE OF US FELT WE WERE IN THE WRONG PLACE, BUT WE WERE. I FEEL CONTRIBUTING FACTORS WERE US WATCHING THE WDB TAXI IN FRONT OF US AND THEN BECOMING A LITTLE CONFUSED ON WHERE WE WERE. WE BOTH HAD THE ARPT DIAGRAMS OUT BUT DID NOT LOOK AT THEM BECAUSE WE BOTH KNEW WHERE FOXTROT WAS. WE JUST GOT CONFUSED. ALSO THE GREEN TXWY CENTER LINE LIGHTS ON THE HIGHSPEED LED US TO BELIEVE WE WERE ON THE CORRECT TXWY. MYSELF AS THE COPLT WAS PROBABLY NOT CONCERNED ENOUGH WITH WATCHING THE CAPT AND DOUBLE CHKING OUR POSITION AS OFTEN AS I SHOULD HAVE. I WILL BE MORE VIGILANT IN THE FUTURE.
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.