Narrative:

On jan/xx/92, while performing the duties of first officer on air carrier X from sfo to lax, air carrier X encountered the following: the flight departed gate on schedule and was cleared to taxi to runway 1L, via the inner, F, outer route. The captain taxied our aircraft via the described route. The captain looking at the airport diagram saw that the end of runway 1L started at taxiway H. He then taxied our aircraft onto taxiway H and held short of runway 1L. I then changed from ground control frequency to tower frequency and the tower operator called air carrier X. I responded and we were then cleared into position and hold on runway 1L. As the captain taxied our aircraft forward, toward runway 1L we noticed the lights of an approaching aircraft from our right. This aircraft was taking off. The captain immediately stopped and prevented a possible collision of air carrier X and the aircraft taking off. I then asked the tower operator why we were cleared into position on runway 1L, with an aircraft departing from our right, which was taxiway M. The tower operator paused and then said that he thought that air carrier X was on taxiway M. I then explained that we were at taxiway H which is the end of the runway. We were then cleared again into position and hold on runway 1L at taxiway H and subsequently cleared for takeoff on runway 1L. We talked by telephone to sfo tower supervisor. We also talked to company lax flight manager, sfo flight manager, and flight safety person. During our discussions, we were told that sfo local procedure is to use taxiway M to enter runway 1L for takeoff. To my knowledge there is no published procedure for using taxiway M, instead of H, to enter runway 1L. Based on using the commercial charts it is not stated that taxiway M is the preferred route to runway 1L from the outer taxiway. Also, in talking with tower supervisor, he said the tower could not see the departure end of runway 1L in low visibility conditions, which was the case during this incident. We also discussed the ground surveillance radar which should be used in low visibility operations. We asked why the tower operator did not know that air carrier X was entering the end of runway 1L at taxiway H. Tower supervisor explained that the sfo tower, ground surveillance radar gives ambiguous returns and cannot be relied upon for correct position of taxiing aircraft. The sfo tower should in some way, advise departing aircraft using runway 1L, that they should enter the runway at taxiway M, not H -- especially in low visibility operations. I recommend that a note, explaining to use M, not H, to enter runway 1L from the outer, should be placed on the airport page in applicable charts. I also recommend that the ground surveillance radar at sfo, and any other airport that conducts low visibility operations, be brought up to 100 percent reliability or suspend operations until the tower operators can visually confirm the position of aircraft they are controling. Had we been cleared into position on runway 1L just 2 or 3 seconds earlier, this incident would have been a major air disaster. Please look into this situation as fast as possible. We, the crew of air carrier X, have notified all the applicable company safety personnel and corrective actions are already being implemented to prevent this incident from happening again.

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Original NASA ASRS Text

Title: ACR X BEYOND RWY HOLD LINE HAD LTSS FROM ACFT DEPARTING. SYS ERROR.

Narrative: ON JAN/XX/92, WHILE PERFORMING THE DUTIES OF FO ON ACR X FROM SFO TO LAX, ACR X ENCOUNTERED THE FOLLOWING: THE FLT DEPARTED GATE ON SCHEDULE AND WAS CLRED TO TAXI TO RWY 1L, VIA THE INNER, F, OUTER RTE. THE CAPT TAXIED OUR ACFT VIA THE DESCRIBED RTE. THE CAPT LOOKING AT THE ARPT DIAGRAM SAW THAT THE END OF RWY 1L STARTED AT TAXIWAY H. HE THEN TAXIED OUR ACFT ONTO TAXIWAY H AND HELD SHORT OF RWY 1L. I THEN CHANGED FROM GND CTL FREQ TO TWR FREQ AND THE TWR OPERATOR CALLED ACR X. I RESPONDED AND WE WERE THEN CLRED INTO POS AND HOLD ON RWY 1L. AS THE CAPT TAXIED OUR ACFT FORWARD, TOWARD RWY 1L WE NOTICED THE LIGHTS OF AN APCHING ACFT FROM OUR R. THIS ACFT WAS TAKING OFF. THE CAPT IMMEDIATELY STOPPED AND PREVENTED A POSSIBLE COLLISION OF ACR X AND THE ACFT TAKING OFF. I THEN ASKED THE TWR OPERATOR WHY WE WERE CLRED INTO POS ON RWY 1L, WITH AN ACFT DEPARTING FROM OUR R, WHICH WAS TAXIWAY M. THE TWR OPERATOR PAUSED AND THEN SAID THAT HE THOUGHT THAT ACR X WAS ON TAXIWAY M. I THEN EXPLAINED THAT WE WERE AT TAXIWAY H WHICH IS THE END OF THE RWY. WE WERE THEN CLRED AGAIN INTO POS AND HOLD ON RWY 1L AT TAXIWAY H AND SUBSEQUENTLY CLRED FOR TKOF ON RWY 1L. WE TALKED BY TELEPHONE TO SFO TWR SUPVR. WE ALSO TALKED TO COMPANY LAX FLT MGR, SFO FLT MGR, AND FLT SAFETY PERSON. DURING OUR DISCUSSIONS, WE WERE TOLD THAT SFO LCL PROC IS TO USE TAXIWAY M TO ENTER RWY 1L FOR TKOF. TO MY KNOWLEDGE THERE IS NO PUBLISHED PROC FOR USING TAXIWAY M, INSTEAD OF H, TO ENTER RWY 1L. BASED ON USING THE COMMERCIAL CHARTS IT IS NOT STATED THAT TAXIWAY M IS THE PREFERRED RTE TO RWY 1L FROM THE OUTER TAXIWAY. ALSO, IN TALKING WITH TWR SUPVR, HE SAID THE TWR COULD NOT SEE THE DEP END OF RWY 1L IN LOW VISIBILITY CONDITIONS, WHICH WAS THE CASE DURING THIS INCIDENT. WE ALSO DISCUSSED THE GND SURVEILLANCE RADAR WHICH SHOULD BE USED IN LOW VISIBILITY OPS. WE ASKED WHY THE TWR OPERATOR DID NOT KNOW THAT ACR X WAS ENTERING THE END OF RWY 1L AT TAXIWAY H. TWR SUPVR EXPLAINED THAT THE SFO TWR, GND SURVEILLANCE RADAR GIVES AMBIGUOUS RETURNS AND CANNOT BE RELIED UPON FOR CORRECT POS OF TAXIING ACFT. THE SFO TWR SHOULD IN SOME WAY, ADVISE DEPARTING ACFT USING RWY 1L, THAT THEY SHOULD ENTER THE RWY AT TAXIWAY M, NOT H -- ESPECIALLY IN LOW VISIBILITY OPS. I RECOMMEND THAT A NOTE, EXPLAINING TO USE M, NOT H, TO ENTER RWY 1L FROM THE OUTER, SHOULD BE PLACED ON THE ARPT PAGE IN APPLICABLE CHARTS. I ALSO RECOMMEND THAT THE GND SURVEILLANCE RADAR AT SFO, AND ANY OTHER ARPT THAT CONDUCTS LOW VISIBILITY OPS, BE BROUGHT UP TO 100 PERCENT RELIABILITY OR SUSPEND OPS UNTIL THE TWR OPERATORS CAN VISUALLY CONFIRM THE POS OF ACFT THEY ARE CTLING. HAD WE BEEN CLRED INTO POS ON RWY 1L JUST 2 OR 3 SECONDS EARLIER, THIS INCIDENT WOULD HAVE BEEN A MAJOR AIR DISASTER. PLEASE LOOK INTO THIS SITUATION AS FAST AS POSSIBLE. WE, THE CREW OF ACR X, HAVE NOTIFIED ALL THE APPLICABLE COMPANY SAFETY PERSONNEL AND CORRECTIVE ACTIONS ARE ALREADY BEING IMPLEMENTED TO PREVENT THIS INCIDENT FROM HAPPENING AGAIN.

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.