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Air carrier X had less than standard separation from air carrier Y. Multiple runway operations intersecting runways. System error.
| Attributes | |
| ACN | 209601 |
| Time | |
| Date | 199205 |
| Day | Tue |
| 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 | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air carrier |
| Make Model Name | Light Transport, Low Wing, 2 Turboprop Eng |
| Flight Phase | climbout : takeoff |
| Flight Plan | IFR |
| Aircraft 2 | |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Flight Phase | landing other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | government : faa |
| Function | controller : local |
| Qualification | controller : non radar |
| Experience | controller military : 5 controller non radar : 10 |
| ASRS Report | 209601 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | conflict : ground less severe non adherence : published procedure non adherence : required legal separation |
| Independent Detector | other controllera |
| Resolutory Action | none taken : anomaly accepted |
| Consequence | faa : investigated |
| Miss Distance | horizontal : 3000 vertical : 300 |
| Supplementary | |
| Primary Problem | ATC Human Performance |
| Air Traffic Incident | Operational Error |
Narrative:
Meant to tell air carrier X to 'taxi into position and hold, traffic landing on the crossing runway.' actually said 'air carrier X, cleared for takeoff.' I was not aware of my mistake until I saw air carrier X break ground at taxiway G on runway 1L. I saw air carrier Y, at the runway 28R threshold. I considered telling air carrier Y to go around, but decided not to make a bad situation worse by trying to achieve 'technical' separation. Reflecting on the incident, I recall being aware that air carrier Y was too close to clear air carrier X or an medium large transport for takeoff, and planned to launch' medium large transport first, then air carrier X, then a heavy jet off runway 1R. While I was planning these moves, I thought I told air carrier X to taxi into position and hold. So, I was thinking about the near future and clearing air carrier X for takeoff and trying to say 'hold.' my wires got crossed. What I said was not appropriate to the moment.
Original NASA ASRS Text
Title: ACR X HAD LTSS FROM ACR Y. MULTIPLE RWY OPS INTERSECTING RWYS. SYS ERROR.
Narrative: MEANT TO TELL ACR X TO 'TAXI INTO POS AND HOLD, TFC LNDG ON THE XING RWY.' ACTUALLY SAID 'ACR X, CLRED FOR TKOF.' I WAS NOT AWARE OF MY MISTAKE UNTIL I SAW ACR X BREAK GND AT TAXIWAY G ON RWY 1L. I SAW ACR Y, AT THE RWY 28R THRESHOLD. I CONSIDERED TELLING ACR Y TO GAR, BUT DECIDED NOT TO MAKE A BAD SITUATION WORSE BY TRYING TO ACHIEVE 'TECHNICAL' SEPARATION. REFLECTING ON THE INCIDENT, I RECALL BEING AWARE THAT ACR Y WAS TOO CLOSE TO CLR ACR X OR AN MLG FOR TKOF, AND PLANNED TO LAUNCH' MLG FIRST, THEN ACR X, THEN A HVY JET OFF RWY 1R. WHILE I WAS PLANNING THESE MOVES, I THOUGHT I TOLD ACR X TO TAXI INTO POS AND HOLD. SO, I WAS THINKING ABOUT THE NEAR FUTURE AND CLRING ACR X FOR TKOF AND TRYING TO SAY 'HOLD.' MY WIRES GOT CROSSED. WHAT I SAID WAS NOT APPROPRIATE TO THE MOMENT.
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.