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|
Attributes | |
ACN | 226705 |
Time | |
Date | 199211 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bur |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi pilot : flight engineer |
Experience | flight time last 90 days : 55 flight time total : 10100 flight time type : 519 |
ASRS Report | 226705 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | conflict : ground less severe incursion : runway non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : reviewed incident with flight crew faa : assigned or threatened penalties faa : investigated |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While in the process of completing the checklist, we were questioned by ground control if our aircraft had a white tail light. My first officer responded that we did not (our strobe lights were not on). As we continued taxi and the 'before takeoff checklist,' we switched to bur tower frequency in the vicinity of A2 and shortly thereafter received clearance for takeoff on runway 15. I acknowledged the clearance. The 'before takeoff checklist' was completed to 'the line' and I called 'below the line' which completes the entire 'before takeoff checklist.' my first officer completed the 'below the line' items to the point of me turning on our landing lights which I did as we rounded the corner at the end of taxiway a to turn on to runway 15. As we rolled into position on the runway, I made a call on the tower frequency that we were rolling. My reason for making this call was that our takeoff clearance was received early and some time had elapsed since receiving the clearance. I wanted to receive confirmation that the clearance was still valid. I distinctly remember making the 'rolling' call because I stumbled getting our call sign out, confusing it with our previous inbound flight number. There was no response from the tower to this call. As we began our takeoff roll, we both noticed an aircraft rolling on runway 8-26 through the intersection of our runway (15) at a fairly fast speed. Seeing that he would not interfere with our takeoff, we continued our takeoff roll. Rotation and liftoff were normal. Just after liftoff, we received a call from bur tower that we were 'cleared for takeoff, maintain 4000 ft.' I responded that we were already airborne and had been previously cleared for takeoff. The tower controller stated that he didn't think he had cleared us for takeoff and I briefly stated that he'd better check the tapes. We then switched to departure frequency and continued the departure. Upon reaching our destination (sea), I initiated a telephone call to bur tower to resolve what had occurred. The first officer and I both feel confident that we heard a takeoff clearance issued to us, however, bur tower reported that the tape confirms a 'position and hold' clearance was issued and acknowledged by us. I have not heard the tape yet or seen a transcript. This is both perplexing and shocking! The only explanations for these apparent contradictions appear to be that we either received an unauthorized radio transmission such as has been notamed in the southern ca area, or that we did misunderstand the clearance. I cannot explain the reported acknowledgement of 'position and hold.' bur tower also stated that no 'rolling' call was heard on the tape. That doesn't seem possible because I am so certain in making the call. If the clearance was misunderstood and acknowledged, we both would have had to be distracted at the same time which I don't believe was the case. Bur is always a 'heads up' operation and demands attention and one strives to keep his attention focused. I was even more aware of this since I was conducting training with a new first officer. If we do prove to be at fault in this occurrence, perhaps I should re-evaluate the load I am under in these training situations. I intend to learn from this experience. Callback conversation with reporter revealed the following information: reporter stated that the FAA FSDO had followed up with an investigation which is concluding in an official letter of correction based on the reported airmen completing a prescribed amount of training. He was amazed to hear that the tape recording of this incident revealed that he had acknowledged to the tower 'taxi into position and hold.' he would still like to hear that for himself. In addition to company training he has voluntarily taken himself off of the instructor work since he believes that this incident may have not happened if he was not instructing a new first officer within 1 month and a few hours in the make and model aircraft. He believed that it was too much to handle too soon in that aircraft. He believes that our reporting service does an excellent job.
Original NASA ASRS Text
Title: CAPT INSTRUCTOR OF ACR MLG ACFT INADVERTENTLY TOOK OFF WITHOUT AN ATC CLRNC.
Narrative: WHILE IN THE PROCESS OF COMPLETING THE CHKLIST, WE WERE QUESTIONED BY GND CTL IF OUR ACFT HAD A WHITE TAIL LIGHT. MY FO RESPONDED THAT WE DID NOT (OUR STROBE LIGHTS WERE NOT ON). AS WE CONTINUED TAXI AND THE 'BEFORE TKOF CHKLIST,' WE SWITCHED TO BUR TWR FREQ IN THE VICINITY OF A2 AND SHORTLY THEREAFTER RECEIVED CLRNC FOR TKOF ON RWY 15. I ACKNOWLEDGED THE CLRNC. THE 'BEFORE TKOF CHKLIST' WAS COMPLETED TO 'THE LINE' AND I CALLED 'BELOW THE LINE' WHICH COMPLETES THE ENTIRE 'BEFORE TKOF CHKLIST.' MY FO COMPLETED THE 'BELOW THE LINE' ITEMS TO THE POINT OF ME TURNING ON OUR LNDG LIGHTS WHICH I DID AS WE ROUNDED THE CORNER AT THE END OF TAXIWAY A TO TURN ON TO RWY 15. AS WE ROLLED INTO POS ON THE RWY, I MADE A CALL ON THE TWR FREQ THAT WE WERE ROLLING. MY REASON FOR MAKING THIS CALL WAS THAT OUR TKOF CLRNC WAS RECEIVED EARLY AND SOME TIME HAD ELAPSED SINCE RECEIVING THE CLRNC. I WANTED TO RECEIVE CONFIRMATION THAT THE CLRNC WAS STILL VALID. I DISTINCTLY REMEMBER MAKING THE 'ROLLING' CALL BECAUSE I STUMBLED GETTING OUR CALL SIGN OUT, CONFUSING IT WITH OUR PREVIOUS INBOUND FLT NUMBER. THERE WAS NO RESPONSE FROM THE TWR TO THIS CALL. AS WE BEGAN OUR TKOF ROLL, WE BOTH NOTICED AN ACFT ROLLING ON RWY 8-26 THROUGH THE INTXN OF OUR RWY (15) AT A FAIRLY FAST SPD. SEEING THAT HE WOULD NOT INTERFERE WITH OUR TKOF, WE CONTINUED OUR TKOF ROLL. ROTATION AND LIFTOFF WERE NORMAL. JUST AFTER LIFTOFF, WE RECEIVED A CALL FROM BUR TWR THAT WE WERE 'CLRED FOR TKOF, MAINTAIN 4000 FT.' I RESPONDED THAT WE WERE ALREADY AIRBORNE AND HAD BEEN PREVIOUSLY CLRED FOR TKOF. THE TWR CTLR STATED THAT HE DIDN'T THINK HE HAD CLRED US FOR TKOF AND I BRIEFLY STATED THAT HE'D BETTER CHK THE TAPES. WE THEN SWITCHED TO DEP FREQ AND CONTINUED THE DEP. UPON REACHING OUR DEST (SEA), I INITIATED A TELEPHONE CALL TO BUR TWR TO RESOLVE WHAT HAD OCCURRED. THE FO AND I BOTH FEEL CONFIDENT THAT WE HEARD A TKOF CLRNC ISSUED TO US, HOWEVER, BUR TWR RPTED THAT THE TAPE CONFIRMS A 'POS AND HOLD' CLRNC WAS ISSUED AND ACKNOWLEDGED BY US. I HAVE NOT HEARD THE TAPE YET OR SEEN A TRANSCRIPT. THIS IS BOTH PERPLEXING AND SHOCKING! THE ONLY EXPLANATIONS FOR THESE APPARENT CONTRADICTIONS APPEAR TO BE THAT WE EITHER RECEIVED AN UNAUTHORIZED RADIO XMISSION SUCH AS HAS BEEN NOTAMED IN THE SOUTHERN CA AREA, OR THAT WE DID MISUNDERSTAND THE CLRNC. I CANNOT EXPLAIN THE RPTED ACKNOWLEDGEMENT OF 'POS AND HOLD.' BUR TWR ALSO STATED THAT NO 'ROLLING' CALL WAS HEARD ON THE TAPE. THAT DOESN'T SEEM POSSIBLE BECAUSE I AM SO CERTAIN IN MAKING THE CALL. IF THE CLRNC WAS MISUNDERSTOOD AND ACKNOWLEDGED, WE BOTH WOULD HAVE HAD TO BE DISTRACTED AT THE SAME TIME WHICH I DON'T BELIEVE WAS THE CASE. BUR IS ALWAYS A 'HEADS UP' OP AND DEMANDS ATTN AND ONE STRIVES TO KEEP HIS ATTN FOCUSED. I WAS EVEN MORE AWARE OF THIS SINCE I WAS CONDUCTING TRAINING WITH A NEW FO. IF WE DO PROVE TO BE AT FAULT IN THIS OCCURRENCE, PERHAPS I SHOULD RE-EVALUATE THE LOAD I AM UNDER IN THESE TRAINING SITUATIONS. I INTEND TO LEARN FROM THIS EXPERIENCE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THE FAA FSDO HAD FOLLOWED UP WITH AN INVESTIGATION WHICH IS CONCLUDING IN AN OFFICIAL LETTER OF CORRECTION BASED ON THE RPTED AIRMEN COMPLETING A PRESCRIBED AMOUNT OF TRAINING. HE WAS AMAZED TO HEAR THAT THE TAPE RECORDING OF THIS INCIDENT REVEALED THAT HE HAD ACKNOWLEDGED TO THE TWR 'TAXI INTO POS AND HOLD.' HE WOULD STILL LIKE TO HEAR THAT FOR HIMSELF. IN ADDITION TO COMPANY TRAINING HE HAS VOLUNTARILY TAKEN HIMSELF OFF OF THE INSTRUCTOR WORK SINCE HE BELIEVES THAT THIS INCIDENT MAY HAVE NOT HAPPENED IF HE WAS NOT INSTRUCTING A NEW FO WITHIN 1 MONTH AND A FEW HRS IN THE MAKE AND MODEL ACFT. HE BELIEVED THAT IT WAS TOO MUCH TO HANDLE TOO SOON IN THAT ACFT. HE BELIEVES THAT OUR RPTING SVC DOES AN EXCELLENT JOB.
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.