Narrative:

Last leg of long flight day (7:50 scheduled, 4 legs, already logged 7:00 hours domestic flight time), 11TH hour of 12 hour duty day, night. Crew made comments of being tired. PF: first officer. Captain taxiing aircraft onto runway. Captain familiar with airport. First officer recently upgraded (6 months earlier) after 6 yrs as flight engineer, had been to cle less than 6 times as first officer. Cleared to follow 2 commuter aircraft to runway 23 by ground control. Followed aircraft, determined takeoff would be in short period of time. While taxiing, started 3RD engine and completed taxi checklist simultaneously. Somewhat rushed. Both commuter aircraft departed runway 23L (the longer way). Captain's earpiece fell out and captain was fumbling with earpiece when tower cleared aircraft to 'cross runway 23L, cleared for takeoff runway 23R.' clearance was read back correctly by first officer, but captain was still fumbling and only heard clearance on cabin speaker. First officer was doing duties and heard clearance for runway 23R, (and was familiar with airport), but heard another clearance given later, but not its contents (it was for a landing aircraft), and assumed our clearance had been changed. Captain taxied onto runway 23L lined up, and transferred control of aircraft to first officer. First officer knew what runway we had been given clearance for, and was actively trying to ascertain we were on the correct runway. He did not say anything to captain, thinking he knew which runway we were on, and what runway we were cleared to depart. First officer did not realize captain thought we were cleared to takeoff on runway 23L. Takeoff roll was started after lining up on runway 23L, tower canceled takeoff clearance after approximately 50 ft of roll. Problem from first officer standpoint: departure ends of cle runways 23L, 23R, and 28 are all very close together. Cleveland is notorious for this and first officer was aware of that. However, this may have been the first officer's first takeoff from runway 23 at night, and he thought that runway 28 was runway 23L and the aircraft was on the correct runway (23R). He even checked the markers thinking he was on the correct runway, and when the captain lined up on runway 23L he assumed the captain knew where he was (as indeed he did)! This was a classic case from start to finish. Long day. Tired crew. Crew member distracted. New first officer. Night. Hurrying checklist. Cle tower contributions to situation: clearing both commuters to takeoff from runway 23L then in 1 instruction clearing us to cross runway 23L, cleared for takeoff runway 23R. Suggestions: crew vigilance, of course. But also, tower clear into position before clearance for takeoff from runway 23R would be suggested. Runways were properly marked, but perhaps more emphasis on what runway is what beyond the legal minimums is appropriate. For example. Runway 23L is marked on the runway, but runway 28 is an intersection at this point with no designation on the surface, and runway 23R has a displaced threshold, so 23R painted on the runway is not visible. All in all, a classic case of numerous small problems combining into a potentially large one. Contributing factors by all crew members and the tower controller. Supplemental information from acn 265336: what caused the problem started during pushback from the gate. Ground told me that there would be a slight delay while they finished loading bags, so I decided to greet the passenger over the PA. I no sooner picked up the microphone to speak when ground called to say they were ready for pushback. The tug gave us a jolt and died. Ground called to say that they were going to have to get another tug, so I picked up the PA microphone again to talk to the passenger. Again, another jolt from the tug, this time without warning. I picked up the microphone to talk to ground, but had turned down the speaker, then turned it up too loud while talking to ground. Squeaks and squalls over the speaker. I was mad. Told them to stop playing with that tug and get another. I then picked up the PA and proceeded with the announcement, but the flight attendant was now speaking. Our chief pilot was on board and I was embarrassed about the pushback and the goof. I was made at myself. We were told to taxi to runway 23L and follow the 2 ATR's at the end of the runway. My glasses became entangled with my headset and in anger with myself ripped my headset to make matters right. Just then the clearance to cross runway 28 and takeoff on runway 23R came. The first officer, who has less than a month in the right seat, heard and read back the clearance. The flight engineer was busy with her takeoff flow and didn't hear the clearance. When I put my headset back on I heard tower clear a plane to land on runway 23R and the 2 ATR's had taken off on runway 23L, so that's what I did -- line up on runway 23L. Wrong! A hundred small mistakes lead to a big mistake.

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Original NASA ASRS Text

Title: RWY TRANSGRESSION OF THE THIRD KIND. UNAUTH RWY ENTRY OP. WRONG RWY TKOF ATTEMPTED. MULTIPLE RWY OP PARALLEL DIVERGING RWYS.

Narrative: LAST LEG OF LONG FLT DAY (7:50 SCHEDULED, 4 LEGS, ALREADY LOGGED 7:00 HRS DOMESTIC FLT TIME), 11TH HR OF 12 HR DUTY DAY, NIGHT. CREW MADE COMMENTS OF BEING TIRED. PF: FO. CAPT TAXIING ACFT ONTO RWY. CAPT FAMILIAR WITH ARPT. FO RECENTLY UPGRADED (6 MONTHS EARLIER) AFTER 6 YRS AS FE, HAD BEEN TO CLE LESS THAN 6 TIMES AS FO. CLRED TO FOLLOW 2 COMMUTER ACFT TO RWY 23 BY GND CTL. FOLLOWED ACFT, DETERMINED TKOF WOULD BE IN SHORT PERIOD OF TIME. WHILE TAXIING, STARTED 3RD ENG AND COMPLETED TAXI CHKLIST SIMULTANEOUSLY. SOMEWHAT RUSHED. BOTH COMMUTER ACFT DEPARTED RWY 23L (THE LONGER WAY). CAPT'S EARPIECE FELL OUT AND CAPT WAS FUMBLING WITH EARPIECE WHEN TWR CLRED ACFT TO 'CROSS RWY 23L, CLRED FOR TKOF RWY 23R.' CLRNC WAS READ BACK CORRECTLY BY FO, BUT CAPT WAS STILL FUMBLING AND ONLY HEARD CLRNC ON CABIN SPEAKER. FO WAS DOING DUTIES AND HEARD CLRNC FOR RWY 23R, (AND WAS FAMILIAR WITH ARPT), BUT HEARD ANOTHER CLRNC GIVEN LATER, BUT NOT ITS CONTENTS (IT WAS FOR A LNDG ACFT), AND ASSUMED OUR CLRNC HAD BEEN CHANGED. CAPT TAXIED ONTO RWY 23L LINED UP, AND TRANSFERRED CTL OF ACFT TO FO. FO KNEW WHAT RWY WE HAD BEEN GIVEN CLRNC FOR, AND WAS ACTIVELY TRYING TO ASCERTAIN WE WERE ON THE CORRECT RWY. HE DID NOT SAY ANYTHING TO CAPT, THINKING HE KNEW WHICH RWY WE WERE ON, AND WHAT RWY WE WERE CLRED TO DEPART. FO DID NOT REALIZE CAPT THOUGHT WE WERE CLRED TO TKOF ON RWY 23L. TKOF ROLL WAS STARTED AFTER LINING UP ON RWY 23L, TWR CANCELED TKOF CLRNC AFTER APPROX 50 FT OF ROLL. PROB FROM FO STANDPOINT: DEP ENDS OF CLE RWYS 23L, 23R, AND 28 ARE ALL VERY CLOSE TOGETHER. CLEVELAND IS NOTORIOUS FOR THIS AND FO WAS AWARE OF THAT. HOWEVER, THIS MAY HAVE BEEN THE FO'S FIRST TKOF FROM RWY 23 AT NIGHT, AND HE THOUGHT THAT RWY 28 WAS RWY 23L AND THE ACFT WAS ON THE CORRECT RWY (23R). HE EVEN CHKED THE MARKERS THINKING HE WAS ON THE CORRECT RWY, AND WHEN THE CAPT LINED UP ON RWY 23L HE ASSUMED THE CAPT KNEW WHERE HE WAS (AS INDEED HE DID)! THIS WAS A CLASSIC CASE FROM START TO FINISH. LONG DAY. TIRED CREW. CREW MEMBER DISTRACTED. NEW FO. NIGHT. HURRYING CHKLIST. CLE TWR CONTRIBUTIONS TO SIT: CLRING BOTH COMMUTERS TO TKOF FROM RWY 23L THEN IN 1 INSTRUCTION CLRING US TO CROSS RWY 23L, CLRED FOR TKOF RWY 23R. SUGGESTIONS: CREW VIGILANCE, OF COURSE. BUT ALSO, TWR CLR INTO POS BEFORE CLRNC FOR TKOF FROM RWY 23R WOULD BE SUGGESTED. RWYS WERE PROPERLY MARKED, BUT PERHAPS MORE EMPHASIS ON WHAT RWY IS WHAT BEYOND THE LEGAL MINIMUMS IS APPROPRIATE. FOR EXAMPLE. RWY 23L IS MARKED ON THE RWY, BUT RWY 28 IS AN INTXN AT THIS POINT WITH NO DESIGNATION ON THE SURFACE, AND RWY 23R HAS A DISPLACED THRESHOLD, SO 23R PAINTED ON THE RWY IS NOT VISIBLE. ALL IN ALL, A CLASSIC CASE OF NUMEROUS SMALL PROBS COMBINING INTO A POTENTIALLY LARGE ONE. CONTRIBUTING FACTORS BY ALL CREW MEMBERS AND THE TWR CTLR. SUPPLEMENTAL INFORMATION FROM ACN 265336: WHAT CAUSED THE PROB STARTED DURING PUSHBACK FROM THE GATE. GND TOLD ME THAT THERE WOULD BE A SLIGHT DELAY WHILE THEY FINISHED LOADING BAGS, SO I DECIDED TO GREET THE PAX OVER THE PA. I NO SOONER PICKED UP THE MIKE TO SPEAK WHEN GND CALLED TO SAY THEY WERE READY FOR PUSHBACK. THE TUG GAVE US A JOLT AND DIED. GND CALLED TO SAY THAT THEY WERE GOING TO HAVE TO GET ANOTHER TUG, SO I PICKED UP THE PA MIKE AGAIN TO TALK TO THE PAX. AGAIN, ANOTHER JOLT FROM THE TUG, THIS TIME WITHOUT WARNING. I PICKED UP THE MIKE TO TALK TO GND, BUT HAD TURNED DOWN THE SPEAKER, THEN TURNED IT UP TOO LOUD WHILE TALKING TO GND. SQUEAKS AND SQUALLS OVER THE SPEAKER. I WAS MAD. TOLD THEM TO STOP PLAYING WITH THAT TUG AND GET ANOTHER. I THEN PICKED UP THE PA AND PROCEEDED WITH THE ANNOUNCEMENT, BUT THE FLT ATTENDANT WAS NOW SPEAKING. OUR CHIEF PLT WAS ON BOARD AND I WAS EMBARRASSED ABOUT THE PUSHBACK AND THE GOOF. I WAS MADE AT MYSELF. WE WERE TOLD TO TAXI TO RWY 23L AND FOLLOW THE 2 ATR'S AT THE END OF THE RWY. MY GLASSES BECAME ENTANGLED WITH MY HEADSET AND IN ANGER WITH MYSELF RIPPED MY HEADSET TO MAKE MATTERS RIGHT. JUST THEN THE CLRNC TO CROSS RWY 28 AND TKOF ON RWY 23R CAME. THE FO, WHO HAS LESS THAN A MONTH IN THE R SEAT, HEARD AND READ BACK THE CLRNC. THE FE WAS BUSY WITH HER TKOF FLOW AND DIDN'T HEAR THE CLRNC. WHEN I PUT MY HEADSET BACK ON I HEARD TWR CLR A PLANE TO LAND ON RWY 23R AND THE 2 ATR'S HAD TAKEN OFF ON RWY 23L, SO THAT'S WHAT I DID -- LINE UP ON RWY 23L. WRONG! A HUNDRED SMALL MISTAKES LEAD TO A BIG MISTAKE.

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.