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|
Attributes | |
ACN | 273938 |
Time | |
Date | 199406 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ord |
State Reference | IL |
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 | ATR 72 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground other : taxi landing other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 150 flight time total : 1100 flight time type : 150 |
ASRS Report | 273938 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 6600 flight time type : 3000 |
ASRS Report | 273426 |
Events | |
Anomaly | incursion : runway non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | none taken : insufficient time |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Upon landing on runway 22R at O'hare field, the local controller instructed flight to exit using the forward high speed taxiway and hold short of runway 27R. I read back those instructions and proceeded to complete my after-landing checklist duties once clear of runway 22R. While the captain resumed control of the aircraft (I had been the PF for that segment of the flight). The captain must not have understood our instructions to hold short and continued to taxi across 27R. He asked me 'we were cleared to cross, right?' and I replied, 'no.' another aircraft had been cleared to land on 27R but had not yet touched down. The local controller called us and gave a verbal reproach, but we were not instructed to call the tower. We then called the ground controller and taxied to our gate. Fatigue may have been one contributing factor in this situation. Both crewmembers obtained minimum rest prior to flight time. This flight was the return portion of a continuous duty overnight flight to traverse city and marquette, mi. These scheduled cdo's provide the company to utilize crewmembers on reduced rest, but often leave crews in mental and physical states that are less than optimum for flight. Lack of proper communication and understanding of instructions between crewmembers was also a large factor in the situation described. Supplemental information from acn 273426: congested tower frequency, flight isn't cleared to land until about 2 mi from the runway on 22R. Company traffic ahead touches down late and almost misses the highspd taxiway off 22R. O'hare tower, in an attempt to expedite this aircraft across runway 27R, mistakenly calls this company aircraft by our call sign and appears to clear us across 27R on the highspd before we even touch down. After touchdown we are instructed to exit at the highspd and hold short of 27R, which I missed but the first officer did recall later, anyway, we cross 27R both of us believing we were cleared across. The cause of this runway incursion is clear: pilot error, and there were several contributing factors. Even though I knew tower wasn't referring to us when he called our company aircraft ahead of us by our call sign and cleared them across 27R, I expected the same expedition across 27R for our flight, and the controllers mistake put the 'bug in my ear.' I had been doing this same flight for almost 2 months, and 22R had been the same runway 90 percent of the time, and every landing on 22R had been followed by 'exit the highspd, cross 27R, join bravo ground on other side.' I mistakenly expected this, and wanted to hear it. Repetition in previous arrs possibly misled me into not listening as I should. This was the third in a series of 3 continuous duty overnights. (Official rest during the day, sleep 4 hours at night) no matter how much sleep you get during the day, your body never gets adjusted to continuous duty overnights. Lack of rem sleep or circadian rhythms or whatever you want to call it, these schedules make you a zombie.
Original NASA ASRS Text
Title: UNAUTH RWY ENTRY XING. CLRNC INTERP.
Narrative: UPON LNDG ON RWY 22R AT O'HARE FIELD, THE LCL CTLR INSTRUCTED FLT TO EXIT USING THE FORWARD HIGH SPD TXWY AND HOLD SHORT OF RWY 27R. I READ BACK THOSE INSTRUCTIONS AND PROCEEDED TO COMPLETE MY AFTER-LNDG CHKLIST DUTIES ONCE CLR OF RWY 22R. WHILE THE CAPT RESUMED CTL OF THE ACFT (I HAD BEEN THE PF FOR THAT SEGMENT OF THE FLT). THE CAPT MUST NOT HAVE UNDERSTOOD OUR INSTRUCTIONS TO HOLD SHORT AND CONTINUED TO TAXI ACROSS 27R. HE ASKED ME 'WE WERE CLRED TO CROSS, RIGHT?' AND I REPLIED, 'NO.' ANOTHER ACFT HAD BEEN CLRED TO LAND ON 27R BUT HAD NOT YET TOUCHED DOWN. THE LCL CTLR CALLED US AND GAVE A VERBAL REPROACH, BUT WE WERE NOT INSTRUCTED TO CALL THE TWR. WE THEN CALLED THE GND CTLR AND TAXIED TO OUR GATE. FATIGUE MAY HAVE BEEN ONE CONTRIBUTING FACTOR IN THIS SIT. BOTH CREWMEMBERS OBTAINED MINIMUM REST PRIOR TO FLT TIME. THIS FLT WAS THE RETURN PORTION OF A CONTINUOUS DUTY OVERNIGHT FLT TO TRAVERSE CITY AND MARQUETTE, MI. THESE SCHEDULED CDO'S PROVIDE THE COMPANY TO UTILIZE CREWMEMBERS ON REDUCED REST, BUT OFTEN LEAVE CREWS IN MENTAL AND PHYSICAL STATES THAT ARE LESS THAN OPTIMUM FOR FLT. LACK OF PROPER COM AND UNDERSTANDING OF INSTRUCTIONS BTWN CREWMEMBERS WAS ALSO A LARGE FACTOR IN THE SIT DESCRIBED. SUPPLEMENTAL INFO FROM ACN 273426: CONGESTED TWR FREQ, FLT ISN'T CLRED TO LAND UNTIL ABOUT 2 MI FROM THE RWY ON 22R. COMPANY TFC AHEAD TOUCHES DOWN LATE AND ALMOST MISSES THE HIGHSPD TXWY OFF 22R. O'HARE TWR, IN AN ATTEMPT TO EXPEDITE THIS ACFT ACROSS RWY 27R, MISTAKENLY CALLS THIS COMPANY ACFT BY OUR CALL SIGN AND APPEARS TO CLR US ACROSS 27R ON THE HIGHSPD BEFORE WE EVEN TOUCH DOWN. AFTER TOUCHDOWN WE ARE INSTRUCTED TO EXIT AT THE HIGHSPD AND HOLD SHORT OF 27R, WHICH I MISSED BUT THE FO DID RECALL LATER, ANYWAY, WE CROSS 27R BOTH OF US BELIEVING WE WERE CLRED ACROSS. THE CAUSE OF THIS RWY INCURSION IS CLEAR: PLT ERROR, AND THERE WERE SEVERAL CONTRIBUTING FACTORS. EVEN THOUGH I KNEW TWR WASN'T REFERRING TO US WHEN HE CALLED OUR COMPANY ACFT AHEAD OF US BY OUR CALL SIGN AND CLRED THEM ACROSS 27R, I EXPECTED THE SAME EXPEDITION ACROSS 27R FOR OUR FLT, AND THE CTLRS MISTAKE PUT THE 'BUG IN MY EAR.' I HAD BEEN DOING THIS SAME FLT FOR ALMOST 2 MONTHS, AND 22R HAD BEEN THE SAME RWY 90 PERCENT OF THE TIME, AND EVERY LNDG ON 22R HAD BEEN FOLLOWED BY 'EXIT THE HIGHSPD, CROSS 27R, JOIN BRAVO GND ON OTHER SIDE.' I MISTAKENLY EXPECTED THIS, AND WANTED TO HEAR IT. REPETITION IN PREVIOUS ARRS POSSIBLY MISLED ME INTO NOT LISTENING AS I SHOULD. THIS WAS THE THIRD IN A SERIES OF 3 CONTINUOUS DUTY OVERNIGHTS. (OFFICIAL REST DURING THE DAY, SLEEP 4 HRS AT NIGHT) NO MATTER HOW MUCH SLEEP YOU GET DURING THE DAY, YOUR BODY NEVER GETS ADJUSTED TO CONTINUOUS DUTY OVERNIGHTS. LACK OF REM SLEEP OR CIRCADIAN RHYTHMS OR WHATEVER YOU WANT TO CALL IT, THESE SCHEDULES MAKE YOU A ZOMBIE.
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.