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|
Attributes | |
ACN | 288555 |
Time | |
Date | 199411 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : slc |
State Reference | UT |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 254 flight time total : 4200 flight time type : 900 |
ASRS Report | 288555 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 270 flight time total : 18132 flight time type : 6000 |
ASRS Report | 288226 |
Events | |
Anomaly | incursion : runway non adherence : clearance other anomaly other |
Independent Detector | other controllera other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Air carrier X was scheduled to depart slc for las vegas at XH35 local time. The flight pushed from the gate on time and after deicing was cleared to taxi behind air carrier Y to runway 34. After waiting several mins for arrs and air carrier Y departure off of runway 34, we were cleared to cross to runway 35. As we proceeded we discussed the deicing hold over time and made an assessment of the conditions to determine if the XH54 local hold over time was still a factor. I switched to runway 35 tower frequency and shortly thereafter I visually acquired that runway. I did not notice runway 32. As we approached the hold short line, I saw 1-2 ft of plowed snow on the end of runway 35 but no accumulation on the runway surface, thus validating my takeoff off performance calculations. By using the wing light I could see that there was no snow on the right wing. About that time we were cleared for takeoff on runway 35. The 'below the line' checklist was accomplished and I visually cleared the approach for aircraft. At the same time the captain was aligning the aircraft and advancing power, subsequently asking for takeoff thrust. After setting the takeoff thrust, I looked outside to check our alignment. The captain was using the windshield wipers to clear melting snow which was causing some glare and visibility problems. My perception was that in the time that I read the checklist, cleared for aircraft on final, and set takeoff power, we had traveled on to runway 35, made a 90 degree turn and started tracking the runway 35 centerline. However, in error we had turned slightly short and in excess of 90 degrees onto runway 32. I made the standard call outs an didn't recognize our mistake until after looking outside at vr and seeing convergence on runway 34. Earlier in the takeoff roll at about 100 KTS I knew something was wrong by the captain's increased alertness and mumbled words. Apparently he had noticed the mistake after we were committed to continue. After safely airborne with the gear retracted we made a turn to avoid overflt of runway 34. We were later told by tower of the error and continued to las vegas. The congruent nature of the approach end of runway 32 and 35, and the fact that runway 32 was NOTAM closed but the runway lights remained on were significant factors. Human factors: in my opinion the following were contributing human factors: unfamiliarity with the airport. Our initial mind-set was for a runway 34 departure and when switched to runway 35 we looked at the airport diagram to see if we were taxiing correctly. Mentally I discounted runway 32 as a factor because I thought that its size and orientation would make easily distinguishable from runway 35. Night/WX operations. The intensifying falling snow presented some visibility and depth perception problems. Initially I saw the correct runway and believed we had turned onto it while I was reading the checklist and setting takeoff power. In retrospect, I actually got disoriented during that time period and should have crosschecked the aircraft heading. Channelized attention. Although there was no significant accumulation of snow on the ground or on the aircraft, it did cause us to bring the deicing considerations into our procedural flow pattern. This is because we didn't know what to expect until we got to the end of the runway. Where the snow caused a major problem was on line up when both of us got 'tunnel vision' trying to align the aircraft with the runway centerline of the wrong runway. Communications. There was a communications breakdown as we were approaching the runways. Each pilot had what he thought was complete and accurate information. However, in the final analysis our overall situational awareness was less than optimal and we should have stopped to confirm that we were proceeding onto the correct runway.
Original NASA ASRS Text
Title: AT SLC, FLC OF A B737 MISTAKENLY TOOK OFF ON THE WRONG RWY -- AND, ONE WHICH WAS CLOSED.
Narrative: ACR X WAS SCHEDULED TO DEPART SLC FOR LAS VEGAS AT XH35 LCL TIME. THE FLT PUSHED FROM THE GATE ON TIME AND AFTER DEICING WAS CLRED TO TAXI BEHIND ACR Y TO RWY 34. AFTER WAITING SEVERAL MINS FOR ARRS AND ACR Y DEP OFF OF RWY 34, WE WERE CLRED TO CROSS TO RWY 35. AS WE PROCEEDED WE DISCUSSED THE DEICING HOLD OVER TIME AND MADE AN ASSESSMENT OF THE CONDITIONS TO DETERMINE IF THE XH54 LCL HOLD OVER TIME WAS STILL A FACTOR. I SWITCHED TO RWY 35 TWR FREQ AND SHORTLY THEREAFTER I VISUALLY ACQUIRED THAT RWY. I DID NOT NOTICE RWY 32. AS WE APCHED THE HOLD SHORT LINE, I SAW 1-2 FT OF PLOWED SNOW ON THE END OF RWY 35 BUT NO ACCUMULATION ON THE RWY SURFACE, THUS VALIDATING MY TKOF OFF PERFORMANCE CALCULATIONS. BY USING THE WING LIGHT I COULD SEE THAT THERE WAS NO SNOW ON THE R WING. ABOUT THAT TIME WE WERE CLRED FOR TKOF ON RWY 35. THE 'BELOW THE LINE' CHKLIST WAS ACCOMPLISHED AND I VISUALLY CLRED THE APCH FOR ACFT. AT THE SAME TIME THE CAPT WAS ALIGNING THE ACFT AND ADVANCING PWR, SUBSEQUENTLY ASKING FOR TKOF THRUST. AFTER SETTING THE TKOF THRUST, I LOOKED OUTSIDE TO CHK OUR ALIGNMENT. THE CAPT WAS USING THE WINDSHIELD WIPERS TO CLEAR MELTING SNOW WHICH WAS CAUSING SOME GLARE AND VISIBILITY PROBS. MY PERCEPTION WAS THAT IN THE TIME THAT I READ THE CHKLIST, CLRED FOR ACFT ON FINAL, AND SET TKOF PWR, WE HAD TRAVELED ON TO RWY 35, MADE A 90 DEG TURN AND STARTED TRACKING THE RWY 35 CTRLINE. HOWEVER, IN ERROR WE HAD TURNED SLIGHTLY SHORT AND IN EXCESS OF 90 DEGS ONTO RWY 32. I MADE THE STANDARD CALL OUTS AN DIDN'T RECOGNIZE OUR MISTAKE UNTIL AFTER LOOKING OUTSIDE AT VR AND SEEING CONVERGENCE ON RWY 34. EARLIER IN THE TKOF ROLL AT ABOUT 100 KTS I KNEW SOMETHING WAS WRONG BY THE CAPT'S INCREASED ALERTNESS AND MUMBLED WORDS. APPARENTLY HE HAD NOTICED THE MISTAKE AFTER WE WERE COMMITTED TO CONTINUE. AFTER SAFELY AIRBORNE WITH THE GEAR RETRACTED WE MADE A TURN TO AVOID OVERFLT OF RWY 34. WE WERE LATER TOLD BY TWR OF THE ERROR AND CONTINUED TO LAS VEGAS. THE CONGRUENT NATURE OF THE APCH END OF RWY 32 AND 35, AND THE FACT THAT RWY 32 WAS NOTAM CLOSED BUT THE RWY LIGHTS REMAINED ON WERE SIGNIFICANT FACTORS. HUMAN FACTORS: IN MY OPINION THE FOLLOWING WERE CONTRIBUTING HUMAN FACTORS: UNFAMILIARITY WITH THE ARPT. OUR INITIAL MIND-SET WAS FOR A RWY 34 DEP AND WHEN SWITCHED TO RWY 35 WE LOOKED AT THE ARPT DIAGRAM TO SEE IF WE WERE TAXIING CORRECTLY. MENTALLY I DISCOUNTED RWY 32 AS A FACTOR BECAUSE I THOUGHT THAT ITS SIZE AND ORIENTATION WOULD MAKE EASILY DISTINGUISHABLE FROM RWY 35. NIGHT/WX OPS. THE INTENSIFYING FALLING SNOW PRESENTED SOME VISIBILITY AND DEPTH PERCEPTION PROBS. INITIALLY I SAW THE CORRECT RWY AND BELIEVED WE HAD TURNED ONTO IT WHILE I WAS READING THE CHKLIST AND SETTING TKOF PWR. IN RETROSPECT, I ACTUALLY GOT DISORIENTED DURING THAT TIME PERIOD AND SHOULD HAVE XCHKED THE ACFT HDG. CHANNELIZED ATTN. ALTHOUGH THERE WAS NO SIGNIFICANT ACCUMULATION OF SNOW ON THE GND OR ON THE ACFT, IT DID CAUSE US TO BRING THE DEICING CONSIDERATIONS INTO OUR PROCEDURAL FLOW PATTERN. THIS IS BECAUSE WE DIDN'T KNOW WHAT TO EXPECT UNTIL WE GOT TO THE END OF THE RWY. WHERE THE SNOW CAUSED A MAJOR PROB WAS ON LINE UP WHEN BOTH OF US GOT 'TUNNEL VISION' TRYING TO ALIGN THE ACFT WITH THE RWY CTRLINE OF THE WRONG RWY. COMS. THERE WAS A COMS BREAKDOWN AS WE WERE APCHING THE RWYS. EACH PLT HAD WHAT HE THOUGHT WAS COMPLETE AND ACCURATE INFO. HOWEVER, IN THE FINAL ANALYSIS OUR OVERALL SITUATIONAL AWARENESS WAS LESS THAN OPTIMAL AND WE SHOULD HAVE STOPPED TO CONFIRM THAT WE WERE PROCEEDING ONTO THE CORRECT RWY.
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.