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|
Attributes | |
ACN | 293140 |
Time | |
Date | 199501 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : mia |
State Reference | FL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | Marginal |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Beech 1900 |
Operating Under FAR Part | Part 135 |
Flight Phase | climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 2600 flight time type : 350 |
ASRS Report | 293140 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | non adherence : clearance non adherence : far other anomaly other |
Independent Detector | other controllera |
Resolutory Action | other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While taxiing to runway 9L on taxiway P, tower advised us of sequence at the pad (the only other aircraft on txwys at this time). We were cleared 'into position and hold' on runway 12. We advised him we could take the intersection which he approved. As I turned to taxi toward runway 12, tower cleared me to takeoff, at which I immediately worked through checklist and hurriedly took it on a roll. As I turned aircraft to line up I fixated on centerline lights and began rolling. As we were approaching about 90 KTS tower canceled takeoff clearance and immediately both myself and the first officer realized that we were on the taxiway paralleling taxiway P and runway 12. We aborted and brought the aircraft to stop with no incident. Tower asked us if we saw the problem. We affirmed and he told us to contact ground. Ground told us to make a 180 degree turn on taxiway Q (the taxiway we had been on) and taxi to runway 12. She gave us a number to phone tower at destination. We contacted tower and departed without incident. Upon reaching destination, I phoned tower, who advised me that what he observed was he cleared me for takeoff, I lined up on parallel taxiway, began a high speed taxi, he canceled my takeoff clearance, we slowed/stopped and we taxied back down taxiway Q for takeoff on runway 12. Factors contributing to such a gross error were: 1) I was/had been sick with cold/congestion/fever possibly for 4 days. 2) we had both been on duty for over 10 hours. 3) we had been flying the past 3-4 flts in hard IFR logging 3 hours actual with no autoplt. 4) both of us were at 30 hours flight time in 4 days. 5) due to late flts all day because of WX, we were being rushed by station's people at every stop. 6) neither of us had had time to eat since very early morning nor to drink fluids. 7) WX in miami was marginal, very dark, not great visibility. 8) the copilot is relatively low time who came to the airline through a program where first officer's are not paid but pay for X number of hours in the aircraft. The training program is minimal at best. Check rides are done in-house. 9) this leg was our 7TH leg of the day, and my 28TH leg in 4 days. More standardization in policy and procedure and training could have helped prevent this. My slowing down and not trying to succumb to schedule and a hard look at far 135 scheduling and duty time/flight time limitations could also prevent future mistakes which are a result of just pure exhaustion and perhaps lack of concentration due to fatigue. This airport is home for me and I still cannot understand how it happened and I just realize the potential danger that could have been.
Original NASA ASRS Text
Title: ATTEMPTED TKOF ON TXWY.
Narrative: WHILE TAXIING TO RWY 9L ON TXWY P, TWR ADVISED US OF SEQUENCE AT THE PAD (THE ONLY OTHER ACFT ON TXWYS AT THIS TIME). WE WERE CLRED 'INTO POS AND HOLD' ON RWY 12. WE ADVISED HIM WE COULD TAKE THE INTXN WHICH HE APPROVED. AS I TURNED TO TAXI TOWARD RWY 12, TWR CLRED ME TO TKOF, AT WHICH I IMMEDIATELY WORKED THROUGH CHKLIST AND HURRIEDLY TOOK IT ON A ROLL. AS I TURNED ACFT TO LINE UP I FIXATED ON CTRLINE LIGHTS AND BEGAN ROLLING. AS WE WERE APCHING ABOUT 90 KTS TWR CANCELED TKOF CLRNC AND IMMEDIATELY BOTH MYSELF AND THE FO REALIZED THAT WE WERE ON THE TXWY PARALLELING TXWY P AND RWY 12. WE ABORTED AND BROUGHT THE ACFT TO STOP WITH NO INCIDENT. TWR ASKED US IF WE SAW THE PROB. WE AFFIRMED AND HE TOLD US TO CONTACT GND. GND TOLD US TO MAKE A 180 DEG TURN ON TXWY Q (THE TXWY WE HAD BEEN ON) AND TAXI TO RWY 12. SHE GAVE US A NUMBER TO PHONE TWR AT DEST. WE CONTACTED TWR AND DEPARTED WITHOUT INCIDENT. UPON REACHING DEST, I PHONED TWR, WHO ADVISED ME THAT WHAT HE OBSERVED WAS HE CLRED ME FOR TKOF, I LINED UP ON PARALLEL TXWY, BEGAN A HIGH SPD TAXI, HE CANCELED MY TKOF CLRNC, WE SLOWED/STOPPED AND WE TAXIED BACK DOWN TXWY Q FOR TKOF ON RWY 12. FACTORS CONTRIBUTING TO SUCH A GROSS ERROR WERE: 1) I WAS/HAD BEEN SICK WITH COLD/CONGESTION/FEVER POSSIBLY FOR 4 DAYS. 2) WE HAD BOTH BEEN ON DUTY FOR OVER 10 HRS. 3) WE HAD BEEN FLYING THE PAST 3-4 FLTS IN HARD IFR LOGGING 3 HRS ACTUAL WITH NO AUTOPLT. 4) BOTH OF US WERE AT 30 HRS FLT TIME IN 4 DAYS. 5) DUE TO LATE FLTS ALL DAY BECAUSE OF WX, WE WERE BEING RUSHED BY STATION'S PEOPLE AT EVERY STOP. 6) NEITHER OF US HAD HAD TIME TO EAT SINCE VERY EARLY MORNING NOR TO DRINK FLUIDS. 7) WX IN MIAMI WAS MARGINAL, VERY DARK, NOT GREAT VISIBILITY. 8) THE COPLT IS RELATIVELY LOW TIME WHO CAME TO THE AIRLINE THROUGH A PROGRAM WHERE FO'S ARE NOT PAID BUT PAY FOR X NUMBER OF HRS IN THE ACFT. THE TRAINING PROGRAM IS MINIMAL AT BEST. CHK RIDES ARE DONE IN-HOUSE. 9) THIS LEG WAS OUR 7TH LEG OF THE DAY, AND MY 28TH LEG IN 4 DAYS. MORE STANDARDIZATION IN POLICY AND PROC AND TRAINING COULD HAVE HELPED PREVENT THIS. MY SLOWING DOWN AND NOT TRYING TO SUCCUMB TO SCHEDULE AND A HARD LOOK AT FAR 135 SCHEDULING AND DUTY TIME/FLT TIME LIMITATIONS COULD ALSO PREVENT FUTURE MISTAKES WHICH ARE A RESULT OF JUST PURE EXHAUSTION AND PERHAPS LACK OF CONCENTRATION DUE TO FATIGUE. THIS ARPT IS HOME FOR ME AND I STILL CANNOT UNDERSTAND HOW IT HAPPENED AND I JUST REALIZE THE POTENTIAL DANGER THAT COULD HAVE BEEN.
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.