37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 337450 |
Time | |
Date | 199606 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : yum |
State Reference | AZ |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | general aviation : corporate |
Make Model Name | PA-28 Cherokee Arrow IV |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : takeoff |
Flight Plan | None |
Person 1 | |
Affiliation | Other |
Function | flight crew : single pilot |
Qualification | pilot : commercial pilot : cfi pilot : atp pilot : instrument |
Experience | flight time last 90 days : 60 flight time total : 3800 flight time type : 1 |
ASRS Report | 337450 |
Person 2 | |
Affiliation | government : faa |
Function | controller : local |
Qualification | controller : non radar |
Events | |
Anomaly | conflict : ground less severe incursion : runway non adherence : required legal separation 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 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After obtaining a duat WX briefing and accomplishing the required preflight actions to assure a safe and legal flight, I taxied from the FBO to runway 8, as instructed by ATC. I held short of runway 8 to accomplish the before takeoff checklist and engine runup. It took me a while longer than usual to accomplish these tasks because of my lack of familiarity with the aircraft's system, switch placement and procedures. The flight nurse that I was taking up to parker was sitting in the right seat next to me. I was using a headset and he was not. The flight nurse had flown in the aircraft before and was interested in flying. He was asking many questions during the whole process of me accomplishing the before takeoff checklist. I called the tower and advised him that I was ready for a northbound departure. The response from tower initially was to 'hold short of runway 8 for landing traffic.' a commuter airliner was landing on runway 26 (opposite direction). Once the airliner taxied clear of the runway, ATC gave the instruction, 'arrow nxxxx taxi into position and hold runway 8, traffic on final for runway 17.' while listening to the instruction from tower, my passenger began asking other questions, unaware of the radio transmission I had been listening to. I subsequently read back 'arrow nxxxx position and hold runway 8.' for some reason, I read back the clearance correctly, however, I did not adhere to it. I translated the clearance in my brain to read 'arrow nxxxx expedite departure for traffic landing runway 8.' I began my takeoff roll and accomplished a normal takeoff on runway 8, not realizing what I had done at that point. About 200 ft AGL on the upwind leg, yuma tower called me back in an urgent tone of voice and said 'arrow nxxxx you were told to position and hold runway 8, please get out a pen and copy down the following telephone number....' at that point I realized what I had done and apologized profusely over the radio. I took down the phone number and told yuma tower I would call them at my destination. I was mentally exhausted and weak in the knees after the 45 min flight to parker. Once on the ground I called the yuma tower supervisor as instructed and we discussed the incident. I learned that the separation between me and the aircraft landing on runway 17 (a crossing runway) was compromised. He stated that he would have to file a report on the incident. I discussed with him the following contributing factors and we agreed that it was a valuable learning experience for me. I have never done anything in aviation that stupid before and hopefully it will be the last time! I feel very fortunate that nothing worse happened that day. Contributing factors: my lack of experience in the specific aircraft was a large distraction. My lack of utilizing sterile cockpit procedures. My eagerness to answer questions regarding aircraft operation to an interested non pilot (the cockpit is a terrible classroom). My loss of situational awareness at the time of takeoff regarding the aircraft landing runway 17. Evidence of complacency in ATC readback/adherence due to not having received a 'position and hold' type of clearance for some time. The utilization of more than 1 active runway at a time at yum at the convenience of inbound traffic's direction of flight (everyone requests a straight-in when winds permit), and the confusion that can result because of it.
Original NASA ASRS Text
Title: THE RPTR TOOK OFF AFTER READING BACK HIS CLRNC TO TAXI INTO POS AND HOLD. THE RPTR HAD NOT BEEN GIVEN A CHKOUT IN THE ACFT.
Narrative: AFTER OBTAINING A DUAT WX BRIEFING AND ACCOMPLISHING THE REQUIRED PREFLT ACTIONS TO ASSURE A SAFE AND LEGAL FLT, I TAXIED FROM THE FBO TO RWY 8, AS INSTRUCTED BY ATC. I HELD SHORT OF RWY 8 TO ACCOMPLISH THE BEFORE TKOF CHKLIST AND ENG RUNUP. IT TOOK ME A WHILE LONGER THAN USUAL TO ACCOMPLISH THESE TASKS BECAUSE OF MY LACK OF FAMILIARITY WITH THE ACFT'S SYS, SWITCH PLACEMENT AND PROCS. THE FLT NURSE THAT I WAS TAKING UP TO PARKER WAS SITTING IN THE R SEAT NEXT TO ME. I WAS USING A HEADSET AND HE WAS NOT. THE FLT NURSE HAD FLOWN IN THE ACFT BEFORE AND WAS INTERESTED IN FLYING. HE WAS ASKING MANY QUESTIONS DURING THE WHOLE PROCESS OF ME ACCOMPLISHING THE BEFORE TKOF CHKLIST. I CALLED THE TWR AND ADVISED HIM THAT I WAS READY FOR A NBOUND DEP. THE RESPONSE FROM TWR INITIALLY WAS TO 'HOLD SHORT OF RWY 8 FOR LNDG TFC.' A COMMUTER AIRLINER WAS LNDG ON RWY 26 (OPPOSITE DIRECTION). ONCE THE AIRLINER TAXIED CLR OF THE RWY, ATC GAVE THE INSTRUCTION, 'ARROW NXXXX TAXI INTO POS AND HOLD RWY 8, TFC ON FINAL FOR RWY 17.' WHILE LISTENING TO THE INSTRUCTION FROM TWR, MY PAX BEGAN ASKING OTHER QUESTIONS, UNAWARE OF THE RADIO XMISSION I HAD BEEN LISTENING TO. I SUBSEQUENTLY READ BACK 'ARROW NXXXX POS AND HOLD RWY 8.' FOR SOME REASON, I READ BACK THE CLRNC CORRECTLY, HOWEVER, I DID NOT ADHERE TO IT. I TRANSLATED THE CLRNC IN MY BRAIN TO READ 'ARROW NXXXX EXPEDITE DEP FOR TFC LNDG RWY 8.' I BEGAN MY TKOF ROLL AND ACCOMPLISHED A NORMAL TKOF ON RWY 8, NOT REALIZING WHAT I HAD DONE AT THAT POINT. ABOUT 200 FT AGL ON THE UPWIND LEG, YUMA TWR CALLED ME BACK IN AN URGENT TONE OF VOICE AND SAID 'ARROW NXXXX YOU WERE TOLD TO POS AND HOLD RWY 8, PLEASE GET OUT A PEN AND COPY DOWN THE FOLLOWING TELEPHONE NUMBER....' AT THAT POINT I REALIZED WHAT I HAD DONE AND APOLOGIZED PROFUSELY OVER THE RADIO. I TOOK DOWN THE PHONE NUMBER AND TOLD YUMA TWR I WOULD CALL THEM AT MY DEST. I WAS MENTALLY EXHAUSTED AND WEAK IN THE KNEES AFTER THE 45 MIN FLT TO PARKER. ONCE ON THE GND I CALLED THE YUMA TWR SUPVR AS INSTRUCTED AND WE DISCUSSED THE INCIDENT. I LEARNED THAT THE SEPARATION BTWN ME AND THE ACFT LNDG ON RWY 17 (A XING RWY) WAS COMPROMISED. HE STATED THAT HE WOULD HAVE TO FILE A RPT ON THE INCIDENT. I DISCUSSED WITH HIM THE FOLLOWING CONTRIBUTING FACTORS AND WE AGREED THAT IT WAS A VALUABLE LEARNING EXPERIENCE FOR ME. I HAVE NEVER DONE ANYTHING IN AVIATION THAT STUPID BEFORE AND HOPEFULLY IT WILL BE THE LAST TIME! I FEEL VERY FORTUNATE THAT NOTHING WORSE HAPPENED THAT DAY. CONTRIBUTING FACTORS: MY LACK OF EXPERIENCE IN THE SPECIFIC ACFT WAS A LARGE DISTR. MY LACK OF UTILIZING STERILE COCKPIT PROCS. MY EAGERNESS TO ANSWER QUESTIONS REGARDING ACFT OP TO AN INTERESTED NON PLT (THE COCKPIT IS A TERRIBLE CLASSROOM). MY LOSS OF SITUATIONAL AWARENESS AT THE TIME OF TKOF REGARDING THE ACFT LNDG RWY 17. EVIDENCE OF COMPLACENCY IN ATC READBACK/ADHERENCE DUE TO NOT HAVING RECEIVED A 'POS AND HOLD' TYPE OF CLRNC FOR SOME TIME. THE UTILIZATION OF MORE THAN 1 ACTIVE RWY AT A TIME AT YUM AT THE CONVENIENCE OF INBOUND TFC'S DIRECTION OF FLT (EVERYONE REQUESTS A STRAIGHT-IN WHEN WINDS PERMIT), AND THE CONFUSION THAT CAN RESULT BECAUSE OF IT.
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.