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|
Attributes | |
ACN | 348541 |
Time | |
Date | 199609 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sna |
State Reference | CA |
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 | MD-90 Series (DC-9-90) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | ground other : taxi |
Flight Plan | IFR |
Aircraft 2 | |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, High Wing, 1 Eng, Fixed Gear |
Flight Phase | landing : go around |
Flight Plan | None |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial |
Experience | flight time last 90 days : 175 flight time total : 6500 flight time type : 500 |
ASRS Report | 348541 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 150 flight time total : 11000 flight time type : 3000 |
ASRS Report | 348540 |
Events | |
Anomaly | aircraft equipment problem : less severe conflict : ground critical incursion : runway non adherence : far non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact other |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 0 vertical : 550 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We had pushed back from gate at sna. After engine start, we had 2 slat abnormals that took several mins to resolve using checklist procedures. While we were in the process of addressing the slat problems, ground was asking us how long it would be before we were ready to taxi. We replied that we had a problem and needed a few mins. At that time we were nose to nose with 2 inbound aircraft and ground needed us to move to allow them to park. We resolved our slat problem and notified ground that we could taxi. They advised us to contact tower and tower instructed us to turn right on taxiway left and hold short of runway 19L. I began the taxi check and made our 'noise abatement' PA to the passenger. I realized too late that we were halfway across runway 19L. Tower sent a cessna on final to runway 19L around and we hurried across and held short of runway 19R. Human performance considerations: obviously, we were at fault and the mistake was serious. Contributing factors: 1) due to the short runway at sna and our takeoff weight, we had been issued a non standard takeoff flap setting in our weight and balance paperwork. When lowering the flaps/slats we had 2 abnormals that demanded attention. 2) the txwys and gate areas at sna are very confined and we were the source of inbound delays. Ground control wanted us out as soon as possible. 3) total distance from the gate to takeoff position is approximately 100 yds so things happen fast. In addition to standard pushback/start, after start, taxi and before takeoff checklist, a PA is suggested to inform the passenger about the steep climb out and power reduction on departure. 4) the captain was accustomed to hearing, 'turn right on taxiway left and hold short of runway 19R.' although he heard the proper instructions, he was expecting to hear something else. 5) I failed to back him up since I was involved in other duties. Conclusion: we telephoned sna tower after landing at slc and apologized. They said not to worry, they were not issuing a violation. The lessons learned from this incident will be remembered for the rest of my career.
Original NASA ASRS Text
Title: MD90 IN GATE ALLEYWAY HAVING PROB WITH SLATS. BLOCKING ENTRY TO GATE FOR OTHER ACFT. SLAT PROB RESOLVED AND ACFT CLRED TO HOLD SHORT RWY 19L. DOING CHKLIST AND PA ANNOUNCEMENT, CAPT FAILED TO HOLD SHORT OF RWY 19L. CESSNA ON APCH HAD TO GAR.
Narrative: WE HAD PUSHED BACK FROM GATE AT SNA. AFTER ENG START, WE HAD 2 SLAT ABNORMALS THAT TOOK SEVERAL MINS TO RESOLVE USING CHKLIST PROCS. WHILE WE WERE IN THE PROCESS OF ADDRESSING THE SLAT PROBS, GND WAS ASKING US HOW LONG IT WOULD BE BEFORE WE WERE READY TO TAXI. WE REPLIED THAT WE HAD A PROB AND NEEDED A FEW MINS. AT THAT TIME WE WERE NOSE TO NOSE WITH 2 INBOUND ACFT AND GND NEEDED US TO MOVE TO ALLOW THEM TO PARK. WE RESOLVED OUR SLAT PROB AND NOTIFIED GND THAT WE COULD TAXI. THEY ADVISED US TO CONTACT TWR AND TWR INSTRUCTED US TO TURN R ON TXWY L AND HOLD SHORT OF RWY 19L. I BEGAN THE TAXI CHK AND MADE OUR 'NOISE ABATEMENT' PA TO THE PAX. I REALIZED TOO LATE THAT WE WERE HALFWAY ACROSS RWY 19L. TWR SENT A CESSNA ON FINAL TO RWY 19L AROUND AND WE HURRIED ACROSS AND HELD SHORT OF RWY 19R. HUMAN PERFORMANCE CONSIDERATIONS: OBVIOUSLY, WE WERE AT FAULT AND THE MISTAKE WAS SERIOUS. CONTRIBUTING FACTORS: 1) DUE TO THE SHORT RWY AT SNA AND OUR TKOF WT, WE HAD BEEN ISSUED A NON STANDARD TKOF FLAP SETTING IN OUR WT AND BAL PAPERWORK. WHEN LOWERING THE FLAPS/SLATS WE HAD 2 ABNORMALS THAT DEMANDED ATTN. 2) THE TXWYS AND GATE AREAS AT SNA ARE VERY CONFINED AND WE WERE THE SOURCE OF INBOUND DELAYS. GND CTL WANTED US OUT ASAP. 3) TOTAL DISTANCE FROM THE GATE TO TKOF POS IS APPROX 100 YDS SO THINGS HAPPEN FAST. IN ADDITION TO STANDARD PUSHBACK/START, AFTER START, TAXI AND BEFORE TKOF CHKLIST, A PA IS SUGGESTED TO INFORM THE PAX ABOUT THE STEEP CLB OUT AND PWR REDUCTION ON DEP. 4) THE CAPT WAS ACCUSTOMED TO HEARING, 'TURN R ON TXWY L AND HOLD SHORT OF RWY 19R.' ALTHOUGH HE HEARD THE PROPER INSTRUCTIONS, HE WAS EXPECTING TO HEAR SOMETHING ELSE. 5) I FAILED TO BACK HIM UP SINCE I WAS INVOLVED IN OTHER DUTIES. CONCLUSION: WE TELEPHONED SNA TWR AFTER LNDG AT SLC AND APOLOGIZED. THEY SAID NOT TO WORRY, THEY WERE NOT ISSUING A VIOLATION. THE LESSONS LEARNED FROM THIS INCIDENT WILL BE REMEMBERED FOR THE REST OF MY CAREER.
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.