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|
Attributes | |
ACN | 372046 |
Time | |
Date | 199706 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sea |
State Reference | WA |
Altitude | agl bound lower : 0 agl bound upper : 50 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : sea tower : bos |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff ground : holding ground other : taxi |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | ground : holding ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : atp pilot : instrument |
Experience | flight time last 90 days : 100 flight time total : 8000 flight time type : 400 |
ASRS Report | 372046 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 160 flight time total : 12000 flight time type : 500 |
ASRS Report | 371753 |
Events | |
Anomaly | conflict : ground critical non adherence : far non adherence : clearance non adherence : published procedure other anomaly other other anomaly other |
Independent Detector | other controllera other other : unspecified |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : investigated Other |
Miss Distance | horizontal : 20 vertical : 50 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
On jun/xa/97 I, as captain, along with first officer, operated flight sea to jfk. All phases of the departure were normal: passenger loading, preflts and checklists, door closing, pushback and taxi. As with the 3 previous legs, there existed an excellent rapport and attention to professional responsibilities in the cockpit. As we taxied down the taxiway parallel to runway 16L, an air carrier DC10 was sitting in the runup block. We wondered if there were departure delays, where we were in the queue, etc. As we approached the turn toward the runway, the first officer dialed in the tower frequency. Tower immediately came on with a clearance for us. Based on reports of the tower tapes, that clearance apparently was to line up on the runway. We were now moved from taxiing as #2, to '#1 and ready to go.' as we transitioned into the 2 left turns, first officer said, 'I'll get the cabin PA,' while I hit the strobes, landing lights, and called for the takeoff checklist. It was a very smooth and professional process. First officer was operating the aircraft, steering on the runway, with throttle control in the air. No comments came from the tower. After liftoff, tower said she didn't believe we had been given takeoff clearance. She then cleared us to departure frequency. Somewhat stunned, I responded we were changing over, with no comment as to her allegation into the interphone. I then selected VHF and switched to departure. My recollection of the takeoff is one of smoothness and order. There was the surprise when we were jumped from taxi mode to flight mode. I suppose my mind jumped from 'taxi-slow' to 'here we go.' I cannot recall repeating to first officer the position and hold directive. Perhaps he seamlessly responded to that clearance on the radio, and immediately went to the cabin PA notification. If so, this would have blocked my normal re-readback time, and in keeping with the takeoff flow of events, I moved on to other chores. I took off believing we were so cleared. Callback conversation with reporter revealed the following information: the captain reporter stated that he was certain that takeoff clearance had been issued but cannot recall hearing the phrase 'cleared for takeoff.' this was his first time into sea in yrs, first time as a captain. The tower had said, '...taxi into position and hold.' the first officer read back, '...position and hold....' note: the tower failed to advise the B757 crew that there was going to be crossing traffic down runway from them. Captain said that if that had occurred, it would have 'broken the error chain.' (he said that it was a calm, quiet day and little or no traffic movement that is usually associated with a busy airport.) captain also felt that the first officer preempted his thought pattern when he went right into the role of advising the flight attendants to be seated. It was normally the PIC's role to ask for that while addressing their clearance status. From that point the captain was thinking 'takeoff' as he went through his motions. This feeling was also enforced by their bypassing the holding DC10 and becoming #1 for takeoff position. Perhaps the first officer's use of the microphone gave further weight to the feeling of 'going' not realizing that the microphone was for the PA announcement, not ATC. The captain did not remember coordination with the first officer by stating, 'cleared for takeoff.' the captain did not communicate with anyone, and was using the yoke switch and a boom microphone. Once airborne, when told of their violation and given a frequency change, the captain transmitted the response but it was on interphone. He had never switched his selector from ground crew communication/interphone back to VHF radio #1 position. As a result, the tower never heard anything from him as he simply switched frequencys to departure control after learning of his selector switch error. He and the first officer received line checks as a result of this. The FAA advised that they are pursuing a violation. The union is handling his response to that. Supplemental information from acn 371753: the captain remarked about who would be next for takeoff because the DC10 appeared to be holding for departure. I said I will ask, as I made the switch from ground to tower frequency. Immediately after the switch was made, clearance was received from sea tower to move into position and hold on runway 16L. I immediately responded with a readback of the clearance. The captain responded with, 'cleared into position to hold, it looks like we're going, before takeoff checklist.' I said, 'I'll set them down,' selected PA on the interphone panel, turned the volume full up, and used the hand microphone to alert the flight attendants to take their seats. This was done because during the previous flight, the fsm said the PA's from the cockpit were difficult to hear. While doing this, I thought I saw the captain respond to a radio transmission and assumed it was with sea tower. The aircraft approached the centerline of runway 16L and the throttles were moving forward. At this time, the captain said, 'your steering,' and I took control of the aircraft, with the exception of the throttles. I believe that I had assumed, in the back of my mind, that we had received takeoff clearance while making the PA announcement. The progression of events were consistent with that assumption. Consequently, I did not question the captain's actions. I know that I should never assume anything and should always question a clearance that I have not personally heard. Supplemental information from acn 371234: landed sea runway 16R ILS, took high speed. Cleared across runway 16L, follow DC10 on other side. B757 in position runway 16L. My captain, air carrier Y, was already across hold bars, but not on runway 16L pavement. He saw air carrier X had lights on, and air carrier X took off. Tower then told air carrier X they had taken off without a clearance. Neither tower nor us told air carrier X to hold.
Original NASA ASRS Text
Title: ACR B757 PERFORMS AN UNAUTH TKOF AT SEA ARPT. ACFT HAD BEEN CLRED INTO POS AND HOLD BUT PIC ASSUMED THAT TKOF CLRNC HAD BEEN ISSUED. TWR CALLS FLT AFTER AIRBORNE TO ADVISE THEM OF THE DEV. ACR Y, AN MD80 CLRED TO CROSS THE RWY, STOPPED SHORT OF RWY 16L OVER THE HOLD LINE TO AVOID THE B757 ON THE ROLL.
Narrative: ON JUN/XA/97 I, AS CAPT, ALONG WITH FO, OPERATED FLT SEA TO JFK. ALL PHASES OF THE DEP WERE NORMAL: PAX LOADING, PREFLTS AND CHKLISTS, DOOR CLOSING, PUSHBACK AND TAXI. AS WITH THE 3 PREVIOUS LEGS, THERE EXISTED AN EXCELLENT RAPPORT AND ATTN TO PROFESSIONAL RESPONSIBILITIES IN THE COCKPIT. AS WE TAXIED DOWN THE TXWY PARALLEL TO RWY 16L, AN ACR DC10 WAS SITTING IN THE RUNUP BLOCK. WE WONDERED IF THERE WERE DEP DELAYS, WHERE WE WERE IN THE QUEUE, ETC. AS WE APCHED THE TURN TOWARD THE RWY, THE FO DIALED IN THE TWR FREQ. TWR IMMEDIATELY CAME ON WITH A CLRNC FOR US. BASED ON RPTS OF THE TWR TAPES, THAT CLRNC APPARENTLY WAS TO LINE UP ON THE RWY. WE WERE NOW MOVED FROM TAXIING AS #2, TO '#1 AND READY TO GO.' AS WE TRANSITIONED INTO THE 2 L TURNS, FO SAID, 'I'LL GET THE CABIN PA,' WHILE I HIT THE STROBES, LNDG LIGHTS, AND CALLED FOR THE TKOF CHKLIST. IT WAS A VERY SMOOTH AND PROFESSIONAL PROCESS. FO WAS OPERATING THE ACFT, STEERING ON THE RWY, WITH THROTTLE CTL IN THE AIR. NO COMMENTS CAME FROM THE TWR. AFTER LIFTOFF, TWR SAID SHE DIDN'T BELIEVE WE HAD BEEN GIVEN TKOF CLRNC. SHE THEN CLRED US TO DEP FREQ. SOMEWHAT STUNNED, I RESPONDED WE WERE CHANGING OVER, WITH NO COMMENT AS TO HER ALLEGATION INTO THE INTERPHONE. I THEN SELECTED VHF AND SWITCHED TO DEP. MY RECOLLECTION OF THE TKOF IS ONE OF SMOOTHNESS AND ORDER. THERE WAS THE SURPRISE WHEN WE WERE JUMPED FROM TAXI MODE TO FLT MODE. I SUPPOSE MY MIND JUMPED FROM 'TAXI-SLOW' TO 'HERE WE GO.' I CANNOT RECALL REPEATING TO FO THE POS AND HOLD DIRECTIVE. PERHAPS HE SEAMLESSLY RESPONDED TO THAT CLRNC ON THE RADIO, AND IMMEDIATELY WENT TO THE CABIN PA NOTIFICATION. IF SO, THIS WOULD HAVE BLOCKED MY NORMAL RE-READBACK TIME, AND IN KEEPING WITH THE TKOF FLOW OF EVENTS, I MOVED ON TO OTHER CHORES. I TOOK OFF BELIEVING WE WERE SO CLRED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CAPT RPTR STATED THAT HE WAS CERTAIN THAT TKOF CLRNC HAD BEEN ISSUED BUT CANNOT RECALL HEARING THE PHRASE 'CLRED FOR TKOF.' THIS WAS HIS FIRST TIME INTO SEA IN YRS, FIRST TIME AS A CAPT. THE TWR HAD SAID, '...TAXI INTO POS AND HOLD.' THE FO READ BACK, '...POS AND HOLD....' NOTE: THE TWR FAILED TO ADVISE THE B757 CREW THAT THERE WAS GOING TO BE XING TFC DOWN RWY FROM THEM. CAPT SAID THAT IF THAT HAD OCCURRED, IT WOULD HAVE 'BROKEN THE ERROR CHAIN.' (HE SAID THAT IT WAS A CALM, QUIET DAY AND LITTLE OR NO TFC MOVEMENT THAT IS USUALLY ASSOCIATED WITH A BUSY ARPT.) CAPT ALSO FELT THAT THE FO PREEMPTED HIS THOUGHT PATTERN WHEN HE WENT RIGHT INTO THE ROLE OF ADVISING THE FLT ATTENDANTS TO BE SEATED. IT WAS NORMALLY THE PIC'S ROLE TO ASK FOR THAT WHILE ADDRESSING THEIR CLRNC STATUS. FROM THAT POINT THE CAPT WAS THINKING 'TKOF' AS HE WENT THROUGH HIS MOTIONS. THIS FEELING WAS ALSO ENFORCED BY THEIR BYPASSING THE HOLDING DC10 AND BECOMING #1 FOR TKOF POS. PERHAPS THE FO'S USE OF THE MIKE GAVE FURTHER WT TO THE FEELING OF 'GOING' NOT REALIZING THAT THE MIKE WAS FOR THE PA ANNOUNCEMENT, NOT ATC. THE CAPT DID NOT REMEMBER COORD WITH THE FO BY STATING, 'CLRED FOR TKOF.' THE CAPT DID NOT COMMUNICATE WITH ANYONE, AND WAS USING THE YOKE SWITCH AND A BOOM MIKE. ONCE AIRBORNE, WHEN TOLD OF THEIR VIOLATION AND GIVEN A FREQ CHANGE, THE CAPT XMITTED THE RESPONSE BUT IT WAS ON INTERPHONE. HE HAD NEVER SWITCHED HIS SELECTOR FROM GND CREW COM/INTERPHONE BACK TO VHF RADIO #1 POS. AS A RESULT, THE TWR NEVER HEARD ANYTHING FROM HIM AS HE SIMPLY SWITCHED FREQS TO DEP CTL AFTER LEARNING OF HIS SELECTOR SWITCH ERROR. HE AND THE FO RECEIVED LINE CHKS AS A RESULT OF THIS. THE FAA ADVISED THAT THEY ARE PURSUING A VIOLATION. THE UNION IS HANDLING HIS RESPONSE TO THAT. SUPPLEMENTAL INFO FROM ACN 371753: THE CAPT REMARKED ABOUT WHO WOULD BE NEXT FOR TKOF BECAUSE THE DC10 APPEARED TO BE HOLDING FOR DEP. I SAID I WILL ASK, AS I MADE THE SWITCH FROM GND TO TWR FREQ. IMMEDIATELY AFTER THE SWITCH WAS MADE, CLRNC WAS RECEIVED FROM SEA TWR TO MOVE INTO POS AND HOLD ON RWY 16L. I IMMEDIATELY RESPONDED WITH A READBACK OF THE CLRNC. THE CAPT RESPONDED WITH, 'CLRED INTO POS TO HOLD, IT LOOKS LIKE WE'RE GOING, BEFORE TKOF CHKLIST.' I SAID, 'I'LL SET THEM DOWN,' SELECTED PA ON THE INTERPHONE PANEL, TURNED THE VOLUME FULL UP, AND USED THE HAND MIKE TO ALERT THE FLT ATTENDANTS TO TAKE THEIR SEATS. THIS WAS DONE BECAUSE DURING THE PREVIOUS FLT, THE FSM SAID THE PA'S FROM THE COCKPIT WERE DIFFICULT TO HEAR. WHILE DOING THIS, I THOUGHT I SAW THE CAPT RESPOND TO A RADIO XMISSION AND ASSUMED IT WAS WITH SEA TWR. THE ACFT APCHED THE CTRLINE OF RWY 16L AND THE THROTTLES WERE MOVING FORWARD. AT THIS TIME, THE CAPT SAID, 'YOUR STEERING,' AND I TOOK CTL OF THE ACFT, WITH THE EXCEPTION OF THE THROTTLES. I BELIEVE THAT I HAD ASSUMED, IN THE BACK OF MY MIND, THAT WE HAD RECEIVED TKOF CLRNC WHILE MAKING THE PA ANNOUNCEMENT. THE PROGRESSION OF EVENTS WERE CONSISTENT WITH THAT ASSUMPTION. CONSEQUENTLY, I DID NOT QUESTION THE CAPT'S ACTIONS. I KNOW THAT I SHOULD NEVER ASSUME ANYTHING AND SHOULD ALWAYS QUESTION A CLRNC THAT I HAVE NOT PERSONALLY HEARD. SUPPLEMENTAL INFO FROM ACN 371234: LANDED SEA RWY 16R ILS, TOOK HIGH SPD. CLRED ACROSS RWY 16L, FOLLOW DC10 ON OTHER SIDE. B757 IN POS RWY 16L. MY CAPT, ACR Y, WAS ALREADY ACROSS HOLD BARS, BUT NOT ON RWY 16L PAVEMENT. HE SAW ACR X HAD LIGHTS ON, AND ACR X TOOK OFF. TWR THEN TOLD ACR X THEY HAD TAKEN OFF WITHOUT A CLRNC. NEITHER TWR NOR US TOLD ACR X TO HOLD.
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.