Captain of a B737 failed to hold short of an active runway during taxi out as instructed. When he ob...

Attributes
ACN	461122
Time
Date	200001
Day	Sun
Local Time Of Day	1801 To 2400
Place
Locale Reference	airport : msy.airport
State Reference	LA
Altitude	agl single value : 0
Environment
Flight Conditions	VMC
Weather Elements	Rain
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	ground : taxi
Flight Plan	IFR
Aircraft 2
Controlling Facilities	tower : msy.tower
Operator	common carrier : air carrier
Make Model Name	Commercial Fixed Wing
Operating Under FAR Part	Part 121
Flight Phase	ground : takeoff roll
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : atp
Experience	flight time last 90 days : 280 flight time total : 13000 flight time type : 9000
ASRS Report	461122
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : atp
Experience	flight time last 90 days : 200 flight time total : 4800 flight time type : 767
ASRS Report	461297
Events
Anomaly	conflict : ground less severe incursion : runway non adherence : far non adherence : clearance
Independent Detector	other flight crewa other flight crewb
Resolutory Action	flight crew : took precautionary avoidance action other
Consequence	Other
Miss Distance	horizontal : 9000 vertical : 0
Supplementary
Problem Areas	Flight Crew Human Performance
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Departure ATIS at msy said 'departing runway 19.' while we were still in the chocks, we heard ground control offer runway 28 to another aircraft. Since that is a much shorter taxi for us, we did our preliminary takeoff data based on runway 28. After pushback, another aircraft asked for runway 28 and was denied. Thunderstorms had moved too close in that direction. So, I fully expected our taxi instruction to be 'taxi to runway 19.' when we called for taxi, sure enough, I heard 'taxi to runway 19.' at that point, I must have shut down my internal receiver, for there was an added phrase which I completely missed: 'hold short of runway 10.' the first officer heard and read back the hold short instruction (I missed it again), and he then began recalculating our takeoff data for runway 19. The recalculation caused the first officer to be head down during my approach to the hold short point. For my part, as soon as I 'heard' what I expected to hear, I switched my attention to 3 other things. As I taxied, I began turning the radar and formulating a WX escape plan. I simultaneously discussed with the first officer bleed air and flap configns for our heavy aircraft on a fairly short wet runway. I was also preparing a rough mental draft of a pre takeoff announcement to warn the passenger about the impending turbulence and to keep the flight attendants seated during the climb out. As I approached runway 10, I saw an aircraft in position at the other end. I assumed he was in position and hold, since I 'had' clearance to cross. To my horror, as I crossed, I saw the other aircraft start rolling. I added power and got quickly out of the way. In the past, I have always said aloud any hold short instruction just to reinforce it to myself. From now on, I will ask my first officer's to ensure I repeat the hold short instruction. Additionally, I will be much more sensitive to the problem of 'hearing what you expect to hear.'

Original NASA ASRS Text

Title: CAPT OF A B737 FAILED TO HOLD SHORT OF AN ACTIVE RWY DURING TAXI OUT AS INSTRUCTED. WHEN HE OBSERVED ANOTHER ACFT AT THE DEP END OF THE RWY HAD STARTED A TKOF ROLL, HE ACCELERATED CLRING THE RWY.

Narrative: DEP ATIS AT MSY SAID 'DEPARTING RWY 19.' WHILE WE WERE STILL IN THE CHOCKS, WE HEARD GND CTL OFFER RWY 28 TO ANOTHER ACFT. SINCE THAT IS A MUCH SHORTER TAXI FOR US, WE DID OUR PRELIMINARY TKOF DATA BASED ON RWY 28. AFTER PUSHBACK, ANOTHER ACFT ASKED FOR RWY 28 AND WAS DENIED. TSTMS HAD MOVED TOO CLOSE IN THAT DIRECTION. SO, I FULLY EXPECTED OUR TAXI INSTRUCTION TO BE 'TAXI TO RWY 19.' WHEN WE CALLED FOR TAXI, SURE ENOUGH, I HEARD 'TAXI TO RWY 19.' AT THAT POINT, I MUST HAVE SHUT DOWN MY INTERNAL RECEIVER, FOR THERE WAS AN ADDED PHRASE WHICH I COMPLETELY MISSED: 'HOLD SHORT OF RWY 10.' THE FO HEARD AND READ BACK THE HOLD SHORT INSTRUCTION (I MISSED IT AGAIN), AND HE THEN BEGAN RECALCULATING OUR TKOF DATA FOR RWY 19. THE RECALCULATION CAUSED THE FO TO BE HEAD DOWN DURING MY APCH TO THE HOLD SHORT POINT. FOR MY PART, AS SOON AS I 'HEARD' WHAT I EXPECTED TO HEAR, I SWITCHED MY ATTN TO 3 OTHER THINGS. AS I TAXIED, I BEGAN TURNING THE RADAR AND FORMULATING A WX ESCAPE PLAN. I SIMULTANEOUSLY DISCUSSED WITH THE FO BLEED AIR AND FLAP CONFIGNS FOR OUR HVY ACFT ON A FAIRLY SHORT WET RWY. I WAS ALSO PREPARING A ROUGH MENTAL DRAFT OF A PRE TKOF ANNOUNCEMENT TO WARN THE PAX ABOUT THE IMPENDING TURB AND TO KEEP THE FLT ATTENDANTS SEATED DURING THE CLBOUT. AS I APCHED RWY 10, I SAW AN ACFT IN POS AT THE OTHER END. I ASSUMED HE WAS IN POS AND HOLD, SINCE I 'HAD' CLRNC TO CROSS. TO MY HORROR, AS I CROSSED, I SAW THE OTHER ACFT START ROLLING. I ADDED PWR AND GOT QUICKLY OUT OF THE WAY. IN THE PAST, I HAVE ALWAYS SAID ALOUD ANY HOLD SHORT INSTRUCTION JUST TO REINFORCE IT TO MYSELF. FROM NOW ON, I WILL ASK MY FO'S TO ENSURE I REPEAT THE HOLD SHORT INSTRUCTION. ADDITIONALLY, I WILL BE MUCH MORE SENSITIVE TO THE PROB OF 'HEARING WHAT YOU EXPECT TO HEAR.'

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.

Captain of a B737 failed to hold short of an active runway during taxi out as instructed. When he observed another aircraft at the departure end of the runway had started a takeoff roll, he accelerated clearing the runway.