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|
Attributes | |
ACN | 469940 |
Time | |
Date | 200004 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : hou.airport |
State Reference | TX |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : hou&.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : hou&.tower |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport |
Operating Under FAR Part | Part 121 |
Flight Phase | landing other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 4100 flight time type : 1100 |
ASRS Report | 469940 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | incursion : runway non adherence : clearance non adherence : published procedure non adherence : far |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : executed go around |
Supplementary | |
Problem Areas | ATC Human Performance Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were 8 mins late pushing back from the gate. When I called for taxi, ground cleared us to taxi to runway 12R via taxiway east and hold short of runway 12L. While we were doing our pre takeoff checklist, the captain called on ground frequency to switch to tower frequency. After being queried twice, the ground controller sent us over to tower frequency. The tower controller was very busy, but with no hesitation issued us clearance to taxi to runway 12R. I read back the clearance and the captain asked me for the 'below the line checklist.' this was a bit unusual since we normally wait until we are cleared into position and hold or cleared for takeoff, before we accomplish this final part of the checklist. But since we had such a short taxi to the active runway, I assumed that the captain wanted to give our flight attendants as much time as possible to get the cabin ready for takeoff. I completed my flow and began to read the 'below the line checklist' to the captain and as I was reading it to him, he continued to taxi. At this point, we were approaching the hold short line at runway 12R at a brisk taxi speed. I noticed that we did not start decelerating to hold short of runway 12R. I was trying to sort out, in my head, whether I had missed a radio call or whether the captain was not complying with our clearance. My normal habit pattern when we enter an active runway is to clear the approach sector for other aircraft. When I did this, I saw an aircraft on approximately 2 1/2 mi final. I told my captain about the aircraft and the fact that I was unsure of our clearance onto the runway. By this time we were on the active runway with most part of the aircraft and were beginning to decelerate. Without hesitation the captain radioed tower and was told that we had not been cleared onto the runway, to exit runway 12R and taxi onto runway 17, turn left on runway 17, and to hold short of runway 12R. The controller sent the aircraft on final around and we immediately exited runway 12R according to the controller's instructions. After 2 additional arrs we were cleared for takeoff and proceeded uneventfully to dallas love. I believe there are 5 contributing factors to this occurrence: 1) we left the gate 8 mins late, which caused an unnecessary urgency to make up for lost time. 2) the very short taxi distance from our gate to the active runway combined with the above-mentioned urgency left no room for error or doublechking the other crew member's actions. 3) an unexpected radio call. When we switched to tower frequency, we were expecting what we normally hear, which is 'cross runway 12L on taxiway east and hold short of runway 12R.' the tower actually said 'taxi to runway 12R,' which does imply to hold short of the runway. I believe that because the captain did not hear what he expected 'cross runway 12L on taxiway east and hold short of runway 12R,' but instead heard 'taxi to runway 12R' that he perceived that as clearance onto runway 12R, which was not correct. 4) tower frequency was very congested and the controller was issuing clrncs at a very fast pace. 5) a lot of things were happening in a very small amount of time, which resulted in a high workload for the flight crew. These are just some of the lessons that I have learned from this event: 1) slow down and give the other crew member a chance to catch up so that there is time for him to voice his concerns before it is too late to stop. 2) do not get complacent just because you have been at an airport many times and think you know what clearance to expect next. 3) be extra vigilant during times of frequency congestion, short taxi rtes and around runways that are in close proximity to each other (houston hobby runway 12R, runway 12L, runway 17). 4) rely on your established habit patterns. Xchking the final approach sector probably helped to prevent this situation from developing into a possible accident. 5) do not hesitate to speak up immediately, if you are unsure of a clearance or unsure of the other crew member's understanding of a clearance.
Original NASA ASRS Text
Title: ACR CREW ENTERS RWY AT HOU, TX, WITHOUT CLRNC CAUSING ANOTHER ACFT TO GO AROUND.
Narrative: WE WERE 8 MINS LATE PUSHING BACK FROM THE GATE. WHEN I CALLED FOR TAXI, GND CLRED US TO TAXI TO RWY 12R VIA TXWY E AND HOLD SHORT OF RWY 12L. WHILE WE WERE DOING OUR PRE TKOF CHKLIST, THE CAPT CALLED ON GND FREQ TO SWITCH TO TWR FREQ. AFTER BEING QUERIED TWICE, THE GND CTLR SENT US OVER TO TWR FREQ. THE TWR CTLR WAS VERY BUSY, BUT WITH NO HESITATION ISSUED US CLRNC TO TAXI TO RWY 12R. I READ BACK THE CLRNC AND THE CAPT ASKED ME FOR THE 'BELOW THE LINE CHKLIST.' THIS WAS A BIT UNUSUAL SINCE WE NORMALLY WAIT UNTIL WE ARE CLRED INTO POS AND HOLD OR CLRED FOR TKOF, BEFORE WE ACCOMPLISH THIS FINAL PART OF THE CHKLIST. BUT SINCE WE HAD SUCH A SHORT TAXI TO THE ACTIVE RWY, I ASSUMED THAT THE CAPT WANTED TO GIVE OUR FLT ATTENDANTS AS MUCH TIME AS POSSIBLE TO GET THE CABIN READY FOR TKOF. I COMPLETED MY FLOW AND BEGAN TO READ THE 'BELOW THE LINE CHKLIST' TO THE CAPT AND AS I WAS READING IT TO HIM, HE CONTINUED TO TAXI. AT THIS POINT, WE WERE APCHING THE HOLD SHORT LINE AT RWY 12R AT A BRISK TAXI SPD. I NOTICED THAT WE DID NOT START DECELERATING TO HOLD SHORT OF RWY 12R. I WAS TRYING TO SORT OUT, IN MY HEAD, WHETHER I HAD MISSED A RADIO CALL OR WHETHER THE CAPT WAS NOT COMPLYING WITH OUR CLRNC. MY NORMAL HABIT PATTERN WHEN WE ENTER AN ACTIVE RWY IS TO CLR THE APCH SECTOR FOR OTHER ACFT. WHEN I DID THIS, I SAW AN ACFT ON APPROX 2 1/2 MI FINAL. I TOLD MY CAPT ABOUT THE ACFT AND THE FACT THAT I WAS UNSURE OF OUR CLRNC ONTO THE RWY. BY THIS TIME WE WERE ON THE ACTIVE RWY WITH MOST PART OF THE ACFT AND WERE BEGINNING TO DECELERATE. WITHOUT HESITATION THE CAPT RADIOED TWR AND WAS TOLD THAT WE HAD NOT BEEN CLRED ONTO THE RWY, TO EXIT RWY 12R AND TAXI ONTO RWY 17, TURN L ON RWY 17, AND TO HOLD SHORT OF RWY 12R. THE CTLR SENT THE ACFT ON FINAL AROUND AND WE IMMEDIATELY EXITED RWY 12R ACCORDING TO THE CTLR'S INSTRUCTIONS. AFTER 2 ADDITIONAL ARRS WE WERE CLRED FOR TKOF AND PROCEEDED UNEVENTFULLY TO DALLAS LOVE. I BELIEVE THERE ARE 5 CONTRIBUTING FACTORS TO THIS OCCURRENCE: 1) WE LEFT THE GATE 8 MINS LATE, WHICH CAUSED AN UNNECESSARY URGENCY TO MAKE UP FOR LOST TIME. 2) THE VERY SHORT TAXI DISTANCE FROM OUR GATE TO THE ACTIVE RWY COMBINED WITH THE ABOVE-MENTIONED URGENCY LEFT NO ROOM FOR ERROR OR DOUBLECHKING THE OTHER CREW MEMBER'S ACTIONS. 3) AN UNEXPECTED RADIO CALL. WHEN WE SWITCHED TO TWR FREQ, WE WERE EXPECTING WHAT WE NORMALLY HEAR, WHICH IS 'CROSS RWY 12L ON TXWY E AND HOLD SHORT OF RWY 12R.' THE TWR ACTUALLY SAID 'TAXI TO RWY 12R,' WHICH DOES IMPLY TO HOLD SHORT OF THE RWY. I BELIEVE THAT BECAUSE THE CAPT DID NOT HEAR WHAT HE EXPECTED 'CROSS RWY 12L ON TXWY E AND HOLD SHORT OF RWY 12R,' BUT INSTEAD HEARD 'TAXI TO RWY 12R' THAT HE PERCEIVED THAT AS CLRNC ONTO RWY 12R, WHICH WAS NOT CORRECT. 4) TWR FREQ WAS VERY CONGESTED AND THE CTLR WAS ISSUING CLRNCS AT A VERY FAST PACE. 5) A LOT OF THINGS WERE HAPPENING IN A VERY SMALL AMOUNT OF TIME, WHICH RESULTED IN A HIGH WORKLOAD FOR THE FLC. THESE ARE JUST SOME OF THE LESSONS THAT I HAVE LEARNED FROM THIS EVENT: 1) SLOW DOWN AND GIVE THE OTHER CREW MEMBER A CHANCE TO CATCH UP SO THAT THERE IS TIME FOR HIM TO VOICE HIS CONCERNS BEFORE IT IS TOO LATE TO STOP. 2) DO NOT GET COMPLACENT JUST BECAUSE YOU HAVE BEEN AT AN ARPT MANY TIMES AND THINK YOU KNOW WHAT CLRNC TO EXPECT NEXT. 3) BE EXTRA VIGILANT DURING TIMES OF FREQ CONGESTION, SHORT TAXI RTES AND AROUND RWYS THAT ARE IN CLOSE PROX TO EACH OTHER (HOUSTON HOBBY RWY 12R, RWY 12L, RWY 17). 4) RELY ON YOUR ESTABLISHED HABIT PATTERNS. XCHKING THE FINAL APCH SECTOR PROBABLY HELPED TO PREVENT THIS SIT FROM DEVELOPING INTO A POSSIBLE ACCIDENT. 5) DO NOT HESITATE TO SPEAK UP IMMEDIATELY, IF YOU ARE UNSURE OF A CLRNC OR UNSURE OF THE OTHER CREW MEMBER'S UNDERSTANDING OF A CLRNC.
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.