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Attributes | |
ACN | 486790 |
Time | |
Date | 200009 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : day.airport |
State Reference | OH |
Altitude | agl bound upper : 300 agl single value : 0 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : day.tower |
Operator | common carrier : air carrier |
Make Model Name | DC-8 63 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : day.tower |
Operator | general aviation : corporate |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 135 |
Navigation In Use | other |
Flight Phase | climbout : initial |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 180 flight time total : 19000 flight time type : 5000 |
ASRS Report | 486790 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial |
Experience | flight time last 90 days : 120 flight time total : 1400 flight time type : 150 |
ASRS Report | 486869 |
Events | |
Anomaly | non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted none taken : insufficient time |
Miss Distance | horizontal : 3000 vertical : 500 |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Operational Error Pilot Deviation |
Narrative:
At the time of the incident my flight (XXX) was in position and holding on runway 6L. My crew and I received what we believed was a clearance to take off and maintain runway heading to 3000 ft. My first officer read back the clearance and I made the takeoff. Just after liftoff, my flight engineer called out traffic ahead of us that was moving right to left at our altitude. He told me that he thought that the aircraft was much closer than normal. Neither my first officer nor I saw the other aircraft. Conditions at the airport were 500 ft overcast 3 mi visibility so we were soon IMC. At this time we received 'another' takeoff clearance from the local controller, followed by a pause and then a heading change to 090 degrees and a handoff to departure. The controller did not state that we had taken off without a clearance. Both members of my crew stated that they did not hear the second clearance, but were probably distracted by the presence of the other aircraft. My analysis of the incident is as follows: shortly before receiving our 'first' takeoff clearance, the local controller was talking to another aircraft which I now know was waiting for takeoff on runway 36. (Runway 36 crosses the extended centerline of runway 6L about 300 ft beyond the end of the runway.) the aircraft had a call sign similar to ours (something like xyx) and was actually given the takeoff clearance that we thought was our own. A subsequent discussion with the ATC controller involved revealed that he had received a 'stepped-on' (by us) readback takeoff clearance from the grumman and therefore did not hear our acknowledgement of an invalid clearance. Shortly after giving the grumman clearance, he issued our clearance and then noted that we had already departed. Unfortunately, this is a classic case of hearing what you want to hear and then acting upon that misperception. I have amended my takeoff briefing to include the admonition to my crew that 'if anyone has a question concerning the meaning of any clearance, we will verify the clearance before acting upon it.' in an increasingly congested operating environment, the use of 'position and hold' clrncs when departures are being made in IMC is questionable at best. Given the prevalence of similar sounding call signs, I believe that the operations are inherently dangerous no matter which person or party may be deemed at fault. Supplemental information from acn 486869: fatigue was also a factor in this situation. We took off from oakland, ca, with about 4 hours sleep prior. I was unable to sleep in before the flight. In the 2 weeks preceding this flight, we had been FLIP-flopping from day to night flying.
Original NASA ASRS Text
Title: FLC RESPONDED TO A TKOF CLRNC THAT WAS GIVEN TO ANOTHER ACFT WITH SIMILAR CALL SIGN.
Narrative: AT THE TIME OF THE INCIDENT MY FLT (XXX) WAS IN POS AND HOLDING ON RWY 6L. MY CREW AND I RECEIVED WHAT WE BELIEVED WAS A CLRNC TO TAKE OFF AND MAINTAIN RWY HDG TO 3000 FT. MY FO READ BACK THE CLRNC AND I MADE THE TKOF. JUST AFTER LIFTOFF, MY FE CALLED OUT TFC AHEAD OF US THAT WAS MOVING R TO L AT OUR ALT. HE TOLD ME THAT HE THOUGHT THAT THE ACFT WAS MUCH CLOSER THAN NORMAL. NEITHER MY FO NOR I SAW THE OTHER ACFT. CONDITIONS AT THE ARPT WERE 500 FT OVCST 3 MI VISIBILITY SO WE WERE SOON IMC. AT THIS TIME WE RECEIVED 'ANOTHER' TKOF CLRNC FROM THE LCL CTLR, FOLLOWED BY A PAUSE AND THEN A HDG CHANGE TO 090 DEGS AND A HDOF TO DEP. THE CTLR DID NOT STATE THAT WE HAD TAKEN OFF WITHOUT A CLRNC. BOTH MEMBERS OF MY CREW STATED THAT THEY DID NOT HEAR THE SECOND CLRNC, BUT WERE PROBABLY DISTRACTED BY THE PRESENCE OF THE OTHER ACFT. MY ANALYSIS OF THE INCIDENT IS AS FOLLOWS: SHORTLY BEFORE RECEIVING OUR 'FIRST' TKOF CLRNC, THE LCL CTLR WAS TALKING TO ANOTHER ACFT WHICH I NOW KNOW WAS WAITING FOR TKOF ON RWY 36. (RWY 36 CROSSES THE EXTENDED CTRLINE OF RWY 6L ABOUT 300 FT BEYOND THE END OF THE RWY.) THE ACFT HAD A CALL SIGN SIMILAR TO OURS (SOMETHING LIKE XYX) AND WAS ACTUALLY GIVEN THE TKOF CLRNC THAT WE THOUGHT WAS OUR OWN. A SUBSEQUENT DISCUSSION WITH THE ATC CTLR INVOLVED REVEALED THAT HE HAD RECEIVED A 'STEPPED-ON' (BY US) READBACK TKOF CLRNC FROM THE GRUMMAN AND THEREFORE DID NOT HEAR OUR ACKNOWLEDGEMENT OF AN INVALID CLRNC. SHORTLY AFTER GIVING THE GRUMMAN CLRNC, HE ISSUED OUR CLRNC AND THEN NOTED THAT WE HAD ALREADY DEPARTED. UNFORTUNATELY, THIS IS A CLASSIC CASE OF HEARING WHAT YOU WANT TO HEAR AND THEN ACTING UPON THAT MISPERCEPTION. I HAVE AMENDED MY TKOF BRIEFING TO INCLUDE THE ADMONITION TO MY CREW THAT 'IF ANYONE HAS A QUESTION CONCERNING THE MEANING OF ANY CLRNC, WE WILL VERIFY THE CLRNC BEFORE ACTING UPON IT.' IN AN INCREASINGLY CONGESTED OPERATING ENVIRONMENT, THE USE OF 'POS AND HOLD' CLRNCS WHEN DEPS ARE BEING MADE IN IMC IS QUESTIONABLE AT BEST. GIVEN THE PREVALENCE OF SIMILAR SOUNDING CALL SIGNS, I BELIEVE THAT THE OPS ARE INHERENTLY DANGEROUS NO MATTER WHICH PERSON OR PARTY MAY BE DEEMED AT FAULT. SUPPLEMENTAL INFO FROM ACN 486869: FATIGUE WAS ALSO A FACTOR IN THIS SIT. WE TOOK OFF FROM OAKLAND, CA, WITH ABOUT 4 HRS SLEEP PRIOR. I WAS UNABLE TO SLEEP IN BEFORE THE FLT. IN THE 2 WKS PRECEDING THIS FLT, WE HAD BEEN FLIP-FLOPPING FROM DAY TO NIGHT FLYING.
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.