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Attributes | |
ACN | 504910 |
Time | |
Date | 200103 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : cvg.airport |
State Reference | KY |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : cvg.tracon tower : cvg.tower tower : tus.tower |
Operator | common carrier : air carrier |
Make Model Name | SF 340A |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff ground : position and hold ground : takeoff roll ground : taxi |
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 : 128 flight time total : 3735 flight time type : 128 |
ASRS Report | 504910 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : multi engine |
Events | |
Anomaly | airspace violation : entry non adherence : clearance non adherence : company policies non adherence : far other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory none taken : detected after the fact |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Environmental Factor Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On the return leg from cvg to mem on a scheduled continuous duty overnight we apparently took off runway 27 without clearance. We departed the gate on time, completed our first flight of the day items, then taxied to a remote deice pad. We were deiced and then asked for clearance to taxi. We had a relatively short taxi to runway 27. During this time we completed the appropriate checklists and briefings. As we approached the hold short line I thought we had been cleared to takeoff. In retrospect, I now believe that our clearance was to 'taxi into position and hold.' as we taxied onto the runway, the first officer completed the final checklist items. I asked if he was ready and we began the takeoff roll. Shortly after the V1/rotate call, the tower controller called out our flight number. It was then that both the first officer and I knew something was wrong. During the initial climb out the first officer asked ATC if our clearance was to position and hold. They responded in the affirmative. The rest of the climb out was normal. The departure controller gave us a number to call. After we landed, I called the supervisor and tried to explain what had happened and apologized for any problems we may have caused. I believe both fatigue and complacency contributed to this incident. I am relatively new to the company and currently hold a reserve schedule. The days prior to the incident I had a series of flts during the day. Consequently, I was not accustomed to the continuous duty overnight schedule and did not sleep well during the layover. I did not feel extremely tired but perhaps not as alert as I could have been. Pilots get used to a routine and flow and can become complacent. I think I became a victim of this. Having replayed this event in my mind many times I have tried to find a reason why I thought we had been cleared for takeoff. There was no aircraft in front of us. I could not see and did not hear of any traffic on a crossing runway. ATC sometimes uses phrases like 'position and hold departing/landing traffic crossing runway.' because I didn't hear or see a reason to 'position and hold' and being caught up in the routine are factors that caused me to believe we were cleared for takeoff. If there had been any doubt about our clearance I would have asked. I have thought of several things that I can do to prevent something like this from happening again. I need to make sure I hear what ATC is saying, not what I expect them to say. Since continuous duty overnights will probably not cease, I must adjust my sleeping pattern to ensure I'm alert and fully awake when I'm called for a trip both night and day. I am going to suggest that a procedure be put in place to help prevent this occurring to anyone else. For example, turning on landing lights whenever takeoff clearance is received.
Original NASA ASRS Text
Title: AN SF340 FLC PERFORMS AN UNAUTH TKOF AT CVG, KY.
Narrative: ON THE RETURN LEG FROM CVG TO MEM ON A SCHEDULED CONTINUOUS DUTY OVERNIGHT WE APPARENTLY TOOK OFF RWY 27 WITHOUT CLRNC. WE DEPARTED THE GATE ON TIME, COMPLETED OUR FIRST FLT OF THE DAY ITEMS, THEN TAXIED TO A REMOTE DEICE PAD. WE WERE DEICED AND THEN ASKED FOR CLRNC TO TAXI. WE HAD A RELATIVELY SHORT TAXI TO RWY 27. DURING THIS TIME WE COMPLETED THE APPROPRIATE CHKLISTS AND BRIEFINGS. AS WE APCHED THE HOLD SHORT LINE I THOUGHT WE HAD BEEN CLRED TO TKOF. IN RETROSPECT, I NOW BELIEVE THAT OUR CLRNC WAS TO 'TAXI INTO POS AND HOLD.' AS WE TAXIED ONTO THE RWY, THE FO COMPLETED THE FINAL CHKLIST ITEMS. I ASKED IF HE WAS READY AND WE BEGAN THE TKOF ROLL. SHORTLY AFTER THE V1/ROTATE CALL, THE TWR CTLR CALLED OUT OUR FLT NUMBER. IT WAS THEN THAT BOTH THE FO AND I KNEW SOMETHING WAS WRONG. DURING THE INITIAL CLBOUT THE FO ASKED ATC IF OUR CLRNC WAS TO POS AND HOLD. THEY RESPONDED IN THE AFFIRMATIVE. THE REST OF THE CLBOUT WAS NORMAL. THE DEP CTLR GAVE US A NUMBER TO CALL. AFTER WE LANDED, I CALLED THE SUPVR AND TRIED TO EXPLAIN WHAT HAD HAPPENED AND APOLOGIZED FOR ANY PROBS WE MAY HAVE CAUSED. I BELIEVE BOTH FATIGUE AND COMPLACENCY CONTRIBUTED TO THIS INCIDENT. I AM RELATIVELY NEW TO THE COMPANY AND CURRENTLY HOLD A RESERVE SCHEDULE. THE DAYS PRIOR TO THE INCIDENT I HAD A SERIES OF FLTS DURING THE DAY. CONSEQUENTLY, I WAS NOT ACCUSTOMED TO THE CONTINUOUS DUTY OVERNIGHT SCHEDULE AND DID NOT SLEEP WELL DURING THE LAYOVER. I DID NOT FEEL EXTREMELY TIRED BUT PERHAPS NOT AS ALERT AS I COULD HAVE BEEN. PLTS GET USED TO A ROUTINE AND FLOW AND CAN BECOME COMPLACENT. I THINK I BECAME A VICTIM OF THIS. HAVING REPLAYED THIS EVENT IN MY MIND MANY TIMES I HAVE TRIED TO FIND A REASON WHY I THOUGHT WE HAD BEEN CLRED FOR TKOF. THERE WAS NO ACFT IN FRONT OF US. I COULD NOT SEE AND DID NOT HEAR OF ANY TFC ON A XING RWY. ATC SOMETIMES USES PHRASES LIKE 'POS AND HOLD DEPARTING/LNDG TFC XING RWY.' BECAUSE I DIDN'T HEAR OR SEE A REASON TO 'POS AND HOLD' AND BEING CAUGHT UP IN THE ROUTINE ARE FACTORS THAT CAUSED ME TO BELIEVE WE WERE CLRED FOR TKOF. IF THERE HAD BEEN ANY DOUBT ABOUT OUR CLRNC I WOULD HAVE ASKED. I HAVE THOUGHT OF SEVERAL THINGS THAT I CAN DO TO PREVENT SOMETHING LIKE THIS FROM HAPPENING AGAIN. I NEED TO MAKE SURE I HEAR WHAT ATC IS SAYING, NOT WHAT I EXPECT THEM TO SAY. SINCE CONTINUOUS DUTY OVERNIGHTS WILL PROBABLY NOT CEASE, I MUST ADJUST MY SLEEPING PATTERN TO ENSURE I'M ALERT AND FULLY AWAKE WHEN I'M CALLED FOR A TRIP BOTH NIGHT AND DAY. I AM GOING TO SUGGEST THAT A PROC BE PUT IN PLACE TO HELP PREVENT THIS OCCURRING TO ANYONE ELSE. FOR EXAMPLE, TURNING ON LNDG LIGHTS WHENEVER TKOF CLRNC IS RECEIVED.
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.