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|
Attributes | |
ACN | 507820 |
Time | |
Date | 200104 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : lgb.airport |
State Reference | CA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Thunderstorm Windshear |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : lgb.tower artcc : zob.artcc |
Operator | general aviation : corporate |
Make Model Name | Sabreliner 265 |
Operating Under FAR Part | Part 91 |
Navigation In Use | ils localizer & glide slope : 30 other |
Flight Phase | descent : approach ground : taxi landing : roll |
Route In Use | approach : instrument precision arrival : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : lgb.tower |
Make Model Name | Cessna 150 |
Operating Under FAR Part | Part 91 |
Flight Phase | landing : touch and go |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : cfi pilot : atp |
Experience | flight time last 90 days : 87 flight time total : 16253 flight time type : 5600 |
ASRS Report | 507820 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Events | |
Anomaly | conflict : ground less severe incursion : runway inflight encounter : weather non adherence : published procedure non adherence : far non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance |
Consequence | faa : investigated faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Airport Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The incident flight was a training flight conducted after the arrival of an executive transportation flight from the midwest to the lgb airport and prior to the evening return flight back to home base. I am a training captain for our organization and was contacted by our director of flight operations 1 hour after landing and asked to accomplish a training flight to upgrade my fellow crew member from his senior first officer status to reserve captain status in our company sabreliner. He explained that this was necessary, prior to our scheduled afternoon return departure, so that my first officer might be used as the PIC on a trip early the next week. On the incident flight, my first officer was the PF and I acted as his first officer while performing the duties of both instructor/check airman and PNF. The departure from lgb, airwork near trm, takeoffs and lndgs in strong winds at trm and psp as well as the en route/approach phase back to lgb were without incident. An ILS takeoff and landing on runway 30 was accomplished and the tower controller instructed us to exit left ahead (onto taxiway a) and to contact ground control. After contact, I heard the ground controller instruct us to 'hold short of runway 25L on taxiway D' which I read back without further response from him. 1/2 way between runway 25R and runway 25L, he again instructed us to hold short of runway 25L on taxiway D, which I read back. He then repeated the same instruction with more urgency, leading me to believe that my previous readback had been covered up, so I read back the hold short on taxiway D clearance and my first officer stopped the airplane well short of runway 25L to wait. After a C150 (aircraft Y) completed his touch-and-go on runway 25L, the ground controller cleared us across runway 25L to the FBO ramp. Approximately 30 seconds after entering the FBO, we were paged to a phone call from the tower supervisor and my first officer began talking to him describing the post landing taxi clearance we'd been given, puzzled by the inquiry. He then handed the phone to me when the supervisor determined the first officer was not the PIC. The supervisor stated that this ground controller was somewhat unsure but thought that we had crossed runway 25R without a clearance and he wanted our version of what we had understood the clearance to be. I described the scenario as above. He indicated that he would call me as soon as he had reviewed the communications recording tape. We departed 1 hour later than scheduled due to late passenger arrival and flew back to home base without further incident. Just after arrival, the tower supervisor called to inform me that the tape contained a clear instruction from the ground controller to hold short of runway 25R on taxiway D and my readback of the clearance. The supervisor told me that he was almost certain that he had a controller misunderstanding problem, after talking to both of us pilots independently and receiving the same specific description of events, but that the tape clearly indicated the runway was crossed without clearance. He advised that he would have to document it as a pilot deviation and forward the report to the lgb FSDO. It is my opinion that this incident was caused by a combination of the fatigue factors in our long scheduled duty day and the distrs of the restr time available to accomplish the required flight training in an unfamiliar high density traffic area and still be back and ready to go on schedule for the return executive flight to home base. This was my second 15+ hour duty day within 4 days coupled with the need to quickly research and locate airspace suitable for training, formulate routing, file IFR flight plans to and from the area near trm/psp, fly to/from the area, accomplish the training syllabus, return to lgb and be ready to fly home on schedule. Although I believe that the communication tape is accurate, I am presently under the honest opinion that we only heard the clearance to hold short of runway 25L and that no reference to runway 25R was ever heard or realized. My fellow crew member also believes that he clearly heard the same thing and we were both shocked to learn that any reference to runway 25R was ever made by ATC. In talking about the situation on the way home, we discussed our mutual visual check of the runway 25R final approach corridor, even though we (then) understood that we were cleared across that runway, thus demonstrating our concern for avoiding any runway incursion. It is also interesting to note that the ground controller was not clear that he had or had not cleared us across runway 25R as evidenced by the supervisor's 2 different remarks about the controller's uncertainty. Further, reference fatigue, it should be noted that our crash fire rescue equipment part 91 operations manual addressed 'scheduled' trip days exceeding 14 hours (this trip was scheduled 14 hours 40 mins and actually was 15 hours 40 mins long) and requires that we go to a place of rest (hotel day room) for a minimum of 5 hours rest before completing an extended duty day such as this one. Adding the training flight precluded needed and required rest.
Original NASA ASRS Text
Title: SBR1 FLC TAXI ACROSS LGB RWY 25R WITHOUT CLRNC.
Narrative: THE INCIDENT FLT WAS A TRAINING FLT CONDUCTED AFTER THE ARR OF AN EXECUTIVE TRANSPORTATION FLT FROM THE MIDWEST TO THE LGB ARPT AND PRIOR TO THE EVENING RETURN FLT BACK TO HOME BASE. I AM A TRAINING CAPT FOR OUR ORGANIZATION AND WAS CONTACTED BY OUR DIRECTOR OF FLT OPS 1 HR AFTER LNDG AND ASKED TO ACCOMPLISH A TRAINING FLT TO UPGRADE MY FELLOW CREW MEMBER FROM HIS SENIOR FO STATUS TO RESERVE CAPT STATUS IN OUR COMPANY SABRELINER. HE EXPLAINED THAT THIS WAS NECESSARY, PRIOR TO OUR SCHEDULED AFTERNOON RETURN DEP, SO THAT MY FO MIGHT BE USED AS THE PIC ON A TRIP EARLY THE NEXT WK. ON THE INCIDENT FLT, MY FO WAS THE PF AND I ACTED AS HIS FO WHILE PERFORMING THE DUTIES OF BOTH INSTRUCTOR/CHK AIRMAN AND PNF. THE DEP FROM LGB, AIRWORK NEAR TRM, TKOFS AND LNDGS IN STRONG WINDS AT TRM AND PSP AS WELL AS THE ENRTE/APCH PHASE BACK TO LGB WERE WITHOUT INCIDENT. AN ILS TKOF AND LNDG ON RWY 30 WAS ACCOMPLISHED AND THE TWR CTLR INSTRUCTED US TO EXIT L AHEAD (ONTO TXWY A) AND TO CONTACT GND CTL. AFTER CONTACT, I HEARD THE GND CTLR INSTRUCT US TO 'HOLD SHORT OF RWY 25L ON TXWY D' WHICH I READ BACK WITHOUT FURTHER RESPONSE FROM HIM. 1/2 WAY BTWN RWY 25R AND RWY 25L, HE AGAIN INSTRUCTED US TO HOLD SHORT OF RWY 25L ON TXWY D, WHICH I READ BACK. HE THEN REPEATED THE SAME INSTRUCTION WITH MORE URGENCY, LEADING ME TO BELIEVE THAT MY PREVIOUS READBACK HAD BEEN COVERED UP, SO I READ BACK THE HOLD SHORT ON TXWY D CLRNC AND MY FO STOPPED THE AIRPLANE WELL SHORT OF RWY 25L TO WAIT. AFTER A C150 (ACFT Y) COMPLETED HIS TOUCH-AND-GO ON RWY 25L, THE GND CTLR CLRED US ACROSS RWY 25L TO THE FBO RAMP. APPROX 30 SECONDS AFTER ENTERING THE FBO, WE WERE PAGED TO A PHONE CALL FROM THE TWR SUPVR AND MY FO BEGAN TALKING TO HIM DESCRIBING THE POST LNDG TAXI CLRNC WE'D BEEN GIVEN, PUZZLED BY THE INQUIRY. HE THEN HANDED THE PHONE TO ME WHEN THE SUPVR DETERMINED THE FO WAS NOT THE PIC. THE SUPVR STATED THAT THIS GND CTLR WAS SOMEWHAT UNSURE BUT THOUGHT THAT WE HAD CROSSED RWY 25R WITHOUT A CLRNC AND HE WANTED OUR VERSION OF WHAT WE HAD UNDERSTOOD THE CLRNC TO BE. I DESCRIBED THE SCENARIO AS ABOVE. HE INDICATED THAT HE WOULD CALL ME AS SOON AS HE HAD REVIEWED THE COMS RECORDING TAPE. WE DEPARTED 1 HR LATER THAN SCHEDULED DUE TO LATE PAX ARR AND FLEW BACK TO HOME BASE WITHOUT FURTHER INCIDENT. JUST AFTER ARR, THE TWR SUPVR CALLED TO INFORM ME THAT THE TAPE CONTAINED A CLR INSTRUCTION FROM THE GND CTLR TO HOLD SHORT OF RWY 25R ON TXWY D AND MY READBACK OF THE CLRNC. THE SUPVR TOLD ME THAT HE WAS ALMOST CERTAIN THAT HE HAD A CTLR MISUNDERSTANDING PROB, AFTER TALKING TO BOTH OF US PLTS INDEPENDENTLY AND RECEIVING THE SAME SPECIFIC DESCRIPTION OF EVENTS, BUT THAT THE TAPE CLRLY INDICATED THE RWY WAS CROSSED WITHOUT CLRNC. HE ADVISED THAT HE WOULD HAVE TO DOCUMENT IT AS A PLTDEV AND FORWARD THE RPT TO THE LGB FSDO. IT IS MY OPINION THAT THIS INCIDENT WAS CAUSED BY A COMBINATION OF THE FATIGUE FACTORS IN OUR LONG SCHEDULED DUTY DAY AND THE DISTRS OF THE RESTR TIME AVAILABLE TO ACCOMPLISH THE REQUIRED FLT TRAINING IN AN UNFAMILIAR HIGH DENSITY TFC AREA AND STILL BE BACK AND READY TO GO ON SCHEDULE FOR THE RETURN EXECUTIVE FLT TO HOME BASE. THIS WAS MY SECOND 15+ HR DUTY DAY WITHIN 4 DAYS COUPLED WITH THE NEED TO QUICKLY RESEARCH AND LOCATE AIRSPACE SUITABLE FOR TRAINING, FORMULATE ROUTING, FILE IFR FLT PLANS TO AND FROM THE AREA NEAR TRM/PSP, FLY TO/FROM THE AREA, ACCOMPLISH THE TRAINING SYLLABUS, RETURN TO LGB AND BE READY TO FLY HOME ON SCHEDULE. ALTHOUGH I BELIEVE THAT THE COM TAPE IS ACCURATE, I AM PRESENTLY UNDER THE HONEST OPINION THAT WE ONLY HEARD THE CLRNC TO HOLD SHORT OF RWY 25L AND THAT NO REF TO RWY 25R WAS EVER HEARD OR REALIZED. MY FELLOW CREW MEMBER ALSO BELIEVES THAT HE CLRLY HEARD THE SAME THING AND WE WERE BOTH SHOCKED TO LEARN THAT ANY REF TO RWY 25R WAS EVER MADE BY ATC. IN TALKING ABOUT THE SIT ON THE WAY HOME, WE DISCUSSED OUR MUTUAL VISUAL CHK OF THE RWY 25R FINAL APCH CORRIDOR, EVEN THOUGH WE (THEN) UNDERSTOOD THAT WE WERE CLRED ACROSS THAT RWY, THUS DEMONSTRATING OUR CONCERN FOR AVOIDING ANY RWY INCURSION. IT IS ALSO INTERESTING TO NOTE THAT THE GND CTLR WAS NOT CLR THAT HE HAD OR HAD NOT CLRED US ACROSS RWY 25R AS EVIDENCED BY THE SUPVR'S 2 DIFFERENT REMARKS ABOUT THE CTLR'S UNCERTAINTY. FURTHER, REF FATIGUE, IT SHOULD BE NOTED THAT OUR CFR PART 91 OPS MANUAL ADDRESSED 'SCHEDULED' TRIP DAYS EXCEEDING 14 HRS (THIS TRIP WAS SCHEDULED 14 HRS 40 MINS AND ACTUALLY WAS 15 HRS 40 MINS LONG) AND REQUIRES THAT WE GO TO A PLACE OF REST (HOTEL DAY ROOM) FOR A MINIMUM OF 5 HRS REST BEFORE COMPLETING AN EXTENDED DUTY DAY SUCH AS THIS ONE. ADDING THE TRAINING FLT PRECLUDED NEEDED AND REQUIRED REST.
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.