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|
Attributes | |
ACN | 513878 |
Time | |
Date | 200106 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : dfw.airport |
State Reference | TX |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | EMB ERJ 145 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : position and hold |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : dfw.tower |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Series (DC-9-80) Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : commercial pilot : cfi pilot : instrument |
Experience | flight time last 90 days : 200 flight time total : 2500 flight time type : 450 |
ASRS Report | 513878 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 12000 flight time type : 1100 |
ASRS Report | 513795 |
Events | |
Anomaly | incursion : runway non adherence : clearance non adherence : far non adherence : published procedure non adherence : required legal separation |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | ATC Human Performance Flight Crew Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error |
Narrative:
I was doing a scheduled flight from dfw to xna. We were cleared into position for runway 36R at dfw. As we proceeded onto the runway, the captain called for the 'before takeoff' checklist. This checklist is partially a challenge and response checklist. The rest of the list is done verbally by the first officer. As we ran through the checklist, I heard 'aircraft X cleared for takeoff.' I responded, 'cleared for takeoff, runway 36R, aircraft X.' as we turned the aircraft onto the centerline, I asked the captain if he wanted the exterior lights on. He said yes. This last item on the checklist is done when we have been cleared for takeoff. I believe that due to the verbal nature of the checklist, this is where the misunderstanding arose. (I will explain this later in this brief). As we rolled down the runway, I heard dfw tower tell aircraft Y to stop where they were. I thought that aircraft Y had misunderstood a taxi clearance. By the time we were abeam them, we were well above them. As we passed over aircraft Y, I noticed that they were a few ft past the hold short line on a taxiway that intersected runway 36R. As we flew to xna, center asked us to call dfw tower when we arrived at xna. Upon arrival at xna, my captain called dfw tower and spoke with a supervisor. The supervisor explained that another aircraft (aircraft Z) had been cleared for takeoff from runway 31L and not us. I think what happened was, while we were verbally doing the takeoff checklist, I must have combined the numbers from aircraft and runway and heard 'aircraft X.' I didn't realize that at XC00 in the afternoon dfw tower was working runway 36R, runway 36L, and runway 31L. Since there was no other aircraft on the runway (runway 36R) and I didn't know tower was working 3 runways, I had no reason to think it couldn't be us they were telling 'cleared for takeoff.' after reviewing the tapes, the supervisor told the captain that dfw tower would take responsibility for what happened. The supervisor said that she could hear my takeoff clearance readback. She said the tower controller should have asked for clarification as to who was taking off from what runway and/or could have asked us to abort the roll when he saw us moving down runway 36R. In closing, I am not the type of pilot that takes off without a clearance. There have been occasions when I have been unsure so I asked the tower for clarification. In this instance, I believe that due to the verbal nature of the checklist, I misheard the instruction, but was sure it was for us and continued the takeoff. Supplemental information from acn 513795: abcd departing dfw to xna at XC00 was holding short of active runway 36R dfw. A heavy aircraft just departed, when we were informed to take position and hold runway 36R. As I slowly took position making an 90 degree entry, I requested before takeoff checklist. the co-pilot read aloud the items. Dfw tower spoke exactly, the same time, items were read. I did not hear what tower said, our voices over-rode towersouth. I did not think it was for us, since wake turbulence separation just started, but the co-pilot heard air carrier X flight abcd cleared for takeoff (runway 36R?). the only part I heard from tower was ending transmission was cleared for takeoff. the co-pilot clearly read back, cleared for takeoff on runway 36R, air carrier X flight abcd. dfw tower did not correct the readback. While still completing the 90 degree turn on the active runway, co-pilot asked if I wanted him to turn on exterior lights, with hands full, I replied yes, turn all the lights on. the point here is, this is where dfw tower was talking to an air carrier Y aircraft and we didnT catch the conversation, because we were still verbally completing the checklist. A normal takeoff was made, when we both heard dfw tower say air carrier Y stop, but we noted air carrier Y aircraft had already stopped. I thought air carrier Y might have missed a transmission. We were well above air carrier Y aircraft, when we flew past abeam. We thought nothing of it till half way to xna, when center told us to call dfw tower. I called at xna airport. Dfw tower manager on duty said we departed without a clearance. Manager on duty said it was for air carrier X efgh for runway 31L. I couldnT believe it and I said, we read back we were departing runway 36R for air carrier X flight abcd. Manager on duty said I know, we heard the tapes. I saidso, now what? manager on duty said itsouth our fault, because you gave a full readback and dfw tower should have caught the mistake and corrected it. manager on duty asked me a few more questions about other aircraft on frequency. I said I was busy with checklist and completing my required duties. The rest is history. Callback conversation with reporter revealed the following information: the crossing air carrier whose clearance to cross was canceled was an MD80. He was unable to stop until slightly across the hold short line, but was well off the runway. The aircraft X was approximately 1400 ft AGL as it went by the intersection that was approximately 9000 ft down the runway.
Original NASA ASRS Text
Title: SIMILAR CALL SIGNS, ACCEPTANCE OF THE WRONG CLRNC AND A MISSED READBACK COUPLED WITH CHKLIST ACTIVITY DISTRS LEAD TO A TAKEOFF WITHOUT CLRNC AND A RWY INCURSION BY A TAXIING ACFT WHEN THE RWY CROSSING CLRNC IS TOO LATE FOR A STOP SHORT OF THE HOLD SHORT LINE.
Narrative: I WAS DOING A SCHEDULED FLT FROM DFW TO XNA. WE WERE CLRED INTO POS FOR RWY 36R AT DFW. AS WE PROCEEDED ONTO THE RWY, THE CAPT CALLED FOR THE 'BEFORE TKOF' CHKLIST. THIS CHKLIST IS PARTIALLY A CHALLENGE AND RESPONSE CHKLIST. THE REST OF THE LIST IS DONE VERBALLY BY THE FO. AS WE RAN THROUGH THE CHKLIST, I HEARD 'ACFT X CLRED FOR TKOF.' I RESPONDED, 'CLRED FOR TKOF, RWY 36R, ACFT X.' AS WE TURNED THE ACFT ONTO THE CTRLINE, I ASKED THE CAPT IF HE WANTED THE EXTERIOR LIGHTS ON. HE SAID YES. THIS LAST ITEM ON THE CHKLIST IS DONE WHEN WE HAVE BEEN CLRED FOR TKOF. I BELIEVE THAT DUE TO THE VERBAL NATURE OF THE CHKLIST, THIS IS WHERE THE MISUNDERSTANDING AROSE. (I WILL EXPLAIN THIS LATER IN THIS BRIEF). AS WE ROLLED DOWN THE RWY, I HEARD DFW TWR TELL ACFT Y TO STOP WHERE THEY WERE. I THOUGHT THAT ACFT Y HAD MISUNDERSTOOD A TAXI CLRNC. BY THE TIME WE WERE ABEAM THEM, WE WERE WELL ABOVE THEM. AS WE PASSED OVER ACFT Y, I NOTICED THAT THEY WERE A FEW FT PAST THE HOLD SHORT LINE ON A TXWY THAT INTERSECTED RWY 36R. AS WE FLEW TO XNA, CTR ASKED US TO CALL DFW TWR WHEN WE ARRIVED AT XNA. UPON ARR AT XNA, MY CAPT CALLED DFW TWR AND SPOKE WITH A SUPVR. THE SUPVR EXPLAINED THAT ANOTHER ACFT (ACFT Z) HAD BEEN CLRED FOR TKOF FROM RWY 31L AND NOT US. I THINK WHAT HAPPENED WAS, WHILE WE WERE VERBALLY DOING THE TKOF CHKLIST, I MUST HAVE COMBINED THE NUMBERS FROM ACFT AND RWY AND HEARD 'ACFT X.' I DIDN'T REALIZE THAT AT XC00 IN THE AFTERNOON DFW TWR WAS WORKING RWY 36R, RWY 36L, AND RWY 31L. SINCE THERE WAS NO OTHER ACFT ON THE RWY (RWY 36R) AND I DIDN'T KNOW TWR WAS WORKING 3 RWYS, I HAD NO REASON TO THINK IT COULDN'T BE US THEY WERE TELLING 'CLRED FOR TKOF.' AFTER REVIEWING THE TAPES, THE SUPVR TOLD THE CAPT THAT DFW TWR WOULD TAKE RESPONSIBILITY FOR WHAT HAPPENED. THE SUPVR SAID THAT SHE COULD HEAR MY TKOF CLRNC READBACK. SHE SAID THE TWR CTLR SHOULD HAVE ASKED FOR CLARIFICATION AS TO WHO WAS TAKING OFF FROM WHAT RWY AND/OR COULD HAVE ASKED US TO ABORT THE ROLL WHEN HE SAW US MOVING DOWN RWY 36R. IN CLOSING, I AM NOT THE TYPE OF PLT THAT TAKES OFF WITHOUT A CLRNC. THERE HAVE BEEN OCCASIONS WHEN I HAVE BEEN UNSURE SO I ASKED THE TWR FOR CLARIFICATION. IN THIS INSTANCE, I BELIEVE THAT DUE TO THE VERBAL NATURE OF THE CHKLIST, I MISHEARD THE INSTRUCTION, BUT WAS SURE IT WAS FOR US AND CONTINUED THE TKOF. SUPPLEMENTAL INFO FROM ACN 513795: ABCD DEPARTING DFW TO XNA AT XC00 WAS HOLDING SHORT OF ACTIVE RWY 36R DFW. A HEAVY ACFT JUST DEPARTED, WHEN WE WERE INFORMED TO TAKE POS AND HOLD RWY 36R. AS I SLOWLY TOOK POS MAKING AN 90 DEG ENTRY, I REQUESTED BEFORE TAKEOFF CHKLIST. THE CO-PLT READ ALOUD THE ITEMS. DFW TWR SPOKE EXACTLY, THE SAME TIME, ITEMS WERE READ. I DID NOT HEAR WHAT TWR SAID, OUR VOICES OVER-RODE TWRS. I DID NOT THINK IT WAS FOR US, SINCE WAKE TURB SEPARATION JUST STARTED, BUT THE CO-PLT HEARD ACR X FLT ABCD CLRED FOR TAKEOFF (RWY 36R?). THE ONLY PART I HEARD FROM TWR WAS ENDING TRANSMISSION WAS CLRED FOR TAKEOFF. THE CO-PLT CLEARLY READ BACK, CLRED FOR TAKEOFF ON RWY 36R, ACR X FLT ABCD. DFW TWR DID NOT CORRECT THE READBACK. WHILE STILL COMPLETING THE 90 DEG TURN ON THE ACTIVE RWY, CO-PLT ASKED IF I WANTED HIM TO TURN ON EXTERIOR LIGHTS, WITH HANDS FULL, I REPLIED YES, TURN ALL THE LIGHTS ON. THE POINT HERE IS, THIS IS WHERE DFW TWR WAS TALKING TO AN ACR Y ACFT AND WE DIDNT CATCH THE CONVERSATION, BECAUSE WE WERE STILL VERBALLY COMPLETING THE CHKLIST. A NORMAL TKOF WAS MADE, WHEN WE BOTH HEARD DFW TWR SAY ACR Y STOP, BUT WE NOTED ACR Y ACFT HAD ALREADY STOPPED. I THOUGHT ACR Y MIGHT HAVE MISSED A TRANSMISSION. WE WERE WELL ABOVE ACR Y ACFT, WHEN WE FLEW PAST ABEAM. WE THOUGHT NOTHING OF IT TILL HALF WAY TO XNA, WHEN CTR TOLD US TO CALL DFW TWR. I CALLED AT XNA ARPT. DFW TWR MANAGER ON DUTY SAID WE DEPARTED WITHOUT A CLRNC. MANAGER ON DUTY SAID IT WAS FOR ACR X EFGH FOR RWY 31L. I COULDNT BELIEVE IT AND I SAID, WE READ BACK WE WERE DEPARTING RWY 36R FOR ACR X FLT ABCD. MANAGER ON DUTY SAID I KNOW, WE HEARD THE TAPES. I SAIDSO, NOW WHAT? MANAGER ON DUTY SAID ITS OUR FAULT, BECAUSE YOU GAVE A FULL READBACK AND DFW TWR SHOULD HAVE CAUGHT THE MISTAKE AND CORRECTED IT. MANAGER ON DUTY ASKED ME A FEW MORE QUESTIONS ABOUT OTHER ACFT ON FREQ. I SAID I WAS BUSY WITH CHECKLIST AND COMPLETING MY REQUIRED DUTIES. THE REST IS HISTORY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CROSSING ACR WHOSE CLRNC TO CROSS WAS CANCELED WAS AN MD80. HE WAS UNABLE TO STOP UNTIL SLIGHTLY ACROSS THE HOLD SHORT LINE, BUT WAS WELL OFF THE RWY. THE ACFT X WAS APPROX 1400 FT AGL AS IT WENT BY THE INTERSECTION THAT WAS APPROX 9000 FT DOWN THE RWY.
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.