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|
Attributes | |
ACN | 577018 |
Time | |
Date | 200303 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : atl.airport |
State Reference | GA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi ground : takeoff roll ground other : abort |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : atl.tower |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi ground : position and hold |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 90 flight time total : 16000 flight time type : 1000 |
ASRS Report | 577018 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | conflict : ground less severe non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance controller : separated traffic controller : issued alert flight crew : rejected takeoff |
Consequence | faa : investigated faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | ATC Human Performance Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Taxiing east on taxiway east, tower said 'air carrier X, taxi into position and hold runway 26L.' my first officer or I acknowledged and read back the clearance. As I was taxiing the aircraft through a heading of about 080 degrees, the first officer reached up and armed the autothrottles. (I don't normally do this action until I am crossing the hold short time.' I shared this with the first officer. This is only the second day I've flown with this first officer. A lot of our flying procedures become 'routines.' arming the autothrottles is normally a captain performed action. While I was taxiing out onto runway 26L, I heard other tower xmissions/cons. As I lined up the aircraft, I thought I heard, or assumed, we were cleared for takeoff, or thought the first officer acknowledged our takeoff clearance. I armed the autothrottles and turned on the landing lights. I then said to the first officer, 'it's your airplane' (first officer's leg). The first officer started to advance the throttle when I heard the tower controller say 'air carrier X, cancel your takeoff clearance.' we were about 60 KTS when I retarded the throttles. I assumed control of the aircraft and acknowledged the cancellation of the takeoff clearance. I slowed the aircraft and turned right off the runway as per tower's instructions. As I turned off runway 26 onto the taxiway B10, the controller said 'air carrier X you were cleared position and hold only.' we acknowledged this transmission. They said continue on taxiway B for takeoff sequence. I believed we had been cleared for takeoff. The first officer thought about asking for verification, but didn't. When I retarded the throttles, I saw air carrier Y (I believe) holding at B4 waiting to cross runway 26L. I am aware of the seriousness of this assumption. Under low visibility, this could have been a perfect set-up for a collision. Contributing factors: mostly fatigue, lack of adequate rest. This was the beginning of second day of a 3 day trip. All 3 days are early reports. The night before day #1, I know I got only 4 hours of sleep. The night before day #2, about the same, because I could not fall asleep early enough and had to wake up at XC30 atlanta time which equals XA30 denver time. We were cleared for takeoff. Then departure or center called us and requested we call atl tower after arrival into denver. So then the mind games started. For 3 hours, we wondered, are we going to get violated? Are we going to get pulled off the trip? To add frosting on the cake, about 120 mi east of memphis, we had to deal with an in-flight medical emergency. We were able to continue to denver. Upon arrival in denver, I called atl tower and discussed the clearance incident with the tower supervisor. He said he reviewed the tapes and said, 'it looks like you folks need to listen more closely.' I told him, 'I agree, and this will not occur again!' he said, 'ok, and we will end it with this conversation.' I understood this to mean no further action or report or violation to follow. Additional contributing factor: the first officer also mentioned suffering from fatigue due to lack of sleep and recovering from the flu. Callback conversation with reporter revealed the following information: the reporter said he saw a couple of aircraft on the far end of the runway but did not realize until they started their takeoff roll that the traffic was crossing the runway. He said the controller had not issued them any traffic. He also said as routine practice, as soon as they cross the hold line going to the runway, he turns his lights on, indicating takeoff clearance. In addition, he was also turning the aircraft over to the first officer for the takeoff, which was somewhat of a distraction.
Original NASA ASRS Text
Title: B737 AT ATL TAXIES INTO POS AND INITIATES TKOF AFTER BEING ISSUED A CLRNC TO TAXI INTO POS AND HOLD. CTLR ABORTS TKOF ROLL.
Narrative: TAXIING E ON TXWY E, TWR SAID 'ACR X, TAXI INTO POS AND HOLD RWY 26L.' MY FO OR I ACKNOWLEDGED AND READ BACK THE CLRNC. AS I WAS TAXIING THE ACFT THROUGH A HDG OF ABOUT 080 DEGS, THE FO REACHED UP AND ARMED THE AUTOTHROTTLES. (I DON'T NORMALLY DO THIS ACTION UNTIL I AM XING THE HOLD SHORT TIME.' I SHARED THIS WITH THE FO. THIS IS ONLY THE SECOND DAY I'VE FLOWN WITH THIS FO. A LOT OF OUR FLYING PROCS BECOME 'ROUTINES.' ARMING THE AUTOTHROTTLES IS NORMALLY A CAPT PERFORMED ACTION. WHILE I WAS TAXIING OUT ONTO RWY 26L, I HEARD OTHER TWR XMISSIONS/CONS. AS I LINED UP THE ACFT, I THOUGHT I HEARD, OR ASSUMED, WE WERE CLRED FOR TKOF, OR THOUGHT THE FO ACKNOWLEDGED OUR TKOF CLRNC. I ARMED THE AUTOTHROTTLES AND TURNED ON THE LNDG LIGHTS. I THEN SAID TO THE FO, 'IT'S YOUR AIRPLANE' (FO'S LEG). THE FO STARTED TO ADVANCE THE THROTTLE WHEN I HEARD THE TWR CTLR SAY 'ACR X, CANCEL YOUR TKOF CLRNC.' WE WERE ABOUT 60 KTS WHEN I RETARDED THE THROTTLES. I ASSUMED CTL OF THE ACFT AND ACKNOWLEDGED THE CANCELLATION OF THE TKOF CLRNC. I SLOWED THE ACFT AND TURNED R OFF THE RWY AS PER TWR'S INSTRUCTIONS. AS I TURNED OFF RWY 26 ONTO THE TXWY B10, THE CTLR SAID 'ACR X YOU WERE CLRED POS AND HOLD ONLY.' WE ACKNOWLEDGED THIS XMISSION. THEY SAID CONTINUE ON TXWY B FOR TKOF SEQUENCE. I BELIEVED WE HAD BEEN CLRED FOR TKOF. THE FO THOUGHT ABOUT ASKING FOR VERIFICATION, BUT DIDN'T. WHEN I RETARDED THE THROTTLES, I SAW ACR Y (I BELIEVE) HOLDING AT B4 WAITING TO CROSS RWY 26L. I AM AWARE OF THE SERIOUSNESS OF THIS ASSUMPTION. UNDER LOW VISIBILITY, THIS COULD HAVE BEEN A PERFECT SET-UP FOR A COLLISION. CONTRIBUTING FACTORS: MOSTLY FATIGUE, LACK OF ADEQUATE REST. THIS WAS THE BEGINNING OF SECOND DAY OF A 3 DAY TRIP. ALL 3 DAYS ARE EARLY RPTS. THE NIGHT BEFORE DAY #1, I KNOW I GOT ONLY 4 HRS OF SLEEP. THE NIGHT BEFORE DAY #2, ABOUT THE SAME, BECAUSE I COULD NOT FALL ASLEEP EARLY ENOUGH AND HAD TO WAKE UP AT XC30 ATLANTA TIME WHICH EQUALS XA30 DENVER TIME. WE WERE CLRED FOR TKOF. THEN DEP OR CTR CALLED US AND REQUESTED WE CALL ATL TWR AFTER ARR INTO DENVER. SO THEN THE MIND GAMES STARTED. FOR 3 HRS, WE WONDERED, ARE WE GOING TO GET VIOLATED? ARE WE GOING TO GET PULLED OFF THE TRIP? TO ADD FROSTING ON THE CAKE, ABOUT 120 MI E OF MEMPHIS, WE HAD TO DEAL WITH AN INFLT MEDICAL EMER. WE WERE ABLE TO CONTINUE TO DENVER. UPON ARR IN DENVER, I CALLED ATL TWR AND DISCUSSED THE CLRNC INCIDENT WITH THE TWR SUPVR. HE SAID HE REVIEWED THE TAPES AND SAID, 'IT LOOKS LIKE YOU FOLKS NEED TO LISTEN MORE CLOSELY.' I TOLD HIM, 'I AGREE, AND THIS WILL NOT OCCUR AGAIN!' HE SAID, 'OK, AND WE WILL END IT WITH THIS CONVERSATION.' I UNDERSTOOD THIS TO MEAN NO FURTHER ACTION OR RPT OR VIOLATION TO FOLLOW. ADDITIONAL CONTRIBUTING FACTOR: THE FO ALSO MENTIONED SUFFERING FROM FATIGUE DUE TO LACK OF SLEEP AND RECOVERING FROM THE FLU. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR SAID HE SAW A COUPLE OF ACFT ON THE FAR END OF THE RWY BUT DID NOT REALIZE UNTIL THEY STARTED THEIR TKOF ROLL THAT THE TFC WAS XING THE RWY. HE SAID THE CTLR HAD NOT ISSUED THEM ANY TFC. HE ALSO SAID AS ROUTINE PRACTICE, AS SOON AS THEY CROSS THE HOLD LINE GOING TO THE RWY, HE TURNS HIS LIGHTS ON, INDICATING TKOF CLRNC. IN ADDITION, HE WAS ALSO TURNING THE ACFT OVER TO THE FO FOR THE TKOF, WHICH WAS SOMEWHAT OF A DISTR.
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.