Narrative:

I received a clearance for departure on runway 6R. After asking for a progressive taxi clearance, I held short at the assigned intersection and changed to tower frequency. I was asked by tower to confirm that the remaining runway from the intersection was sufficient. I shifted my attention to the 'shorter' end of the runway, confirmed it was sufficient, and was cleared to the local equivalent of 'position and hold.' on turning onto the runway, I confirmed the direction of turn towards the assigned runway on the directional gyro and held in position to await takeoff clearance. After a short period, was cleared for takeoff. On climb out, I was advised by the tower I had departed on runway 24L rather than runway 6R and was told to turn to a specific heading. I immediately began a steep turn to the assigned heading. About 1/2 way through the turn, the clearance was repeated, in such a way that I assumed I was turning to the heading in the wrong direction. In my readback, I confirmed the new direction of turn to the assigned heading. Soon the controller, sounding more concerned, assigned a new heading. I immediately turned to that heading and was flying it when the controller repeated the assignment. I confirmed that I was flying the assigned heading. At this point, the controller advised a DC9 on approach to runway 6L that a light aircraft was not listening to directions. Simultaneously, I recognized I must not actually have been flying the assigned heading I thought I was flying. I determined that the directional gyro was incorrectly set, reset the directional gyro and turned to the actual assigned heading. The captain of the DC9 replied to the controller that my aircraft was in sight and advised the controller that I was turning away his flight path and would not be a factor. I advised the controller I was now on the correct heading. On leaving his airspace, he requested I call him. The remainder of the flight was uneventful. On calling him, I explained my lack of directional control was due to an incorrectly set directional gyro and that on diagnosing and correcting that problem I was able to follow his instructions. The primary factors involved in this incident related to: 1) stress related to operating at an unfamiliar airfield, interping a new clearance from that filed. 2) failure to correctly set the directional gyro (in spite of following a printed checklist). 3) fatigue. 4) lack of independent corroboration or xchking of data. A) unfamiliar with field -- progressive taxi, no cues from other aircraft regarding direction of runway to use, held short at an intersection for departure. B) discussion of adequacy of remaining runway at intersection -- shifted mental focus to short end. C) overlapping error with directional gyro setting confounded directional check on turning onto runway. D) failure to corroborate with available aids in aircraft -- airport diagram on moving map display. 5) failure to heed 'inner voice' that recognized something was not right as takeoff roll began. 6) the calm professionalism of the controller -- directly and significantly contributed positively to the 'containment' of this incident. He issued instructions in a manner, which did not compound the stress inherent in dealing with what was clearly a major error. Operational suggestion: in cases where a controller determines an aircraft is not under directional control (eg, failing to fly an assigned heading once, or even based solely on departure on an unassigned runway) and potential for conflict with other aircraft exists, it may make more sense to give a specific turn instruction, rather than a heading. For example, on departure on a wrong runway, an instruction to turn 90 degrees left may save valuable seconds. This would help cover those circumstances where the initial error may extend beyond pilot stupidity and include a functional deficiency in the aircraft set-up.

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Original NASA ASRS Text

Title: CLRED FOR TKOF FROM AN INTXN AT CYUL, C210 PLT TAKES OFF ON RWY 24L VICE RWY 6R. SEPARATION PROB WITH INBOUND DC9 RESULTS.

Narrative: I RECEIVED A CLRNC FOR DEP ON RWY 6R. AFTER ASKING FOR A PROGRESSIVE TAXI CLRNC, I HELD SHORT AT THE ASSIGNED INTXN AND CHANGED TO TWR FREQ. I WAS ASKED BY TWR TO CONFIRM THAT THE REMAINING RWY FROM THE INTXN WAS SUFFICIENT. I SHIFTED MY ATTN TO THE 'SHORTER' END OF THE RWY, CONFIRMED IT WAS SUFFICIENT, AND WAS CLRED TO THE LCL EQUIVALENT OF 'POS AND HOLD.' ON TURNING ONTO THE RWY, I CONFIRMED THE DIRECTION OF TURN TOWARDS THE ASSIGNED RWY ON THE DIRECTIONAL GYRO AND HELD IN POS TO AWAIT TKOF CLRNC. AFTER A SHORT PERIOD, WAS CLRED FOR TKOF. ON CLBOUT, I WAS ADVISED BY THE TWR I HAD DEPARTED ON RWY 24L RATHER THAN RWY 6R AND WAS TOLD TO TURN TO A SPECIFIC HDG. I IMMEDIATELY BEGAN A STEEP TURN TO THE ASSIGNED HDG. ABOUT 1/2 WAY THROUGH THE TURN, THE CLRNC WAS REPEATED, IN SUCH A WAY THAT I ASSUMED I WAS TURNING TO THE HDG IN THE WRONG DIRECTION. IN MY READBACK, I CONFIRMED THE NEW DIRECTION OF TURN TO THE ASSIGNED HDG. SOON THE CTLR, SOUNDING MORE CONCERNED, ASSIGNED A NEW HDG. I IMMEDIATELY TURNED TO THAT HDG AND WAS FLYING IT WHEN THE CTLR REPEATED THE ASSIGNMENT. I CONFIRMED THAT I WAS FLYING THE ASSIGNED HDG. AT THIS POINT, THE CTLR ADVISED A DC9 ON APCH TO RWY 6L THAT A LIGHT ACFT WAS NOT LISTENING TO DIRECTIONS. SIMULTANEOUSLY, I RECOGNIZED I MUST NOT ACTUALLY HAVE BEEN FLYING THE ASSIGNED HDG I THOUGHT I WAS FLYING. I DETERMINED THAT THE DIRECTIONAL GYRO WAS INCORRECTLY SET, RESET THE DIRECTIONAL GYRO AND TURNED TO THE ACTUAL ASSIGNED HDG. THE CAPT OF THE DC9 REPLIED TO THE CTLR THAT MY ACFT WAS IN SIGHT AND ADVISED THE CTLR THAT I WAS TURNING AWAY HIS FLT PATH AND WOULD NOT BE A FACTOR. I ADVISED THE CTLR I WAS NOW ON THE CORRECT HDG. ON LEAVING HIS AIRSPACE, HE REQUESTED I CALL HIM. THE REMAINDER OF THE FLT WAS UNEVENTFUL. ON CALLING HIM, I EXPLAINED MY LACK OF DIRECTIONAL CTL WAS DUE TO AN INCORRECTLY SET DIRECTIONAL GYRO AND THAT ON DIAGNOSING AND CORRECTING THAT PROB I WAS ABLE TO FOLLOW HIS INSTRUCTIONS. THE PRIMARY FACTORS INVOLVED IN THIS INCIDENT RELATED TO: 1) STRESS RELATED TO OPERATING AT AN UNFAMILIAR AIRFIELD, INTERPING A NEW CLRNC FROM THAT FILED. 2) FAILURE TO CORRECTLY SET THE DIRECTIONAL GYRO (IN SPITE OF FOLLOWING A PRINTED CHKLIST). 3) FATIGUE. 4) LACK OF INDEPENDENT CORROBORATION OR XCHKING OF DATA. A) UNFAMILIAR WITH FIELD -- PROGRESSIVE TAXI, NO CUES FROM OTHER ACFT REGARDING DIRECTION OF RWY TO USE, HELD SHORT AT AN INTXN FOR DEP. B) DISCUSSION OF ADEQUACY OF REMAINING RWY AT INTXN -- SHIFTED MENTAL FOCUS TO SHORT END. C) OVERLAPPING ERROR WITH DIRECTIONAL GYRO SETTING CONFOUNDED DIRECTIONAL CHK ON TURNING ONTO RWY. D) FAILURE TO CORROBORATE WITH AVAILABLE AIDS IN ACFT -- ARPT DIAGRAM ON MOVING MAP DISPLAY. 5) FAILURE TO HEED 'INNER VOICE' THAT RECOGNIZED SOMETHING WAS NOT RIGHT AS TKOF ROLL BEGAN. 6) THE CALM PROFESSIONALISM OF THE CTLR -- DIRECTLY AND SIGNIFICANTLY CONTRIBUTED POSITIVELY TO THE 'CONTAINMENT' OF THIS INCIDENT. HE ISSUED INSTRUCTIONS IN A MANNER, WHICH DID NOT COMPOUND THE STRESS INHERENT IN DEALING WITH WHAT WAS CLRLY A MAJOR ERROR. OPERATIONAL SUGGESTION: IN CASES WHERE A CTLR DETERMINES AN ACFT IS NOT UNDER DIRECTIONAL CTL (EG, FAILING TO FLY AN ASSIGNED HDG ONCE, OR EVEN BASED SOLELY ON DEP ON AN UNASSIGNED RWY) AND POTENTIAL FOR CONFLICT WITH OTHER ACFT EXISTS, IT MAY MAKE MORE SENSE TO GIVE A SPECIFIC TURN INSTRUCTION, RATHER THAN A HDG. FOR EXAMPLE, ON DEP ON A WRONG RWY, AN INSTRUCTION TO TURN 90 DEGS L MAY SAVE VALUABLE SECONDS. THIS WOULD HELP COVER THOSE CIRCUMSTANCES WHERE THE INITIAL ERROR MAY EXTEND BEYOND PLT STUPIDITY AND INCLUDE A FUNCTIONAL DEFICIENCY IN THE ACFT SET-UP.

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.