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Attributes | |
ACN | 614936 |
Time | |
Date | 200404 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bwi.airport |
State Reference | MD |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 12000 flight time type : 7000 |
ASRS Report | 614936 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 200 flight time total : 10000 flight time type : 2000 |
ASRS Report | 614939 |
Events | |
Anomaly | incursion : runway non adherence : clearance non adherence : far non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance controller : issued advisory |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company Airport |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This was our 3RD leg of day 2 of a 3-DAY am trip. This was our 3RD airplane in as many legs. We came into the gate, had a plane swap, and departed. During the flight briefing, I briefed the first officer that we would probably use runway 15R and we would taxi via taxiway P. Our taxi clearance was 'company number taxi to runway 15R via taxiway P.' my first officer read the clearance back to ATC and I read it to him. I even pointed to it on my chart. Approaching the intersection of txwys PA and right, I saw the flashing lights at runway 15R and taxiway right. My first thought was why are these on. I then said to my first officer, 'we are cleared to cross right?' he said, 'he didn't tell us to hold short, do you want me to ask him?' I agreed he did not tell us to hold short, so we proceeded to taxi across runway 15R at taxiway right. I should have turned right at taxiway P. We followed our new procedures and cleared the runway both directions and illuminated all lights. At about romeo 1 my first officer said, 'where are we going?' and I said, 'we were supposed to taxi to runway 15R not cross it.' ATC called us at this time and we replied, 'we just realized it.' ATC gave us new taxi instructions to turn right and hold short of runway 15R at taxiway F. We were eventually cleared for takeoff and the rest of the flight was uneventful. I consider myself someone who pays attention to details and in 21 yrs, I have never made a mistake like this. How did this happen? I think these are some contributing factors. This particular intersection is a known hot spot (HS3). The txwys are very confusing and so is the signage. I am familiar with bwi and know this. We crossed flashing light at intersection right. I was on my 6TH leg with our new manual procedures. They require both pilots agree that they are cleared to cross any runway. When I said to my first officer, 'we are cleared to cross, right?' I was just not asking, I was complying with procedures. My first officer's response I took as an affirmative. We both were trying very hard to get all the new procedures right. The procedures designed to prevent this situation, may have contributed somewhat. We were more concerned with the mechanics of crossing a runway. Supplemental information from acn 614939: a few things contributed to this error: 1) taxiway P curves around the whole terminal. 2) prior conflicts between ground control in bwi and the asking to cross runway 4/22 taxiing to runway 28. 3) new procedures -- trying to get everything right, ie, clearing the runway and turning all lights on. I think any briefing of hot spots and the saying of will cross or will not cross any runway in the taxi brief will correct this kind of event.
Original NASA ASRS Text
Title: B737 TAXIING FOR DEP AT BWI CROSSED RWY WITHOUT ATC CLRNC.
Narrative: THIS WAS OUR 3RD LEG OF DAY 2 OF A 3-DAY AM TRIP. THIS WAS OUR 3RD AIRPLANE IN AS MANY LEGS. WE CAME INTO THE GATE, HAD A PLANE SWAP, AND DEPARTED. DURING THE FLT BRIEFING, I BRIEFED THE FO THAT WE WOULD PROBABLY USE RWY 15R AND WE WOULD TAXI VIA TXWY P. OUR TAXI CLRNC WAS 'COMPANY NUMBER TAXI TO RWY 15R VIA TXWY P.' MY FO READ THE CLRNC BACK TO ATC AND I READ IT TO HIM. I EVEN POINTED TO IT ON MY CHART. APCHING THE INTXN OF TXWYS PA AND R, I SAW THE FLASHING LIGHTS AT RWY 15R AND TXWY R. MY FIRST THOUGHT WAS WHY ARE THESE ON. I THEN SAID TO MY FO, 'WE ARE CLRED TO CROSS RIGHT?' HE SAID, 'HE DIDN'T TELL US TO HOLD SHORT, DO YOU WANT ME TO ASK HIM?' I AGREED HE DID NOT TELL US TO HOLD SHORT, SO WE PROCEEDED TO TAXI ACROSS RWY 15R AT TXWY R. I SHOULD HAVE TURNED R AT TXWY P. WE FOLLOWED OUR NEW PROCS AND CLRED THE RWY BOTH DIRECTIONS AND ILLUMINATED ALL LIGHTS. AT ABOUT ROMEO 1 MY FO SAID, 'WHERE ARE WE GOING?' AND I SAID, 'WE WERE SUPPOSED TO TAXI TO RWY 15R NOT CROSS IT.' ATC CALLED US AT THIS TIME AND WE REPLIED, 'WE JUST REALIZED IT.' ATC GAVE US NEW TAXI INSTRUCTIONS TO TURN R AND HOLD SHORT OF RWY 15R AT TXWY F. WE WERE EVENTUALLY CLRED FOR TKOF AND THE REST OF THE FLT WAS UNEVENTFUL. I CONSIDER MYSELF SOMEONE WHO PAYS ATTN TO DETAILS AND IN 21 YRS, I HAVE NEVER MADE A MISTAKE LIKE THIS. HOW DID THIS HAPPEN? I THINK THESE ARE SOME CONTRIBUTING FACTORS. THIS PARTICULAR INTXN IS A KNOWN HOT SPOT (HS3). THE TXWYS ARE VERY CONFUSING AND SO IS THE SIGNAGE. I AM FAMILIAR WITH BWI AND KNOW THIS. WE CROSSED FLASHING LIGHT AT INTXN R. I WAS ON MY 6TH LEG WITH OUR NEW MANUAL PROCS. THEY REQUIRE BOTH PLTS AGREE THAT THEY ARE CLRED TO CROSS ANY RWY. WHEN I SAID TO MY FO, 'WE ARE CLRED TO CROSS, RIGHT?' I WAS JUST NOT ASKING, I WAS COMPLYING WITH PROCS. MY FO'S RESPONSE I TOOK AS AN AFFIRMATIVE. WE BOTH WERE TRYING VERY HARD TO GET ALL THE NEW PROCS RIGHT. THE PROCS DESIGNED TO PREVENT THIS SIT, MAY HAVE CONTRIBUTED SOMEWHAT. WE WERE MORE CONCERNED WITH THE MECHS OF XING A RWY. SUPPLEMENTAL INFO FROM ACN 614939: A FEW THINGS CONTRIBUTED TO THIS ERROR: 1) TXWY P CURVES AROUND THE WHOLE TERMINAL. 2) PRIOR CONFLICTS BTWN GND CTL IN BWI AND THE ASKING TO CROSS RWY 4/22 TAXIING TO RWY 28. 3) NEW PROCS -- TRYING TO GET EVERYTHING RIGHT, IE, CLRING THE RWY AND TURNING ALL LIGHTS ON. I THINK ANY BRIEFING OF HOT SPOTS AND THE SAYING OF WILL CROSS OR WILL NOT CROSS ANY RWY IN THE TAXI BRIEF WILL CORRECT THIS KIND OF EVENT.
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.