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Attributes | |
ACN | 621682 |
Time | |
Date | 200406 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sna.airport |
State Reference | CA |
Altitude | agl single value : 0 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : sna.tower tower : rap.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : sna.tower |
Operator | general aviation : personal |
Make Model Name | PA-28 Cherokee/Archer II/Dakota/Pillan/Warrior |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach landing : go around |
Route In Use | approach : straight in approach : traffic pattern |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 3500 flight time type : 1500 |
ASRS Report | 621682 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : multi engine pilot : cfi |
Experience | flight time last 90 days : 140 flight time total : 12000 flight time type : 8000 |
ASRS Report | 621986 |
Events | |
Anomaly | conflict : ground less severe ground encounters other incursion : runway non adherence : required legal separation non adherence : published procedure non adherence : far non adherence : company policies non adherence : clearance |
Independent Detector | other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance flight crew : executed go around flight crew : took evasive action other |
Miss Distance | vertical : 500 |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
While holding short of taxiway left on taxiway a, tower instructed us to taxi to runway 19R, hold short runway 19L. The taxi clearance was read back and the captain started the taxi. Shortly after we started the taxi I was looking in the cockpit to do some last min FMC inputs. I looked up to see the captain getting ready to cross runway 19L. I said 'we need to hold short of runway 19L,' but in retrospect I should have been more assertive in my actions. The captain crossed runway 19L. The tower realized our situation and instructed us to then hold short of runway 19R. It had been a long day already with a 3 1/2 hour delay and an airborne mechanical which resulted with return to ZZZ after takeoff. Contributing factors were probably fatigue although we didn't realize it. Supplemental information from acn 621986: I looked to the right and saw an aircraft on final for the runway and nothing for the left. As I crossed the limit line, I heard the first officer say something (hesitantly) that didn't register at first. Then it struck me that he had said 'hold short.' I started to stop and looked out the right side window up high and saw a cherokee starting a go around. My first officer was on his first revenue flight after his IOE training and was doing a fine job, but required some extra attention from me during the preflight planning and preparation for each leg. He was also a little unsure of himself and, therefore, did not advocate what he knew was right until it was too late. I talked with my first officer about the need to advocate information more forcefully and clearly when it is necessary, even to the point of stepping on the brakes when the airplane should be stopped and the captain isn't stopping it. I will be verbally reconfirming clrncs to cross all runways or to hold short with my first officer before crossing any lines. This will be difficult because it is during a very busy time for both pilots, but I believe it is a critical step in preventing this kind of incursion from happening again.
Original NASA ASRS Text
Title: B737-700 CREW HAD A RWY INCURSION AT SNA THAT REQUIRED A PA28 PLT TO GO AROUND.
Narrative: WHILE HOLDING SHORT OF TXWY L ON TXWY A, TWR INSTRUCTED US TO TAXI TO RWY 19R, HOLD SHORT RWY 19L. THE TAXI CLRNC WAS READ BACK AND THE CAPT STARTED THE TAXI. SHORTLY AFTER WE STARTED THE TAXI I WAS LOOKING IN THE COCKPIT TO DO SOME LAST MIN FMC INPUTS. I LOOKED UP TO SEE THE CAPT GETTING READY TO CROSS RWY 19L. I SAID 'WE NEED TO HOLD SHORT OF RWY 19L,' BUT IN RETROSPECT I SHOULD HAVE BEEN MORE ASSERTIVE IN MY ACTIONS. THE CAPT CROSSED RWY 19L. THE TWR REALIZED OUR SIT AND INSTRUCTED US TO THEN HOLD SHORT OF RWY 19R. IT HAD BEEN A LONG DAY ALREADY WITH A 3 1/2 HR DELAY AND AN AIRBORNE MECHANICAL WHICH RESULTED WITH RETURN TO ZZZ AFTER TKOF. CONTRIBUTING FACTORS WERE PROBABLY FATIGUE ALTHOUGH WE DIDN'T REALIZE IT. SUPPLEMENTAL INFO FROM ACN 621986: I LOOKED TO THE R AND SAW AN ACFT ON FINAL FOR THE RWY AND NOTHING FOR THE L. AS I CROSSED THE LIMIT LINE, I HEARD THE FO SAY SOMETHING (HESITANTLY) THAT DIDN'T REGISTER AT FIRST. THEN IT STRUCK ME THAT HE HAD SAID 'HOLD SHORT.' I STARTED TO STOP AND LOOKED OUT THE R SIDE WINDOW UP HIGH AND SAW A CHEROKEE STARTING A GAR. MY FO WAS ON HIS FIRST REVENUE FLT AFTER HIS IOE TRAINING AND WAS DOING A FINE JOB, BUT REQUIRED SOME EXTRA ATTN FROM ME DURING THE PREFLT PLANNING AND PREPARATION FOR EACH LEG. HE WAS ALSO A LITTLE UNSURE OF HIMSELF AND, THEREFORE, DID NOT ADVOCATE WHAT HE KNEW WAS RIGHT UNTIL IT WAS TOO LATE. I TALKED WITH MY FO ABOUT THE NEED TO ADVOCATE INFO MORE FORCEFULLY AND CLRLY WHEN IT IS NECESSARY, EVEN TO THE POINT OF STEPPING ON THE BRAKES WHEN THE AIRPLANE SHOULD BE STOPPED AND THE CAPT ISN'T STOPPING IT. I WILL BE VERBALLY RECONFIRMING CLRNCS TO CROSS ALL RWYS OR TO HOLD SHORT WITH MY FO BEFORE XING ANY LINES. THIS WILL BE DIFFICULT BECAUSE IT IS DURING A VERY BUSY TIME FOR BOTH PLTS, BUT I BELIEVE IT IS A CRITICAL STEP IN PREVENTING THIS KIND OF INCURSION FROM HAPPENING AGAIN.
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.