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|
Attributes | |
ACN | 629443 |
Time | |
Date | 200408 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sfo.airport |
State Reference | CA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi landing : roll |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : sfo.tower |
Operator | common carrier : air carrier |
Make Model Name | Widebody Transport |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : roll |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : commercial pilot : flight engineer pilot : instrument pilot : multi engine pilot : private |
Experience | flight time last 90 days : 130 flight time total : 8260 flight time type : 4140 |
ASRS Report | 629443 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | conflict : ground critical incursion : runway non adherence : clearance non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted none taken : insufficient time |
Supplementary | |
Problem Areas | ATC Human Performance Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I landed on sfo runway 28R. I planned to exit the runway on the high-speed taxiway T. Our rollout speed was set for a gentle exit when sfo tower directed us to exit taxiway east and hold short, runway 28L. We were just crossing runway 19L/right. I heard 'taxiway east,' realized how close it was and immediately diverted my attention from the rest of the clearance to making the turn. Not what I was planning, but doable. I increased braking and made the turn off. My situational awareness was just coming back up to speed as I noticed the yellow runway hold short markings come into view and the landing lights of an air carrier Y 'heavy' jet approaching from the left. I realized that I hadn't been cleared to cross runway 28L, and stopped the aircraft as the hold short markings went under our nose. It was too dark to know how far over the line I was, though not enough to elicit a comment from sfo tower or the air carrier Y jet as they swept past seconds later. Once they had past, sfo tower cleared us to cross runway 28L and sfo ground control cleared us, txwys B, H, a to park. As I contemplated how close that situation could have come to real disaster, and how to avoid it in the future, several thoughts come to mind. If it is so important for us to exit the 11870 ft runway at the midpoint, wouldn't it be nice to know sometime before cockpit workload reaches a peak for this phase of flight? It seems to be the trend at a lot of larger airports, that tower controllers are issuing clrncs during this critical phase of landing. Yes, it is my responsibility, but it's a setup. We've just touched down, both pilots' attention is focused on safely slowing the aircraft, spoilers, reversers, autobrakes disarmed, airspeed, runway remaining, crosswind drift. A snap decision is required when one is really not necessary. A simple 'negative' or even no response would have been more appropriate, but my first officer read back the clearance and I latched on to 'taxiway east,' because we can make it happen. Was exiting runway 28R at taxiway east instead of the high-speed, taxiway T really that critical, especially since the distance is nearly identical? As we cleared at taxiway east, I had not repeated the 'hold short' clearance, as is company policy as well as my personal habit, because I had not heard it. My attention was focused almost completely on acquiring the taxiway and making the turn off. I should specifically brief my first officer's to insure they get a clearance readback from me. My first officer's attention was complacently diverted to looking up the ground control frequency instead of backing me up. Expect the unexpected. I can focus a little more on the rollout portion of the flight when I am briefing the approach and landing, ready for the 'taxiway east' call with a quick 'negative.'
Original NASA ASRS Text
Title: THE LATE CALL FOR A B737 TO EXIT RWY 28R AT TXWY E INSTEAD OF THE CREW PLANNED EXIT AT TXWY T RESULTS IN XING THE HOLD SHORT LINE FOR RWY 28L WITH A HVY JET APCHING ON ITS LNDG ROLLOUT.
Narrative: I LANDED ON SFO RWY 28R. I PLANNED TO EXIT THE RWY ON THE HIGH-SPD TXWY T. OUR ROLLOUT SPD WAS SET FOR A GENTLE EXIT WHEN SFO TWR DIRECTED US TO EXIT TXWY E AND HOLD SHORT, RWY 28L. WE WERE JUST XING RWY 19L/R. I HEARD 'TXWY E,' REALIZED HOW CLOSE IT WAS AND IMMEDIATELY DIVERTED MY ATTN FROM THE REST OF THE CLRNC TO MAKING THE TURN. NOT WHAT I WAS PLANNING, BUT DOABLE. I INCREASED BRAKING AND MADE THE TURN OFF. MY SITUATIONAL AWARENESS WAS JUST COMING BACK UP TO SPD AS I NOTICED THE YELLOW RWY HOLD SHORT MARKINGS COME INTO VIEW AND THE LNDG LIGHTS OF AN ACR Y 'HVY' JET APCHING FROM THE L. I REALIZED THAT I HADN'T BEEN CLRED TO CROSS RWY 28L, AND STOPPED THE ACFT AS THE HOLD SHORT MARKINGS WENT UNDER OUR NOSE. IT WAS TOO DARK TO KNOW HOW FAR OVER THE LINE I WAS, THOUGH NOT ENOUGH TO ELICIT A COMMENT FROM SFO TWR OR THE ACR Y JET AS THEY SWEPT PAST SECONDS LATER. ONCE THEY HAD PAST, SFO TWR CLRED US TO CROSS RWY 28L AND SFO GND CTL CLRED US, TXWYS B, H, A TO PARK. AS I CONTEMPLATED HOW CLOSE THAT SIT COULD HAVE COME TO REAL DISASTER, AND HOW TO AVOID IT IN THE FUTURE, SEVERAL THOUGHTS COME TO MIND. IF IT IS SO IMPORTANT FOR US TO EXIT THE 11870 FT RWY AT THE MIDPOINT, WOULDN'T IT BE NICE TO KNOW SOMETIME BEFORE COCKPIT WORKLOAD REACHES A PEAK FOR THIS PHASE OF FLT? IT SEEMS TO BE THE TREND AT A LOT OF LARGER ARPTS, THAT TWR CTLRS ARE ISSUING CLRNCS DURING THIS CRITICAL PHASE OF LNDG. YES, IT IS MY RESPONSIBILITY, BUT IT'S A SETUP. WE'VE JUST TOUCHED DOWN, BOTH PLTS' ATTN IS FOCUSED ON SAFELY SLOWING THE ACFT, SPOILERS, REVERSERS, AUTOBRAKES DISARMED, AIRSPD, RWY REMAINING, XWIND DRIFT. A SNAP DECISION IS REQUIRED WHEN ONE IS REALLY NOT NECESSARY. A SIMPLE 'NEGATIVE' OR EVEN NO RESPONSE WOULD HAVE BEEN MORE APPROPRIATE, BUT MY FO READ BACK THE CLRNC AND I LATCHED ON TO 'TXWY E,' BECAUSE WE CAN MAKE IT HAPPEN. WAS EXITING RWY 28R AT TXWY E INSTEAD OF THE HIGH-SPD, TXWY T REALLY THAT CRITICAL, ESPECIALLY SINCE THE DISTANCE IS NEARLY IDENTICAL? AS WE CLRED AT TXWY E, I HAD NOT REPEATED THE 'HOLD SHORT' CLRNC, AS IS COMPANY POLICY AS WELL AS MY PERSONAL HABIT, BECAUSE I HAD NOT HEARD IT. MY ATTN WAS FOCUSED ALMOST COMPLETELY ON ACQUIRING THE TXWY AND MAKING THE TURN OFF. I SHOULD SPECIFICALLY BRIEF MY FO'S TO INSURE THEY GET A CLRNC READBACK FROM ME. MY FO'S ATTN WAS COMPLACENTLY DIVERTED TO LOOKING UP THE GND CTL FREQ INSTEAD OF BACKING ME UP. EXPECT THE UNEXPECTED. I CAN FOCUS A LITTLE MORE ON THE ROLLOUT PORTION OF THE FLT WHEN I AM BRIEFING THE APCH AND LNDG, READY FOR THE 'TXWY E' CALL WITH A QUICK 'NEGATIVE.'
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.