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|
Attributes | |
ACN | 684724 |
Time | |
Date | 200601 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sfo.airport |
State Reference | CA |
Altitude | agl single value : 0 |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A319 |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : taxi landing : roll landing : hold short |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : sfo.tower |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 231 flight time total : 10000 flight time type : 4000 |
ASRS Report | 684724 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | conflict : ground less severe incursion : runway non adherence : clearance |
Independent Detector | other controllerb other flight crewa |
Resolutory Action | controller : separated traffic flight crew : became reoriented |
Supplementary | |
Problem Areas | Airport Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This was the last flight of a 4-DAY trip and the third flight out of 3 today. We kept the same airplane for all 3 legs. We had extensive delays all day due to maintenance. I briefed the tipp-toe visual to runway 28L at sfo and we talked about exiting the runway on taxiway D. Since the ACARS was no communication all day; we called sfo operation so we could come up with a good exit and taxi plan prior to landing. We were told the gate and we decided taxiway D would work well. Around menlo on the arrival; approach started us on a vector to the northeast for arrival traffic. The farther east we flew; the more we wondered if we really were going to runway 28L; so the captain asked the controller who informed us he was sending us to runway 28R. This was a little late on the arrival; in my opinion; to give us an unexpected runway; but not out of the ordinary. We switched runways in the mcdu while getting another vector back to course and then getting cleared for the visual to runway 28R and to follow the traffic 5 mi ahead. The landing was uneventful despite having the #2 thrust reverser OTS. This thrust reverser had been OTS; per maintenance; for all 3 legs. Tower told us to exit the runway using taxiway T and hold short of runway 28L. The captain took control of the airplane at approximately 50 or 60 KTS. I cleaned up the airplane (spoilers; flaps; flight directors; etc) as the captain exited on taxiway T. I looked at the hold short line for runway 28L while we still had plenty of time to stop. I expected; like always; that the captain would start braking when he was ready to. By the time I realized he might not stop in time; I started to second guess; and think like he did; that it was the exit line and that we needed to get past it to be fully off runway 28R. I tried quickly to see if it was runway 28L beyond the line; but could not determine quickly enough in the dark if it was; by looking at the pavement alone. I can't remember exactly what I said; but it was something to the effect of 'we need to stop.' what I was trying to convey was that we should stop so that we could figure out exactly where we were in relation to runway 28L. The captain stopped the airplane well prior to any part of our airplane being over or on runway 28L; but definitely over the runway 28L hold short line. At that point I was about to tell the tower where we were when the tower canceled the takeoff clearance of the airplane getting ready to start their takeoff roll. I attribute this runway incursion to a few things: 1) fatigue. This occurred at 12 hours 30 mins into our duty day after dealing with several maintenance issues and some extensive delays. 2) nighttime visual cues. My first instinct was to look at the pavement rather than the sides of the taxiway for the lights and signs the moment I realized there was some confusion. By the time I realized I couldn't make a clear determination looking at the pavement; it was too late to look for additional visual cues. I have always felt that the hold short pavement markings; dashed and solid lines; were inadequate and not instantly recognizable for determining which side you are on. However; I also thought that these shortcomings were made up for by the wigwag lights and signage. Tonight I realize that this is not adequate either. I believe that an instantly recognizable marking on the pavement that will blatantly and boldly indicate which side of the line you are on will quickly bolster situational awareness if there is any confusion at that point. Reinforced braking expectations. For all taxi operations; I have to trust the captain will start braking in time to stop at all holding lines. 9 times out of 10 the capts I fly with do not start braking until after the point where I initially feel the braking should begin; and yet they always do a fine job taxiing and stopping in time at the holding lines. This time seemed exactly the same but ended differently.
Original NASA ASRS Text
Title: A320 FLT CREW HAS A RWY INCURSION.
Narrative: THIS WAS THE LAST FLT OF A 4-DAY TRIP AND THE THIRD FLT OUT OF 3 TODAY. WE KEPT THE SAME AIRPLANE FOR ALL 3 LEGS. WE HAD EXTENSIVE DELAYS ALL DAY DUE TO MAINT. I BRIEFED THE TIPP-TOE VISUAL TO RWY 28L AT SFO AND WE TALKED ABOUT EXITING THE RWY ON TXWY D. SINCE THE ACARS WAS NO COM ALL DAY; WE CALLED SFO OP SO WE COULD COME UP WITH A GOOD EXIT AND TAXI PLAN PRIOR TO LNDG. WE WERE TOLD THE GATE AND WE DECIDED TXWY D WOULD WORK WELL. AROUND MENLO ON THE ARR; APCH STARTED US ON A VECTOR TO THE NE FOR ARR TFC. THE FARTHER E WE FLEW; THE MORE WE WONDERED IF WE REALLY WERE GOING TO RWY 28L; SO THE CAPT ASKED THE CTLR WHO INFORMED US HE WAS SENDING US TO RWY 28R. THIS WAS A LITTLE LATE ON THE ARR; IN MY OPINION; TO GIVE US AN UNEXPECTED RWY; BUT NOT OUT OF THE ORDINARY. WE SWITCHED RWYS IN THE MCDU WHILE GETTING ANOTHER VECTOR BACK TO COURSE AND THEN GETTING CLRED FOR THE VISUAL TO RWY 28R AND TO FOLLOW THE TFC 5 MI AHEAD. THE LNDG WAS UNEVENTFUL DESPITE HAVING THE #2 THRUST REVERSER OTS. THIS THRUST REVERSER HAD BEEN OTS; PER MAINT; FOR ALL 3 LEGS. TWR TOLD US TO EXIT THE RWY USING TXWY T AND HOLD SHORT OF RWY 28L. THE CAPT TOOK CTL OF THE AIRPLANE AT APPROX 50 OR 60 KTS. I CLEANED UP THE AIRPLANE (SPOILERS; FLAPS; FLT DIRECTORS; ETC) AS THE CAPT EXITED ON TXWY T. I LOOKED AT THE HOLD SHORT LINE FOR RWY 28L WHILE WE STILL HAD PLENTY OF TIME TO STOP. I EXPECTED; LIKE ALWAYS; THAT THE CAPT WOULD START BRAKING WHEN HE WAS READY TO. BY THE TIME I REALIZED HE MIGHT NOT STOP IN TIME; I STARTED TO SECOND GUESS; AND THINK LIKE HE DID; THAT IT WAS THE EXIT LINE AND THAT WE NEEDED TO GET PAST IT TO BE FULLY OFF RWY 28R. I TRIED QUICKLY TO SEE IF IT WAS RWY 28L BEYOND THE LINE; BUT COULD NOT DETERMINE QUICKLY ENOUGH IN THE DARK IF IT WAS; BY LOOKING AT THE PAVEMENT ALONE. I CAN'T REMEMBER EXACTLY WHAT I SAID; BUT IT WAS SOMETHING TO THE EFFECT OF 'WE NEED TO STOP.' WHAT I WAS TRYING TO CONVEY WAS THAT WE SHOULD STOP SO THAT WE COULD FIGURE OUT EXACTLY WHERE WE WERE IN RELATION TO RWY 28L. THE CAPT STOPPED THE AIRPLANE WELL PRIOR TO ANY PART OF OUR AIRPLANE BEING OVER OR ON RWY 28L; BUT DEFINITELY OVER THE RWY 28L HOLD SHORT LINE. AT THAT POINT I WAS ABOUT TO TELL THE TWR WHERE WE WERE WHEN THE TWR CANCELED THE TKOF CLRNC OF THE AIRPLANE GETTING READY TO START THEIR TKOF ROLL. I ATTRIBUTE THIS RWY INCURSION TO A FEW THINGS: 1) FATIGUE. THIS OCCURRED AT 12 HRS 30 MINS INTO OUR DUTY DAY AFTER DEALING WITH SEVERAL MAINT ISSUES AND SOME EXTENSIVE DELAYS. 2) NIGHTTIME VISUAL CUES. MY FIRST INSTINCT WAS TO LOOK AT THE PAVEMENT RATHER THAN THE SIDES OF THE TXWY FOR THE LIGHTS AND SIGNS THE MOMENT I REALIZED THERE WAS SOME CONFUSION. BY THE TIME I REALIZED I COULDN'T MAKE A CLR DETERMINATION LOOKING AT THE PAVEMENT; IT WAS TOO LATE TO LOOK FOR ADDITIONAL VISUAL CUES. I HAVE ALWAYS FELT THAT THE HOLD SHORT PAVEMENT MARKINGS; DASHED AND SOLID LINES; WERE INADEQUATE AND NOT INSTANTLY RECOGNIZABLE FOR DETERMINING WHICH SIDE YOU ARE ON. HOWEVER; I ALSO THOUGHT THAT THESE SHORTCOMINGS WERE MADE UP FOR BY THE WIGWAG LIGHTS AND SIGNAGE. TONIGHT I REALIZE THAT THIS IS NOT ADEQUATE EITHER. I BELIEVE THAT AN INSTANTLY RECOGNIZABLE MARKING ON THE PAVEMENT THAT WILL BLATANTLY AND BOLDLY INDICATE WHICH SIDE OF THE LINE YOU ARE ON WILL QUICKLY BOLSTER SITUATIONAL AWARENESS IF THERE IS ANY CONFUSION AT THAT POINT. REINFORCED BRAKING EXPECTATIONS. FOR ALL TAXI OPS; I HAVE TO TRUST THE CAPT WILL START BRAKING IN TIME TO STOP AT ALL HOLDING LINES. 9 TIMES OUT OF 10 THE CAPTS I FLY WITH DO NOT START BRAKING UNTIL AFTER THE POINT WHERE I INITIALLY FEEL THE BRAKING SHOULD BEGIN; AND YET THEY ALWAYS DO A FINE JOB TAXIING AND STOPPING IN TIME AT THE HOLDING LINES. THIS TIME SEEMED EXACTLY THE SAME BUT ENDED DIFFERENTLY.
Data retrieved from NASA's ASRS site as of January 2009 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.