Narrative:

I was working ground control 2 (124.25) combined with ground control 1 (121.8) during a west plan operation; landing runways 28; departing runways 1. An light transport called for taxi from the FBO requesting runway 28R at intersection east. I taxied the light transport to runway 28R at intersection east and issued him the required amended altitude. As he was taxiing on taxiway C approaching taxiway D; I saw that there were many departures; including many heavy jets already waiting to depart runway 28. I decided to take the light transport to runway 1R. I told the light transport that there would be a long wait for runway 28R at taxiway east. I told the light transport to turn right on taxiway D and hold short of runway 28R; but before you do that; let me tell you the wind. I gave him the wind and asked if he could accept runway 1R. As I was saying this; I saw that it was a good time to coordination the runway crossing with local control; so I punched in to local control on the landline. I heard the pilot reading back that he could take runway 1 and hold short of runway 28; on the override speaker and I requested to cross runway 28R after traffic touching down and runway 28L after traffic touching down. Local control said; 'cross runway 28R after...oh; it looks like he's crossing now....' I looked at taxiway D and saw the light transport entering runway 28R on taxiway D. Chain of events/how the problem arose: the problem began when the light transport requested to depart runway 28R at taxiway east. The light transport was routed over lin so the advertised departure runway for his route would be runway 1R. I was quite busy and even behind; so it was easiest for me to just taxi him to runway 28R at taxiway east as he requested. In doing this; I would still have to amend his initial altitude assignment and 'expect higher in' time; but at least his taxi route was easy. Taking the light transport to runway 28R at taxiway east would make my job easiest; but I also knew that it would make local control's job and nct departure control sector's job much harder. Then I saw that he would incur a significant delay for runway 28R at taxiway east so I decided to get him to runway 1R. This required a lot more work for me since he now had to also cross 2 runways and I needed to coordination that and I would need to re-amend his altitudes and expect higher time. The finals were very busy and I was now getting in local control's way with the light transport by blocking taxiway D; so I wanted to get him across runways 28 and out of local control's way as quickly as I could. I saw an opportunity to get him across runways 28 after 2 arrs which were over the numbers for runways 28R and 28L; and right now would be a good time to coordination with local control. But before I could do this; I had to get the light transport turned at taxiway D; stopped short of runway 28R and; as I was thinking this; I saw that the wind was now picking up out of the south so it would be a tailwind for the light transport to depart runway 1R; so I felt that I also needed to ask the light transport if they could accept the departure with the tailwind. So I implemented my plan which required that I accomplish many tasks in a very short period of time. Contributing factors/staffing: due to low staffing it was necessary to combine the 2 ground control position so that a controller could be released from duty at the end of his shift. There was also insufficient staffing for the cabin attendant-coordinator position to be staffed. Combining ground control position: normally; when we combine the ground control position we get a 'heads up' advisory from the supervisor/controller in charge. Example: 'combine the grounds when you can' or 'as soon as you can' or in a general period of time. In this case it was very near the end of the ground control 2 controller's shift and the supervisor told me to move over to ground control 2 and take both grounds. Since I was still quite busy with ground control 1 traffic I wanted to get the briefing from ground control 2 and make the move over to ground control 2 as quickly as possible. At the moment I had no xmissions to make to my traffic; but I saw that soon I would have several xmissions to make. I wanted to combine the position and move myself and all my strips over to ground control 2 during a short lull in my workload very quickly. Working 2 frequencys: when I moved over to ground control 2 to take both grounds; I selected 121.8 but I did not put 124.25 on speaker. So now I had 2 frequencys in my headset. I became so busy with trying to sort out 2 xmissions at once that I didn't find the opportunity to put 124.25 on speaker and my workload increased substantially since I could not understand simultaneous xmissions from the 2 frequencys I was working and I had to repeat many xmissions. Wind: a runway change was imminent due to wind. My workload at the time of this incident was greatly increased due to the wind. Some aircraft that I taxied to the advertised runway 1 requested runway 28 due to the wind. Changing their runway assignment requires both new verbal clearance for their taxi route; altitude assignment and expect higher time as well as strip marking changes which need to be accomplished. And I must also ensure that all pilot readbacks are correct. Complexity; airport confign; clearance items; coordination traffic: we were working 4 active runways which intersect in the middle. We had aircraft landing on runways 28; departing runways 14; 1L; 28L; 28R; and 28R at intersection east. I had to get aircraft from the west end of the airport to the east end by crossing runways 1; from the FBO on the north side of the runways 1 on the south side; from the south side to the north side; from the landing runways to the gates. Any change in runway assignment requires a change in altitude; expect higher time and strip marking. The pilot readbacks are very often incorrect. When aircraft are changed from departing runways 1 to departing runways 28 on west plan; they most often (shoreline and rebas expected) need to be changed to 'maintain 3000 ft; expect filed altitude 3 mins after departure.' pilots most often read back the altitude correctly but read back the 'expect filed altitude' time wrong. This must first be heard by the controller and then corrected with the pilot. All this takes time and concentration when both pilot and controller are very busy. Runway crossing rules: my failure to use concise; standard phraseology resulted in confusion and misunderstanding between myself and the pilots. My original clearance to the light transport was 'taxi to runway 28R at east.' this clearance did not allow the light transport to cross any runways at all. I subsequently issued the clearance: 'turn right at D; hold short of runway 28R....' since I added a lot of other information to the clearance I can understand the confusion that resulted. However; in order for the light transport's pilots to cross an active runway 28R in this situation; they must either hear the clearance: 'cross runway 28R...' or 'runway 1R; taxi via taxiway D; hold short of runway 28L.' they thought I said 'hold short of runway 28L.' in my opinion; the rules should be simplified at least to the extent that a positive clearance be required to cross any active runway. Corrective actions: in order to comply with the 7110.65 handbook requirement to ensure that pilot readbacks are correct; I must allow time and opportunity in my plan to hear the readback and ensure that it is correct. In this situation; I should have begun by stopping the light transport short of taxiway D or short of runway 28R; and obtain a good readback. Then continue with all the rest of my plan. I need to find some way of getting adequate rest during my work week. This is very difficult given the rotating schedule that we are required to work. Controllers should be rotated through different position instead of working the same position multiple times in a shift. Staffing cabin attendant-coordinator during busy or complex traffic would greatly decrease workload for the ground controllers. Simplified runway crossing rules would greatly reduce the likelihood of runway incursions. Human performance considerations/perception; judgement; decisions: I expected the light transport to stop short of D on C when I said 'but before you do that....' with this perception in my mind; I was not so concerned about hearing his complete readback so I could now coordination for the runway crossing. My judgement to change the runway for the light transport was based on trying to avoid any delay for him. My perception was that he was in a hurry. The pilot spoke very quickly; the aircraft was taxied briskly and this put me in 'work fast mode' as far as this aircraft was concerned. Had I been less fatigued I believe I would have worked at my pace; not his. Changing my plan and putting the light transport at taxiway D now put him in local control's way; so now I felt that I had to get him out of local control's way as quickly as possible. Thisalso rushed me causing me to take shortcuts. Factors affecting the quality of human performance/fatigue: I believe that fatigue was the biggest factor for me in this incident. At the time of this incident; I was very fatigued. It was near the end of my 8 hour shift (7 rs 10 mins into my shift). This was my third ground control session in the shift. I had in the shift previously worked ground control 2 combined with ground control 1; ground control 2 decombined then ground control 1 decombined. It was the 4TH day of my work week and I was working on a 'quick turn.' I had worked XA00-xi-- on my first day of the work week; XW30-XG30 the second ay; XW30-XG30 the third day and I had started this shift at XP30. I had slept approximately 5 hours between shifts and I had been up since XN30. Workload and complexity: this narrative describes the workload and control actions required for just 1 aircraft during a time when many other aircraft also required air traffic services from the ground controller. I had to make many changes to many clrncs. I had to scan the entire airport surface as well as the ASR display; asde and strips. In trying to look out the windows; I often had to look around the other tower personnel in order to see what I needed to see. 1 aircraft; a B777; was completely hidden behind a window post and it took me considerable effort to determine his position on the airport. Inactions: I failed to actively listen for the pilot readback of the hold short instruction. As I was coordinating with local control on the landline I did hear him read back over the speaker; but since I was listening to 2 different things at once I did not comprehend his full readback. My plan and my actions did not allow time or opportunity for me to hear the readback.

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Original NASA ASRS Text

Title: SFO TWR GND CTLR DESCRIBED COMBINED OPERROR/PLTDEV EVENT WHEN ACFT CROSSED OCCUPIED RWY; MULTIPLE FACTORS LISTED AS CONTRIBUTORY.

Narrative: I WAS WORKING GND CTL 2 (124.25) COMBINED WITH GND CTL 1 (121.8) DURING A W PLAN OP; LNDG RWYS 28; DEPARTING RWYS 1. AN LTT CALLED FOR TAXI FROM THE FBO REQUESTING RWY 28R AT INTXN E. I TAXIED THE LTT TO RWY 28R AT INTXN E AND ISSUED HIM THE REQUIRED AMENDED ALT. AS HE WAS TAXIING ON TXWY C APCHING TXWY D; I SAW THAT THERE WERE MANY DEPS; INCLUDING MANY HVY JETS ALREADY WAITING TO DEPART RWY 28. I DECIDED TO TAKE THE LTT TO RWY 1R. I TOLD THE LTT THAT THERE WOULD BE A LONG WAIT FOR RWY 28R AT TXWY E. I TOLD THE LTT TO TURN R ON TXWY D AND HOLD SHORT OF RWY 28R; BUT BEFORE YOU DO THAT; LET ME TELL YOU THE WIND. I GAVE HIM THE WIND AND ASKED IF HE COULD ACCEPT RWY 1R. AS I WAS SAYING THIS; I SAW THAT IT WAS A GOOD TIME TO COORD THE RWY XING WITH LCL CTL; SO I PUNCHED IN TO LCL CTL ON THE LANDLINE. I HEARD THE PLT READING BACK THAT HE COULD TAKE RWY 1 AND HOLD SHORT OF RWY 28; ON THE OVERRIDE SPEAKER AND I REQUESTED TO CROSS RWY 28R AFTER TFC TOUCHING DOWN AND RWY 28L AFTER TFC TOUCHING DOWN. LCL CTL SAID; 'CROSS RWY 28R AFTER...OH; IT LOOKS LIKE HE'S XING NOW....' I LOOKED AT TXWY D AND SAW THE LTT ENTERING RWY 28R ON TXWY D. CHAIN OF EVENTS/HOW THE PROB AROSE: THE PROB BEGAN WHEN THE LTT REQUESTED TO DEPART RWY 28R AT TXWY E. THE LTT WAS ROUTED OVER LIN SO THE ADVERTISED DEP RWY FOR HIS RTE WOULD BE RWY 1R. I WAS QUITE BUSY AND EVEN BEHIND; SO IT WAS EASIEST FOR ME TO JUST TAXI HIM TO RWY 28R AT TXWY E AS HE REQUESTED. IN DOING THIS; I WOULD STILL HAVE TO AMEND HIS INITIAL ALT ASSIGNMENT AND 'EXPECT HIGHER IN' TIME; BUT AT LEAST HIS TAXI RTE WAS EASY. TAKING THE LTT TO RWY 28R AT TXWY E WOULD MAKE MY JOB EASIEST; BUT I ALSO KNEW THAT IT WOULD MAKE LCL CTL'S JOB AND NCT DEP CTL SECTOR'S JOB MUCH HARDER. THEN I SAW THAT HE WOULD INCUR A SIGNIFICANT DELAY FOR RWY 28R AT TXWY E SO I DECIDED TO GET HIM TO RWY 1R. THIS REQUIRED A LOT MORE WORK FOR ME SINCE HE NOW HAD TO ALSO CROSS 2 RWYS AND I NEEDED TO COORD THAT AND I WOULD NEED TO RE-AMEND HIS ALTS AND EXPECT HIGHER TIME. THE FINALS WERE VERY BUSY AND I WAS NOW GETTING IN LCL CTL'S WAY WITH THE LTT BY BLOCKING TXWY D; SO I WANTED TO GET HIM ACROSS RWYS 28 AND OUT OF LCL CTL'S WAY AS QUICKLY AS I COULD. I SAW AN OPPORTUNITY TO GET HIM ACROSS RWYS 28 AFTER 2 ARRS WHICH WERE OVER THE NUMBERS FOR RWYS 28R AND 28L; AND RIGHT NOW WOULD BE A GOOD TIME TO COORD WITH LCL CTL. BUT BEFORE I COULD DO THIS; I HAD TO GET THE LTT TURNED AT TXWY D; STOPPED SHORT OF RWY 28R AND; AS I WAS THINKING THIS; I SAW THAT THE WIND WAS NOW PICKING UP OUT OF THE S SO IT WOULD BE A TAILWIND FOR THE LTT TO DEPART RWY 1R; SO I FELT THAT I ALSO NEEDED TO ASK THE LTT IF THEY COULD ACCEPT THE DEP WITH THE TAILWIND. SO I IMPLEMENTED MY PLAN WHICH REQUIRED THAT I ACCOMPLISH MANY TASKS IN A VERY SHORT PERIOD OF TIME. CONTRIBUTING FACTORS/STAFFING: DUE TO LOW STAFFING IT WAS NECESSARY TO COMBINE THE 2 GND CTL POS SO THAT A CTLR COULD BE RELEASED FROM DUTY AT THE END OF HIS SHIFT. THERE WAS ALSO INSUFFICIENT STAFFING FOR THE CAB-COORDINATOR POS TO BE STAFFED. COMBINING GND CTL POS: NORMALLY; WHEN WE COMBINE THE GND CTL POS WE GET A 'HEADS UP' ADVISORY FROM THE SUPVR/CIC. EXAMPLE: 'COMBINE THE GROUNDS WHEN YOU CAN' OR 'AS SOON AS YOU CAN' OR IN A GENERAL PERIOD OF TIME. IN THIS CASE IT WAS VERY NEAR THE END OF THE GND CTL 2 CTLR'S SHIFT AND THE SUPVR TOLD ME TO MOVE OVER TO GND CTL 2 AND TAKE BOTH GROUNDS. SINCE I WAS STILL QUITE BUSY WITH GND CTL 1 TFC I WANTED TO GET THE BRIEFING FROM GND CTL 2 AND MAKE THE MOVE OVER TO GND CTL 2 AS QUICKLY AS POSSIBLE. AT THE MOMENT I HAD NO XMISSIONS TO MAKE TO MY TFC; BUT I SAW THAT SOON I WOULD HAVE SEVERAL XMISSIONS TO MAKE. I WANTED TO COMBINE THE POS AND MOVE MYSELF AND ALL MY STRIPS OVER TO GND CTL 2 DURING A SHORT LULL IN MY WORKLOAD VERY QUICKLY. WORKING 2 FREQS: WHEN I MOVED OVER TO GND CTL 2 TO TAKE BOTH GROUNDS; I SELECTED 121.8 BUT I DID NOT PUT 124.25 ON SPEAKER. SO NOW I HAD 2 FREQS IN MY HEADSET. I BECAME SO BUSY WITH TRYING TO SORT OUT 2 XMISSIONS AT ONCE THAT I DIDN'T FIND THE OPPORTUNITY TO PUT 124.25 ON SPEAKER AND MY WORKLOAD INCREASED SUBSTANTIALLY SINCE I COULD NOT UNDERSTAND SIMULTANEOUS XMISSIONS FROM THE 2 FREQS I WAS WORKING AND I HAD TO REPEAT MANY XMISSIONS. WIND: A RWY CHANGE WAS IMMINENT DUE TO WIND. MY WORKLOAD AT THE TIME OF THIS INCIDENT WAS GREATLY INCREASED DUE TO THE WIND. SOME ACFT THAT I TAXIED TO THE ADVERTISED RWY 1 REQUESTED RWY 28 DUE TO THE WIND. CHANGING THEIR RWY ASSIGNMENT REQUIRES BOTH NEW VERBAL CLRNC FOR THEIR TAXI RTE; ALT ASSIGNMENT AND EXPECT HIGHER TIME AS WELL AS STRIP MARKING CHANGES WHICH NEED TO BE ACCOMPLISHED. AND I MUST ALSO ENSURE THAT ALL PLT READBACKS ARE CORRECT. COMPLEXITY; ARPT CONFIGN; CLRNC ITEMS; COORD TFC: WE WERE WORKING 4 ACTIVE RWYS WHICH INTERSECT IN THE MIDDLE. WE HAD ACFT LNDG ON RWYS 28; DEPARTING RWYS 14; 1L; 28L; 28R; AND 28R AT INTXN E. I HAD TO GET ACFT FROM THE W END OF THE ARPT TO THE E END BY XING RWYS 1; FROM THE FBO ON THE N SIDE OF THE RWYS 1 ON THE S SIDE; FROM THE S SIDE TO THE N SIDE; FROM THE LNDG RWYS TO THE GATES. ANY CHANGE IN RWY ASSIGNMENT REQUIRES A CHANGE IN ALT; EXPECT HIGHER TIME AND STRIP MARKING. THE PLT READBACKS ARE VERY OFTEN INCORRECT. WHEN ACFT ARE CHANGED FROM DEPARTING RWYS 1 TO DEPARTING RWYS 28 ON W PLAN; THEY MOST OFTEN (SHORELINE AND REBAS EXPECTED) NEED TO BE CHANGED TO 'MAINTAIN 3000 FT; EXPECT FILED ALT 3 MINS AFTER DEP.' PLTS MOST OFTEN READ BACK THE ALT CORRECTLY BUT READ BACK THE 'EXPECT FILED ALT' TIME WRONG. THIS MUST FIRST BE HEARD BY THE CTLR AND THEN CORRECTED WITH THE PLT. ALL THIS TAKES TIME AND CONCENTRATION WHEN BOTH PLT AND CTLR ARE VERY BUSY. RWY XING RULES: MY FAILURE TO USE CONCISE; STANDARD PHRASEOLOGY RESULTED IN CONFUSION AND MISUNDERSTANDING BTWN MYSELF AND THE PLTS. MY ORIGINAL CLRNC TO THE LTT WAS 'TAXI TO RWY 28R AT E.' THIS CLRNC DID NOT ALLOW THE LTT TO CROSS ANY RWYS AT ALL. I SUBSEQUENTLY ISSUED THE CLRNC: 'TURN R AT D; HOLD SHORT OF RWY 28R....' SINCE I ADDED A LOT OF OTHER INFO TO THE CLRNC I CAN UNDERSTAND THE CONFUSION THAT RESULTED. HOWEVER; IN ORDER FOR THE LTT'S PLTS TO CROSS AN ACTIVE RWY 28R IN THIS SITUATION; THEY MUST EITHER HEAR THE CLRNC: 'CROSS RWY 28R...' OR 'RWY 1R; TAXI VIA TXWY D; HOLD SHORT OF RWY 28L.' THEY THOUGHT I SAID 'HOLD SHORT OF RWY 28L.' IN MY OPINION; THE RULES SHOULD BE SIMPLIFIED AT LEAST TO THE EXTENT THAT A POSITIVE CLRNC BE REQUIRED TO CROSS ANY ACTIVE RWY. CORRECTIVE ACTIONS: IN ORDER TO COMPLY WITH THE 7110.65 HANDBOOK REQUIREMENT TO ENSURE THAT PLT READBACKS ARE CORRECT; I MUST ALLOW TIME AND OPPORTUNITY IN MY PLAN TO HEAR THE READBACK AND ENSURE THAT IT IS CORRECT. IN THIS SITUATION; I SHOULD HAVE BEGUN BY STOPPING THE LTT SHORT OF TXWY D OR SHORT OF RWY 28R; AND OBTAIN A GOOD READBACK. THEN CONTINUE WITH ALL THE REST OF MY PLAN. I NEED TO FIND SOME WAY OF GETTING ADEQUATE REST DURING MY WORK WK. THIS IS VERY DIFFICULT GIVEN THE ROTATING SCHEDULE THAT WE ARE REQUIRED TO WORK. CTLRS SHOULD BE ROTATED THROUGH DIFFERENT POS INSTEAD OF WORKING THE SAME POS MULTIPLE TIMES IN A SHIFT. STAFFING CAB-COORDINATOR DURING BUSY OR COMPLEX TFC WOULD GREATLY DECREASE WORKLOAD FOR THE GND CTLRS. SIMPLIFIED RWY XING RULES WOULD GREATLY REDUCE THE LIKELIHOOD OF RWY INCURSIONS. HUMAN PERFORMANCE CONSIDERATIONS/PERCEPTION; JUDGEMENT; DECISIONS: I EXPECTED THE LTT TO STOP SHORT OF D ON C WHEN I SAID 'BUT BEFORE YOU DO THAT....' WITH THIS PERCEPTION IN MY MIND; I WAS NOT SO CONCERNED ABOUT HEARING HIS COMPLETE READBACK SO I COULD NOW COORD FOR THE RWY XING. MY JUDGEMENT TO CHANGE THE RWY FOR THE LTT WAS BASED ON TRYING TO AVOID ANY DELAY FOR HIM. MY PERCEPTION WAS THAT HE WAS IN A HURRY. THE PLT SPOKE VERY QUICKLY; THE ACFT WAS TAXIED BRISKLY AND THIS PUT ME IN 'WORK FAST MODE' AS FAR AS THIS ACFT WAS CONCERNED. HAD I BEEN LESS FATIGUED I BELIEVE I WOULD HAVE WORKED AT MY PACE; NOT HIS. CHANGING MY PLAN AND PUTTING THE LTT AT TXWY D NOW PUT HIM IN LCL CTL'S WAY; SO NOW I FELT THAT I HAD TO GET HIM OUT OF LCL CTL'S WAY AS QUICKLY AS POSSIBLE. THISALSO RUSHED ME CAUSING ME TO TAKE SHORTCUTS. FACTORS AFFECTING THE QUALITY OF HUMAN PERFORMANCE/FATIGUE: I BELIEVE THAT FATIGUE WAS THE BIGGEST FACTOR FOR ME IN THIS INCIDENT. AT THE TIME OF THIS INCIDENT; I WAS VERY FATIGUED. IT WAS NEAR THE END OF MY 8 HR SHIFT (7 RS 10 MINS INTO MY SHIFT). THIS WAS MY THIRD GND CTL SESSION IN THE SHIFT. I HAD IN THE SHIFT PREVIOUSLY WORKED GND CTL 2 COMBINED WITH GND CTL 1; GND CTL 2 DECOMBINED THEN GND CTL 1 DECOMBINED. IT WAS THE 4TH DAY OF MY WORK WK AND I WAS WORKING ON A 'QUICK TURN.' I HAD WORKED XA00-XI-- ON MY FIRST DAY OF THE WORK WK; XW30-XG30 THE SECOND AY; XW30-XG30 THE THIRD DAY AND I HAD STARTED THIS SHIFT AT XP30. I HAD SLEPT APPROX 5 HRS BTWN SHIFTS AND I HAD BEEN UP SINCE XN30. WORKLOAD AND COMPLEXITY: THIS NARRATIVE DESCRIBES THE WORKLOAD AND CTL ACTIONS REQUIRED FOR JUST 1 ACFT DURING A TIME WHEN MANY OTHER ACFT ALSO REQUIRED AIR TFC SVCS FROM THE GND CTLR. I HAD TO MAKE MANY CHANGES TO MANY CLRNCS. I HAD TO SCAN THE ENTIRE ARPT SURFACE AS WELL AS THE ASR DISPLAY; ASDE AND STRIPS. IN TRYING TO LOOK OUT THE WINDOWS; I OFTEN HAD TO LOOK AROUND THE OTHER TWR PERSONNEL IN ORDER TO SEE WHAT I NEEDED TO SEE. 1 ACFT; A B777; WAS COMPLETELY HIDDEN BEHIND A WINDOW POST AND IT TOOK ME CONSIDERABLE EFFORT TO DETERMINE HIS POS ON THE ARPT. INACTIONS: I FAILED TO ACTIVELY LISTEN FOR THE PLT READBACK OF THE HOLD SHORT INSTRUCTION. AS I WAS COORDINATING WITH LCL CTL ON THE LANDLINE I DID HEAR HIM READ BACK OVER THE SPEAKER; BUT SINCE I WAS LISTENING TO 2 DIFFERENT THINGS AT ONCE I DID NOT COMPREHEND HIS FULL READBACK. MY PLAN AND MY ACTIONS DID NOT ALLOW TIME OR OPPORTUNITY FOR ME TO HEAR THE READBACK.

Data retrieved from NASA's ASRS site as of May 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.