37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 800893 |
Time | |
Date | 200808 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : zbaa.tower |
Operator | general aviation : corporate |
Make Model Name | Light Transport |
Operating Under FAR Part | Part 91 |
Flight Phase | ground : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | oversight : pic |
Qualification | pilot : commercial pilot : instrument pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 80 flight time total : 7000 flight time type : 3500 |
ASRS Report | 800893 |
Events | |
Anomaly | incursion : runway non adherence : clearance non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
I was the PIC; and operational control; of an aircraft that; I am ashamed to say; crossed the departure end of runway X without permission from the control tower. (I was still monitoring the ground control frequency.) the following is submitted; not as an excuse; for what happened. In my mind; there are no excuses for runway incursions; they simply must not happen; and I am profoundly ashamed; as a veteran professional pilot; to have committed one. The following is simply an explanation of the reasons why it happened along with steps that have already been taken to see it never happens again. At approximately XA00 I went onto the internet to copy a previously created flight plan; as well as attain a copy of the WX and NOTAMS for my pending XC00 local flight. I then called FSS and filed an IFR flight plan to ZZZ1. As was the case the previous night when we arrived at ZZZ there were numerous NOTAMS for ZZZ and I verbally reviewed them with my copilot. I specifically mentioned that 'runway X/Y remained closed;' as well as runway a/B; the runway was had arrived on the previous evening. In truth however; I misread the NOTAM. The NOTAM read; 'ZZZ runway X/Y closed wef...XR00.' not 'til'...XR00; as was the case for runway a/B in the NOTAM listed above; but on ...XR00. It seemed that runway X/Y has been closed 'off and on' quite a bit since I have been flying into ZZZ so it was not unusual for it to be closed now; and in fact we may have misread the NOTAM on our arrival from the night before. It may have been open then; as well. In any case; I had 'written runway X/Y off' as being closed. Big mistake. I was further; content in the fact that the open/active runway was runway a/B; the runway that was nearest the FBO; the runway we had already used for our departures from ZZZ so it was no 'big deal.' big mistake. With contentment comes complacency; and that; in my mind; was the initial cause to this infraction. Upon starting engines for the flight; we went through the normal routine of 'assigned duties.' I prepared the aircraft for flight while my copilot attained the latest ATIS and completed his usual tasks. I selected the frequency over which he was attaining the ATIS but apparently did so as he was reviewing the initial portion for a second time; as all I heard was information... Winds 360 at 9; visibility 10; scattered at 2200 ft; broken at 5550 ft; temperature 27/dew point 21; altimeter 29.82;' at which time the copilot switched frequency to attain our IFR clearance. (I know he had listened to the entire ATIS broadcast from notes he had taken; as reviewed by me; subsequent to this incident.) upon receiving our clearance; we ran the before taxi checklist and requested our taxi clearance from ground control. As I started 'leaving the chocks' (we were facing north on the FBO ramp); the copilot read back the clearance. Whether because of concentration/distraction as I made the initial right turn sbound out of my spot on the ramp; or not; I do not know; but I simply did not 'hear' the initial ground control instruction of 'cleared to taxi to runway X.' I do remember his instruction of 'taxi K; cleared to cross runway B right turn on left;' which is what my copilot read back to him. As we were leaving the FBO ramp area onto taxiway yy (sbound); I commented to my copilot 'why is he taking us across runway B instead of taxiing us sbound on taxiway M?' we continued with the taxi checklist; crossed runway B; and started sbound on taxiway left. Still taxiing; my copilot; somewhat perplexed; turned to the airport diagram page to see if he could understand why we were using this taxi routing. I then remembered; as I told him; 'oh; I know; taxiway left goes all the way to the departure end of the runway vs M2 and since it's the only active; they're taking us all the way to the end.' at that time; I announced to my copilot that we were crossing a runway (an announcement we always make); 'but that it was runway X/Y which was NOTAM'd closed.' because of my taxi speed and the fact that he was looking down at the approach plate; he had no chance to question what I was about to do or respond with a command to stop. In the same regard; while my action; because of my taxi speed; with no amount of slowing as I approached runway X/Y may have appeared to be reckless and intentional to the guys in the tower cabin attendant; I sincerely thought I was cleared to taxi all the way to the end of left taxiway for a departure on runway B. At it turned out; what really happened was my copilot understood we were taxiing to runway X (which was the runway he thought I was taxiing to) and his perplexion with why we were not assigned taxiway M was embedded in the fact that he thought runway X indeed intersected with runway a/B and joined taxiway M; so why were we assigned taxiway left. It devastates me to admit it; but we were an aircraft taxiing with the pilot going to runway B and the copilot; with his head down referring to the airport diagram going to runway X. What a disaster! Upset; ashamed; disgusted; I called the supervisor upon my return to ZZZ1; as instructed. After a sleepless night going over what happened in my mind and; more importantly; how to keep this from happening in the future; I spoke with one of the inspectors at the FSDO the following morning about the runway incursion and the propriety of revising the before taxi checklist that we use for our aircraft. As a result; I have inserted the following before chock departure checklist prior to the taxi checklist; in the challenge/response checklist we use for our aircraft: before chock departure; 1) ATIS -- review. 2) taxi clearance/runway -- acknowledge. 3) taxi via -- txwys -- review/acknowledge. 4) hold short instructions -- review/acknowledge. The following is a list of mistakes that were made (to my perception) along with lessons learned: 1) flight preparation is only as good as attentiveness. Make sure you accurately read and understand the NOTAMS. 2) merely because of good WX and familiar surroundings; never assume a flight is a 'slam/dunk' and allow yourself to become complacent. 3) NOTAMS tell you what to expect; ATC (ATIS; ground control; tower; approach; center) will tell you what is. Things may have changed since you read the NOTAMS. 4) know where you are going and how you were instructed to get there before you leave your parking spot on the ramp. 5) if you don't understand; ask the controlling agent to clarify or verify their instructions to you. 6) if you are unsure about where you are on the aerodrome or how txwys/runways are configured; stop the aircraft and clarify the situation; once again with the assistance of ground control. Do not taxi with one of the pilots in a 'head down' position. 7) make sure you are cleared to cross a runway prior to doing so. (It is going to be very difficult for me to cross a runway on taxi out in the future; even though taxi clearance to a runway by the ground control agency entitles you to cross all other runways on taxi-out with no hold short instructions assigned.) 8) in my opinion; the crew briefing item occurs way too late in our approved checklist. It should come much earlier in the flight profile; just prior to taxi. In summary; I cannot begin to express my regret; shame; and embarrassment in the apparent lapse of professionalism in my part with their incident. Having said this; I know these feelings do not exonerate me from its potentially disastrous results.
Original NASA ASRS Text
Title: A CORP PLT HAD A RWY INCURSION AFTER MISREADING AN ARPT'S NOTAMS ABOUT RWY CLOSURES THEN MISINTERPRETING ATC'S TAXI INSTRUCTIONS.
Narrative: I WAS THE PIC; AND OPERATIONAL CTL; OF AN ACFT THAT; I AM ASHAMED TO SAY; CROSSED THE DEP END OF RWY X WITHOUT PERMISSION FROM THE CTL TWR. (I WAS STILL MONITORING THE GND CTL FREQUENCY.) THE FOLLOWING IS SUBMITTED; NOT AS AN EXCUSE; FOR WHAT HAPPENED. IN MY MIND; THERE ARE NO EXCUSES FOR RWY INCURSIONS; THEY SIMPLY MUST NOT HAPPEN; AND I AM PROFOUNDLY ASHAMED; AS A VETERAN PROFESSIONAL PLT; TO HAVE COMMITTED ONE. THE FOLLOWING IS SIMPLY AN EXPLANATION OF THE REASONS WHY IT HAPPENED ALONG WITH STEPS THAT HAVE ALREADY BEEN TAKEN TO SEE IT NEVER HAPPENS AGAIN. AT APPROX XA00 I WENT ONTO THE INTERNET TO COPY A PREVIOUSLY CREATED FLT PLAN; AS WELL AS ATTAIN A COPY OF THE WX AND NOTAMS FOR MY PENDING XC00 LCL FLT. I THEN CALLED FSS AND FILED AN IFR FLT PLAN TO ZZZ1. AS WAS THE CASE THE PREVIOUS NIGHT WHEN WE ARRIVED AT ZZZ THERE WERE NUMEROUS NOTAMS FOR ZZZ AND I VERBALLY REVIEWED THEM WITH MY COPLT. I SPECIFICALLY MENTIONED THAT 'RWY X/Y REMAINED CLOSED;' AS WELL AS RWY A/B; THE RWY WAS HAD ARRIVED ON THE PREVIOUS EVENING. IN TRUTH HOWEVER; I MISREAD THE NOTAM. THE NOTAM READ; 'ZZZ RWY X/Y CLOSED WEF...XR00.' NOT 'TIL'...XR00; AS WAS THE CASE FOR RWY A/B IN THE NOTAM LISTED ABOVE; BUT ON ...XR00. IT SEEMED THAT RWY X/Y HAS BEEN CLOSED 'OFF AND ON' QUITE A BIT SINCE I HAVE BEEN FLYING INTO ZZZ SO IT WAS NOT UNUSUAL FOR IT TO BE CLOSED NOW; AND IN FACT WE MAY HAVE MISREAD THE NOTAM ON OUR ARR FROM THE NIGHT BEFORE. IT MAY HAVE BEEN OPEN THEN; AS WELL. IN ANY CASE; I HAD 'WRITTEN RWY X/Y OFF' AS BEING CLOSED. BIG MISTAKE. I WAS FURTHER; CONTENT IN THE FACT THAT THE OPEN/ACTIVE RWY WAS RWY A/B; THE RWY THAT WAS NEAREST THE FBO; THE RWY WE HAD ALREADY USED FOR OUR DEPS FROM ZZZ SO IT WAS NO 'BIG DEAL.' BIG MISTAKE. WITH CONTENTMENT COMES COMPLACENCY; AND THAT; IN MY MIND; WAS THE INITIAL CAUSE TO THIS INFRACTION. UPON STARTING ENGINES FOR THE FLT; WE WENT THROUGH THE NORMAL ROUTINE OF 'ASSIGNED DUTIES.' I PREPARED THE ACFT FOR FLIGHT WHILE MY COPLT ATTAINED THE LATEST ATIS AND COMPLETED HIS USUAL TASKS. I SELECTED THE FREQ OVER WHICH HE WAS ATTAINING THE ATIS BUT APPARENTLY DID SO AS HE WAS REVIEWING THE INITIAL PORTION FOR A SECOND TIME; AS ALL I HEARD WAS INFORMATION... WINDS 360 AT 9; VISIBILITY 10; SCATTERED AT 2200 FT; BROKEN AT 5550 FT; TEMP 27/DEW POINT 21; ALTIMETER 29.82;' AT WHICH TIME THE COPLT SWITCHED FREQ TO ATTAIN OUR IFR CLRNC. (I KNOW HE HAD LISTENED TO THE ENTIRE ATIS BROADCAST FROM NOTES HE HAD TAKEN; AS REVIEWED BY ME; SUBSEQUENT TO THIS INCIDENT.) UPON RECEIVING OUR CLRNC; WE RAN THE BEFORE TAXI CHKLIST AND REQUESTED OUR TAXI CLRNC FROM GND CTL. AS I STARTED 'LEAVING THE CHOCKS' (WE WERE FACING N ON THE FBO RAMP); THE COPLT READ BACK THE CLRNC. WHETHER BECAUSE OF CONCENTRATION/DISTR AS I MADE THE INITIAL RIGHT TURN SBOUND OUT OF MY SPOT ON THE RAMP; OR NOT; I DO NOT KNOW; BUT I SIMPLY DID NOT 'HEAR' THE INITIAL GND CTL INSTRUCTION OF 'CLRED TO TAXI TO RWY X.' I DO REMEMBER HIS INSTRUCTION OF 'TAXI K; CLEARED TO CROSS RWY B R TURN ON L;' WHICH IS WHAT MY COPLT READ BACK TO HIM. AS WE WERE LEAVING THE FBO RAMP AREA ONTO TXWY YY (SBOUND); I COMMENTED TO MY COPLT 'WHY IS HE TAKING US ACROSS RWY B INSTEAD OF TAXIING US SBOUND ON TXWY M?' WE CONTINUED WITH THE TAXI CHKLIST; CROSSED RWY B; AND STARTED SBOUND ON TXWY L. STILL TAXIING; MY COPLT; SOMEWHAT PERPLEXED; TURNED TO THE ARPT DIAGRAM PAGE TO SEE IF HE COULD UNDERSTAND WHY WE WERE USING THIS TAXI ROUTING. I THEN REMEMBERED; AS I TOLD HIM; 'OH; I KNOW; TXWY L GOES ALL THE WAY TO THE DEP END OF THE RWY VS M2 AND SINCE IT'S THE ONLY ACTIVE; THEY'RE TAKING US ALL THE WAY TO THE END.' AT THAT TIME; I ANNOUNCED TO MY COPLT THAT WE WERE CROSSING A RWY (AN ANNOUNCEMENT WE ALWAYS MAKE); 'BUT THAT IT WAS RWY X/Y WHICH WAS NOTAM'D CLOSED.' BECAUSE OF MY TAXI SPEED AND THE FACT THAT HE WAS LOOKING DOWN AT THE APCH PLATE; HE HAD NO CHANCE TO QUESTION WHAT I WAS ABOUT TO DO OR RESPOND WITH A COMMAND TO STOP. IN THE SAME REGARD; WHILE MY ACTION; BECAUSE OF MY TAXI SPEED; WITH NO AMOUNT OF SLOWING AS I APCHED RWY X/Y MAY HAVE APPEARED TO BE RECKLESS AND INTENTIONAL TO THE GUYS IN THE TWR CAB; I SINCERELY THOUGHT I WAS CLRED TO TAXI ALL THE WAY TO THE END OF L TXWY FOR A DEP ON RWY B. AT IT TURNED OUT; WHAT REALLY HAPPENED WAS MY COPLT UNDERSTOOD WE WERE TAXIING TO RWY X (WHICH WAS THE RWY HE THOUGHT I WAS TAXIING TO) AND HIS PERPLEXION WITH WHY WE WERE NOT ASSIGNED TXWY M WAS EMBEDDED IN THE FACT THAT HE THOUGHT RWY X INDEED INTERSECTED WITH RWY A/B AND JOINED TXWY M; SO WHY WERE WE ASSIGNED TXWY L. IT DEVASTATES ME TO ADMIT IT; BUT WE WERE AN ACFT TAXIING WITH THE PLT GOING TO RWY B AND THE COPLT; WITH HIS HEAD DOWN REFERRING TO THE ARPT DIAGRAM GOING TO RWY X. WHAT A DISASTER! UPSET; ASHAMED; DISGUSTED; I CALLED THE SUPVR UPON MY RETURN TO ZZZ1; AS INSTRUCTED. AFTER A SLEEPLESS NIGHT GOING OVER WHAT HAPPENED IN MY MIND AND; MORE IMPORTANTLY; HOW TO KEEP THIS FROM HAPPENING IN THE FUTURE; I SPOKE WITH ONE OF THE INSPECTORS AT THE FSDO THE FOLLOWING MORNING ABOUT THE RWY INCURSION AND THE PROPRIETY OF REVISING THE BEFORE TAXI CHKLIST THAT WE USE FOR OUR ACFT. AS A RESULT; I HAVE INSERTED THE FOLLOWING BEFORE CHOCK DEP CHKLIST PRIOR TO THE TAXI CHKLIST; IN THE CHALLENGE/RESPONSE CHKLIST WE USE FOR OUR ACFT: BEFORE CHOCK DEP; 1) ATIS -- REVIEW. 2) TAXI CLRNC/RWY -- ACKNOWLEDGE. 3) TAXI VIA -- TXWYS -- REVIEW/ACKNOWLEDGE. 4) HOLD SHORT INSTRUCTIONS -- REVIEW/ACKNOWLEDGE. THE FOLLOWING IS A LIST OF MISTAKES THAT WERE MADE (TO MY PERCEPTION) ALONG WITH LESSONS LEARNED: 1) FLT PREPARATION IS ONLY AS GOOD AS ATTENTIVENESS. MAKE SURE YOU ACCURATELY READ AND UNDERSTAND THE NOTAMS. 2) MERELY BECAUSE OF GOOD WX AND FAMILIAR SURROUNDINGS; NEVER ASSUME A FLT IS A 'SLAM/DUNK' AND ALLOW YOURSELF TO BECOME COMPLACENT. 3) NOTAMS TELL YOU WHAT TO EXPECT; ATC (ATIS; GND CTL; TWR; APCH; CTR) WILL TELL YOU WHAT IS. THINGS MAY HAVE CHANGED SINCE YOU READ THE NOTAMS. 4) KNOW WHERE YOU ARE GOING AND HOW YOU WERE INSTRUCTED TO GET THERE BEFORE YOU LEAVE YOUR PARKING SPOT ON THE RAMP. 5) IF YOU DON'T UNDERSTAND; ASK THE CONTROLLING AGENT TO CLARIFY OR VERIFY THEIR INSTRUCTIONS TO YOU. 6) IF YOU ARE UNSURE ABOUT WHERE YOU ARE ON THE AERODROME OR HOW TXWYS/RWYS ARE CONFIGURED; STOP THE ACFT AND CLARIFY THE SIT; ONCE AGAIN WITH THE ASSISTANCE OF GND CTL. DO NOT TAXI WITH ONE OF THE PLTS IN A 'HEAD DOWN' POSITION. 7) MAKE SURE YOU ARE CLRED TO CROSS A RWY PRIOR TO DOING SO. (IT IS GOING TO BE VERY DIFFICULT FOR ME TO CROSS A RWY ON TAXI OUT IN THE FUTURE; EVEN THOUGH TAXI CLRNC TO A RWY BY THE GND CTL AGENCY ENTITLES YOU TO CROSS ALL OTHER RWYS ON TAXI-OUT WITH NO HOLD SHORT INSTRUCTIONS ASSIGNED.) 8) IN MY OPINION; THE CREW BRIEFING ITEM OCCURS WAY TOO LATE IN OUR APPROVED CHKLIST. IT SHOULD COME MUCH EARLIER IN THE FLT PROFILE; JUST PRIOR TO TAXI. IN SUMMARY; I CANNOT BEGIN TO EXPRESS MY REGRET; SHAME; AND EMBARRASSMENT IN THE APPARENT LAPSE OF PROFESSIONALISM IN MY PART WITH THEIR INCIDENT. HAVING SAID THIS; I KNOW THESE FEELINGS DO NOT EXONERATE ME FROM ITS POTENTIALLY DISASTROUS RESULTS.
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.