37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 836334 |
Time | |
Date | 200905 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | Light Transport High Wing 2 Turboprop Eng |
Operating Under FAR Part | Part 121 |
Flight Phase | Taxi |
Flight Plan | IFR |
Person 1 | |
Function | First Officer Pilot Not Flying |
Person 2 | |
Function | Captain |
Events | |
Anomaly | ATC Issue All Types Deviation - Procedural FAR Ground Incursion Taxiway |
Narrative:
In this event the crew taxied without a clearance onto an active taxiway. The taxi clearance was given to a different flight that was adjacent to this flight on the ramp. The captain misunderstood the taxi instructions that were given. Because no other taxiing aircraft were involved; no runway incursion occurred; and the crew followed clearance instructions issued by ground control for a different flight to taxi from the same ramp area; safety was not really compromised. Our flight was delayed 15 minutes due to a maintenance issue. This was the last leg of a two-day trip. After completing all the paperwork and checklists; a pushback clearance was received and the flight pushed off. The number two engine was started and the after start checklist was completed. I called ramp for taxi and was told 'spot xx and ground point nine.' since we were almost at spot xx already; as soon as the captain started forward and turned I switched to the ground frequency. Ground control was very busy; but soon after I switched over there was a brief break and I keyed the microphone and announced; 'flight abc; spot xx; information papa.' ground did not respond; but continued handling aircraft in different areas of the airport. After we were stopped at spot xx; another flight (def) called ground for taxi from spot; adjacent to us. As far as I know; we were number one coming out of the alley. Ground did not respond to flight def's call either. Ground continued to be very busy. After a couple minutes; and as soon as I could without stepping on another transmission; I called ground again; 'flight abc; spot xx; papa.' following the second or perhaps third time I called ground; the controller responded with something like: 'flight def taxi to runway xxl via echo and hold short of xxr at echo.' this was the exact instruction we were expecting; but it was not our call sign. Upon hearing the clearance; our captain released the parking brake and began to taxi. I almost keyed the mike; but paused while I considered the incorrect flight number; and the first officer from flight def; answered ground with the read-back. I turned to the captain and said something like; that wasn't our flight number or that wasn't for us. The captain disagreed and said he heard our flight number and continued taxiing. While I had my head turned left to address the captain; he saw the captain of flight def to our right wave us on; as if the clearance was for us; number one coming out of the alley; even though the first officer from flight def read back the clearance. This just added to the confusion. In the very short time it took us to travel from spot xx to the hold-short line between the ramp and taxiway hotel; the captain told me what he saw and asked if I had seen the other captain wave us on. I had not; and told him so. I also expressed my doubts again that we were cleared to taxi. I began to question what I heard; especially given the captain's confidence and the fact that he continued taxiing. I quickly turned on our transponder in hopes it would alert the controller; who was still extremely busy. As soon as another transmission ended (and before crossing the hold-short line) I keyed the mike again and said; 'ground; confirm flight abc is cleared to taxi xxl; hold short xxr.' ground again did not respond. Soon we were crossing the hold line onto hotel; then making the turn onto echo. The captain and I discussed it a little more; but I remember being rather upset with the captain and feeling like there was not much else I could do. The ground frequency was so congested it wasn't possible to get a word in. Fortunately the captain decided to stop on echo about halfway from hotel to kilo to resolve the issue. There was a break on the frequency and he keyed the mike and spoke to ground. This time ground responded. It was immediately apparent that ground was confused and that the clearance was issued for the other carrier flight. After a brief exchange between ground andour captain; the captain from flight def confirmed to ground that they were number two behind us. Ground then issued a proper taxi clearance for our flight. We continued the taxi and flight to our destination without further incident; or comment from ATC regarding the confusion. Of minor note; when being cleared into position-and-hold on runway xxl; the tower controller read our flight number incorrectly. We confirmed the correct flight number before taxiing into position. As with any event; there were multiple factors that contributed to this crew taxiing without a clearance. The most significant factor was the heavy congestion on the ground control frequency and our belief that ground must have heard one of our several calls despite the fact that they had not acknowledged our call sign. The fact that the flight was delayed contributed to the crew's stress and motivation to taxi for departure as quickly as possible. Poor CRM and communication between the first officer and captain was a significant factor. I was timid based on passed history with this captain and I never clearly and confidently told the captain to stop the plane when I saw him taxiing without a clearance. Certain hazardous attitudes; including get-home-it is and aspects of anti-authority; invulnerability; and macho definitely affected the captain's decision making. In avoiding a recurrence of this event I could say the obvious; such as: confirm a clearance if there is any doubt; don't proceed when there is any doubt regarding a clearance; if both pilots don't agree; discuss it and come to agreement before action is taken; slow down; be more proactive and confident in my own experience and judgment; be more clear and assertive when I see the captain taking inappropriate action; etc. However; I don't feel that any of these things will prevent a re occurrence of a similar event. The root cause of this event was a breakdown of CRM that stems from certain attitudes held by a few of our more senior and very experienced captains and their pairings with certain first officers. In talking with other first officers and captains that have flown with some of these senior captains when they were first officers; there seems to be consensus. A few of our best; most experienced; and most senior captains; who have been flying the same plane; in command from the captain's seat for decades; have developed a dominant; almost single-pilot approach to running the cockpit. First officers are seen as significantly inferior and at times not worthy. Important decisions are made without consulting with the first officer. Often first officer input is dismissed and discouraged. Often first officers are reprimanded in a demeaning and inappropriate way for their human mistakes and inexperience. The result is a breakdown of proper teamwork and open communication between pilots in the cockpit; and an operation that decays toward a single-pilot operation by the captain. First officers; depending on their personality; often feel powerless to address these issues; and feel like their jobs might be in jeopardy if they did. In this case; the captain clearly disregarded the first officer's input and proceeded as he saw fit in his overconfident manor. The two-pilot concept and CRM are extremely important in preventing common errors. Even the best of us are all susceptible to human error; and standard operating procedures are in place as a safety net to help prevent errors. Often these senior captains are so good that the sops don't apply to them. They develop their own techniques that are sometimes in direct opposition to sops. I even questioned the captain on this trip about one such repeated action that I felt was unsafe. The response was an explanation of why it was safe for him to do it. Again; I reference the hazardous attitude that the rules don't apply to him.
Original NASA ASRS Text
Title: Commuter Captain begins to taxi from ramp spot believing another aircraft's clearance was for him. The First Officer did not read back the clearance and informed the Captain the clearance was not for them. After taxiing some distance; the aircraft is stopped and clarification received; frequency congestion was an issue.
Narrative: In this event the crew taxied without a clearance onto an active taxiway. The taxi clearance was given to a different flight that was adjacent to this flight on the ramp. The Captain misunderstood the taxi instructions that were given. Because no other taxiing aircraft were involved; no runway incursion occurred; and the crew followed clearance instructions issued by Ground Control for a different flight to taxi from the same ramp area; safety was not really compromised. Our flight was delayed 15 minutes due to a maintenance issue. This was the last leg of a two-day trip. After completing all the paperwork and checklists; a pushback clearance was received and the flight pushed off. The number two engine was started and the after start checklist was completed. I called ramp for taxi and was told 'Spot XX and ground point nine.' Since we were almost at Spot XX already; as soon as the Captain started forward and turned I switched to the ground frequency. Ground Control was very busy; but soon after I switched over there was a brief break and I keyed the microphone and announced; 'Flight ABC; Spot XX; information Papa.' Ground did not respond; but continued handling aircraft in different areas of the airport. After we were stopped at Spot XX; another flight (DEF) called Ground for taxi from Spot; adjacent to us. As far as I know; we were number one coming out of the alley. Ground did not respond to flight DEF's call either. Ground continued to be very busy. After a couple minutes; and as soon as I could without stepping on another transmission; I called ground again; 'Flight ABC; Spot XX; Papa.' Following the second or perhaps third time I called Ground; the Controller responded with something like: 'Flight DEF taxi to Runway XXL via Echo and hold short of XXR at Echo.' This was the exact instruction we were expecting; but it was not our call sign. Upon hearing the clearance; our Captain released the parking brake and began to taxi. I almost keyed the mike; but paused while I considered the incorrect flight number; and the First Officer from Flight DEF; answered Ground with the read-back. I turned to the Captain and said something like; that wasn't our flight number or that wasn't for us. The Captain disagreed and said he heard our flight number and continued taxiing. While I had my head turned left to address the Captain; he saw the Captain of Flight DEF to our right wave us on; as if the clearance was for us; number one coming out of the alley; even though the First Officer from Flight DEF read back the clearance. This just added to the confusion. In the very short time it took us to travel from Spot XX to the hold-short line between the ramp and Taxiway Hotel; the Captain told me what he saw and asked if I had seen the other Captain wave us on. I had not; and told him so. I also expressed my doubts again that we were cleared to taxi. I began to question what I heard; especially given the Captain's confidence and the fact that he continued taxiing. I quickly turned on our transponder in hopes it would alert the controller; who was still extremely busy. As soon as another transmission ended (and before crossing the hold-short line) I keyed the mike again and said; 'Ground; confirm Flight ABC is cleared to Taxi XXL; hold short XXR.' Ground again did not respond. Soon we were crossing the hold line onto Hotel; then making the turn onto Echo. The Captain and I discussed it a little more; but I remember being rather upset with the Captain and feeling like there was not much else I could do. The Ground frequency was so congested it wasn't possible to get a word in. Fortunately the Captain decided to stop on Echo about halfway from Hotel to Kilo to resolve the issue. There was a break on the frequency and he keyed the mike and spoke to Ground. This time ground responded. It was immediately apparent that Ground was confused and that the clearance was issued for the other Carrier flight. After a brief exchange between Ground andour Captain; the Captain from Flight DEF confirmed to Ground that they were number two behind us. Ground then issued a proper taxi clearance for our flight. We continued the taxi and flight to our destination without further incident; or comment from ATC regarding the confusion. Of minor note; when being cleared into position-and-hold on Runway XXL; the tower controller read our flight number incorrectly. We confirmed the correct flight number before taxiing into position. As with any event; there were multiple factors that contributed to this crew taxiing without a clearance. The most significant factor was the heavy congestion on the Ground Control frequency and our belief that Ground must have heard one of our several calls despite the fact that they had not acknowledged our call sign. The fact that the flight was delayed contributed to the crew's stress and motivation to taxi for departure as quickly as possible. Poor CRM and communication between the First Officer and Captain was a significant factor. I was timid based on passed history with this Captain and I never clearly and confidently told the Captain to stop the plane when I saw him taxiing without a clearance. Certain hazardous attitudes; including get-home-it is and aspects of anti-authority; invulnerability; and macho definitely affected the Captain's decision making. In avoiding a recurrence of this event I could say the obvious; such as: confirm a clearance if there is any doubt; don't proceed when there is any doubt regarding a clearance; if both pilots don't agree; discuss it and come to agreement before action is taken; slow down; be more proactive and confident in my own experience and judgment; be more clear and assertive when I see the Captain taking inappropriate action; etc. However; I don't feel that any of these things will prevent a re occurrence of a similar event. The root cause of this event was a breakdown of CRM that stems from certain attitudes held by a few of our more senior and very experienced Captains and their pairings with certain First Officers. In talking with other First Officers and Captains that have flown with some of these senior Captains when they were First Officers; there seems to be consensus. A few of our best; most experienced; and most senior Captains; who have been flying the same plane; in command from the Captain's seat for decades; have developed a dominant; almost single-pilot approach to running the cockpit. First Officers are seen as significantly inferior and at times not worthy. Important decisions are made without consulting with the First Officer. Often First Officer input is dismissed and discouraged. Often First Officers are reprimanded in a demeaning and inappropriate way for their human mistakes and inexperience. The result is a breakdown of proper teamwork and open communication between pilots in the cockpit; and an operation that decays toward a single-pilot operation by the Captain. First Officers; depending on their personality; often feel powerless to address these issues; and feel like their jobs might be in jeopardy if they did. In this case; the Captain clearly disregarded the First Officer's input and proceeded as he saw fit in his overconfident manor. The two-pilot concept and CRM are extremely important in preventing common errors. Even the best of us are all susceptible to human error; and Standard Operating Procedures are in place as a safety net to help prevent errors. Often these senior Captains are so good that the SOPs don't apply to them. They develop their own techniques that are sometimes in direct opposition to SOPs. I even questioned the Captain on this trip about one such repeated action that I felt was unsafe. The response was an explanation of why it was safe for him to do it. Again; I reference the hazardous attitude that the rules don't apply to him.
Data retrieved from NASA's ASRS site as of April 2012 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.