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Runway transgression by commuter. Less than standard separation and near midair collision as air carrier Y overflew commuter X.
| Attributes | |
| ACN | 188837 |
| Time | |
| Date | 199109 |
| Day | Wed |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : ewr |
| State Reference | NJ |
| Altitude | agl bound lower : 0 agl bound upper : 400 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zkc |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Transport, High Wing, 2 Turboprop Eng |
| Flight Phase | ground : holding ground other : taxi |
| Flight Plan | IFR |
| Aircraft 2 | |
| Operator | common carrier : air carrier |
| Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
| Navigation In Use | Other |
| Flight Phase | climbout : initial climbout : takeoff |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : cfi pilot : instrument |
| Experience | flight time last 90 days : 400 flight time total : 12000 flight time type : 400 |
| ASRS Report | 188837 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| ASRS Report | 188840 |
| Events | |
| Anomaly | conflict : ground critical incursion : runway non adherence : required legal separation non adherence : clearance |
| Independent Detector | other controllera |
| Resolutory Action | none taken : detected after the fact |
| Consequence | faa : reviewed incident with flight crew |
| Miss Distance | horizontal : 0 vertical : 400 |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Tower issued clearance 'back taxi into position and hold runway 29 at right.' I back taxied through 29R to next taxiway 29P. This created a conflict with departure path of another runway. Crew fatigue definitely was a factor in this incident due to reduced rest period schedules. Callback conversation with reporter revealed the following information: made callback as part of runway incursion study. Reporter gave type aircraft. Says normal taxi route for runway 29 intersection taxiway right takeoff is via ramp, taxiway U, taxiway X, taxiway south, then back taxi on 29 to taxiway right. On this day the clearance was different and they went via taxiway U, taxiway X to taxiway right, so there was no need to back taxi, but from force of habit when cleared into position and hold they taxied onto runway and made right turn to next taxiway which was actually taxiway P in this case. Widebody transport air carrier taking off on runway 4L passed over reporter aircraft at altitude of about 400 ft. Flight crew thought they were at taxiway south when cleared into position. Says fatigue was big factor in bad situational awareness for flight crew. They had 6 hours sleep the previous night, but on first night of 3 day trip they had very little rest. Reporter thinks commuter flight crew scheduling contributes to fatigue and mental lapses such as occurred in this incident.
Original NASA ASRS Text
Title: RWY TRANSGRESSION BY COMMUTER. LTSS AND NMAC AS ACR Y OVERFLEW COMMUTER X.
Narrative: TWR ISSUED CLRNC 'BACK TAXI INTO POS AND HOLD RWY 29 AT R.' I BACK TAXIED THROUGH 29R TO NEXT TAXIWAY 29P. THIS CREATED A CONFLICT WITH DEP PATH OF ANOTHER RWY. CREW FATIGUE DEFINITELY WAS A FACTOR IN THIS INCIDENT DUE TO REDUCED REST PERIOD SCHEDULES. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: MADE CALLBACK AS PART OF RWY INCURSION STUDY. RPTR GAVE TYPE ACFT. SAYS NORMAL TAXI RTE FOR RWY 29 INTXN TAXIWAY R TKOF IS VIA RAMP, TAXIWAY U, TAXIWAY X, TAXIWAY S, THEN BACK TAXI ON 29 TO TAXIWAY R. ON THIS DAY THE CLRNC WAS DIFFERENT AND THEY WENT VIA TAXIWAY U, TAXIWAY X TO TAXIWAY R, SO THERE WAS NO NEED TO BACK TAXI, BUT FROM FORCE OF HABIT WHEN CLRED INTO POS AND HOLD THEY TAXIED ONTO RWY AND MADE R TURN TO NEXT TAXIWAY WHICH WAS ACTUALLY TAXIWAY P IN THIS CASE. WDB ACR TAKING OFF ON RWY 4L PASSED OVER RPTR ACFT AT ALT OF ABOUT 400 FT. FLC THOUGHT THEY WERE AT TAXIWAY S WHEN CLRED INTO POS. SAYS FATIGUE WAS BIG FACTOR IN BAD SITUATIONAL AWARENESS FOR FLC. THEY HAD 6 HRS SLEEP THE PREVIOUS NIGHT, BUT ON FIRST NIGHT OF 3 DAY TRIP THEY HAD VERY LITTLE REST. RPTR THINKS COMMUTER FLC SCHEDULING CONTRIBUTES TO FATIGUE AND MENTAL LAPSES SUCH AS OCCURRED IN THIS INCIDENT.
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.