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Air carrier Y unauthorized takeoff on multiple runway operation intersecting runways had near midair collision less than standard separation from air carrier X. Pilot deviation. System error.
| Attributes | |
| ACN | 234091 |
| Time | |
| Date | 199302 |
| Day | Fri |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | atc facility : jax |
| State Reference | FL |
| Altitude | agl bound lower : 300 agl bound upper : 300 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tower : jax |
| Operator | common carrier : air carrier |
| Make Model Name | Light Transport, High Wing, 2 Turboprop Eng |
| Flight Phase | climbout : initial climbout : takeoff |
| Flight Plan | IFR |
| Aircraft 2 | |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Navigation In Use | Other |
| Flight Phase | climbout : initial climbout : takeoff |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | government : faa |
| Function | controller : local |
| Qualification | controller : non radar |
| ASRS Report | 234091 |
| Person 2 | |
| Affiliation | government : faa |
| Function | controller : ground |
| Qualification | controller : non radar |
| Events | |
| Anomaly | conflict : nmac non adherence : published procedure non adherence : required legal separation non adherence : clearance |
| Independent Detector | other controllera |
| Resolutory Action | other |
| Consequence | faa : investigated |
| Miss Distance | horizontal : 400 vertical : 0 |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation Operational Error |
Narrative:
I was working local at jax tower. I taxied air carrier X into position and hold runway 25. I then taxied air carrier Y into position and hold runway 31 and told him traffic departing runway 25. I then told a preceding arrival to runway 25 to turn off and contact ground. I then told air carrier X cleared for takeoff runway 25. A few seconds later, the ground controller asked me if I had cleared the air carrier Y for takeoff on runway 31. I then saw the air carrier Y on takeoff roll past mid field. Air carrier X was now airborne but had not reached the end of runway 25. I instructed air carrier Y to make an immediate right turn after departure and issued the traffic to him. He made a hard right turn and passed behind air carrier X. After listening to the tape I realized I missed a readback by the air carrier X on his takeoff clearance. The readback of air carrier X takeoff clearance for runway 25 was 'air carrier Y rolling.' after clearing air carrier X for takeoff, I visually scanned both aircraft and saw air carrier Y in position. I then watched air carrier X during his takeoff and didn't notice air carrier Y on the roll until it was brought to my attention by the ground controller. I believe the situation happened because the air carrier Y crew was not concentrating on the tower's instruction. Listen carefully to instructions and readbacks!
Original NASA ASRS Text
Title: ACR Y UNAUTH TKOF ON MULTIPLE RWY OP INTERSECTING RWYS HAD NMAC LTSS FROM ACR X. PLTDEV. SYS ERROR.
Narrative: I WAS WORKING LCL AT JAX TWR. I TAXIED ACR X INTO POS AND HOLD RWY 25. I THEN TAXIED ACR Y INTO POS AND HOLD RWY 31 AND TOLD HIM TFC DEPARTING RWY 25. I THEN TOLD A PRECEDING ARR TO RWY 25 TO TURN OFF AND CONTACT GND. I THEN TOLD ACR X CLRED FOR TKOF RWY 25. A FEW SECONDS LATER, THE GND CTLR ASKED ME IF I HAD CLRED THE ACR Y FOR TKOF ON RWY 31. I THEN SAW THE ACR Y ON TKOF ROLL PAST MID FIELD. ACR X WAS NOW AIRBORNE BUT HAD NOT REACHED THE END OF RWY 25. I INSTRUCTED ACR Y TO MAKE AN IMMEDIATE R TURN AFTER DEP AND ISSUED THE TFC TO HIM. HE MADE A HARD R TURN AND PASSED BEHIND ACR X. AFTER LISTENING TO THE TAPE I REALIZED I MISSED A READBACK BY THE ACR X ON HIS TKOF CLRNC. THE READBACK OF ACR X TKOF CLRNC FOR RWY 25 WAS 'ACR Y ROLLING.' AFTER CLRING ACR X FOR TKOF, I VISUALLY SCANNED BOTH ACFT AND SAW ACR Y IN POS. I THEN WATCHED ACR X DURING HIS TKOF AND DIDN'T NOTICE ACR Y ON THE ROLL UNTIL IT WAS BROUGHT TO MY ATTN BY THE GND CTLR. I BELIEVE THE SIT HAPPENED BECAUSE THE ACR Y CREW WAS NOT CONCENTRATING ON THE TWR'S INSTRUCTION. LISTEN CAREFULLY TO INSTRUCTIONS AND READBACKS!
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.