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An air carrier B757 flight crew was given detailed instructions for taxi to runway 4L. At the end of the instructions they were, apparently, also told to follow another air carrier. Unfortunately, the other air carrier was going to runway 9L. The ATCT local controller allowed them to depart on runway 9L after they mistakenly taxi into position on it.
| Attributes | |
| ACN | 377460 |
| Time | |
| Date | 199708 |
| Day | Wed |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : ord |
| State Reference | IL |
| Altitude | agl bound lower : 0 agl bound upper : 0 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tower : bfi |
| Operator | common carrier : air carrier |
| Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
| Navigation In Use | Other Other |
| Flight Phase | ground other : taxi |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 150 flight time total : 12000 flight time type : 1500 |
| ASRS Report | 377460 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp pilot : flight engineer |
| Experience | flight time last 90 days : 50 flight time total : 7000 flight time type : 140 |
| ASRS Report | 377061 |
| Events | |
| Anomaly | incursion : runway non adherence : clearance other anomaly other |
| Independent Detector | other controllera other flight crewa |
| Resolutory Action | controller : issued new clearance other |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
During initial taxi out, ground told us to go to runway 4L, follow another air carrier from our left. We followed him out, switched to tower per instructions early in the taxi. Unfortunately, I followed the other air carrier too much. He went to runway 9L. Tower cleared us into position on runway 4L(?) (he must not have been watching, or we misunderstood him.) as we entered the runway, I noticed that the runway symbol on our FMC map did not agree with the direction of the concrete, and saw '9L' painted on the runway. Tower cleared us to takeoff on runway 9L. The first officer had the weights in mind and said we were ok on weight, no traffic conflict, so we took off. Remedy for next time: 1) don't mindlessly follow aircraft on taxiway. 2) look at electronic map before taking position. 3) stay alert. Supplemental information from acn 377061: we got a lot of instructions very early (ground was slow), but this should not normally be a problem. We had a distracting discussion with the ground controller, but that had ended long before we missed our turn. I had my map out (always do), but somehow, it didn't 'click' that we needed to turn on 'west' for runway 4L. I had been flying with the captain all month. A very competent pilot with a meticulous attention to detail. I don't feel I had to 'watch him.' we were told to 'follow the other air carrier.' perhaps a better term would have been 'give way to.' perhaps I was complacent. Perhaps I'm not back on top of my game (I'd just returned from a 14 month leave of absence). I'm just searching in hindsight for an answer to 'why?' I think a combination of all of the above. I think the most disconcerting part of all this for me is that I didn't realize the error was made until it was much too late -- and that I can't come up with 1 good reason as to how or why it happened.
Original NASA ASRS Text
Title: AN ACR B757 FLC WAS GIVEN DETAILED INSTRUCTIONS FOR TAXI TO RWY 4L. AT THE END OF THE INSTRUCTIONS THEY WERE, APPARENTLY, ALSO TOLD TO FOLLOW ANOTHER ACR. UNFORTUNATELY, THE OTHER ACR WAS GOING TO RWY 9L. THE ATCT LCL CTLR ALLOWED THEM TO DEPART ON RWY 9L AFTER THEY MISTAKENLY TAXI INTO POS ON IT.
Narrative: DURING INITIAL TAXI OUT, GND TOLD US TO GO TO RWY 4L, FOLLOW ANOTHER ACR FROM OUR L. WE FOLLOWED HIM OUT, SWITCHED TO TWR PER INSTRUCTIONS EARLY IN THE TAXI. UNFORTUNATELY, I FOLLOWED THE OTHER ACR TOO MUCH. HE WENT TO RWY 9L. TWR CLRED US INTO POS ON RWY 4L(?) (HE MUST NOT HAVE BEEN WATCHING, OR WE MISUNDERSTOOD HIM.) AS WE ENTERED THE RWY, I NOTICED THAT THE RWY SYMBOL ON OUR FMC MAP DID NOT AGREE WITH THE DIRECTION OF THE CONCRETE, AND SAW '9L' PAINTED ON THE RWY. TWR CLRED US TO TKOF ON RWY 9L. THE FO HAD THE WTS IN MIND AND SAID WE WERE OK ON WT, NO TFC CONFLICT, SO WE TOOK OFF. REMEDY FOR NEXT TIME: 1) DON'T MINDLESSLY FOLLOW ACFT ON TXWY. 2) LOOK AT ELECTRONIC MAP BEFORE TAKING POS. 3) STAY ALERT. SUPPLEMENTAL INFO FROM ACN 377061: WE GOT A LOT OF INSTRUCTIONS VERY EARLY (GND WAS SLOW), BUT THIS SHOULD NOT NORMALLY BE A PROB. WE HAD A DISTRACTING DISCUSSION WITH THE GND CTLR, BUT THAT HAD ENDED LONG BEFORE WE MISSED OUR TURN. I HAD MY MAP OUT (ALWAYS DO), BUT SOMEHOW, IT DIDN'T 'CLICK' THAT WE NEEDED TO TURN ON 'W' FOR RWY 4L. I HAD BEEN FLYING WITH THE CAPT ALL MONTH. A VERY COMPETENT PLT WITH A METICULOUS ATTN TO DETAIL. I DON'T FEEL I HAD TO 'WATCH HIM.' WE WERE TOLD TO 'FOLLOW THE OTHER ACR.' PERHAPS A BETTER TERM WOULD HAVE BEEN 'GIVE WAY TO.' PERHAPS I WAS COMPLACENT. PERHAPS I'M NOT BACK ON TOP OF MY GAME (I'D JUST RETURNED FROM A 14 MONTH LEAVE OF ABSENCE). I'M JUST SEARCHING IN HINDSIGHT FOR AN ANSWER TO 'WHY?' I THINK A COMBINATION OF ALL OF THE ABOVE. I THINK THE MOST DISCONCERTING PART OF ALL THIS FOR ME IS THAT I DIDN'T REALIZE THE ERROR WAS MADE UNTIL IT WAS MUCH TOO LATE -- AND THAT I CAN'T COME UP WITH 1 GOOD REASON AS TO HOW OR WHY IT HAPPENED.
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.