Narrative:

I was working ground and local control combined this saturday afternoon. A BE36 was issued a taxi clearance to runway 28L, with instructions to hold short of runway 23 (the hold short instructions are now required to be issued for each and every taxi clearance to runway 28L via taxiway D, due to continued pilot confusion in this area). The pilot did as instructed, and held short of the combined hold short line for runways 23 and 28L. The bonanza then called ready for departure on runway 28L. I had a 4 mi gap, so after the first arrival passed, I instructed the bonanza to taxi into position and hold on runway 28L. The pilot read back the clearance verbatim. It was going to be a little tight to get the bonanza out, but not anything out of the ordinary. However, once I got the first arrival off the runway and was about to issue the takeoff clearance to the bonanza, I discovered that the pilot had taxied into position and was holding on runway 23. I had to explain to the pilot that he had lined up on the incorrect runway, and that he needed to taxi via runway 23 to get to runway 28L. I urged him to hurry, and I cleared him for takeoff. The pilot complied, and apologized for his mistake. I barely had minimum separation with the second arrival. This taxiway D/runway 23/runway 28L area has caused confusion for many a pilot. There has been a lot of discussion about this problem, mostly resulting in responses stating that all signage/marking meets minimum FAA standards. If this is the case, then possibly the standards are flawed, as this type of mistake occurs, even with professional pilots.

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Original NASA ASRS Text

Title: RPTR ALLEGES THERE IS CONFUSION WITH RWYS 28L-23 CONFIGN SIGNAGE CITING A BE36 WHO WAS GIVEN POS AND HOLD ON RWY 28L BUT WENT INTO POS ON RWY 23.

Narrative: I WAS WORKING GND AND LCL CTL COMBINED THIS SATURDAY AFTERNOON. A BE36 WAS ISSUED A TAXI CLRNC TO RWY 28L, WITH INSTRUCTIONS TO HOLD SHORT OF RWY 23 (THE HOLD SHORT INSTRUCTIONS ARE NOW REQUIRED TO BE ISSUED FOR EACH AND EVERY TAXI CLRNC TO RWY 28L VIA TXWY D, DUE TO CONTINUED PLT CONFUSION IN THIS AREA). THE PLT DID AS INSTRUCTED, AND HELD SHORT OF THE COMBINED HOLD SHORT LINE FOR RWYS 23 AND 28L. THE BONANZA THEN CALLED READY FOR DEP ON RWY 28L. I HAD A 4 MI GAP, SO AFTER THE FIRST ARR PASSED, I INSTRUCTED THE BONANZA TO TAXI INTO POS AND HOLD ON RWY 28L. THE PLT READ BACK THE CLRNC VERBATIM. IT WAS GOING TO BE A LITTLE TIGHT TO GET THE BONANZA OUT, BUT NOT ANYTHING OUT OF THE ORDINARY. HOWEVER, ONCE I GOT THE FIRST ARR OFF THE RWY AND WAS ABOUT TO ISSUE THE TKOF CLRNC TO THE BONANZA, I DISCOVERED THAT THE PLT HAD TAXIED INTO POS AND WAS HOLDING ON RWY 23. I HAD TO EXPLAIN TO THE PLT THAT HE HAD LINED UP ON THE INCORRECT RWY, AND THAT HE NEEDED TO TAXI VIA RWY 23 TO GET TO RWY 28L. I URGED HIM TO HURRY, AND I CLRED HIM FOR TKOF. THE PLT COMPLIED, AND APOLOGIZED FOR HIS MISTAKE. I BARELY HAD MINIMUM SEPARATION WITH THE SECOND ARR. THIS TXWY D/RWY 23/RWY 28L AREA HAS CAUSED CONFUSION FOR MANY A PLT. THERE HAS BEEN A LOT OF DISCUSSION ABOUT THIS PROB, MOSTLY RESULTING IN RESPONSES STATING THAT ALL SIGNAGE/MARKING MEETS MINIMUM FAA STANDARDS. IF THIS IS THE CASE, THEN POSSIBLY THE STANDARDS ARE FLAWED, AS THIS TYPE OF MISTAKE OCCURS, EVEN WITH PROFESSIONAL PLTS.

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.