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A ba-3100 flight crew inadvertently cross the hold short line with an aircraft on takeoff roll resulting in a C172 aborting his takeoff due to cockpit distrs and after landing assumptions.
| Attributes | |
| ACN | 588212 |
| Time | |
| Date | 200307 |
| Day | Mon |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : cgi.airport |
| State Reference | MO |
| Altitude | agl single value : 0 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Operator | common carrier : air taxi |
| Make Model Name | Jetstream 32 |
| Operating Under FAR Part | Part 135 |
| Flight Phase | ground : taxi |
| Flight Plan | IFR |
| Aircraft 2 | |
| Controlling Facilities | tower : cgi.tower |
| Operator | general aviation : personal |
| Make Model Name | Skyhawk 172/Cutlass 172 |
| Operating Under FAR Part | Part 91 |
| Flight Phase | ground : takeoff roll |
| Person 1 | |
| Affiliation | company : air taxi |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : multi engine |
| Experience | flight time last 90 days : 200 flight time total : 10000 flight time type : 7500 |
| ASRS Report | 588212 |
| Person 2 | |
| Affiliation | company : air taxi |
| Function | flight crew : first officer |
| Qualification | pilot : commercial pilot : instrument pilot : multi engine |
| Experience | flight time last 90 days : 225 flight time total : 1800 flight time type : 1200 |
| ASRS Report | 588557 |
| Events | |
| Anomaly | conflict : ground less severe incursion : runway non adherence : published procedure non adherence : clearance |
| Independent Detector | other controllera |
| Resolutory Action | controller : issued alert flight crew : took evasive action flight crew : became reoriented flight crew : rejected takeoff |
| Miss Distance | horizontal : 1000 vertical : 0 |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
After landing on runway 28 at cgi, we were told to taxi to the terminal and hold short of runway 20. My first officer read it back, but I missed the hold short instructions. As we approached runway 20, I looked both ways and saw a cessna starting a takeoff roll. I immediately stopped and, at the same time, the ground controller told me to hold short. I stopped short of runway 20, but had passed the hold short line. The cessna also aborted his takeoff. The chain of events that caused this situation were: 1) my inattn/distrs, 2) my first officer being involved with after landing checklist and not being heads up. There was no near collision due to the following: 1) my habit of looking even though I think I am cleared to cross. 2) the alert ground controller issued us hold short instructions a second time as we approached the runway and were crossing the hold short line. 3) the cessna pilot was alert to his environment and either saw me approaching or heard the ground controller's second hold short command. So, while human failures set up a chain of events that could have led to an accident, human performance on the part of several people also broke that chain. In the future I will be more diligent and less complacent in listening to taxi instructions. I will also have my first officer's monitor more closely during this critical phase of operations. Supplemental information from acn 588557: when I looked up, we had passed the hold short line, but weren't in the runway yet. I told the captain to stop. The tower at that time called us to hold short. My captain had not heard the hold short instruction. I hadn't looked up quickly enough to make sure we were doing everything correctly. Complacency and assumption caused this problem. My captain has been flying all his life. I assumed that he knows everything and doesn't need help, so I got lazy watching out for us. He assumed that I was watching out for us and didn't pay close attention to the instructions. We go to that airport 3 times per week and the instructions are always, 'taxi to the ramp, remain my frequency.' except for this time, of course.
Original NASA ASRS Text
Title: A BA-3100 FLT CREW INADVERTENTLY CROSS THE HOLD SHORT LINE WITH AN ACFT ON TKOF ROLL RESULTING IN A C172 ABORTING HIS TKOF DUE TO COCKPIT DISTRS AND AFTER LNDG ASSUMPTIONS.
Narrative: AFTER LNDG ON RWY 28 AT CGI, WE WERE TOLD TO TAXI TO THE TERMINAL AND HOLD SHORT OF RWY 20. MY FO READ IT BACK, BUT I MISSED THE HOLD SHORT INSTRUCTIONS. AS WE APCHED RWY 20, I LOOKED BOTH WAYS AND SAW A CESSNA STARTING A TKOF ROLL. I IMMEDIATELY STOPPED AND, AT THE SAME TIME, THE GND CTLR TOLD ME TO HOLD SHORT. I STOPPED SHORT OF RWY 20, BUT HAD PASSED THE HOLD SHORT LINE. THE CESSNA ALSO ABORTED HIS TKOF. THE CHAIN OF EVENTS THAT CAUSED THIS SIT WERE: 1) MY INATTN/DISTRS, 2) MY FO BEING INVOLVED WITH AFTER LNDG CHKLIST AND NOT BEING HEADS UP. THERE WAS NO NEAR COLLISION DUE TO THE FOLLOWING: 1) MY HABIT OF LOOKING EVEN THOUGH I THINK I AM CLRED TO CROSS. 2) THE ALERT GND CTLR ISSUED US HOLD SHORT INSTRUCTIONS A SECOND TIME AS WE APCHED THE RWY AND WERE XING THE HOLD SHORT LINE. 3) THE CESSNA PLT WAS ALERT TO HIS ENVIRONMENT AND EITHER SAW ME APCHING OR HEARD THE GND CTLR'S SECOND HOLD SHORT COMMAND. SO, WHILE HUMAN FAILURES SET UP A CHAIN OF EVENTS THAT COULD HAVE LED TO AN ACCIDENT, HUMAN PERFORMANCE ON THE PART OF SEVERAL PEOPLE ALSO BROKE THAT CHAIN. IN THE FUTURE I WILL BE MORE DILIGENT AND LESS COMPLACENT IN LISTENING TO TAXI INSTRUCTIONS. I WILL ALSO HAVE MY FO'S MONITOR MORE CLOSELY DURING THIS CRITICAL PHASE OF OPS. SUPPLEMENTAL INFO FROM ACN 588557: WHEN I LOOKED UP, WE HAD PASSED THE HOLD SHORT LINE, BUT WEREN'T IN THE RWY YET. I TOLD THE CAPT TO STOP. THE TWR AT THAT TIME CALLED US TO HOLD SHORT. MY CAPT HAD NOT HEARD THE HOLD SHORT INSTRUCTION. I HADN'T LOOKED UP QUICKLY ENOUGH TO MAKE SURE WE WERE DOING EVERYTHING CORRECTLY. COMPLACENCY AND ASSUMPTION CAUSED THIS PROB. MY CAPT HAS BEEN FLYING ALL HIS LIFE. I ASSUMED THAT HE KNOWS EVERYTHING AND DOESN'T NEED HELP, SO I GOT LAZY WATCHING OUT FOR US. HE ASSUMED THAT I WAS WATCHING OUT FOR US AND DIDN'T PAY CLOSE ATTN TO THE INSTRUCTIONS. WE GO TO THAT ARPT 3 TIMES PER WK AND THE INSTRUCTIONS ARE ALWAYS, 'TAXI TO THE RAMP, REMAIN MY FREQ.' EXCEPT FOR THIS TIME, OF COURSE.
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.