|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1801 To 2400|
|Locale Reference||airport : yng.airport|
|Altitude||agl single value : 0|
|Operator||general aviation : personal|
|Make Model Name||PA-28 Cherokee/Archer II/Dakota/Pillan/Warrior|
|Operating Under FAR Part||Part 91|
|Flight Phase||ground : taxi|
|Controlling Facilities||tower : yng.tower|
|Make Model Name||Gulfstream V|
|Flight Phase||ground : taxi|
|Affiliation||government : faa|
|Function||controller : local|
|Qualification||controller : radar|
|Experience||controller limited radar : 15|
controller radar : 3.5
flight time total : 40
|Function||flight crew : single pilot|
|Anomaly||other anomaly other|
|Independent Detector||other controllera|
|Resolutory Action||none taken : anomaly accepted|
|Miss Distance||horizontal : 5|
vertical : 1000
|Problem Areas||Flight Crew Human Performance|
|ATC Facility||procedure or policy : yng.tower|
WX: good nighttime VFR (only scattered layers at high altitudes). Backgnd pertinent to actual situation that occurred later in the evening: a PA28; a few hours earlier; landed runway 32; requested to taxi back to remain in the pattern for 10 touch-and-goes and 3 stop-and-goes. The local controller; once the aircraft was holding short of the runway at the approach end of the runway; instructed aircraft Y to 'make left traffic; runway 32; cleared for takeoff.' the aircraft turned left onto the runway instead of right and attempted to take off toward the approach lights. The local controller immediately took corrective action. The pilot required numerous 'progressive' instructions while in the traffic pattern to keep him from becoming a factor for a military C130 conducting training. When I relieved the controller from local control; aircraft Y was still in the pattern and I was advised of his earlier actions. Aircraft Y landed without incident and required progressive taxi instructions to the ramp to get fuel. Actual incident: called for his IFR clearance to ZZZ and requested progressive taxi instructions to runway 32. The ramp area is only a few hundred ft from the approach end of the runway. Aircraft Y had difficulty with the instructions ('taxi southwest and taxiway M will be the furthest taxiway on your left.'). When the aircraft called ready; I cleared it for takeoff. My next transmission was 'stop' as aircraft Y was rolling swbound away from the runway. I instructed the aircraft to make a 180 degree turn and turn left onto runway 32 and again cleared the aircraft for takeoff. He attempted to take off in the wrong direction again and I stopped him. I then turned all the lights on the field off except the runway 32 lights and attempted to clear him for takeoff again. He went toward the same southwest direction that was now unlighted. I again stopped him; turned the runway lights up to their highest setting; and instructed him to taxi onto runway 32; with white lights on his l- and r-hand sides and taxi slowly on a 320 degree heading to ensure that he was correctly lined up on the runway. It took over 7 mins from the time aircraft Y called ready for him to get airborne safely. The new taxi into position and hold procedures attempt to address what are individual performance issues by placing restrs on the entire work force that can contribute and/or cause other unsafe sits. Taxi into position and hold was not only used as a capacity tool; but as a safety tool; as this situation clearly illustrates. I've previously worked at a facility ZZZ2 where an intersection departure for one runway was exceedingly close to another runway (runway 22R/T and runway 15R) and it was standard procedure to taxi into position and hold at the intersection first to ensure the aircraft lined up on the correct runway before issuing a takeoff clearance. Many factors are considered by a controller when deciding to use taxi into position and hold and traffic on final is only one of them. An uncertain pilot; a pilot's unusual actions; etc; also come into play when making a decision to taxi into position and hold. In my opinion; the new taxi into position and hold procedures contributed to this situation. By virtue of the fact that I was alone in the operational environment; I was prohibited from using a useful and; in this situation; a critical too. Even had I not been briefed on the aircraft's earlier performance; the fact that he had difficulty finding the runway from the ramp would have prompted me to issue a taxi into position and hold clearance initially instead of a takeoff clearance to ensure he was where he needed to be. Knowing the difficulties the pilot had experienced earlier would have ensured that I only issued a taxi into position and hold instruction; not a takeoff clearance. I honestly don't know if my corrective actions to ensure the safety of that takeoff violated the new taxi into position and hold procedures or not. I had an airport vehicle standing by to have the aircraft follow him into position on the runway as a last resort; which I am sure would've been a violation of the new rules.
Original NASA ASRS Text
Title: YNG CTLR DESCRIBED PLT ATTEMPT TO DEPART IN THE WRONG DIRECTION; CLAIMING TIPH PROCS AS CONTRIBUTORY.
Narrative: WX: GOOD NIGHTTIME VFR (ONLY SCATTERED LAYERS AT HIGH ALTS). BACKGND PERTINENT TO ACTUAL SIT THAT OCCURRED LATER IN THE EVENING: A PA28; A FEW HRS EARLIER; LANDED RWY 32; REQUESTED TO TAXI BACK TO REMAIN IN THE PATTERN FOR 10 TOUCH-AND-GOES AND 3 STOP-AND-GOES. THE LCL CTLR; ONCE THE ACFT WAS HOLDING SHORT OF THE RWY AT THE APCH END OF THE RWY; INSTRUCTED ACFT Y TO 'MAKE L TFC; RWY 32; CLRED FOR TKOF.' THE ACFT TURNED L ONTO THE RWY INSTEAD OF R AND ATTEMPTED TO TAKE OFF TOWARD THE APCH LIGHTS. THE LCL CTLR IMMEDIATELY TOOK CORRECTIVE ACTION. THE PLT REQUIRED NUMEROUS 'PROGRESSIVE' INSTRUCTIONS WHILE IN THE TFC PATTERN TO KEEP HIM FROM BECOMING A FACTOR FOR A MIL C130 CONDUCTING TRAINING. WHEN I RELIEVED THE CTLR FROM LCL CTL; ACFT Y WAS STILL IN THE PATTERN AND I WAS ADVISED OF HIS EARLIER ACTIONS. ACFT Y LANDED WITHOUT INCIDENT AND REQUIRED PROGRESSIVE TAXI INSTRUCTIONS TO THE RAMP TO GET FUEL. ACTUAL INCIDENT: CALLED FOR HIS IFR CLRNC TO ZZZ AND REQUESTED PROGRESSIVE TAXI INSTRUCTIONS TO RWY 32. THE RAMP AREA IS ONLY A FEW HUNDRED FT FROM THE APCH END OF THE RWY. ACFT Y HAD DIFFICULTY WITH THE INSTRUCTIONS ('TAXI SW AND TXWY M WILL BE THE FURTHEST TXWY ON YOUR L.'). WHEN THE ACFT CALLED READY; I CLRED IT FOR TKOF. MY NEXT XMISSION WAS 'STOP' AS ACFT Y WAS ROLLING SWBOUND AWAY FROM THE RWY. I INSTRUCTED THE ACFT TO MAKE A 180 DEG TURN AND TURN L ONTO RWY 32 AND AGAIN CLRED THE ACFT FOR TKOF. HE ATTEMPTED TO TAKE OFF IN THE WRONG DIRECTION AGAIN AND I STOPPED HIM. I THEN TURNED ALL THE LIGHTS ON THE FIELD OFF EXCEPT THE RWY 32 LIGHTS AND ATTEMPTED TO CLR HIM FOR TKOF AGAIN. HE WENT TOWARD THE SAME SW DIRECTION THAT WAS NOW UNLIGHTED. I AGAIN STOPPED HIM; TURNED THE RWY LIGHTS UP TO THEIR HIGHEST SETTING; AND INSTRUCTED HIM TO TAXI ONTO RWY 32; WITH WHITE LIGHTS ON HIS L- AND R-HAND SIDES AND TAXI SLOWLY ON A 320 DEG HDG TO ENSURE THAT HE WAS CORRECTLY LINED UP ON THE RWY. IT TOOK OVER 7 MINS FROM THE TIME ACFT Y CALLED READY FOR HIM TO GET AIRBORNE SAFELY. THE NEW TAXI INTO POS AND HOLD PROCS ATTEMPT TO ADDRESS WHAT ARE INDIVIDUAL PERFORMANCE ISSUES BY PLACING RESTRS ON THE ENTIRE WORK FORCE THAT CAN CONTRIBUTE AND/OR CAUSE OTHER UNSAFE SITS. TAXI INTO POS AND HOLD WAS NOT ONLY USED AS A CAPACITY TOOL; BUT AS A SAFETY TOOL; AS THIS SIT CLRLY ILLUSTRATES. I'VE PREVIOUSLY WORKED AT A FACILITY ZZZ2 WHERE AN INTXN DEP FOR ONE RWY WAS EXCEEDINGLY CLOSE TO ANOTHER RWY (RWY 22R/T AND RWY 15R) AND IT WAS STANDARD PROC TO TAXI INTO POS AND HOLD AT THE INTXN FIRST TO ENSURE THE ACFT LINED UP ON THE CORRECT RWY BEFORE ISSUING A TKOF CLRNC. MANY FACTORS ARE CONSIDERED BY A CTLR WHEN DECIDING TO USE TAXI INTO POS AND HOLD AND TFC ON FINAL IS ONLY ONE OF THEM. AN UNCERTAIN PLT; A PLT'S UNUSUAL ACTIONS; ETC; ALSO COME INTO PLAY WHEN MAKING A DECISION TO TAXI INTO POS AND HOLD. IN MY OPINION; THE NEW TAXI INTO POS AND HOLD PROCS CONTRIBUTED TO THIS SIT. BY VIRTUE OF THE FACT THAT I WAS ALONE IN THE OPERATIONAL ENVIRONMENT; I WAS PROHIBITED FROM USING A USEFUL AND; IN THIS SIT; A CRITICAL TOO. EVEN HAD I NOT BEEN BRIEFED ON THE ACFT'S EARLIER PERFORMANCE; THE FACT THAT HE HAD DIFFICULTY FINDING THE RWY FROM THE RAMP WOULD HAVE PROMPTED ME TO ISSUE A TAXI INTO POS AND HOLD CLRNC INITIALLY INSTEAD OF A TKOF CLRNC TO ENSURE HE WAS WHERE HE NEEDED TO BE. KNOWING THE DIFFICULTIES THE PLT HAD EXPERIENCED EARLIER WOULD HAVE ENSURED THAT I ONLY ISSUED A TAXI INTO POS AND HOLD INSTRUCTION; NOT A TKOF CLRNC. I HONESTLY DON'T KNOW IF MY CORRECTIVE ACTIONS TO ENSURE THE SAFETY OF THAT TKOF VIOLATED THE NEW TAXI INTO POS AND HOLD PROCS OR NOT. I HAD AN ARPT VEHICLE STANDING BY TO HAVE THE ACFT FOLLOW HIM INTO POS ON THE RWY AS A LAST RESORT; WHICH I AM SURE WOULD'VE BEEN A VIOLATION OF THE NEW RULES.
Data retrieved from NASA's ASRS site as of January 2009 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.