<< >> NASA ASRS Report 790281, June 2008

B737-700 flight crew fails to hear hold short clearance. Ground controller fails to note lack of acknowledgment of his hold short clearance. Runway incursion results.

Attributes
ACN	790281
Time
Date	200806
Local Time Of Day	0601 To 1200
Place
Locale Reference	airport : zzz.airport
State Reference	US
Altitude	agl single value : 0
Environment
Flight Conditions	VMC
Light	Daylight
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	B737-700
Operating Under FAR Part	Part 121
Flight Phase	ground : taxi
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Experience	flight time last 90 days : 244
ASRS Report	790281
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Experience	flight time last 90 days : 256 flight time type : 5600
ASRS Report	790412
Events
Anomaly	conflict : ground less severe incursion : runway other anomaly other
Independent Detector	other controllera
Resolutory Action	none taken : detected after the fact
Consequence	faa : reviewed incident with flight crew
Supplementary
Problem Areas	Flight Crew Human Performance ATC Human Performance
Primary Problem	ATC Human Performance

Narrative:

Approaching xy; we were told to hold short of xy. We neither heard nor acknowledged this instruction. The controller said to hold short again. By this time; our forward momentum had carried us into the intersection. We stopped on xy; later to be cleared to xxr. I called back from our next city. By this time the ATC tape had been played. It was clear to them that we did not acknowledge the revised clearance. The supervisor said no further action was required on our part. The controller made the mistake. Be more aware of changing events. The controller assumed we heard him -- a human error.

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Original NASA ASRS Text

Title: B737-700 FLT CREW FAILS TO HEAR HOLD SHORT CLRNC. GND CTLR FAILS TO NOTE LACK OF ACKNOWLEDGMENT OF HIS HOLD SHORT CLRNC. RWY INCURSION RESULTS.

Narrative: APCHING XY; WE WERE TOLD TO HOLD SHORT OF XY. WE NEITHER HEARD NOR ACKNOWLEDGED THIS INSTRUCTION. THE CTLR SAID TO HOLD SHORT AGAIN. BY THIS TIME; OUR FORWARD MOMENTUM HAD CARRIED US INTO THE INTXN. WE STOPPED ON XY; LATER TO BE CLRED TO XXR. I CALLED BACK FROM OUR NEXT CITY. BY THIS TIME THE ATC TAPE HAD BEEN PLAYED. IT WAS CLR TO THEM THAT WE DID NOT ACKNOWLEDGE THE REVISED CLRNC. THE SUPVR SAID NO FURTHER ACTION WAS REQUIRED ON OUR PART. THE CTLR MADE THE MISTAKE. BE MORE AWARE OF CHANGING EVENTS. THE CTLR ASSUMED WE HEARD HIM -- A HUMAN ERROR.

Data retrieved from NASA's ASRS site as of May 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.