CAPT OF MLG ACR ACFT FAILED TO ADHERE TO THE STANDARD TAXI INSTRUCTIONS RESULTING IN NOT OBTAINING A CLRNC AT AN INTXN LIMIT.
Synopsis
CAPT OF MLG ACR ACFT FAILED TO ADHERE TO THE STANDARD TAXI INSTRUCTIONS RESULTING IN NOT OBTAINING A CLRNC AT AN INTXN LIMIT.
Narrative
THE PROBLEM AROSE WHEN I HEARD THE CTLR SAY 'TAXI TO 5R VIA S RTE.' SINCE I DID NOT HEAR THE WORD 'STANDARD'; I THOUGHT I WAS CLRED TO 5R VIA ECHO AND ALPHA; AND NOT THE 'STANDARD' TAXI PROC; WHICH REQUIRES YOU TO HOLD SHORT OF ALPHA. THE PROBLEM WAS DISCOVERED WHEN WE SWITCHED TO TWR FREQ ON ALPHA. THEY ASKED IF WE HAD CONTACTED GND ON 121.9. WE HAD MISSED THE FREQ CHANGE AND HAD GONE DIRECTLY FROM WSIDE GND CTL TO TWR FREQ. CONTRIBUTING FACTORS -- UNFAMILIARITY WITH 5R STANDARD TAXI VIA S RTE PROC. ALSO; THE WORDING OF THE PROC 'RWY 5R; TAXI VIA S RTE' DOES NOT WARN THAT IT IS ONLY CLRNC TO A POINT SHORT OF THE RWY. CORRECTIVE ACTIONS: MAKE THE CLRNC ONLY TO THE SPECIFIC 'HOLD SHORT' POINT; NOT THE RWY. IF WE ARE CLRED VIA ECHO; HOLD SHORT OF ALPHA; WE WILL KNOW WE ARE GOING TO DEPART ON 5R. ALSO; A CLRLY VISIBLE SIGN ON THE TAXIWAY STATING CONTACT GND ON XXX NOW SHOULD BE IN PLACE. PERCEPTIONS -- I WAS LULLED INTO A FALSE SENSE OF SECURITY BECAUSE I WAS SURE OF WHERE I WAS GOING. THERE WAS NO CONFLICTING TFC; SO I HAD NO CAUSE FOR ALARM. HUMAN PERFORMANCE FACTORS -- FATIGUE WAS A CONTRIBUTING FACTOR. THIS WAS THE FOURTH LEG OF A 12 HR DUTY DAY. THE SYS MUST BE DESIGNED TO CATCH MISTAKES BEFORE THEY BECOME A PROBLEM. GND CTLRS SHOULD CONTACT THE ACFT IF IT HASN'T CONTACTED THEM BY A CERTAIN POINT. BOTH GND CTLRS AND AIRCREW HAVE A RESPONSIBILITY TO PREVENT INCIDENTS.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.