SMT CONFUSES CLRNC AND MOVES INTO POS AND HOLD WITH LNDG TFC.

Date: 1994-03 · Aircraft: Cessna 310/T310C

Anomalies: conflict-ground-conflict|critical|ground-incursion-runway

Synopsis

SMT CONFUSES CLRNC AND MOVES INTO POS AND HOLD WITH LNDG TFC.

Narrative

I WAS TAXIING FOR TKOF BEHIND AN ACR PAX JET. I WAS SOLO PLT FLYING A CESSNA 310. WX WAS LOW IFR. TWR HAD LIMITED OR NO VISIBILITY TO TKOF AREA. ACTIVITY WAS BUSY. I HAVE NOT LISTENED TO THE TAPES THOUGH I HAD A LENGTHY DISCUSSION WITH THE CTLR BY PHONE UPON LNDG. HE HAD LISTENED TO THE TAPES. WHAT FOLLOWS IS MY BEST MEMORY RECOLLECTION OF WHAT ACTUALLY HAPPENED. TWR TOLD THE ACR TO 'CROSS RWY 5R; TAXI INTO POS AND HOLD ON RWY 5L;' IMMEDIATELY AFTER TWR TOLD ME TO 'HOLD SHORT RWY 5R.' UPON HEARING THIS; I APPARENTLY REGISTERED THE 'INTO POS AND HOLD' INSTRUCTION FOR THE ACR AND HEARD THE RWY 5R IN MY CLRNC AND PROCEEDED TO TAXI INTO POS AND HOLD ON RWY 5R. I READ BACK MY INSTRUCTIONS (ACCORDING TO THE BEST OF MY MEMORY) AS WHAT I INCORRECTLY DID AND NOT WHAT I HAD BEEN ACTUALLY TOLD. BECAUSE OF THE BUSINESS OF THE FREQS THERE HAD BEEN SOME TENDENCIES TOWARD ABBREVIATION WHICH I MAY ALSO HAVE DONE IN MY READBACK BUT I AM FAIRLY CERTAIN I SAID THE WORDS 'INTO POS AND HOLD.' THE TWR HAD NO VISUAL CONTACT TO CATCH THE ERROR AND EITHER DID NOT HEAR OR MISINTERPRETED MY READBACK WHICH WAS INCORRECT. MEANWHILE A JET WAS ON FINAL FOR LNDG ON RWY 5R. WHEN THE JET BROKE OUT IT APPARENTLY SAW ME ON THE RWY AND INITIATED A MISSED APCH. TWR INQUIRED AS TO WHETHER I WAS ON THE RWY OR HOLDING SHORT. MEANWHILE THE JET HAD PASSED OVERHEAD; I REALIZED THE MISTAKE; TWR INSTRUCTED ME TO PROCEED TO RWY 5L AND SHORTLY CLRED ME FOR TKOF. THE JET CIRCLED AND LANDED WITH NO APPARENT MISHAP. MY OBSERVATIONS ARE SUCH: DID I MAKE A MISTAKE? WITHOUT LISTENING TO THE TAPES I WILL NOT SAY BUT THERE IS A VERY STRONG LIKELIHOOD THAT I DID HEAR THE INSTRUCTIONS TO THE ACR AND MYSELF SO CLOSELY TOGETHER THAT I INCORRECTLY INTERPRETED THEM. DID I DO A READBACK? YES. WAS MY READBACK CORRECT? AGAIN; WITHOUT LISTENING TO THE TAPES I CANNOT SAY FOR SURE WHAT WAS SAID BUT IN A CONVERSATION WITH THE CTLR HE INDICATED THAT I HAD READ BACK WHAT I DID -- NOT WHAT I WAS TOLD TO DO. DID THE TWR MAKE A MISTAKE? PERHAPS; BUT THIS IS CLRLY A CASE WHERE BLAME PROBABLY DOES NOT REST 100 PERCENT ON ANYONE'S SHOULDERS BUT IS PROBABLY SPREAD BTWN THE PLT AND THE TWR. WHAT COULD HAVE BEEN DONE TO PREVENT THIS INCIDENT? NEEDLESS TO SAY; I; AS A PLT; MUST EXERCISE 100 PERCENT CONCENTRATION ON GND INSTRUCTION; PARTICULARLY IN POOR VISIBILITY SITS. HOWEVER; IT IS MUCH MORE COMMON FOR ME TO HEAR IN HOLD SHORT INSTRUCTIONS THE PHRASE 'LNDG TFC.' WHILE I REALIZE THE CTLR IS NOT REQUIRED TO SAY THIS AND THAT AS A PLT I AM SUPPOSED TO HEAR 'HOLD SHORT' ALONE AND OBEY REGARDLESS OF THE REASON. IN THIS CASE WITH AN INSTRUCTION OF 'TAXI INTO POS AND HOLD' BEING GIVEN TO THE OTHER PLT FOLLOWED BY THE PHRASE 'HOLD SHORT' TO ME; IF THE PHRASE THAT HAD BEEN GIVEN TO ME WAS 'HOLD SHORT RWY 5R LNDG TFC' I THINK I WOULD HAVE CAUGHT THIS AND NOT MADE THIS ERROR. IT WOULD BE MY SUGGESTION TO ATC TO CONSIDER REQUIRING THE USE OF THE PHRASE 'LNDG TFC' FOR ALL HOLD SHORT INSTRUCTIONS IN CONDITIONS OF LOW VISIBILITY WHERE NEITHER THE TWR NOR THE TWO PLTS HAVE THE ABILITY TO VISUALLY SEE MISTAKES IN ACTIONS BY THE PLT ON THE GND. THE TENERIFE PANAM COLLISION AND THE LAX USAIR ACCIDENT SHOW THAT THIS ERROR CAN ALSO HAPPEN WITH PLTS WHO HAVE FAR MORE HRS THAN MYSELF. IN BOTH INCIDENTS WAS THE PHRASE 'LNDG TFC' USED? AND IF IT WASN'T; WOULD THOSE 2 WORDS HAVE MADE A DIFFERENCE IN THE PLT'S INTERP OF THE INFO?

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.