AT SLC; FLC OF A B737 MISTAKENLY TOOK OFF ON THE WRONG RWY -- AND; ONE WHICH WAS CLOSED.

Date: 1994-11 · Aircraft: B737 Undifferentiated or Other Model · Phase: takeoff

Anomalies: deviation-discrepancy-procedural-clearance|ground-incursion-runway|other-unspecified

Synopsis

AT SLC; FLC OF A B737 MISTAKENLY TOOK OFF ON THE WRONG RWY -- AND; ONE WHICH WAS CLOSED.

Narrative

ACR X WAS SCHEDULED TO DEPART SLC FOR LAS VEGAS AT XH35 LCL TIME. THE FLT PUSHED FROM THE GATE ON TIME AND AFTER DEICING WAS CLRED TO TAXI BEHIND ACR Y TO RWY 34. AFTER WAITING SEVERAL MINS FOR ARRS AND ACR Y DEP OFF OF RWY 34; WE WERE CLRED TO CROSS TO RWY 35. AS WE PROCEEDED WE DISCUSSED THE DEICING HOLD OVER TIME AND MADE AN ASSESSMENT OF THE CONDITIONS TO DETERMINE IF THE XH54 LCL HOLD OVER TIME WAS STILL A FACTOR. I SWITCHED TO RWY 35 TWR FREQ AND SHORTLY THEREAFTER I VISUALLY ACQUIRED THAT RWY. I DID NOT NOTICE RWY 32. AS WE APCHED THE HOLD SHORT LINE; I SAW 1-2 FT OF PLOWED SNOW ON THE END OF RWY 35 BUT NO ACCUMULATION ON THE RWY SURFACE; THUS VALIDATING MY TKOF OFF PERFORMANCE CALCULATIONS. BY USING THE WING LIGHT I COULD SEE THAT THERE WAS NO SNOW ON THE R WING. ABOUT THAT TIME WE WERE CLRED FOR TKOF ON RWY 35. THE 'BELOW THE LINE' CHKLIST WAS ACCOMPLISHED AND I VISUALLY CLRED THE APCH FOR ACFT. AT THE SAME TIME THE CAPT WAS ALIGNING THE ACFT AND ADVANCING PWR; SUBSEQUENTLY ASKING FOR TKOF THRUST. AFTER SETTING THE TKOF THRUST; I LOOKED OUTSIDE TO CHK OUR ALIGNMENT. THE CAPT WAS USING THE WINDSHIELD WIPERS TO CLEAR MELTING SNOW WHICH WAS CAUSING SOME GLARE AND VISIBILITY PROBS. MY PERCEPTION WAS THAT IN THE TIME THAT I READ THE CHKLIST; CLRED FOR ACFT ON FINAL; AND SET TKOF PWR; WE HAD TRAVELED ON TO RWY 35; MADE A 90 DEG TURN AND STARTED TRACKING THE RWY 35 CTRLINE. HOWEVER; IN ERROR WE HAD TURNED SLIGHTLY SHORT AND IN EXCESS OF 90 DEGS ONTO RWY 32. I MADE THE STANDARD CALL OUTS AN DIDN'T RECOGNIZE OUR MISTAKE UNTIL AFTER LOOKING OUTSIDE AT VR AND SEEING CONVERGENCE ON RWY 34. EARLIER IN THE TKOF ROLL AT ABOUT 100 KTS I KNEW SOMETHING WAS WRONG BY THE CAPT'S INCREASED ALERTNESS AND MUMBLED WORDS. APPARENTLY HE HAD NOTICED THE MISTAKE AFTER WE WERE COMMITTED TO CONTINUE. AFTER SAFELY AIRBORNE WITH THE GEAR RETRACTED WE MADE A TURN TO AVOID OVERFLT OF RWY 34. WE WERE LATER TOLD BY TWR OF THE ERROR AND CONTINUED TO LAS VEGAS. THE CONGRUENT NATURE OF THE APCH END OF RWY 32 AND 35; AND THE FACT THAT RWY 32 WAS NOTAM CLOSED BUT THE RWY LIGHTS REMAINED ON WERE SIGNIFICANT FACTORS. HUMAN FACTORS: IN MY OPINION THE FOLLOWING WERE CONTRIBUTING HUMAN FACTORS: UNFAMILIARITY WITH THE ARPT. OUR INITIAL MIND-SET WAS FOR A RWY 34 DEP AND WHEN SWITCHED TO RWY 35 WE LOOKED AT THE ARPT DIAGRAM TO SEE IF WE WERE TAXIING CORRECTLY. MENTALLY I DISCOUNTED RWY 32 AS A FACTOR BECAUSE I THOUGHT THAT ITS SIZE AND ORIENTATION WOULD MAKE EASILY DISTINGUISHABLE FROM RWY 35. NIGHT/WX OPS. THE INTENSIFYING FALLING SNOW PRESENTED SOME VISIBILITY AND DEPTH PERCEPTION PROBS. INITIALLY I SAW THE CORRECT RWY AND BELIEVED WE HAD TURNED ONTO IT WHILE I WAS READING THE CHKLIST AND SETTING TKOF PWR. IN RETROSPECT; I ACTUALLY GOT DISORIENTED DURING THAT TIME PERIOD AND SHOULD HAVE XCHKED THE ACFT HDG. CHANNELIZED ATTN. ALTHOUGH THERE WAS NO SIGNIFICANT ACCUMULATION OF SNOW ON THE GND OR ON THE ACFT; IT DID CAUSE US TO BRING THE DEICING CONSIDERATIONS INTO OUR PROCEDURAL FLOW PATTERN. THIS IS BECAUSE WE DIDN'T KNOW WHAT TO EXPECT UNTIL WE GOT TO THE END OF THE RWY. WHERE THE SNOW CAUSED A MAJOR PROB WAS ON LINE UP WHEN BOTH OF US GOT 'TUNNEL VISION' TRYING TO ALIGN THE ACFT WITH THE RWY CTRLINE OF THE WRONG RWY. COMS. THERE WAS A COMS BREAKDOWN AS WE WERE APCHING THE RWYS. EACH PLT HAD WHAT HE THOUGHT WAS COMPLETE AND ACCURATE INFO. HOWEVER; IN THE FINAL ANALYSIS OUR OVERALL SITUATIONAL AWARENESS WAS LESS THAN OPTIMAL AND WE SHOULD HAVE STOPPED TO CONFIRM THAT WE WERE PROCEEDING ONTO THE CORRECT RWY.

More incidents for this aircraft family →

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