A B757-200 FLC PERFORMS A RWY INCURSION WITH TFC ON SHORT FINAL. CAPT HAD READ BACK TO HOLD SHORT RWY 28L BUT FORGOT THE CLRNC AND CROSSED RWY 28L AT SFO; CA.
Synopsis
A B757-200 FLC PERFORMS A RWY INCURSION WITH TFC ON SHORT FINAL. CAPT HAD READ BACK TO HOLD SHORT RWY 28L BUT FORGOT THE CLRNC AND CROSSED RWY 28L AT SFO; CA.
Narrative
THE FO MADE A NORMAL APCH AND LNDG ON RWY 28R AT SFO. WHILE REQUIRED AIRSPD CALLS FOR 80 KTS/60 KTS AS WELL AS COMMANDS BY ME TO ASSUME CTL OF THE ACFT; SFO TWR TOLD US TO (WHAT I THOUGHT) CROSS RWY 28L. I RESPONDED TO THE CLRNC. AS WE CROSSED RWY 28L THE FO AND I BOTH CLRED FINAL ON RWY 28L. ALTHOUGH WE BOTH US SAW AN ACFT ON FINAL; IT APPEARED TO BE ABOUT 2 MI OUT SO WE MADE A NORMAL XING. I NEXT SAW THE ACFT THAT HAD BEEN ON FINAL FOR RWY 28L ROLLING OUT ON RWY 28L AFTER WE HAD RECEIVED CLRNC TO TAXI TO OUR GATE AND WE WERE ON TXWY A; THE TWR SUPVR TOLD US TO TELEPHONE HIM AFTER WE HAD PARKED. LATER HE TOLD ME THAT HE HAD LISTENED TO THE TAPES AND WE WERE TOLD AND HAD READ BACK TO HOLD SHORT OF RWY 28L. I DO NOT REMEMBER READING BACK THE HOLD SHORT CLRNC. I REMEMBER RESPONDING BUT NOT TO HOLD SHORT. ALTHOUGH THIS IS A CLR EXAMPLE OF VIOLATING AN ATC CLRNC; THERE WERE CONTRIBUTING FACTORS TO THIS INCIDENT. (I AM NOT MAKING EXCUSES BUT RATHER REASONING OUT HOW THIS HAPPENED.) 1) WE RECEIVED OUR CLRNC TO HOLD SHORT WHILE WE WERE GIVING/RECEIVING THE REQUIRED CALLOUTS/COMMANDS IN THE COCKPIT. 2) AT THE SAME TIME I WAS MAKING THE DECISION OF WHETHER TO TURN OFF ON THE HIGH-SPEED TURNOFF (TXWY T) OR MAKE HEAVIER BRAKING TO TURN OFF ON TXWY E. 3) RESPONDING ON THE RADIO WHILE BUSY WITH OTHER COCKPIT DUTIES. 4) FATIGUE -- I HAD BEEN UP FOR 18 HRS. POSSIBLE SOLUTIONS TO HELP PREVENT THIS TYPE OF INCIDENT FROM HAPPENING AGAIN: 1) HAVE ATC GIVE FURTHER CLRNCS ONLY WHEN ACFT IS CLRING THE RWY -- NOT WHILE ACFT IS IN FINAL STAGES OF THE ROLLOUT. 2) PLACE STOP BARS AT CRITICAL POINTS ON ARPTS TO PREVENT INCURSIONS. 3) DON'T TRY TO DO TOO MUCH; COMPLETE REQUIRED COCKPIT DUTIES FIRST AND THEN RESPOND TO CLRNCS; IE; 'PRIORITIZE.' SUPPLEMENTAL INFO FROM ACN 469577: DURING LNDG ROLLOUT TWR ISSUED A CLRNC TO US THAT I WAS ONLY PARTIALLY ABLE TO COPY DUE TO THE FACT I WAS STILL CTLING THE ACFT.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.