CREW TOOK OFF ON THE WRONG RWY AT BDL.
Synopsis
CREW TOOK OFF ON THE WRONG RWY AT BDL.
Narrative
FLT WAS THE 4TH SEGMENT OF A 3 DAY TRIP THAT BEGAN THE DAY BEFORE. IT WAS THE FIRST FLT OF OUR SECOND DUTY PERIOD AND WE HAD HAD A RESTFUL 20 HR LAYOVER. OUR CREW HAD AMPLE TIME FOR PREFLT PREPARATIONS. A PLACARDED INOP FUEL GAUGE WOULD REQUIRE SUPERVISION OF FUELING. AS OUR PREFLT PROGRESSED; I BECAME CONCERNED THAT THE FUELING WOULD CAUSE A DELAY AND BEGAN COORD WITH OPS. THE FLT ULTIMATELY WAS DELAYED BY NEARLY 1 HR; RAISING PROBS FOR NUMEROUS CONNECTING ITINERARIES. A DELAY OF OVER 50 MINS WOULD JEOPARDIZE OUR NEXT REST PERIOD. DURING THE PERIODIC DISTR OF MANAGING OUR DELAY; OUR COCKPIT PREFLT PROCEEDED NORMALLY AND INCLUDED A REVIEW OF OUR DEP CLRNC; SPECIAL ENG-OUT PROCS FOR RWY 33 AND REVIEW OF THE WT MANIFEST INCLUDING PROGRAMMING OF THE FMC. I BRIEFED THAT WE WOULD REQUEST RWY 33 OVER RWY 6 AND BRIEFED BOTH THE FLT ATTENDANTS AND FO THAT OUR TAXI TIME WOULD BE QUICK. IN RETROSPECT; THIS WAS A MISSED OPPORTUNITY TO EXAMINE AND BRIEF MORE THOROUGHLY OUR TAXI RTE. I APCHED THE TAXI PLANNING WITH CONFIDENCE THAT IT WAS A SIMPLE; FAMILIAR RTE. THE ARPT LAYOUT WAS FAMILIAR ENOUGH THAT I DID NOT CONTEMPLATE THE POSSIBILITY FOR CONFUSION. MY MENTAL PICTURE OF THE RTE HAD 1 90-DEG R TURN; A SHORT; STRAIGHT AHEAD SEGMENT DURING WHICH THE TAXI CHK WOULD BE BRISKLY ACCOMPLISHED. WE WOULD THEN XFER FROM GND TO TWR FOR A RWY HDG DEP. IT WAS LATE DUSK. WE WERE CLRED AS EXPECTED TO RWY 33. THE PROGRESSION OF THE TAXI CHK PROCEEDED AS EXPECTED. IN SHORT ORDER; I WAS APCHING RED SIGNAGE INDICATING RWY 15/33. I BELIEVE I DIRECTED THE FO TO SWITCH TO TWR JUST AS HE WAS ANNOUNCING THE TAXI CHK COMPLETE. THE FO THEN; AT MY DIRECTION; TOLD THE TWR WE WERE READY. THE TWR IMMEDIATELY CLRED US FOR TKOF ON RWY 33; RWY HDG. I CALLED FOR THE BEFORE TKOF CHK. THE FO PICKED UP AND DROPPED THE PA MIKE. AFTER DISENTANGLING THE MIKE; HE COMPLETED THE BEFORE TKOF CHK AS I TURNED TO ALIGN WITH THE RWY THAT HAD IMBEDDED THRESHOLD LIGHTS ORIENTED ON A REVERSE DIAGONAL TO MY TXWY. THIS WAS A BIG MISTAKE. I WAS OPERATING ON A MENTAL PICTURE OF US TURNING FROM A BASICALLY EASTERLY TXWY ONTO A REVERSE DIAGONAL THAT WAS BASICALLY NORTHWESTERLY. WRONG. THE REVERSE DIAGONAL ALIGNED ME WITH RWY 1. I SIMPLY HAD A DIAGONAL ORIENTATION TO A CARDINAL RWY LAYOUT ON MY BRAIN; ALL IN KEEPING WITH WHAT A PLEASANT AND SIMPLE JOB I HAD. I HAD ACTUALLY BEGUN TO STAND THE THROTTLE AS I XFERRED CTL OF THE AIRPLANE TO THE FO FOR HIS TKOF; A TELLTALE SIGN OF MY IMPATIENCE TO GET OUR TRIP BACK ON SCHEDULE. I REMEMBER TAKING A GLANCE AT THE HDG SELECTION DIALED INTO THE AUTO FLT MCP AND IT AGREEING WITH RWY 33. I ALSO NOTED THE EFIS MAP DISPLAY. I PERCEIVED SOMETHING SLIGHTLY OUT OF WHACK; BUT ATTRIBUTED TO IT THE RTE LINE FROM THE ARPT TO THE FIRST FIX AND SMALL RWY SYMBOLOGY DUE TO PERHAPS BEING IN THE 20 MI SCALE INSTEAD OF THE USUAL 10 MI SCALE. THE FIRST REALIZATION THAT WE HAD JUST TAKEN OFF ON THE WRONG RWY OCCURRED AFTER HDG SELECT PRODUCED A MAJOR TURN. NONE OF THE LCL ATC CTLRS QUERIED OUR ACTIONS. ZBW LATER FORWARDED A REQUEST THAT WE CONTACT BRADLEY ATC BY PHONE AFTER LNDG. OBSERVATIONS: THIS IS THE MOST DANGEROUS MISTAKE I'VE COMMITTED DURING MY AIRLINE CAREER. I CAUSED THE PROB BY ALLOWING COMPLACENCY AND HURRY TO DOMINATE MY MINDSET. I DIMINISHED MY FO'S MONITORING CAPABILITY BY OVERLOADING AND HURRYING HIM. I HAVE NOT HAD THE OPPORTUNITY TO STUDY WHETHER RWY SIGNAGE WAS A SIGNIFICANT FACTOR. I BELIEVE THE FMC SOFTWARE SHOULD INCORPORATE A TKOF WARNING WHEN TOGA IS PUSHED WHILE OUT OF ALIGNMENT WITH SELECTED RWY.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.