PA28 PLT STARTS TKOF ROLL ON OCCUPIED RWY WITHOUT CLRNC.

Date: 2002-03 · Aircraft: PA-28 Cherokee/Archer/Dakota/Pillan/Warrior

Anomalies: conflict-ground-conflict|less-severe|deviation-discrepancy-procedural-clearance|ground-incursion-runway

Synopsis

PA28 PLT STARTS TKOF ROLL ON OCCUPIED RWY WITHOUT CLRNC.

Narrative

I WAS INVOLVED IN A RWY INCURSION AT VERO BEACH MUNICIPAL ARPT AT APPROX XA20 ON MAR/THU/02. I AM A STUDENT PLT AT FLT SCHOOL WITH A PVT PLT CERTIFICATE; CURRENTLY WORKING ON MY COMMERCIAL RATING. THE SIT WAS AS FOLLOWS: AFTER RECEIVING CLRNC FROM GND CTL TO TAXI TO RWY 22 VIA TXWY A; I ENTERED THE RUN-UP AREA; PERFORMED MY RUN-UP CHKLIST; AND SET FLAPS TO 25 DEGS IN PREPARATION FOR A SOFT FIELD TKOF. I THEN PROCEEDED TOWARD THE ENTRANCE TO RWY 22 AND STOPPED BEHIND ANOTHER ACFT WAITING TO ENTER THE RWY. THAT ACFT WAS GIVEN A POS AND HOLD DIRECTIVE; AND DID SO. I THEN TAXIED TO THE HOLD SHORT LINE AND WAITED WHILE THE CTL TWR CONTINUED WITH CALLS. ONE OF THOSE CALLS WAS A 'POS AND HOLD' COMMAND FOR AN ACFT; WHICH WAS DEPARTING ON RWY 29L. RWY 29L INTERSECTS RWY 4/22 ABOUT 2/3 DOWN THE RWY FROM MY POS; AND TXWY C PARALLELS RWY 29L/11R ON THE OPPOSITE SIDE. THE CTLR THEN ISSUED A CLRNC FOR THE ACFT ON RWY 22 TO TAKE OFF. AS I WATCHED THAT ACFT DEPART; I WAITED A SHORT TIME TO CALL; AS THE TWR WAS QUITE BUSY. THE CTLR MADE THE CALL 'WHOSE NEXT ON RWY 29? -- CORRECTION; RWY 22?' I RESPONDED 'ACFT X #1 FOR DEP ON RWY 22.' TWR GAVE THE INSTRUCTION 'ACFT X RWY 22; POS AND HOLD; TFC DEPARTING RWY 29L.' I RESPONDED 'POS AND HOLD ON RWY 22.' I THEN PROCEEDED ONTO THE RWY. AS THE TFC DEPARTED ON RWY 29L; A CALL WENT OUT TO THE TWR. 'VERO BEACH TWR; ACFT Y ON RWY 22 AT TXWY C HOLDING.' I DID NOT SEE HIM; AS HE WAS POSITIONED ABOUT 3000 FT DOWN; R OF RWY 22 ON THE OPPOSITE SIDE OF RWY 29L/11R. THE CALL CAME AS I WAS TAXIING AND PERFORMING MY LINE-UP CHK; AND I DID NOT NOTICE THE SIMILARITY OF THIS TAIL NUMBER TO MY OWN. I DID NOT ATTAIN A CLR PICTURE OF WHERE THAT ACFT WAS. I MADE THE MISTAKE OF 'TUNING OUT' THE CALL SINCE IT WAS NOT DIRECTED TO ME. THE TWR RESPONDED 'ACFT Y; RWY 22; INTXN C; CLR FOR TKOF.' I FAILED TO NOTICE THE WORD 'INTXN;' AND MISTOOK THE CLRNC FOR 'ACFT X.' I RESPONDED 'ACFT X CLR FOR TKOF ON RWY 22.' HOWEVER; THE OTHER ACFT ENTERING RWY 22 HAD ALSO RESPONDED; AND SUBSEQUENTLY THE CTLR HEARD 'TALK-OVER.' AT THIS POINT; I HAD NOT YET ARRIVED AT THE RWY CTRLINE; AND PROCEEDED TO PULL FULL AFT ON THE YOKE; ADDED FULL THROTTLE AND ALIGNED THE ACFT FOR A SOFT FIELD TKOF. THE CTLR DID NOT REPEAT THE CLRNC CALL; AND RESPONDED TO A CALL FROM AN ACFT ALREADY IN THE PATTERN. ONCE CTRED AND ROLLING; I CHKED MY AIRSPD INDICATOR AS WELL AS MY ENG INSTS. AFTER THIS BRIEF SCAN; I LOOKED UP AS THE ACFT ENTERED A 'NOSE HIGH' ATTITUDE. FROM MY VANTAGE; I COULD SEE ONLY THE GND ON EITHER SIDE; THE NOSE OF THE ACFT; AND THE SKY ABOVE. THERE WAS NO WAY FOR ME TO SEE THE TFC AT THE OTHER END OF THE RWY. MY ACFT LEFT THE GND AND I RELEASED PRESSURE TO REMAIN IN GND EFFECT. AS I STARTED TO BUILD SPD; AND PUSHED FORWARD ON THE YOKE; THE CTLR CALLED ABRUPTLY; 'ACFT X CANCEL TKOF CLRNC AND HOLD POS!' THIS IS WHEN I FIRST SAW THE TFC; WHICH WAS CTRED ON THE RWY A FEW THOUSAND FT AWAY -- I COULD NOT DETERMINE IF IT WAS MOVING OR STATIONARY. I IMMEDIATELY PULLED MY THROTTLE TO IDLE AND PITCHED DOWN AS I CALLED BACK 'CANCELING TKOF AND HOLDING.' I LANDED ON THE RWY AND USED MAX BRAKING. I WAS DOWN TO TAXI SPD BY THE TIME I WAS XING RWY 29L AND WOULD HAVE STOPPED COMPLETELY; HAD IT BEEN NECESSARY. BY THIS TIME THE OTHER ACFT WAS STARTING TO LIFT OFF. THE TWR CALLED 'ACFT X CLR AT TXWY C AND CONTACT GND.' IT IS MY BELIEF; AND I THINK THOSE INVOLVED AGREE; THAT THE SEQUENCE OF EVENTS IN THIS SIT PLAYED OUT IN AN ALMOST 'SCRIPTED' MANNER AS IF ONE WERE ATTEMPTING TO CREATE A SCENARIO TO TEST BOTH PLT AND CTL OFFICER; IE; THE SIMILAR TAIL NUMBERS. THE ABBREVIATION OF THOSE NUMBERS; THE COMMON TERM 'CHARLIE' USED; THE AMOUNT OF DEPARTING TFC; THE UNUSUAL ENTRY OF TFC ON THE RWY; THE 'TALK-OVER' ON THE RADIO; THE VISUAL LIMITATIONS OF A SOFT FIELD TKOF; THE SEPARATION ON THE RWY ETC. I TAKE FULL RESPONSIBILITY AS PIC FOR MY MISS IN FAILING TO LISTEN MORE CAREFULLY TO RESPONSIBILITY AS PIC FOR MY MISTAKES IN FAILING TO LISTEN MORE CAREFULLY TO THE CALLS GIVEN DURING THIS EVENT. I NOW HAVE A FULL UNDERSTANDING OF WHAT I DID WRONG; AND HOW I CAN ACT DIFFERENTLY IN THE FUTURE TO AVOID A RECURRENCE OF THIS TYPE OF INCURSION. ACCORDING TO THE TWR MGR; THE CTLR INVOLVED ALSO MIGHT HAVE ACTED DIFFERENTLY; WHICH COULD POSSIBLY HAVE CORRECTED MY MISTAKE BEFORE IT BECAME IMMINENT. IN THIS CASE; THE RESULT OF THE CIRCUMSTANCES AND THE MISTAKES WHICH WERE MADE; WAS A BREAKDOWN IN COM; AND A GENERAL LACK OF SITUATIONAL AWARENESS. AS I HAVE LEARNED IN CRM TRAINING; THIS IS MOST OFTEN THE CAUSE OF ACCIDENTS IN AVIATION. I HAVE LEARNED FROM THIS EXPERIENCE; AND HOPE NEVER TO REPEAT IT AGAIN.

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