2002-04 · NASA ASRS report 545541
A NEAR RWY INCURSION OCCURS WHEN A TIRED CREW ACCEPTS AN ERRED TAXI INSTRUCTION FROM THE GND CTLR AT LAX; CA.
WE HAD BEEN PARKED AT THE LAX W GATES. PREPARING FOR A REPOSITION FERRY FLT TO PHX; WE HAD BEEN DELAYED ABOUT 2 HRS DEALING WITH A MAINT PROB. WE PLANNED AND BRIEFED FOR A DEP FROM RWY 24L. OUR INITIAL TAXI INSTRUCTIONS WERE SOMETHING CLOSE TO; 'WE HAVE FLOW GOING TO PHOENIX THIS AFTERNOON; SO WE'LL TAKE YOU OVER TO RWY 25R. TAXI VIA E17; TURN N OR S; WHICHEVER WORKS BETTER FOR YOU. BRIDGE RTE; RWY 25R.' MY FO AND I WERE NOT FAMILIAR WITH THE BRIDGE RTE; AND SELDOM DEPART FROM RWY 25L. WE DELAYED TAXIING UNTIL WE HAD BOTH READ AND DISCUSSED THE BRIDGE RTE; DECIDING THAT WE WOULD TURN S ON E17; FOLLOWING THAT UNTIL WE JOINED TXWY AA. GND CTL CALLED US INQUIRING ABOUT OUR STATUS; AS HE HAD SEEN ON A VIDEO MONITOR THAT WE WERE NOT TAXIING YET. WE TOLD HIM WE WERE UNFAMILIAR WITH THE RTE; AND ASKED HIM TO VERIFY THAT OUR INTENTIONS WERE ACCEPTABLE. HE TOLD US THAT WAS FINE; AND TO CALL HIM IF WE NEEDED FURTHER DIRECTIONS. AT CHK POINT; WE WERE INSTRUCTED TO TAXI VIA TXWY B; HOLD SHORT OF TXWY S. APCHING TXWY S; WE WERE INSTRUCTED TO CONTINUE; HOLD SHORT OF C10. AT THIS POINT THE FO LEFT THE GND CTL FREQ TO INFORM COMPANY OPS ABOUT THE CHANGE IN DEP RWY (COMPANY REQUIRED CALL). APCHING C10; THE FO CAME BACK ON GND CTL FREQ JUST AS WE WERE INSTRUCTED; '...CONTINUE; TURN R AT C7; C TO C1.' THE FO READ BACK; 'R TURN ON C7; C TO C1.' I TOLD THE FO THAT WE WOULD LOOK FOR THE C7 SIGN; TURN R; AND JOIN THE NEXT PARALLEL TXWY; CONTINUING ON IT TO C1. WE ASSUMED THAT GND CTL WANTED US TO BYPASS THE LINE OF ACFT TAXIING ON TXWY B; PROBABLY BECAUSE OF THE FLOW TIME TO PHX. APCHING C7; I WAS BEGINNING TO MENTALLY QUESTION THE SIT; AS I COULD SEE A C7 SIGN TO THE L; BUT NOT R; AND THE VISUAL IMAGE I SAW OF THE RWY/TXWY CONFIGN DID NOT MAKE SENSE TO ME. THIS WAS DEFINITELY A SIT WHERE THE MENTAL MODEL I HAD ACCEPTED WAS AT ODDS WITH THE VISUAL SCENE; WHICH CREATED CONFUSION. I SLOWED CONSIDERABLY; AND STARTED A SLOW TURN ONTO WHAT I THOUGHT WAS C7 BUT WAS ACTUALLY TXWY J. I REALIZED THAT THE 'TXWY' AHEAD WAS ACTUALLY A RWY; AND STOPPED; JUST AS GND CTL SAID; 'STOP!!' THERE WAS NO ACFT ON RWY 25R; THERE WERE SEVERAL ARRS USING RWY 25L. AT THIS POINT WE FIGURED OUT WHERE WE WERE; AND ASKED GND CTL TO VERIFY THAT HE WANTED US TO TURN L ON C6 AND JOIN TXWY C TO C1. WE WERE TOLD THAT WAS CORRECT; AND NOTHING FURTHER WAS SAID. WE DEPARTED RWY 25R FROM TXWY F. IN RETROSPECT; I THINK THAT WE WERE BOTH SO FOCUSED ON THE 'TURN R' INSTRUCTION THAT WE BOTH ACCEPTED THE MENTAL MODEL THAT I VERBALIZED. WE BOTH FELT THAT THE CTLR'S INSTRUCTION TO TURN R WAS PROBABLY A MISTAKE CAUSED BY HIM WANTING US TO TURN R IN RELATION TO HIM; SINCE WE WERE COMING TOWARD THE CTL TWR. SINCE WE READ BACK 'TURN R' AND THIS WASN'T CORRECTED; IT FURTHER INGRAINED THE MENTAL MODEL THAT A R TURN WAS REQUIRED. THE FO SAID HE DIDN'T REALIZE ANYTHING WAS WRONG UNTIL HE SAW RUBBER MARKS ON THE 'TXWY' AHEAD; WHICH DIDN'T LOOK RIGHT TO HIM AND CREATED MORE CONFUSION. CONTRIBUTING TO OUR SUSCEPTIBILITY TO CONFUSION IN THIS INSTANCE WAS FATIGUE. WE HAD ALREADY HAD 2 'MINIMUM (CONTRACTUAL) REST' OVERNIGHTS; EACH ONLY AFFORDING AN OPPORTUNITY FOR LESS THAN 6 HRS OF SLEEP. WHILE NEITHER OF US FELT TOO TIRED TO FLY SAFELY; WE BOTH AGREED THAT WE MIGHT NOT HAVE MADE THE MISTAKE HAD WE BEEN MORE RESTED.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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