B717-200 CREW ENTERED THE WRONG TXWY AND WENT TO THE WRONG RWY BECAUSE OF REDUCED VISIBILITY RESTRS AND EXTREME CREW FATIGUE CAUSED BY REPEATED CREW 'STAND UP OVERNIGHTS.'

Date: 2003-07 · Aircraft: B717 (Formerly MD-95) · Phase: taxi

Anomalies: deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-far|deviation-discrepancy-procedural-published-material-policy|ground-incursion-taxiway|other-crew-fatigue

Synopsis

B717-200 CREW ENTERED THE WRONG TXWY AND WENT TO THE WRONG RWY BECAUSE OF REDUCED VISIBILITY RESTRS AND EXTREME CREW FATIGUE CAUSED BY REPEATED CREW 'STAND UP OVERNIGHTS.'

Narrative

PUSHED BACK FROM GATE; GIVEN 'TAXI TO RWY 7 VIA TXWYS J AND A.' AS I STARTED THE TAXI; I COULDN'T MAKE OUT TXWY J. VISIBILITY WAS ADVERTISED 6 SM ON ATIS; I ASKED GND AND THEY REPLIED CURRENT VISIBILITY 1/4 SM. TURNED ON A TXWY I THOUGHT WAS TXWY J VIA THE ARPT DIAGRAM (IT WASN'T LABELED) AND IT TURNED OUT TO BE TXWY H. I STOPPED AND WE ASKED GND IF WE COULD USE TXWY H (APPROVED). AT THE INTXN OF TXWYS H AND A; I TURNED R INSTEAD OF L. VISIBILITY WAS BELOW MINIMUMS SO WE NEEDED A TKOF ALTERNATE. WE CALLED DISPATCH AND RECEIVED MCO. UPON REACHING RWY 25; SWITCHED TO TWR; AND I DID A RWY CHK. NOTICED DIRECTIONAL GYROSCOPE AND RWY SIGN AND REALIZED WE TAXIED TO THE WRONG RWY. NOTIFIED ATC AND WERE APPROVED FOR TKOF ON RWY 25. I BELIEVE 3 FACTORS (AT LEAST) WERE CONTRIBUTING: 1) THIS WAS A CONTINUOUS DUTY OVERNIGHT -- ARRIVED AT XA45 PREVIOUS NIGHT AND HAD AN XH20 DEP (4 1/2 HRS SLEEP!) 'FATIGUE.' 2) 'VISIBILITY' MADE TAXI DIFFICULT TO SEE SIGNAGE -- 1/4 SM (GND CTLR COULD NOT SEE US TAXI WRONG WAY). 3) 'PREOCCUPATION' WITH THE WX AND GETTING A TKOF ALTERNATE. THIS WAS THE 3RD CONTINUOUS DUTY OVERNIGHT IN A ROW; I WAS VERY FATIGUED AND IT AFFECTED MY AWARENESS; JUDGEMENT AND I DIDN'T NOTICE ERRORS I WAS MAKING.

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