THE LATE CALL FOR A B737 TO EXIT RWY 28R AT TXWY E INSTEAD OF THE CREW PLANNED EXIT AT TXWY T RESULTS IN XING THE HOLD SHORT LINE FOR RWY 28L WITH A HVY JET APCHING ON ITS LNDG ROLLOUT.

Date: 2004-08 · Aircraft: B737-300

Anomalies: conflict-ground-conflict|critical|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-published-material-policy|ground-incursion-runway

Synopsis

THE LATE CALL FOR A B737 TO EXIT RWY 28R AT TXWY E INSTEAD OF THE CREW PLANNED EXIT AT TXWY T RESULTS IN XING THE HOLD SHORT LINE FOR RWY 28L WITH A HVY JET APCHING ON ITS LNDG ROLLOUT.

Narrative

I LANDED ON SFO RWY 28R. I PLANNED TO EXIT THE RWY ON THE HIGH-SPD TXWY T. OUR ROLLOUT SPD WAS SET FOR A GENTLE EXIT WHEN SFO TWR DIRECTED US TO EXIT TXWY E AND HOLD SHORT; RWY 28L. WE WERE JUST XING RWY 19L/R. I HEARD 'TXWY E;' REALIZED HOW CLOSE IT WAS AND IMMEDIATELY DIVERTED MY ATTN FROM THE REST OF THE CLRNC TO MAKING THE TURN. NOT WHAT I WAS PLANNING; BUT DOABLE. I INCREASED BRAKING AND MADE THE TURN OFF. MY SITUATIONAL AWARENESS WAS JUST COMING BACK UP TO SPD AS I NOTICED THE YELLOW RWY HOLD SHORT MARKINGS COME INTO VIEW AND THE LNDG LIGHTS OF AN ACR Y 'HVY' JET APCHING FROM THE L. I REALIZED THAT I HADN'T BEEN CLRED TO CROSS RWY 28L; AND STOPPED THE ACFT AS THE HOLD SHORT MARKINGS WENT UNDER OUR NOSE. IT WAS TOO DARK TO KNOW HOW FAR OVER THE LINE I WAS; THOUGH NOT ENOUGH TO ELICIT A COMMENT FROM SFO TWR OR THE ACR Y JET AS THEY SWEPT PAST SECONDS LATER. ONCE THEY HAD PAST; SFO TWR CLRED US TO CROSS RWY 28L AND SFO GND CTL CLRED US; TXWYS B; H; A TO PARK. AS I CONTEMPLATED HOW CLOSE THAT SIT COULD HAVE COME TO REAL DISASTER; AND HOW TO AVOID IT IN THE FUTURE; SEVERAL THOUGHTS COME TO MIND. IF IT IS SO IMPORTANT FOR US TO EXIT THE 11870 FT RWY AT THE MIDPOINT; WOULDN'T IT BE NICE TO KNOW SOMETIME BEFORE COCKPIT WORKLOAD REACHES A PEAK FOR THIS PHASE OF FLT? IT SEEMS TO BE THE TREND AT A LOT OF LARGER ARPTS; THAT TWR CTLRS ARE ISSUING CLRNCS DURING THIS CRITICAL PHASE OF LNDG. YES; IT IS MY RESPONSIBILITY; BUT IT'S A SETUP. WE'VE JUST TOUCHED DOWN; BOTH PLTS' ATTN IS FOCUSED ON SAFELY SLOWING THE ACFT; SPOILERS; REVERSERS; AUTOBRAKES DISARMED; AIRSPD; RWY REMAINING; XWIND DRIFT. A SNAP DECISION IS REQUIRED WHEN ONE IS REALLY NOT NECESSARY. A SIMPLE 'NEGATIVE' OR EVEN NO RESPONSE WOULD HAVE BEEN MORE APPROPRIATE; BUT MY FO READ BACK THE CLRNC AND I LATCHED ON TO 'TXWY E;' BECAUSE WE CAN MAKE IT HAPPEN. WAS EXITING RWY 28R AT TXWY E INSTEAD OF THE HIGH-SPD; TXWY T REALLY THAT CRITICAL; ESPECIALLY SINCE THE DISTANCE IS NEARLY IDENTICAL? AS WE CLRED AT TXWY E; I HAD NOT REPEATED THE 'HOLD SHORT' CLRNC; AS IS COMPANY POLICY AS WELL AS MY PERSONAL HABIT; BECAUSE I HAD NOT HEARD IT. MY ATTN WAS FOCUSED ALMOST COMPLETELY ON ACQUIRING THE TXWY AND MAKING THE TURN OFF. I SHOULD SPECIFICALLY BRIEF MY FO'S TO INSURE THEY GET A CLRNC READBACK FROM ME. MY FO'S ATTN WAS COMPLACENTLY DIVERTED TO LOOKING UP THE GND CTL FREQ INSTEAD OF BACKING ME UP. EXPECT THE UNEXPECTED. I CAN FOCUS A LITTLE MORE ON THE ROLLOUT PORTION OF THE FLT WHEN I AM BRIEFING THE APCH AND LNDG; READY FOR THE 'TXWY E' CALL WITH A QUICK 'NEGATIVE.'

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