B767-300 FLT CREW DEPARTING SFO EXECUTE A RWY INCURSION.
Synopsis
B767-300 FLT CREW DEPARTING SFO EXECUTE A RWY INCURSION.
Narrative
ATC CLRNC CONFUSION: LED TO A QUICK SEQUENCE OF CONFUSING AND TASK SATURATING CLRNCS AND ERRORS. CALLED FOR TAXI AT SFO ABEAM TXWY U FACING E. THE CTLR SOUNDED AS IF HE WAS THINKING OUT-LOUD AS HE GAVE US A CLRNC TO TURN 'IF ABLE' USING TXWY U. THE CAPT INDICATED HE COULD MAKE THE TURN SO I READ BACK SOMETHING TO THE ORDER OF 'YES WE WILL MAKE THE TURN USING UNIFORM.' IF THERE WAS A RWY ASSIGNMENT DURING THE RADIO COMS; IT WAS OVERSHADOWED BY THE CONVERSATION CONCERNING THE USE OF TXWY U TO TURN OUT OF OUR PUSHBACK POS. THE CAPT AND I BOTH ASSUMED WE HEARD 'RWY 10R' AS THE RWY BUT TO THIS MOMENT I'M NOT SURE IF WE WERE EVEN GIVEN A RWY ASSIGNMENT AT THIS POINT IN THE TAXI CLRNC. JUST AS THE CAPT MADE THE TURN HE BEGAN TO TAKE TXWY K TOWARDS RWY 10R WHEN THE GND CTLR ASKED US IF WE COULD STILL MAKE TXWY U. I HAD JUST COMPLETED PUTTING THE FLAPS OUT AND MY CTLS CHK AND LOOKED UP IN A CONFUSED WAY; THINKING THE CTLR MUST NOT SEE US BECAUSE WE ALREADY MADE THE TURN USING TXWY U. BECAUSE OF MY CONFUSED DELAY; THE CAPT ANSWERED THE CALL FOR ME WITH 'YES WE CAN MAKE UNIFORM.' I THEN SAW THAT TXWY U CONTINUED TO RWY 10R AS AN INTXN TKOF! THIS WAS FRUSTRATING BECAUSE WE WERE NOT ASKED IF WE COULD PERFORM AN INTXN TKOF; BUT I IMMEDIATELY WENT HEADS DOWN TO RETRIEVE THE INTXN CODE AND THEN THE TKOF DATA FOR RWY 10R INTXN U TKOF. IMMEDIATELY DURING THIS PROCESS; THE GND CTLR TOLD US TO MONITOR TWR. I SWITCHED TO TWR ONLY TO HEAR AN IMMEDIATE 'ACR X; THE ACR Y IS WAITING ON YOU; CROSS RWY 10R AND INTO POS AND HOLD RWY 10L.' I READ BACK THIS CLRNC; AND IMMEDIATELY WENT HEADS DOWN AGAIN TO RETRIEVE RWY 10L TKOF DATA. NO SOONER HAD I LOOKED UP AND EXAMINED THE RWY AND CHART TO NOTICE WE WERE BEING CLRED ONTO RWY 10L FOR ANOTHER INTXN TKOF! NOW TOTALLY TASK SATURATED AND RESOLVED THAT WE COULD NOT HAVE RECEIVED THIS CLRNC FROM THE INITIAL TAXI CLRNC BECAUSE THERE WAS DEFINITELY NO CLUE OR INDICATION THAT WE WERE GOING TO AN INTXN TKOF POS; I GLANCED AT THE ARPT CHART AND NOTICED THAT RWY 10L WAS LONGER THAN RWY 10R EVEN FROM THE INTXN AND SIMPLY REACHED UP AND PRESSED THE 'TKOF' BUTTON TO COMMAND 'MAX' TKOF THRUST WHILE INFORMING THE CAPT THAT I DIDN'T HAVE DATA FOR RWY 10L INTXN U TKOF; BUT IT WAS LONGER THAN RWY 10R (FOR WHICH WE WERE PLANNING A REDUCED THRUST TKOF). THE CAPT THEN TOLD ME TO GET THE DATA; SO I BEGAN THE MULTI-MIN PROCESS OF RETRIEVING THE INTXN DESIGNATOR FROM ACARS AND THEN INPUTTING THAT CODE INTO ACARS TO RETRIEVE THE ACTUAL DATA. BY THIS TIME I HAD BEEN HEADS DOWN EXCEPT FOR ABOUT 10 SECONDS SINCE WE BEGAN OUR TAXI. AS THE DATA WAS COMING UP; THE CAPT MENTIONED THAT HE HAD MADE THE TURN ONTO TXWY U AT THE RWY 10R INTXN AND WAS 'OVER THE LINE' BEFORE WE RECEIVED THE CLRNC ACROSS RWY 10R TO POS ON RWY 10L. I SIMPLY SAID 'I THINK THE CTLRS WERE JUST 'MAKING IT HAPPEN ON-THE-FLY' BECAUSE WE WERE NEVER TOLD OF THE INTXN TKOF PLAN AND; THEREFORE; I DIDN'T EVEN THINK IT WAS THE ORIGINAL PLAN.' I THEN EXAMINED; SET UP; AND BRIEFED THE NEW TKOF DATA FOR RWY 10L INTXN U TKOF. AS I WAS TALKING WE WERE CLRED FOR TKOF; WHICH I TUNED-OUT COMPLETELY BUT HEARD THE LAST PART OF THE CLRNC. THE CAPT TOLD ME THAT WE WERE CLRED FOR TKOF; AND SO I QUICKLY INFORMED THE FLT ATTENDANTS AND SWITCHED TO READ BACK 'ACR X CLRED FOR TKOF; RWY 10L.' I THEN INFORMED THE CAPT THAT WE HAD OUR 8 MIN ENG WARM-UP. THE CAPT PROCEEDED TO TAKE OFF; AND WHEN HE CALLED FOR 'HDG SELECT;' RATHER THAN LNAV; I WAS AGAIN CONFUSED. I BEGAN TO ASK HIM IF HE WAS GOING TO MAKE THE L TURN TO INTERCEPT THE SFO 090 DEG RADIAL FOR THE SID. OF COURSE; WE WERE IN THE MIDDLE OF FLAP RETRACTION AND RADIO CHANGE TO DEP CTL. THE CAPT THEN MENTIONED THAT THE XPONDER HAD BEEN LEFT IN STANDBY; SO WE QUICKLY GOT IT ON BY THE TIME WE TALKED TO DEP. I THEN ASKED DEP IF THEY WANTED US ON RWY HDG; WHICH THEY CONFIRMED. SO BY NOW I REALIZED THAT WE HAD NOT COMPLETED THE 'FINAL ITEMS' OF THE 'BEFORE TKOF CHKLIST.' I ALSO REALIZED THAT I HAD NOT BEEN RELAYED THE ENTIRE TKOF CLRNC; NOR DID IREAD BACK THE ENTIRE CLRNC TO TWR (COMPLETE WITH THE CLRNC TO MAINTAIN RWY HDG). AS WE PASSED FL180 WE BEGAN TO REVIEW THE SERIES OF EVENTS. MY OWN CONFUSION HAD BEEN PEGGED AT 'EXTREME' AND THE TASK SATURATION OF BEING HEADS DOWN TO RETRIEVE NO LESS THAN 3 NEW RWY TKOF DATA INCLUDING THE EXTRA WORK INVOLVED WITH RETRIEVING INTXN CRYPTOLOGY FOR SUBSEQUENT ACARS INPUT; HAD TOTALLY CONSUMED ME DURING THIS VERY SHORT TAXI SEQUENCE. THE CAPT AND I THEN REALIZED THAT WE HAD FAILED TO RUN THE ENTIRE 'BEFORE TKOF CHKLIST' AS WELL. SO WE HAD PERHAPS ENCROACHED A RWY HOLD LINE; FAILED TO PERFORM SOP CHKLISTS; AND PERFORMED A TKOF WITH SOME CONFUSION ABOUT THE SID CLRNC. I CAN ONLY SAY THAT THERE WAS SEEMINGLY ONLY 1 POINT AT WHICH WE COULD HAVE SET THE BRAKE AND CLARIFIED ALL THE CONFUSION; AND IT WAS BEFORE ACCEPTING THE SECOND TURN BACK ONTO TXWY U TOWARDS RWY 10R/L. ONCE THE TURN WAS MADE; THE CTLRS BECAME VERY PUSHY IN THE SEQUENCE TO GET US OUT OF THE WAY OF ARPT TFC IN POS ON RWY 10L. I HAVE NO REAL EXCUSE FOR NOT CALLING 'TIME OUT' AND INSISTING ON THE TIME TO THINK THROUGH EACH PHASE AND ENSURE WE HAD ACCOMPLISHED ALL SOP. I THOUGHT WE HAD; BUT ONLY THE MISSED XPONDER BEGAN TO PUT THINGS IN PERSPECTIVE. THE OUTCOME IN SIGHT OF THE SFO CTLRS WAS LIMITED TO OUR TURN ONTO TXWY U WHICH IMMEDIATELY ENCROACHED RWY 10R BEFORE CHANGING TO TWR FREQ. WE WERE STOPPED STILL NOT ENTIRELY TURNED ONTO TXWY U WHEN THE GND CTLR PUSHED US TO TWR FREQ. I WAS SO TASK SATURATED WITH THE ACARS TASKS INVOLVED THAT I MISSED THIS ENCROACHMENT ENTIRELY. THE CTLRS DID NOT MENTION IT AT ALL. HOWEVER; IF THE GND CTLR THOUGHT HE GAVE US CLRNC TO TAKE TXWY U TO RWY 10L THEN PERHAPS WE HAD A CLRNC TO DO EVERYTHING WE DID; INCLUDING THE 'ENCROACHMENT;' BECAUSE WE HAD CLRNC TO TAXI TO RWY 10L ON TXWY U. SO THE CTLRS WERE SIMPLY FRUSTRATED THAT WE STOPPED AND THEN HAD TO BE TOLD TO SWITCH TO TWR AND CONTINUE OUR CLRNC TO RWY 10L. EITHER WAY; IT WOULD SEEM IMPROPER TO ASSUME WE COULD PERFORM A RWY 10L INTXN TKOF WITHOUT ASKING US; BUT THEN AGAIN; EVEN THE CTLR COULD SEE THAT RWY 10L WAS LONGER THAN RWY 10R EVEN FROM THE INTXN; SO PERHAPS THEY DON'T CONSIDER OUR SOP REQUIREMENT WHEN ISSUING SUCH A CLRNC; IN THIS CASE. RWY 10R/L IS RARELY USED FOR TKOF AT SFO AND IT WAS MY FIRST TIME DOING SO; DESPITE 2 YRS AS AN FO ON THE B747. HUMAN FACTORS: YES; THE CTLRS WERE SETTING THE PACE DUE TO OUR PROX TO RWY 10R ON-ARPT TFC; AND I'M NOT SURE IF THE CAPT REALIZED JUST HOW MUCH THE SEQUENCE OF CONFUSING CLRNCS TOOK ME OUT-OF-THE-LOOP DURING EXTENSIVE HEADS DOWN ACARS WORK FOR 3 NEW SETS OF TKOF DATA. WE WOULD HAVE CAUSED MAJOR ARPT DISRUPTION AND GARS IF WE WOULD HAVE DELAYED ON THE RWY IN ORDER TO PROPERLY STOP AND THINK THROUGH THE SOP SEQUENCE; AND PERHAPS MADE THE CTLRS MAD ENOUGH TO TAKE VIOLATION ACTION AGAINST US FOR OUR CONFUSION THROUGHOUT; BUT IN HINDSIGHT THAT WOULD HAVE BEEN THE BEST COURSE OF ACTION.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.