SFO CTLR EXPERIENCED OPERROR AFTER ISSUING TKOF CLRNC TO PARALLEL RWY DEPS; BOTH ASSIGNED THE SAME ROUTE; CITING SEVERAL CONTRIBUTING FACTORS.
Synopsis
SFO CTLR EXPERIENCED OPERROR AFTER ISSUING TKOF CLRNC TO PARALLEL RWY DEPS; BOTH ASSIGNED THE SAME ROUTE; CITING SEVERAL CONTRIBUTING FACTORS.
Narrative
I WAS WORKING LCL CTL AT SFO ATCT FOR 1 HR 30 MINS. LNDG RWYS 28; DEPARTING RWYS 1. I HAD TFC LNDG ON BOTH RWYS 28 WITH ANOTHER PAIR OF ARRS APCHING 2 MI FINAL FOR RWYS 28L AND 28R. ACFT Y WAS HOLDING IN POS ON RWY 1R. ACR X WAS HOLDING IN POS ON RWY 1L WITH A WHEELS-UP TIME (FLOW TIME) OF XA01. I DID NOT NOTICE THAT ACR X WAS AN SFO8 DEP OVER LIN. THIS IS THE SAME DEP SID THAT ACFT Y WAS ON. THERE WAS NO RED 'L' ON ACR X STRIP TO ALERT ME THAT A R TURN WAS AT RWY 1L; AS REQUIRED BY SOP. BOTH ACFT Y AND ACR X HAD TO HOLD IN POS ON RWYS 1 WHILE SEVERAL ACFT LANDED ON RWYS 28. THE FINALS STRAIGHTENED OUT JUST IN TIME TO MAKE THE XA01 TIME FOR ACR X. WHEN THE ARRS CLRED RWY 1R I CLRED ACFT Y FOR TKOF. A FEW SECONDS LATER THE ARRS CLRED RWY 1L AND I CLRED ACR X FOR TKOF. I THOUGHT ACR X WAS A PT3 DEP; A L TURN. A CTLR PLUGGED IN TO RELIEVE ME SO I BEGAN SEARCHING FOR THE POS RELIEF BRIEFING CHKLIST. I BEGAN THE POS RELIEF BRIEFING CHKLIST. I BEGAN THE POS RELIEF BRIEFING WHILE I CONTINUED TO WORK TFC. DURING THE POS RELIEF BRIEFING I SHIPPED ACFT Y TO DEP. AT THE END OF THE POS RELIEF BRIEFING I SHIPPED ACR X TO DEP. I NOTICED THAT ACR X WAS STILL GOING STRAIGHT OUT; THEY HAD NOT STARTED A TURN YET; ABOUT 1/2 MI OFF DEP END. I CHANGED PLACES WITH THE RELIEVING CTLR AND HE BEGAN WORKING THE POS. I MOVED BACK TO THE COMPUTER TO MAKE THE CHANGES TO THE DUTY BOARD. WHEN I RETURNED I SAW THAT ACR X WAS NOW NEBOUND. CHAIN OF EVENTS: ACR X WAS RERTED FROM PT3 TO SFO8. ACR X TAXIED TO RWY 1L BY GND CTL BUT NOT MARKED WITH RED 'L' (TMC WORKING GND CTL). ACR X WAS ISSUED XA01 WHEELS-UP TIME. I LOADED ACR X ON RWY 1L WITHOUT NOTICING THAT ACR X WAS SFO8-LIN. ALL I SAW WAS XA01 WHEELS-UP TIME AND ZZZ DEST. ZZZ FLTS USUALLY GET PT3 DEP AT SFO. MY ATTN WAS PRIMARILY FOCUSED ON THE LNDG RWYS TO ENSURE THAT THEY WERE CLR AND ON FINALS. I CLRED ACFT Y AND ACR X IN A TIGHT HOLE WITH LNDG TFC ON A 2 MI FINAL. I ONLY CLRED ACR X BECAUSE I WANTED TO MAKE THE XA01 WHEELS-UP TIME. IF THERE HAD BEEN NO WHEELS-UP TIME I WOULD SURELY HAVE WAITED FOR A BIGGER HOLE.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.