GND CONFLICT CRITICAL. ACR-LGT TKOF OVER ACR-SMT IN POSITION AT MIDFIELD.
Synopsis
GND CONFLICT CRITICAL. ACR-LGT TKOF OVER ACR-SMT IN POSITION AT MIDFIELD.
Narrative
FLT FROM BOSTON LOGAN TO NEW YORK LAGUARDIA WAS CLRED FOR TKOF ON RWY 22R. AT APPROXIMATELY 95 KTS; THE F/O OBSERVED AN ACFT ENTER RWY 22R ABOUT 1500-2000' AHEAD. THE CAPTAIN APPLIED FIREWALL THRUST (FULL FORWARD LIMIT OF THROTTLE TRAVEL) AND STEERED SLIGHTLY RIGHT AS IT APPEARED THAT THE OTHER ACFT WAS SLIGHTLY LEFT OF THE CENTERLINE. THE COMPUTER VR WAS 125 KTS; BUT THE F/O INITIATED AN EARLY ROTATION AT ABOUT 110 KTS TO AVOID HITTING THE OTHER ACFT. THE ACFT BECAME AIRBORNE AT ABOUT 120 KTS AFTER STRIKING BOTH THE TAIL SKID AND #2 ENGINE LOWER REVERSER HOUSING ON THE RWY. ABOUT 2-3 SECONDS AFTER LIFTOFF; THE STICK SHAKER ACTIVATED FOR SEVERAL SECONDS--PITCH WAS AROUND 25 DEG AND THE AIRSPEED WAS 120 KTS. ONCE CLEAR OF THE ACFT ON THE RWY; THE NOSE WAS LOWERED TO ACCELERATE AND THE GEAR WAS RETRACTED. CLIMB TO A VISUAL DOWNWIND WAS INITIATED AND AN IMMEDIATE LANDING WAS ACCOMPLISHED. NO CONTACT OCCURRED BETWEEN THE TWO ACFT; AND THE VERTICAL MISS DISTANCE WAS ESTIMATED AT 20'. THE ACFT THAT ENTERED THE RWY IN FRONT OF US WAS Y AIRLINES FLIGHT--SMT. APPARENTLY THE TWR CLRED THIS FLIGHT INTO POSITION TO HOLD; THINKING THAT THEY WERE IN LINE BEHIND US FOR TKOF--WHEN THEY ACTUALLY HAD REQUESTED AN INTERSECTION TKOF FROM TXWY TANGO. TWO FACTORS CONTRIBUTED TO THIS EXTREMELY CLOSE CALL. FIRST; AND OF PRIMARY IMPORTANCE; WAS THE FAILURE OF THE TWR CTLR TO NOTICE THE REQUEST FOR AN INTXN DEPARTURE MIXED IN WITH THE HEAVY FLOW OF NORMAL TFC DEPARTING AT THE TIME. THIS MAY BE AS MUCH A DESIGN FLAW IN THE TFC CONTROL SYSTEM BEING USED AS IT WAS PURE HUMAN ERROR ON THE PART OF THE CTLR. SECOND; THE CREW OF FLIGHT Y FAILED TO ADEQUATELY CHECK THE RWY FOR TFC BEFORE ENTERING IT. WE WERE LESS THAN 2000' AWAY WITH ALL LIGHTS ON AND STILL WERE NOT NOTICED. SUPPLEMENTAL INFORMATION FROM ACN 98222: A FEW SECONDS LATER THE F/O CALLED OUT AN ACFT XING THE RWY. THE ACFT APPEARED TO BE ABOUT 1500' AHEAD OF US AS WE ACCELERATED DOWN THE RWY. I CALLED FOR FIREWALL THRUST AND SHOVED THE THROTTLES FULL FORWARD AT THE SAME TIME. AT APPROXIMATELY 110 KTS; I CALLED ROTATE AND AT THAT SAME TIME THE F/O BEGAN THE ROTATION. VR SHOULD HAVE BEEN 123 KTS FOR OUR WEIGHT OF 143; 000 LBS. WE WERE NOW ALMOST UPON THE SMT. THE F/O MADE A RAPID ROTATION TO 20 DEG NOSE UP AND THE ACFT LEAPT INTO THE AIR. THE ROTATION CONTINUED TO ABOUT 23 DEG NOSE UP AND THE AIRSPEED BEGAN TO DECREASE FOLLOWED BY THE STICK SHAKER WHICH LASTED ONLY TWO TO THREE SECONDS AS THE F/O HAD ALREADY INITIATED RECOVERY ACTION. AT ABOUT THE SAME TIME THE FLIGHT ENGINEER SAID; 'OK GUYS; FLY THE ACFT' WHICH LOWERED MY FRIGHT LEVEL FROM A HIGH 5 TO ABOUT A 2. WE RAISED THE LANDING GEAR AND TWR ADVISED US TO TURN TO A HEADING OF 140. I REPLIED 'TURNING TO 140 TO RETURN AND LAND DUE TO SEVERE OVERBOOST OF OUR ENGINES AVOIDING AN ACFT ON THE RWY.' THE TWR HAD CLRED ACFT TO CROSS THE TKOF RWY PRIOR TO OUR TKOF CLRNC; BUT I NEVER HEARD THE TWR CLEAR THE SMT TO POSITION AND HOLD ON RWY 22R. I WILL NOW PAY A LOT MORE ATTN TO THE CALL SIGNS OF THE ACFT JUST AHEAD OF ME AND JUST BEHIND ME IN LINE FOR TKOF. I THINK MY EARS ARE CONDITIONED TO HEAR INSTRUCTIONS PASSED WITH MY CALL SIGN AND WITH TOTAL DISREGARD FOR INSTRUCTIONS PASSED FOR OTHER ACFT. IN THIS CASE; HOWEVER; I DON'T THINK IT WOULD HAVE CLICKED THAT THE ACFT WAS AT THE MIDFIELD INTERSECTION. PERHAPS ANOTHER CASE FOR FULL LENGTH TKOFS FOR ALL ACFT. LIGHTS AT NIGHT. SEVERAL MONTHS AGO I READ A LETTER TO THE EDITOR IN A MAGAZINE ABOUT TURNING OFF YOUR LANDING LIGHTS WHILE ON THE RWY UNTIL TKOF CLRNC IS RECEIVED. BY WAITING TO TURN ON THOSE BIG ILLUMINATORS UNTIL ONE HAS RECEIVED TKOF CLRNC; A VERY BRIGHT AND VALUABLE NON-VERBAL SIGNAL IS SENT TO ANYONE APPROACHING THAT RWY THAT YOU ARE UNDERWAY. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: ALL PARTIES INVOLVED HAVE TALKED TO EACH OTHER. TWR SUPVR REPORTED THAT INCIDENT WAS CAUSED WHEN ATC TWR LCL MISSED THE NOTATION ON THE FLT PROGRESS SLIP PASSED FROM THE GND CTLR THAT THE SMT WAS MAKING TKOF FROM DOWN FIELD INTERSECTION AND CLRED THE SMT INTO POSITION AND HOLD UNDER THE IMPRESSION THE SMT WAS BEHIND THE LGT AT RWY END. PF OF SMT KNEW LGT WAS GOING ONTO RWY BUT HAD MISSED TKOF CLRNC AND THOUGHT LGT WAS TO POSITION AND HOLD AND WOULD BE TAKING OFF BEHIND THE SMT. SMT ALSO THOUGHT LGT LNDG LIGHTS ON JUST BECAUSE HE WAS MANEUVERING ONTO RWY OTHERWISE WOULD NOT HAVE TAKEN RWY WITHOUT CLARIFICATION REGARDS LGT INTENTIONS. SUPPLEMENTAL INFORMATION FROM ACN 99066: OUR ACFT WAS CLRED INTO POSITION AND HOLD 22R AT TANGO INTERSECTION. AN LGT WAS CLRED FOR TKOF FROM 22R FULL LENGTH. THE PILOT OF THE LGT PULLED UP ABRUPTLY DRAGGING THE LGT TAIL SKID FOR 200'. THE NUMBER TWO ENGINES' EXHAUST FAIRING DRAGGED FOR ANOTHER 100'. THE DRAG MARKS FROM THE NUMBER TWO ENGINES EXHAUST ENDED 100' FROM TANGO INTXN WHERE OUR ACFT WAS SITTING IN POSITION. THE PILOT OF THE LGT VEERED RIGHT AND CLIMBED AT AN EXCESSIVE ANGLE OF ATTACK TO AVOID HITTING OUR ACFT. THE LOCAL CTLR ASSUMED OUR ACFT WAS WAITING FOR TKOF CLRNC FROM THE FULL LENGTH OF 22R NOT FROM THE TANGO INTERSECTION. THE CTLR DID NOT REALIZE THAT HE CLRED OUR ACFT INTO POSITION AND HOLD FRONT OF THE DEPARTING LGT.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.