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experienced CO poisoning during cruise fl ight.
The reporter later learned that the right engine of this
aircraft was replaced because the precise source of the
carbon monoxide could not be determined.
Hypoxia and Carbon Monoxide Effects
on Pilot Performance
Number 342 June 2008
According to the FAA’s Runway Safety Report: September
2007, pilot deviations accounted for 54% of runway
incursions that occurred over a four-year period from
2003-2006. During this same period, controller operational
errors accounted for 29% of incursions, while vehicle/
pedestrian deviations accounted for the remaining 17% of
incursions.
A review of recent ASRS runway incursion incidents
revealed that some of the following factors may contribute
to runway incursion events. These include:
• Low visibility conditions
• Complex airport confi guration
• Cockpit management issues
• Non-Tower airport operations
In this month’s selection of ASRS reports, we will see how
some of these factors play out.
Low Visibility Conditions
A PA28 student pilot reported that poor lighting, approaching
darkness, and low visibility conditions contributed to a
runway incursion.
■ I was holding short of Runway 12 on taxiway A when
ATC directed me to ‘Cross Runway 12.’ Taxiway A continues
for a short distance on the far side of the runway. The area
was poorly lit, it was getting dark, there was some ground
fog, and the signage was unclear to me that the taxiway
continued on the other side of the runway....When I taxied
onto the runway I looked and saw the end of the runway
which was lit up but I couldn’t see the taxiway, so I thought
I was to back-taxi to the runway end, which is normally
what I do at my home airport. When the controller saw I
was on the runway he told the approaching commuter fl ight
to go around and told me to clear the runway. Contributing
factors to this incident were my inexperience, confusion,
and the fact that I did not ask the controller for clarifi cation
prior to back-taxiing.....
At a major international airport, low visibility and
weather conditions played a role in an air carrier’s runway
incursion. More from a Captain’s report to the ASRS:
■ ...We received a clearance to hold short of the new
Runway 04L approach hold point. While holding at this
point, we observed air carrier Y holding just past the
Runway 04L approach hold point on Taxiway J. The crew
moved down Taxiway J as instructed and held short of the
Runway 14 departure hold short line...At this time ATC
cleared our aircraft to hold further down on Taxiway J. We
continued down and held abeam the Taxiway J holding
bays. The markings on the holding bays were hard to
discern because of the lower visibility and fog with drizzle.
Ground then requested air carrier Y to turn left and
A Monthly Safety Bulletin from
The Offi ce of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
April 2008 Report Intake
Air Carrier/Air Taxi Pilots 2753
General Aviation Pilots 902
Controllers 110
Cabin/Mechanics/Military/Other 411
TOTAL 4176
ASRS Report Intake Is Growing
(12 Month Rolling Count)
Air Carrier/Air Taxi Pilots 32956
General Aviation Pilots 10579
Controllers 1238
Cabin/Mechanics/Military/Other 3057
TOTAL 47830
pull forward and onto one of the holding positions. They
complied, however, they were too far forward and crossed
the Runway 14 hold short line. We keyed up on the radio
as soon as possible, ‘Air carrier Y, stop moving.’ The crew of
air carrier Y then discovered their position and started to
turn away from Runway 14. ATC then cleared air carrier Y
to join Runway 14 and continue their taxi....
We believe Ground may either have mistaken our fl ight’s
position with the position of air carrier Y, combined with
the...wet foggy conditions which made the ground markings
(painted type) diffi cult to see.
Complex Airport Confi guration
A complex airport confi guration with multiple runways in
use was a factor in an air carrier’s inadvertent penetration
of an active runway after landing.
■ Landed on Runway 30 after being cleared to land
by Tower, I had planned on exiting the Runway 30 at
Taxiway K to go to the air carrier ramp. The Pilot Flying
(First Offi cer) landed a little long and we could not make
Taxiway K, which is a reverse turn kind of exit. We exited
on Runway 34L/K area but in the runway area of Runway
　
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