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In taxi-in, reporters cited after-landing checklists
and company radio calls. The distraction pattern
was consistent: the pilot taxiing the aircraft did not
adhere to the hold short instruction while the nontaxiing
pilot was preoccupied with inside-thecockpit
tasks.
“This incident could have been avoided if our
company did not pressure the flight crews to
spend so much time talking to the passengers
when we should be operating the aircraft …”
complained one First Officer.
The Hazards of “Hold Short of the Runway” Instructions
The breakdown in cockpit cross-check duties
during taxi is recognized by flight crews. “ … A
common problem …” summarized a reporter, “is
how the first officer is loaded up with work while
we are taxiing out to a point that he/she can’t
always pay attention to the taxi procedure.” (This
applies to any pilot handling communications
chores.)
The non-flying pilots’ workload distractions were
most critical when the aircraft neared the departure
runway. With the First Officer running the
pre-takeoff check lists, or being off tower frequency
while making the passenger departure announcement,
there was no double check on Captain
misunderstandings of “hold short” and “hold,” as a
clearance for “position and hold.” Go-arounds
frequently resulted.
“We were number two for departure on Runway
24R…. The first aircraft was cleared on the
Runway for takeoff. At this time, the First
Officer began to make the departure passenger
announcement to the Flight Attendants. Simultaneously
… Tower, as I understood … [incorrectly],
said ‘ … cleared into position and hold.’
Since the First Officer was still making his
passenger announcement, I acknowledged [the
instruction]…. An aircraft on final had to go
around.”
Visibility Problems
Restricted visibility — blowing snow, fog, and rain
— served as contributory factors in three reports of
flight crew disorientation. Such conditions call for
extra caution on the part of pilots and controllers
alike.
“Due to the visibility restrictions, I didn’t know
where we were. I stopped. As I stopped … a
company jet passed us left to right with minimum
clearance.”
20 Summer 1992 ASRS Directline
C. CONTROLLER ERRORS
The limited number of ATC controller reports in
this classification did not permit a ranking of cause
and circumstance for incidents perceived to be
controller-induced events. Nonetheless, a review of
reports in this study does indicate that incidents
spanned a range of mental lapses, verbal slips, and
visual misperceptions. Controllers neglected to tell
aircraft to hold short, “thought one thing and said
another,” and became workload distracted with
other aircraft movements. “The airplanes moved
faster than my attention,” was one Controller’s
explanation for a “near-tie” at a runway intersection.
In four go-around events, Tower Controllers
cleared air carriers into position and hold with an
aircraft on short final.
The following causal factors were identified in
reports of controller lapses:
• Missed erroneous readbacks of hold short
messages
• Failed to issue hold short instructions
• Mis-coordinated with Ground or Tower Controller
positions
• Distracted by other traffic
• Distracted by conversation in the Tower
• Miscellaneous: inadequate briefing of relief,
developmental controller error, changed his
mind, etc.
Hearback
Controller hearback misses of erroneous hold short
readbacks were confirmed by “running the tapes.”
In six incidents, erroneous readbacks of hold short
instructions were not caught by the controller. Two
reports suggested heavy traffic volume as the
underlying factor in controller errors.
“I was preoccupied with trying to move some …
[aircraft around delayed aircraft] … and didn’t
hear air carrier X read back that he was crossing
… with a departure rolling on [the] runway….”
Editor’s Note: Refer to the next
article in this issue — “TAXI !” — for
conclusions and recommendations
for “on-the-ground operations.”
CriticalTiming
Timing of important communications was a factor
in a number of incidents where flight crews did not
　
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