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timing of ATC
instructions, that is, during periods of high cockpit
workload.
Misunderstanding
Flight crew misunderstandings of their hold
short clearances developed from the garden
path taxi instructions “to follow that ZZ aircraft
in front of you to Runway YY, hold short of
Runway XX.” Three flight crews “were led to
believe,” or “understood,” that when the aircraft
they were following was cleared to cross
Runway “XX,” their flight needed no additional
clearance to cross the active Runway “XX”.
“ … we were still following [aircraft] X as we
were told to do. As [aircraft] X was crossing
8L, his jet blast was blowing snow, temporarily
lowering visibility. After he crossed the
runway and the visibility began to improve,
we started to cross 8L [as well]. We were
almost across when we heard the tower cancel
air carrier B’s takeoff clearance.”
18 Summer 1992 ASRS Directline
Readback
When flight crews misheard or misinterpreted
their “hold short” instructions, the abbreviated
response of “Roger, ABC,” eliminated a crucial
element in pilot/controller communication —
that of the controller’s ability to confirm the
flight crew’s readback. In post-incident
reflection, reporters regretted their short cut
procedures:
“I guess it was my fault for not giving a full
readback …”
“Our mistake was in not reading back the
Controller’s instructions …”
“A complete readback on my part … would
have prevented this incident.”
A Controller noted the second purpose of the
double check step:
“Perhaps a full readback would have helped
me catch my mistake?” (Emphasis added.)
In an attempt to pass the buck, several reporters
blamed the Ground Controller for not
issuing instructions to acknowledge all hold
short clearances.
Too Busy to Hear…
Reporters criticized the issuance of hold-short
messages during periods of high workload,
particularly when busily occupied with reversing,
slowing, and braking on the runway. Pilot
preparedness for potential hold short clearances
could reduce the number of incidents in which
unfortunately timed ATC instructions are a
factor.
“ … we were so … [involved] with the landing
and roll-out that we honestly did not hear the
requirement to hold short.”
“ … [a] twin turboprop … rotated and
climbed out over me…. ATC issued my taxi
clearance and holding instructions while I
was still rolling out from my landing, where
workload is high….”
“The [ATC] instructions to ‘hold short of
Runway 9L …’ came at a very bad time, and I
missed it due to involvement in landing.”
PositionalAwareness
Many reports cited errors in the flight crews’
perception of their position. Thirty-three pilot
reporters attributed their inadvertent blunders
onto active runways to their uncertainty about
their precise location on the airport. Frequently
used was the term “confusion:”
“Captain became confused … I was momentarily
confused … I repeated back the
instructions to hold short of Runway XX before I
knew exactly where I was … I became confused
as to where Runway XX actually was … I found
the intersections of Runways 36 and 23 and
Taxiways Romeo and Lima confusing …
taxiways, runways and intersections — extremely
confusing.”
ASRS Directline Summer 1992 19
AttentionManagement
The chronic problem of distraction emerged in
twenty-three hold short incidents. At times, both
pilots were “heads turned around” as “the Flight
Attendant entered the cockpit with
coffee …,” or “heads down” as both pilots focused
upon FMS entries.
The source of breakdown in attention management
(task management) on the flight deck are
ranked as follows:
• Checklists
• Passenger announcements
• Company radio calls
• Miscellaneous (system malfunction, putting
away manuals, etc.)
• Flight attendant entering the cockpit
• Conversation
• FMS programming.
In taxi-out, reporters consistently referenced
necessary but distracting tasks such as starting up
an engine, running pre-takeoff checklists, and
making the required passenger announcements.
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