This is an excerpt from a report made to the Aviation Safety Reporting System. The narrative is written by the pilot, rather than FAA or NTSB officials. To maintain anonymity, many details, such as aircraft model or airport, are often scrubbed from the reports.
Narrative 1 from Pilot
I taxied from the southeast ramp intending to use Runway XXR for takeoff. When exiting the ramp Taxiway Alpha has an unmarked entrance at the very southeast end of the airport.
While holding at the entrance line to Alpha, ground cleared me to the Bravo run-up area just ahead of me. I did so crossing two separate dash lines on the pavement and then turned 180° facing back at the ramp. I saw no sign for the Bravo Taxiway nor for Runway XXR.
The Tower cleared me for takeoff, but did not say to use Bravo to get to the runway, which was behind me. Once cleared for takeoff I crossed both sets of dashed lines thinking I was on Runway XXR, but later realized I was aligned with a taxiway.
The contributing factors were entering Taxiway A at an unmarked intersection and then crossing two sets of dashed lines to the run-up area that had no marking signs. Once at the run-up area I did not see any signs for Taxiway Bravo or Runway XXR.
Perhaps another contributing factor was not flying for seven months prior to this flight because of COVID.
In retrospect during flight planning, I should have gotten an enlarged airport diagram and studied it thoroughly, anticipating my route to the assigned runway and noting any potential issues in advance. I would then zoom in on satellite maps to clarify what it actually looked like on the ground.
If that didn’t clear it up I would call Ground Control and discuss it with them before arrival. If I’m ever uncertain when actually taxiing I can always ask for progressive taxi instructions from Ground Control.
Narrative 2 from Controller
Aircraft X was issued a takeoff clearance for Runway XXR and departed on Taxiway A, which runs parallel to the runway.
The Local Controller was issuing traffic to other aircraft and did not see Aircraft X rolling on Taxiway A. By the time we caught it I told the local controller not to cancel the takeoff clearance as it was heading directly for Aircraft Y that was taxiing opposite direction on Alpha and the departing aircraft would not have had the space to stop before a collision would’ve ensued.
The departing aircraft passed what I estimate to be 70-90 feet above Aircraft Y on the taxiway.
Recommendation: Continuation by the FAA to inform and educate pilots on the hazards associated with wrong surface departures.
Narrative 3 from Local Controller
Aircraft X was in the Taxiway Bravo run-up area when he called me ready for departure. An aircraft landed on Runway XXL and was instructed to hold short of Runway XXR at Delta for the departing traffic. I cleared Aircraft X for takeoff off of Runway XXR, but he only read back his call sign, which I did not realize until the read back was listened to. I see Aircraft X start to pull forward away from Aircraft Z that was in the run-up area with him and I continue with my scan and other tasks.
A few seconds go by and my scan brings me back to the departing Aircraft X and I notice he is on takeoff roll on Taxiway A. Not on frequency, I yell “whoa whoa whoa” while looking down for his call sign to cancel his takeoff clearance. I start my transmission to cancel his takeoff clearance but decide to let him continue with his takeoff because he started to rotate.
There was Aircraft Y on Taxiway A taxiing toward Aircraft X. Aircraft X passed over Aircraft Y by approximately 100 feet.
Aircraft X asked if I cleared him for takeoff off of Runway XXR, in an attempt to figure out what he did wrong. I informed him that his clearance was for Runway XXR, however he departed off of Taxiway A.
This event was caused by the pilot not recognizing that he was departing from a taxiway. The only way I can prevent this from happening again is if I keep my eyes on aircraft that are cleared for takeoff from the moment I issue the clearance until they start their takeoff roll. I am not sure if that is the expectation while working other aircraft.
Primary Problem: Human Factors
ACN: 1805820
This falls in the FAA category of “wrong surface operations,” which means a pilot landed or departed from a surface they were not cleared on. Sorry, I’m not buying the “unmarked intersection” or lack of signage excuses. I think the pilot could have kept track of his position if he had pulled his head out of his rectal orifice, looked out the window and compared his position to an airport diagram. As a pilot of over 50 years and an airport management professional for 12 years, I’m pretty sure that a towered airport with parallel runways has FAA standard markings and signs. Plus not having flown for 7 months is a big red flag. The COVID excuse is a lame one for not maintaining currency. Ever heard of flying solo? Dude, do us all a favor and get a flight review, and go online to any number of FAA or AOPA courses on airport signs and markings, and runway incursions prevention.
If a pilot is going to take off; any pilot, they are supposed to look at the numbers that coincide with the runway that they are supposed to be on. If they don’t see those numbers, they should not take off. At least that is what I was taught. You turn onto the runway and look at the numbers and say it out loud. Clear for takeoff runway 25 turn onto the runway there is the two and the five you are on the right runway. I don’t understand people who would take off without seeing those numbers. Back to school with you! CRAZY!
I’m thinking the solid yellow “centerline” vs. a dashed white one, probably should have been a clue also.
“To maintain anonymity, many details, such as aircraft model or airport, are often scrubbed from the reports.”
I understand the importance of protecting the pilot’s “anonymity”, and possibly that of the controllers.
But scrubbing the name of the airport, especially in cases like this, really limits the number of valuable lessons learned we could all benefit from…
It would be great if we could actually “see” how this scenario generated…Might prevent a similar incident from occurring somewhere else.
Absolutely!
My thinking was, if the signage was missing, there should have been a NOTAM for this, and the controller would have verified with pilot that the sign/marking is missing if the NOTAM had not yet been “published” (in other words, it was in the process of being filed).
Anyone can fly to a major metro city, rent a car, and negotiate traffic and signs without a problem. Airports, with relatively few options, not so much.
Likely was normal signage. Likely pilot just was distracted and not really thinking straight (he had just taxied down on alpha).
Neither Controller commented on the pilot’s statement about lack of signage.