Narrative:

I was the captain and pilot flying on a visual approach at night. The weather was clear and 10 SM visibility. It was; strictly by weather standards; a perfect night. During the final approach portion of our visual approach; we suddenly and surprisingly received a GPWS too low terrain aural alert. I would like to present this report from three distinct perspectives: what occurred; the 'human element'; and lessons learned. So what happened? Quite simply we were flying a visual approach on a beautiful VFR evening. Relatively close-in on final we received a too low terrain alert. I immediately adjusted pitch and power to increase aircraft altitude. As I did this; I also crosschecked the terrain display; FMC; and my visual references. One brief and surprising alert; but everything looked 'fine.' there appeared no problem (stabilized; etc...) [with] continuing the approach to a safe landing and that is what I elected to do. We landed uneventfully. Now the 'human element' part. I do not profess or pretend to be a human factors expert. Nonetheless; after considerable thought; and self reflection; I cannot help but believe there were at least a few elements involved (at least for me personally) in this event. To begin; unlike so many other as soon as possible reports I have read; there were no substantial internal or external threats; aside from the obvious terrain. My first officer was very friendly and professional. No 'issues' with the flight attendants or passengers. No ATC; weather; maintenance; or other problems. We were not at all task saturated. We were actually ahead of schedule with no reason to rush. And; I don't believe we were at all being complacent. In fact; we both had commented about the close proximity of towers on the final; had seemed to have our [situational awareness] very high; etc. Yet; the bottom line is; I failed to execute a complete go-around (as required) when we received the terrain alert. Why was I not aware the fom (while providing some relief for day VMC cautions) mandates a go-around for any night/IMC terrain or obstacle alert? I certainly was. Indeed; if you were to sit me down; give me this same type scenario; and ask what my response would be; I would say without hesitation; go-around. Was it then because I opted to blatantly disregard established policy/procedure? Absolutely not. Was it caused by unwittingly heeding to some sort of time pressure; operational pressure; personal pressure; or just plain ego? Also; unequivocally not. This is where; I believe; a few human factors come into play....in my mind I have always rehearsed (if you will) the words 'caution' and 'warning.' you will note this was not a 'caution terrain' nor 'terrain; terrain; pull up.' it was 'too low terrain.' as ignorant as it may sound; for me; I think the verbiage trigger wasn't there exactly. Therefore; while the reflective action to get away from the ground was present; I did not add 1+1 mentally in this surprising situation to come up with; go-around! The response it did trigger was the compelling desire to correct the aircraft flight path; assess the situation; and then determine a safe and proper response. This is where my perceptions led. I looked at the terrain display; no problem. I checked my FMC (programmed as my backup) descent path; no problem. I verified my visual with the runway; no problem. And; I assessed my ability to continue a stabilized approach to landing; once again; no problem. But; there was an overriding problem; I failed to simply do as I should have done and execute a go-around! This brings me to my lessons learned. First; one can read 100 as soon as possible reports or 1;000 and think; 'gee; that was dumb;' or 'wow; I would never have done that;' but one might be wrong. Second; even under the best circumstances; you...must strive to ensure reaction to any given situation results in getting the '1+1' correct. That is to say; book knowledge plus execution have to be combined to ultimately ensure a safe outcome regardless of circumstance. In the context of this incident; I realize now this was not at all the time for crosschecking; figuring out what was happening; or whatever else; it was precisely the time to do what I have been trained to do; to do the proper thing; to comply with procedure; to do the safest thing; to execute a go-around! I realize the litigious world we live in today has changed things dramatically from straight forward common sense to more 'how do we protect against a lawsuit?' this; at least in my opinion; has much to do with why...the fom has gone from about the size of today's ops binder to a multi-volume set it takes me personally two months prior to each pt/pc to completely review. As I alluded to in my narrative; something more akin to; 'if you hear the words 'obstacle;' or 'terrain' at night or in IMC; go around;' may not be legally all-inclusive and elegant; but might just some day preclude the lawsuit from the monumental verbiage to begin with. Certainly aircraft; and the flying environment itself; have gotten considerably more complex over time; but volumes and volumes more complex? Almost daily bulletins are more complex? Literally hundreds of pages of revisions are nearly each month more complex? You decide. However; I think I am as conscientious as the next guy where studying and keeping up with change is concerned. And; it has become a real challenge these days. For instance; exactly how many manual pages and checklists does it take to get across the 'clean aircraft' concept? How about this? 'Do not takeoff with frozen contaminants adhering to any critical aircraft surface!' I know we have likely spent 'tons' of time and money to incorporate the 'best' in CRM training corporate america has to offer; but again; what about getting back to perhaps the more simplified (maybe even more effective) approach.

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Original NASA ASRS Text

Title: Upon receiving a 'Too Low; Terrain' alert on a night visual approach; B737-300 First Officer advised a go-around which the Captain initiated; but then resumed the approach since terrain was visible and not a factor. Captain subsequently reviewed the human factors elements of his 'wrong' decision.

Narrative: I was the Captain and pilot flying on a visual approach at night. The weather was clear and 10 SM visibility. It was; strictly by weather standards; a perfect night. During the final approach portion of our visual approach; we suddenly and surprisingly received a GPWS Too Low Terrain aural alert. I would like to present this report from three distinct perspectives: what occurred; the 'human element'; and lessons learned. So what happened? Quite simply we were flying a visual approach on a beautiful VFR evening. Relatively close-in on final we received a Too Low Terrain alert. I immediately adjusted pitch and power to increase aircraft altitude. As I did this; I also crosschecked the terrain display; FMC; and my visual references. One brief and surprising alert; but everything looked 'fine.' There appeared no problem (stabilized; etc...) [with] continuing the approach to a safe landing and that is what I elected to do. We landed uneventfully. Now the 'human element' part. I do not profess or pretend to be a human factors expert. Nonetheless; after considerable thought; and self reflection; I cannot help but believe there were at least a few elements involved (at least for me personally) in this event. To begin; unlike so many other ASAP reports I have read; there were no substantial internal or external threats; aside from the obvious terrain. My First Officer was very friendly and professional. No 'issues' with the flight attendants or passengers. No ATC; weather; maintenance; or other problems. We were not at all task saturated. We were actually ahead of schedule with no reason to rush. And; I don't believe we were at all being complacent. In fact; we both had commented about the close proximity of towers on the final; had seemed to have our [situational awareness] very high; etc. Yet; the bottom line is; I failed to execute a complete go-around (as required) when we received the terrain alert. Why was I not aware the FOM (while providing some relief for day VMC cautions) mandates a go-around for any night/IMC terrain or obstacle alert? I certainly was. Indeed; if you were to sit me down; give me this same type scenario; and ask what my response would be; I would say without hesitation; go-around. Was it then because I opted to blatantly disregard established policy/procedure? Absolutely not. Was it caused by unwittingly heeding to some sort of time pressure; operational pressure; personal pressure; or just plain ego? Also; unequivocally not. This is where; I believe; a few human factors come into play....In my mind I have always rehearsed (if you will) the words 'caution' and 'warning.' You will note this was not a 'Caution Terrain' nor 'Terrain; Terrain; Pull Up.' It was 'Too Low Terrain.' As ignorant as it may sound; for me; I think the verbiage trigger wasn't there exactly. Therefore; while the reflective action to get away from the ground was present; I did not add 1+1 mentally in this surprising situation to come up with; go-around! The response it did trigger was the compelling desire to correct the aircraft flight path; assess the situation; and then determine a safe and proper response. This is where my perceptions led. I looked at the terrain display; no problem. I checked my FMC (programmed as my backup) descent path; no problem. I verified my visual with the runway; no problem. And; I assessed my ability to continue a stabilized approach to landing; once again; no problem. But; there was an overriding problem; I failed to simply do as I should have done and execute a go-around! This brings me to my lessons learned. First; one can read 100 ASAP reports or 1;000 and think; 'Gee; that was dumb;' or 'Wow; I would never have done that;' but one might be wrong. Second; even under the best circumstances; you...must strive to ensure reaction to any given situation results in getting the '1+1' correct. That is to say; book knowledge plus execution have to be combined to ultimately ensure a safe outcome regardless of circumstance. In the context of this incident; I realize now this was not at all the time for crosschecking; figuring out what was happening; or whatever else; it was precisely the time to do what I have been trained to do; to do the proper thing; to comply with procedure; to do the safest thing; to execute a go-around! I realize the litigious world we live in today has changed things dramatically from straight forward common sense to more 'how do we protect against a lawsuit?' This; at least in my opinion; has much to do with why...the FOM has gone from about the size of today's Ops binder to a multi-volume set it takes me personally two months prior to each PT/PC to completely review. As I alluded to in my narrative; something more akin to; 'If you hear the words 'obstacle;' or 'terrain' at night or in IMC; go around;' may not be legally all-inclusive and elegant; but might just some day preclude the lawsuit from the monumental verbiage to begin with. Certainly aircraft; and the flying environment itself; have gotten considerably more complex over time; but volumes and volumes more complex? Almost daily bulletins are more complex? Literally hundreds of pages of revisions are nearly each month more complex? You decide. However; I think I am as conscientious as the next guy where studying and keeping up with change is concerned. And; it has become a real challenge these days. For instance; exactly how many manual pages and checklists does it take to get across the 'clean aircraft' concept? How about this? 'Do not takeoff with frozen contaminants adhering to any critical aircraft surface!' I know we have likely spent 'tons' of time and money to incorporate the 'best' in CRM training corporate America has to offer; but again; what about getting back to perhaps the more simplified (maybe even more effective) approach.

Data retrieved from NASA's ASRS site as of July 2013 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.