37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1119041 |
Time | |
Date | 201309 |
Local Time Of Day | 0001-0600 |
Place | |
Locale Reference | ZSPD.Airport |
State Reference | FO |
Environment | |
Flight Conditions | Mixed |
Light | Night |
Aircraft 1 | |
Make Model Name | Widebody Low Wing 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Flight Phase | Final Approach Initial Approach Landing |
Route In Use | STAR DUMET 23F |
Flight Plan | IFR |
Person 1 | |
Function | First Officer Pilot Not Flying |
Experience | Flight Crew Last 90 Days 65 Flight Crew Total 9150 Flight Crew Type 4150 |
Person 2 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 122 Flight Crew Total 9969 Flight Crew Type 7469 |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy Deviation - Procedural Clearance Deviation - Track / Heading All Types |
Narrative:
Zspd ATIS reported landing on 34 and 35L. We loaded; set up; and briefed the ILS 35L from the dumet 21A [?]arrival. During our descent to 6;900 ft; we were advised to prepare for the ILS 34 and the dumet 23F arrival. I requested the ILS to 35L and was told to standby. We were 10 miles from dumet and knew that we had to comply with our clearance. I selected the ILS 34; dumet 23F arrival. I was then offered 13 transitions to choose. None of the choices appeared obvious to me for linking the arrival to the approach; so I began selecting the ones that I believed might work and then checking the route and legs page to scan the results. I was trying to close my discontinuity with the proper transition. None of the selected choices appeared to cleanly link the arrival and approach properly. As I did this drill; we were given descents to 5;900 and 4;900 ft as well as a frequency change. I again requested 35L with the new controller and he issued a clearance to 35L. This new clearance required a full approach set up. As I turned to my chart page to set the localizer and final approach course; the captain advised me that he had set the new (ILS 35L) frequency and final approach course in the box. I checked both as well as the ident. I never changed the FMC for the new runway. We continued with descents and vectors as well as configuring the aircraft for approach and landing. We were given a vector to final and told to intercept the localizer and advise when we were established. We looked down at the HSI and saw that our turn occurred very close to the HSI 'map picture' of what we thought was our approach to 35L. We adjusted our heading to intercept final since we assumed that the controller had 'missed' the turn and made it to late. I again checked the frequency and final course as well as the ident. All items checked out. Controller then advised us that we were lined up on 34 not 35L. Missed approach. On our next attempt; once established and configured; we were cleared for the ILS and told to 'maintain 170 KTS until 7 NM.' my captain then announced that he was going to autoland; as the aircraft required one within the week. At 500 ft we got a 'too low flaps' call. Flaps only set at 20. Go around. Third approach ended without further incidence. After shutdown; we determined that the following items contributed to this event. 1) mind set enroute that we would be given the arrival and approach that we briefed. Anticipation bias 2) getting runway and arrival clearance different from what we had set up; in close to the field. 3) needing to load new clearance in close to the field. Distraction/stress 4) difficulty loading FMC as transitions are labeled in a very ambiguious way. No transitions were obvious choices. 5) having multiple altitude clearances issued as well as frequency changes while attempting to load FMC. Task overload causing further distractions 6) being issued our anticipated clearance which needed to be loaded. Manual set up of approach and 'quick' brief of approach also needing to be accomplished in very short period of time. 7) not double checking all items; but assuming that my captain had set up the box when he advised me that he had the new approach ready to go. 8) not combining good listening (runway 35L) with good looking (runway 34 on HSI) 9) assuming we were right and that the controller made a mistake by turning us late causing us to miss the localizer from capturing. This assumption caused us to adjust our heading to make the HSI map picture appear correct. During our 3 hours on the ground in zspd I reviewed the dumet 23F with the ILS to 34. This was the item that I got bogged down on and caused the most distraction and absorbed the greatest amount of our valuable time. I went through all of the transitions (without the previous stress). I still did not see any instant way to identify the transition that I would need; but at least figured out some pattern of how the transitions are set up; and how to make them work in linking up arrivals with approaches. It would be nice if the software on the FMC and the chart plate were more obvious for selecting the appropriate transition. We discussed the need for remaining in our habit patterns and checking the work of the other pilot when in high stress; high workload environments. How critical precise communication is; at all times. How important it is to not get frustrated with foreign controllers and the associated language barriers. That is how they do business and it will not change. Not to linger on previous errors (first approach) thus allowing them to cause you further problems (second approach). Bottom line is this: we became time crunched and task overloaded. Listen and look at all times. This becomes much more critical when FMC programming is changed and then changed again. I was aware that a problem might develop as we were issued the second clearance to runway 34 as I briefly considered putting in the dumet 23F and leaving the 35L approach in the FMC. I was afraid that if we did not get our request; I would forget that I had not set in the ILS to 34 and that it would cause us problems later on. The opposite ended up occurring. We prepared for the 35L approach; because it made sense at [the late hour] with very little traffic inbound to zspd; as well as the fact that ATIS advised that 35L was the landing runway. We did not want to taxi from the east side of the field after a runway 34 landing. Controllers should know that that is the runway we want since landing on 35L requires a 2-3 minute taxi to the gate verse a 20+ minute taxi from 34. This strategy saves valuable time and fuel. Controllers should be briefed to only offer the best operational runway to our flights. This would mean west side runways for all landing configurations. What the zspd controllers offer; only costs time and money and started a chain of events that I personally wished had never happened.
Original NASA ASRS Text
Title: Air carrier flight crew experiences confusion during descent and approach to ZSPD due to a late runway change and lack of familiarity with the arrivals and approaches. Two go-arounds result; the first due to line up with the wrong runway and the second due to flap setting.
Narrative: ZSPD ATIS reported landing on 34 and 35L. We loaded; set up; and briefed the ILS 35L from the DUMET 21A [?]arrival. During our descent to 6;900 FT; we were advised to prepare for the ILS 34 and the DUMET 23F arrival. I requested the ILS to 35L and was told to standby. We were 10 miles from Dumet and knew that we had to comply with our clearance. I selected the ILS 34; DUMET 23F arrival. I was then offered 13 transitions to choose. None of the choices appeared obvious to me for linking the arrival to the approach; so I began selecting the ones that I believed might work and then checking the route and legs page to scan the results. I was trying to close my discontinuity with the proper transition. None of the selected choices appeared to cleanly link the arrival and approach properly. As I did this drill; we were given descents to 5;900 and 4;900 FT as well as a frequency change. I again requested 35L with the new Controller and he issued a clearance to 35L. This new clearance required a full approach set up. As I turned to my chart page to set the LOC and final approach course; the Captain advised me that he had set the new (ILS 35L) frequency and final approach course in the box. I checked both as well as the ident. I never changed the FMC for the new runway. We continued with descents and vectors as well as configuring the aircraft for approach and landing. We were given a vector to final and told to intercept the localizer and advise when we were established. We looked down at the HSI and saw that our turn occurred very close to the HSI 'map picture' of what we thought was our approach to 35L. We adjusted our heading to intercept final since we assumed that the Controller had 'missed' the turn and made it to late. I again checked the frequency and final course as well as the ident. All items checked out. Controller then advised us that we were lined up on 34 not 35L. Missed approach. On our next attempt; once established and configured; we were cleared for the ILS and told to 'maintain 170 KTS until 7 NM.' My Captain then announced that he was going to autoland; as the aircraft required one within the week. At 500 FT we got a 'too low flaps' call. Flaps only set at 20. Go around. Third approach ended without further incidence. After shutdown; we determined that the following items contributed to this event. 1) Mind set enroute that we would be given the arrival and approach that we briefed. ANTICIPATION BIAS 2) Getting runway and arrival clearance different from what we had set up; in close to the field. 3) Needing to load new clearance in close to the field. DISTRACTION/STRESS 4) Difficulty loading FMC as transitions are labeled in a very AMBIGUIOUS way. No transitions were obvious choices. 5) Having multiple altitude clearances issued as well as frequency changes while attempting to load FMC. TASK OVERLOAD causing further DISTRACTIONS 6) Being issued our anticipated clearance which needed to be loaded. Manual set up of approach and 'quick' brief of approach also needing to be accomplished in very short period of time. 7) Not double checking all items; but assuming that my Captain had set up the box when he advised me that he had the new approach ready to go. 8) Not combining good listening (Runway 35L) with good looking (Runway 34 on HSI) 9) Assuming we were right and that the Controller made a mistake by turning us late causing us to miss the LOC from capturing. This assumption caused us to adjust our heading to make the HSI map picture appear correct. During our 3 hours on the ground in ZSPD I reviewed the DUMET 23F with the ILS to 34. This was the item that I got bogged down on and caused the most distraction and absorbed the greatest amount of our valuable time. I went through all of the transitions (without the previous stress). I still did not see any instant way to identify the transition that I would need; but at least figured out some pattern of how the transitions are set up; and how to make them work in linking up arrivals with approaches. It would be nice if the software on the FMC and the chart plate were more obvious for selecting the appropriate transition. We discussed the need for remaining in our habit patterns and checking the work of the other pilot when in high stress; high workload environments. How critical precise communication is; at all times. How important it is to not get frustrated with foreign controllers and the associated language barriers. That is how they do business and it will not change. Not to linger on previous errors (first approach) thus allowing them to cause you further problems (second approach). Bottom line is this: we became time crunched and task overloaded. Listen and look at all times. This becomes much more critical when FMC programming is changed and then changed again. I was aware that a problem might develop as we were issued the second clearance to Runway 34 as I briefly considered putting in the DUMET 23F and leaving the 35L approach in the FMC. I was afraid that if we did not get our request; I would forget that I had not set in the ILS to 34 and that it would cause us problems later on. The opposite ended up occurring. We prepared for the 35L approach; because it made sense at [the late hour] with very little traffic inbound to ZSPD; as well as the fact that ATIS advised that 35L was the landing runway. We did not want to taxi from the east side of the field after a Runway 34 landing. Controllers should know that that is the runway we want since landing on 35L requires a 2-3 minute taxi to the gate verse a 20+ minute taxi from 34. This strategy saves valuable time and fuel. Controllers should be briefed to only offer the best operational runway to our flights. This would mean west side runways for all landing configurations. What the ZSPD controllers offer; only costs time and money and started a chain of events that I personally wished had never happened.
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.