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|
Attributes | |
ACN | 114631 |
Time | |
Date | 198906 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : lax |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 4000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : lax tower : lax tower : fll |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | descent : approach descent other landing other |
Route In Use | approach : visual enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 200 flight time total : 13000 flight time type : 7000 |
ASRS Report | 114631 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | incursion : runway inflight encounter : weather non adherence : published procedure non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Flight was a normal scheduled flight from hawaii to los angeles. After landing, the captain said, 'wrong runway!' and sure enough, we had landed on 25L though we had been cleared to land on 25R. About an hour out of lax, we discovered a slowly leaking hydraulic system. We spent much of the remainder of the cruise segment troubleshooting, communicating with maintenance, the company, referencing flight manuals and checklists, diagnosing and discussing the problem, and planning procedures for approach and landing. The details of the hydraulic problem are not pertinent here except to note that it consumed much of our attention and energies. We made the decision to make a normal landing with that hydraulic system deactivated. After landing, we would activate the system because it would be needed for full nose wheel control needed for 'docking' at the gate. The worst that could happen would be that we would have to call for a tug sometime after clearing the runway. We expected we would not have to do that. ATC was only informed that we would require to be down to 210 KTS by seal beach VORTAC. Basic WX at lax was given a partially obscured, 700' 4 mi visibility 'ILS runway 25L and 24?.' I got out the approach plate for 25L and did a quick review, noting the inbound heading and ILS frequency. After reducing below 230 KTS, we lowered the gear and got normal indications. Approach had us on vectors, and while we were VFR with good visibility most of the way in from catalina, as we got vectored north, then nwbnd, into the evening sun, the visibility got quite bad in haze. With the initial vector, approach told us we were being vectored to 25R. I immediately flipped my approach charts to that runway plate, checked the frequency and inbound heading. I set my instruments and checked that the captain had the same settings. He did. I did not 'identification' the ILS. Approach asked if we saw the widebody transport at 12 O'clock inbound (we were on a left base) and I reported we did. He said 'follow him, he's going to 25L, you're cleared visual approach 25R, tower at ...'. The localizer started in (we were on about a 40 degree intercept) and the captain started a left turn. Simultaneously, approach told us to turn to 260 degree. I replied, 'yes, we're bringing it around now.' we were now in full landing confign and at the assigned fix I called the tower and gave our identification and location. He acknowledged and cleared us to land on 25R. I noted we were stabilized on the glide slope, but 2 dots right on the localizer. The widebody transport is plainly visible ahead and slightly to our left. We can see nothing west of him. I asked the captain if he were deliberately staying north of course. He said 'yes'. I asked why, and he replied in effect that he's trying to point the aircraft toward the runway. I'm confused, and a little concerned about encroaching on traffic going to runways 24. At this point, a brief discussion about who's going where ensues. I can't be sure, now, of what was said. But I believe the captain, who knew we were not flying an ILS to 25R, tried to tell me that. 'That's the 25L ILS, we're going to 25R!' (to mean, 'he's flying the 25L ILS -- we're flying the 25R ILS.' I watch the widebody transport disappear into the haze and notice we're approaching 1000 AGL and make the 1000' call. The captain should respond '(named runway) in sight', or 'going to (MDA)'. He does not respond. The second officer calls, 'MDA (XXX) MSL'. Captain 'do you have it?' me: 'no'. At about 700', both runways come into view and I call 'runways in sight'. Captain: 'I have it'. I go back into the cockpit and monitor instruments and call '500' feet. Captain: '35 flap landing'. Now at about 300', I look up and see we are aligned with 25L. I check the localizer and it is centered. We land. 1) I was not cognizant of the fact the 25L and 25R use the same ILS frequency, and so also not aware that ILS's for both runways could not be on simultaneously. 2) we were assigned an illegal approach. We were not visual. We were not asked, nor did we say we had either the airport or the runway in sight. 3) we accepted the illegal approach. I actually did not understand that we were cleared for a visual, though I heard and acknowledged that clearance. I 'felt' we were flying 'visually' behind the widebody transport to the airport where we could, and would if we had to fly an ILS 25R approach. After all, the frequency and course set up agreed with the information on the 25R ILS approach plate before me. 4) by not checking the ILS identification, I missed a chance to recognize the error. 5) with these mind sets, I could easily misinterpret the captain's statement (referenced above) to mean, 'he's flying the 25L ILS -- we're flying the 25R ILS.' 6) finally, when I saw that we were aligned with 25L instead of 25R, I allowed myself to dismiss my previous belief that we were cleared to land 25R because both the ILS indication and the captain's flying agreed that I was wrong. I just lapsed into the copilot syndrome and assumed I had heard or now remember wrong. Contributing factors: 1) poor air-ground communications. I found listening to la controllers difficult. Speech was very rapid, annunciation poor. I was having a high workload hearing what was said, let along understanding what it meant. The early gear down increased cockpit noise too. The captain and I both had several clues to the fact that we did not clearly agree on exactly what approach we were flying. Although we discussed it, I think we either didn't fully recognize the confusion or the possible consequences of it. In either case, we failed to properly resolve it.
Original NASA ASRS Text
Title: AIR CARRIER FLT CLEARED FOR A VISUAL TO A PARALLEL RWY IN RESTRICTED VISIBILITY LANDS ON WRONG RWY.
Narrative: FLT WAS A NORMAL SCHEDULED FLT FROM HAWAII TO LOS ANGELES. AFTER LNDG, THE CAPT SAID, 'WRONG RWY!' AND SURE ENOUGH, WE HAD LANDED ON 25L THOUGH WE HAD BEEN CLRED TO LAND ON 25R. ABOUT AN HOUR OUT OF LAX, WE DISCOVERED A SLOWLY LEAKING HYDRAULIC SYSTEM. WE SPENT MUCH OF THE REMAINDER OF THE CRUISE SEGMENT TROUBLESHOOTING, COMMUNICATING WITH MAINT, THE COMPANY, REFERENCING FLT MANUALS AND CHECKLISTS, DIAGNOSING AND DISCUSSING THE PROBLEM, AND PLANNING PROCS FOR APCH AND LNDG. THE DETAILS OF THE HYDRAULIC PROBLEM ARE NOT PERTINENT HERE EXCEPT TO NOTE THAT IT CONSUMED MUCH OF OUR ATTN AND ENERGIES. WE MADE THE DECISION TO MAKE A NORMAL LNDG WITH THAT HYDRAULIC SYSTEM DEACTIVATED. AFTER LNDG, WE WOULD ACTIVATE THE SYSTEM BECAUSE IT WOULD BE NEEDED FOR FULL NOSE WHEEL CONTROL NEEDED FOR 'DOCKING' AT THE GATE. THE WORST THAT COULD HAPPEN WOULD BE THAT WE WOULD HAVE TO CALL FOR A TUG SOMETIME AFTER CLEARING THE RWY. WE EXPECTED WE WOULD NOT HAVE TO DO THAT. ATC WAS ONLY INFORMED THAT WE WOULD REQUIRE TO BE DOWN TO 210 KTS BY SEAL BEACH VORTAC. BASIC WX AT LAX WAS GIVEN A PARTIALLY OBSCURED, 700' 4 MI VISIBILITY 'ILS RWY 25L AND 24?.' I GOT OUT THE APCH PLATE FOR 25L AND DID A QUICK REVIEW, NOTING THE INBND HDG AND ILS FREQ. AFTER REDUCING BELOW 230 KTS, WE LOWERED THE GEAR AND GOT NORMAL INDICATIONS. APCH HAD US ON VECTORS, AND WHILE WE WERE VFR WITH GOOD VISIBILITY MOST OF THE WAY IN FROM CATALINA, AS WE GOT VECTORED N, THEN NWBND, INTO THE EVENING SUN, THE VISIBILITY GOT QUITE BAD IN HAZE. WITH THE INITIAL VECTOR, APCH TOLD US WE WERE BEING VECTORED TO 25R. I IMMEDIATELY FLIPPED MY APCH CHARTS TO THAT RWY PLATE, CHECKED THE FREQ AND INBND HDG. I SET MY INSTRUMENTS AND CHECKED THAT THE CAPT HAD THE SAME SETTINGS. HE DID. I DID NOT 'ID' THE ILS. APCH ASKED IF WE SAW THE WDB AT 12 O'CLOCK INBND (WE WERE ON A LEFT BASE) AND I REPORTED WE DID. HE SAID 'FOLLOW HIM, HE'S GOING TO 25L, YOU'RE CLRED VISUAL APCH 25R, TWR AT ...'. THE LOC STARTED IN (WE WERE ON ABOUT A 40 DEG INTERCEPT) AND THE CAPT STARTED A LEFT TURN. SIMULTANEOUSLY, APCH TOLD US TO TURN TO 260 DEG. I REPLIED, 'YES, WE'RE BRINGING IT AROUND NOW.' WE WERE NOW IN FULL LNDG CONFIGN AND AT THE ASSIGNED FIX I CALLED THE TWR AND GAVE OUR ID AND LOCATION. HE ACKNOWLEDGED AND CLRED US TO LAND ON 25R. I NOTED WE WERE STABILIZED ON THE GLIDE SLOPE, BUT 2 DOTS RIGHT ON THE LOC. THE WDB IS PLAINLY VISIBLE AHEAD AND SLIGHTLY TO OUR LEFT. WE CAN SEE NOTHING W OF HIM. I ASKED THE CAPT IF HE WERE DELIBERATELY STAYING N OF COURSE. HE SAID 'YES'. I ASKED WHY, AND HE REPLIED IN EFFECT THAT HE'S TRYING TO POINT THE ACFT TOWARD THE RWY. I'M CONFUSED, AND A LITTLE CONCERNED ABOUT ENCROACHING ON TFC GOING TO RWYS 24. AT THIS POINT, A BRIEF DISCUSSION ABOUT WHO'S GOING WHERE ENSUES. I CAN'T BE SURE, NOW, OF WHAT WAS SAID. BUT I BELIEVE THE CAPT, WHO KNEW WE WERE NOT FLYING AN ILS TO 25R, TRIED TO TELL ME THAT. 'THAT'S THE 25L ILS, WE'RE GOING TO 25R!' (TO MEAN, 'HE'S FLYING THE 25L ILS -- WE'RE FLYING THE 25R ILS.' I WATCH THE WDB DISAPPEAR INTO THE HAZE AND NOTICE WE'RE APCHING 1000 AGL AND MAKE THE 1000' CALL. THE CAPT SHOULD RESPOND '(NAMED RWY) IN SIGHT', OR 'GOING TO (MDA)'. HE DOES NOT RESPOND. THE S/O CALLS, 'MDA (XXX) MSL'. CAPT 'DO YOU HAVE IT?' ME: 'NO'. AT ABOUT 700', BOTH RWYS COME INTO VIEW AND I CALL 'RWYS IN SIGHT'. CAPT: 'I HAVE IT'. I GO BACK INTO THE COCKPIT AND MONITOR INSTRUMENTS AND CALL '500' FEET. CAPT: '35 FLAP LNDG'. NOW AT ABOUT 300', I LOOK UP AND SEE WE ARE ALIGNED WITH 25L. I CHECK THE LOC AND IT IS CENTERED. WE LAND. 1) I WAS NOT COGNIZANT OF THE FACT THE 25L AND 25R USE THE SAME ILS FREQ, AND SO ALSO NOT AWARE THAT ILS'S FOR BOTH RWYS COULD NOT BE ON SIMULTANEOUSLY. 2) WE WERE ASSIGNED AN ILLEGAL APCH. WE WERE NOT VISUAL. WE WERE NOT ASKED, NOR DID WE SAY WE HAD EITHER THE ARPT OR THE RWY IN SIGHT. 3) WE ACCEPTED THE ILLEGAL APCH. I ACTUALLY DID NOT UNDERSTAND THAT WE WERE CLRED FOR A VISUAL, THOUGH I HEARD AND ACKNOWLEDGED THAT CLRNC. I 'FELT' WE WERE FLYING 'VISUALLY' BEHIND THE WDB TO THE ARPT WHERE WE COULD, AND WOULD IF WE HAD TO FLY AN ILS 25R APCH. AFTER ALL, THE FREQ AND COURSE SET UP AGREED WITH THE INFO ON THE 25R ILS APCH PLATE BEFORE ME. 4) BY NOT CHECKING THE ILS ID, I MISSED A CHANCE TO RECOGNIZE THE ERROR. 5) WITH THESE MIND SETS, I COULD EASILY MISINTERPRET THE CAPT'S STATEMENT (REFERENCED ABOVE) TO MEAN, 'HE'S FLYING THE 25L ILS -- WE'RE FLYING THE 25R ILS.' 6) FINALLY, WHEN I SAW THAT WE WERE ALIGNED WITH 25L INSTEAD OF 25R, I ALLOWED MYSELF TO DISMISS MY PREVIOUS BELIEF THAT WE WERE CLRED TO LAND 25R BECAUSE BOTH THE ILS INDICATION AND THE CAPT'S FLYING AGREED THAT I WAS WRONG. I JUST LAPSED INTO THE COPLT SYNDROME AND ASSUMED I HAD HEARD OR NOW REMEMBER WRONG. CONTRIBUTING FACTORS: 1) POOR AIR-GND COMS. I FOUND LISTENING TO LA CTLRS DIFFICULT. SPEECH WAS VERY RAPID, ANNUNCIATION POOR. I WAS HAVING A HIGH WORKLOAD HEARING WHAT WAS SAID, LET ALONG UNDERSTANDING WHAT IT MEANT. THE EARLY GEAR DOWN INCREASED COCKPIT NOISE TOO. THE CAPT AND I BOTH HAD SEVERAL CLUES TO THE FACT THAT WE DID NOT CLEARLY AGREE ON EXACTLY WHAT APCH WE WERE FLYING. ALTHOUGH WE DISCUSSED IT, I THINK WE EITHER DIDN'T FULLY RECOGNIZE THE CONFUSION OR THE POSSIBLE CONSEQUENCES OF IT. IN EITHER CASE, WE FAILED TO PROPERLY RESOLVE IT.
Data retrieved from NASA's ASRS site as of August 2007 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.