Narrative:

Small aircraft X was being sequenced to the airport for landing on runway 16. He was sequenced behind traffic executing a practice back-course approach and low approach to runway 25R. Coordination was accomplished with the tower through the cabin coordinator position. OJT was in progress on local control position. Local control had small aircraft Y in position and holding on the approach end of runway 16. Attention was diverted away from the approach end of runway 16 as the local controller and the cabin coordinator were separating a previous departure and the low approach southwest of the airport. The approach controller thought small aircraft X had been changed to the tower frequency, when in actuality he had not been changed. Small aircraft X then landed on runway 16 west/O a landing clearance over the small aircraft Y in position, even though small aircraft X had seen the small aircraft Y on the runway. The local controller and the cabin coordinator observed small aircraft X on his rollout. Evasive action should have been required by the controllers in the tower, but since they did not observe the landing traffic on final, none was taken. Small aircraft X made no other xmissions to the approach controller just prior to turning a 3 mi final. Not being aware that she had not transferred communications to the tower, no evasive action was possible. The small aircraft X pilot should have taken his own evasive action by executing a go around or by requesting instructions from ATC, since he had the small aircraft Y sighted on the runway. This was also not done. The situation occurred due to all of the above circumstances happening at the same time. Prevention of a recurrence would be difficult due to the fact that this was a case of murphy's law, and given the same circumstances again it will probably happen again. However, some suggestions to help prevent another one: 1) better controller awareness--both for the approach controller (for not realizing she hadn't switched the aircraft to the tower) and for the local controllers (for not scanning the final). 2) pilot education--ultimately, I feel the pilot could and should have prevented the incident from happening. He knowingly landed over another aircraft and did not question ATC either for a landing clearance or alternate instructions.

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Original NASA ASRS Text

Title: SMA X LANDED WITHOUT CLRNC. PLT DEVIATION.

Narrative: SMA X WAS BEING SEQUENCED TO THE ARPT FOR LNDG ON RWY 16. HE WAS SEQUENCED BEHIND TFC EXECUTING A PRACTICE BACK-COURSE APCH AND LOW APCH TO RWY 25R. COORD WAS ACCOMPLISHED WITH THE TWR THROUGH THE CABIN COORDINATOR POS. OJT WAS IN PROGRESS ON LCL CTL POS. LCL CTL HAD SMA Y IN POS AND HOLDING ON THE APCH END OF RWY 16. ATTN WAS DIVERTED AWAY FROM THE APCH END OF RWY 16 AS THE LCL CTLR AND THE CABIN COORDINATOR WERE SEPARATING A PREVIOUS DEP AND THE LOW APCH SW OF THE ARPT. THE APCH CTLR THOUGHT SMA X HAD BEEN CHANGED TO THE TWR FREQ, WHEN IN ACTUALITY HE HAD NOT BEEN CHANGED. SMA X THEN LANDED ON RWY 16 W/O A LNDG CLRNC OVER THE SMA Y IN POS, EVEN THOUGH SMA X HAD SEEN THE SMA Y ON THE RWY. THE LCL CTLR AND THE CABIN COORDINATOR OBSERVED SMA X ON HIS ROLLOUT. EVASIVE ACTION SHOULD HAVE BEEN REQUIRED BY THE CTLRS IN THE TWR, BUT SINCE THEY DID NOT OBSERVE THE LNDG TFC ON FINAL, NONE WAS TAKEN. SMA X MADE NO OTHER XMISSIONS TO THE APCH CTLR JUST PRIOR TO TURNING A 3 MI FINAL. NOT BEING AWARE THAT SHE HAD NOT TRANSFERRED COMS TO THE TWR, NO EVASIVE ACTION WAS POSSIBLE. THE SMA X PLT SHOULD HAVE TAKEN HIS OWN EVASIVE ACTION BY EXECUTING A GAR OR BY REQUESTING INSTRUCTIONS FROM ATC, SINCE HE HAD THE SMA Y SIGHTED ON THE RWY. THIS WAS ALSO NOT DONE. THE SITUATION OCCURRED DUE TO ALL OF THE ABOVE CIRCUMSTANCES HAPPENING AT THE SAME TIME. PREVENTION OF A RECURRENCE WOULD BE DIFFICULT DUE TO THE FACT THAT THIS WAS A CASE OF MURPHY'S LAW, AND GIVEN THE SAME CIRCUMSTANCES AGAIN IT WILL PROBABLY HAPPEN AGAIN. HOWEVER, SOME SUGGESTIONS TO HELP PREVENT ANOTHER ONE: 1) BETTER CTLR AWARENESS--BOTH FOR THE APCH CTLR (FOR NOT REALIZING SHE HADN'T SWITCHED THE ACFT TO THE TWR) AND FOR THE LCL CTLRS (FOR NOT SCANNING THE FINAL). 2) PLT EDUCATION--ULTIMATELY, I FEEL THE PLT COULD AND SHOULD HAVE PREVENTED THE INCIDENT FROM HAPPENING. HE KNOWINGLY LANDED OVER ANOTHER ACFT AND DID NOT QUESTION ATC EITHER FOR A LNDG CLRNC OR ALTERNATE INSTRUCTIONS.

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.