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|
Attributes | |
ACN | 123523 |
Time | |
Date | 198909 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : ord |
State Reference | IL |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | ground other : taxi landing other |
Route In Use | approach : straight in |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial |
Experience | flight time last 90 days : 240 flight time total : 4000 flight time type : 1000 |
ASRS Report | 123523 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | incursion : landing without clearance |
Independent Detector | other controllera other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Captain and first officer went to bed late and woke up at X45 for a X+2:30 show, X+3:30 flight ord-sdf-tys-sdf-ord-hou. Sdf-ord leg, both flight crew members extremely tired. Center told us we were #1 for ord way out. Kept speed up as long as possible. Close turn in to 27R at ord at 7000' (very high). Kept up to stay above departures. While concentrating on slowing, getting down, intercepting localizer, final descent check, etc, etc, captain forgot to call the tower at the marker. At 500' AGL, normal call-outs accomplished, PNF (captain): '500'.' PF (first officer): 'flaps should be 30 degrees.' PNF: 'flaps are 30 degrees, 5 green lights, cleared to land.' at that point I (PF) inquired, 'are we cleared to land?' captain responded, 'yes, cleared to land.' ATIS had told us to expect to hold short of 22R, and upon inspection of the 22R approach corridor a widebody transport was approaching from the same altitude and at the same speed. After landing and holding short of 22R (we would have collided with the widebody transport if we had not held short), captain realized he had never switched radio to tower. He then informed the tower of his mistake, to which they replied, 'contact ground.' high workload, being rushed by controllers, and fatigue led to a mistake by the captain, a lack of a second inquiry by the first officer, and an incorrect answer to the first first officer inquiry by the captain. Thank goodness for the ATIS remark, 'expect to hold short of 22R,' or we might have been so busy that we did not see the widebody transport and a tragedy could have occurred.
Original NASA ASRS Text
Title: FLT CREW NEGLECTED TO CONTACT TWR, LANDED WITHOUT CLRNC.
Narrative: CAPT AND F/O WENT TO BED LATE AND WOKE UP AT X45 FOR A X+2:30 SHOW, X+3:30 FLT ORD-SDF-TYS-SDF-ORD-HOU. SDF-ORD LEG, BOTH FLT CREW MEMBERS EXTREMELY TIRED. CENTER TOLD US WE WERE #1 FOR ORD WAY OUT. KEPT SPD UP AS LONG AS POSSIBLE. CLOSE TURN IN TO 27R AT ORD AT 7000' (VERY HIGH). KEPT UP TO STAY ABOVE DEPS. WHILE CONCENTRATING ON SLOWING, GETTING DOWN, INTERCEPTING LOC, FINAL DSCNT CHK, ETC, ETC, CAPT FORGOT TO CALL THE TWR AT THE MARKER. AT 500' AGL, NORMAL CALL-OUTS ACCOMPLISHED, PNF (CAPT): '500'.' PF (F/O): 'FLAPS SHOULD BE 30 DEGS.' PNF: 'FLAPS ARE 30 DEGS, 5 GREEN LIGHTS, CLRED TO LAND.' AT THAT POINT I (PF) INQUIRED, 'ARE WE CLRED TO LAND?' CAPT RESPONDED, 'YES, CLRED TO LAND.' ATIS HAD TOLD US TO EXPECT TO HOLD SHORT OF 22R, AND UPON INSPECTION OF THE 22R APCH CORRIDOR A WDB WAS APCHING FROM THE SAME ALT AND AT THE SAME SPD. AFTER LNDG AND HOLDING SHORT OF 22R (WE WOULD HAVE COLLIDED WITH THE WDB IF WE HAD NOT HELD SHORT), CAPT REALIZED HE HAD NEVER SWITCHED RADIO TO TWR. HE THEN INFORMED THE TWR OF HIS MISTAKE, TO WHICH THEY REPLIED, 'CONTACT GND.' HIGH WORKLOAD, BEING RUSHED BY CTLRS, AND FATIGUE LED TO A MISTAKE BY THE CAPT, A LACK OF A SECOND INQUIRY BY THE F/O, AND AN INCORRECT ANSWER TO THE FIRST F/O INQUIRY BY THE CAPT. THANK GOODNESS FOR THE ATIS REMARK, 'EXPECT TO HOLD SHORT OF 22R,' OR WE MIGHT HAVE BEEN SO BUSY THAT WE DID NOT SEE THE WDB AND A TRAGEDY COULD HAVE OCCURRED.
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.