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|
Attributes | |
ACN | 123801 |
Time | |
Date | 198909 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : den |
State Reference | CO |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : den artcc : zla |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | descent : approach landing other |
Route In Use | approach : visual |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 150 flight time total : 13000 flight time type : 3000 |
ASRS Report | 123801 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | incursion : landing without clearance non adherence : far non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On right downwind for runways 26 den, IFR operation in VMC, approach control asked if we had the runways and other aircraft on final. Cap flying, first officer PNF. Responded affirmative. Controller cleared us visual 26R. Responded, 'negative, too heavy today, need 26L.' were cleared to follow other traffic to 26L, cleared visual 26L, contact tower at marker. First officer dialed tower frequency into pre-select tuning head. Then a subsequent exchange between approach control and flight went something like this -- approach: 'in future, please advise in advance if you can't take 26R.' captain: 'sorry, (I didn't do that because) in my experience I've never been given 26R in a wide body without first being asked if we could accept it.' approach: 'you're supposed to tell us if you have a particular runway need.' we continued the approach, completed checklists, and landed on 26L. As we cleared the runway, first officer began 'cleanup chores', and reached for the VHF tuning head to select ground frequency and noticed that the selected frequency was still approach, and then noticed that the voice in the head set was still approach control. While uttering an expletive, he switched the selector to the already dialed tower frequency and transmitted: '(flight identification) holding short 26R.' subsequent taxi to the gate was normal. All 3 crew members were concerned that we may have landed without landing clearance. Yet all 3 felt they had heard (and had acknowledged) a 'cleared to land' clearance. The second officer commented that, 'if tower needed to talk to us, he could have had approach tell us.' after blocking, crew called tower on landline. Tower said, 'you were cleared to land. You may not have heart it, but you were cleared.' troubling things: this was an experienced crew. The captain has over 30 yrs with this carrier, the first officer 25, 6 yrs in that seat. The second officer had only 2 or 3 yrs experience, but was unusually competent at monitoring the operation and not at all shy about speaking out if he saw anything wrong. So how did all 3 of us not realize we were listening to approach control all the way to landing? Did we all 'feel' we heard a landing clearance because approach issued it, or because that's what we wanted to believe? Contributing factors: fatigue. This was the end of a long 3RD day of a 4 day trip. Both the captain and first officer had commended that they had gotten little sleep on the short layover. Experience and workload: while obviously competent and skillful, the captain was new-in-type, and had demonstrated a tendency to 'get behind' while trying to operate the foreign flight guidance system. This was his first line trip -- he flew every leg. As a result, the first officer was spending more than usual attention to monitoring the flight parameters and flight guidance system settings. Cues and psychological inputs. The first officer had primary responsibility for ATC communication. Could the act of dialing the tower frequency in the dual tuning head, combined with the not-too-usual dialogue between him and approach (about runway needs) have influenced his perception of where he was in the communication chain of events? Normally, passing the outer marker, locator is a cue here -- but though the locator was tuned and identified on this approach, no one noticed the outer. The 'marker' switch was not on, so no aural signal was heard. The blue light and ADF needle swing went unnoticed. To what extent was this due to everyone's preoccupation with monitoring the aircraft's physical flight parameters?
Original NASA ASRS Text
Title: ACR WDB FLT CREW DID NOT CONTACT TWR AS INSTRUCTED ON FINAL AND LANDED WITHOUT GETTING CLRNC ALTHOUGH ONE WAS IN FACT ISSUED.
Narrative: ON RIGHT DOWNWIND FOR RWYS 26 DEN, IFR OPERATION IN VMC, APCH CTL ASKED IF WE HAD THE RWYS AND OTHER ACFT ON FINAL. CAP FLYING, F/O PNF. RESPONDED AFFIRMATIVE. CTLR CLRED US VISUAL 26R. RESPONDED, 'NEGATIVE, TOO HEAVY TODAY, NEED 26L.' WERE CLRED TO FOLLOW OTHER TFC TO 26L, CLRED VISUAL 26L, CONTACT TWR AT MARKER. F/O DIALED TWR FREQ INTO PRE-SELECT TUNING HEAD. THEN A SUBSEQUENT EXCHANGE BETWEEN APCH CTL AND FLT WENT SOMETHING LIKE THIS -- APCH: 'IN FUTURE, PLEASE ADVISE IN ADVANCE IF YOU CAN'T TAKE 26R.' CAPT: 'SORRY, (I DIDN'T DO THAT BECAUSE) IN MY EXPERIENCE I'VE NEVER BEEN GIVEN 26R IN A WIDE BODY WITHOUT FIRST BEING ASKED IF WE COULD ACCEPT IT.' APCH: 'YOU'RE SUPPOSED TO TELL US IF YOU HAVE A PARTICULAR RWY NEED.' WE CONTINUED THE APCH, COMPLETED CHECKLISTS, AND LANDED ON 26L. AS WE CLRED THE RWY, F/O BEGAN 'CLEANUP CHORES', AND REACHED FOR THE VHF TUNING HEAD TO SELECT GND FREQ AND NOTICED THAT THE SELECTED FREQ WAS STILL APCH, AND THEN NOTICED THAT THE VOICE IN THE HEAD SET WAS STILL APCH CTL. WHILE UTTERING AN EXPLETIVE, HE SWITCHED THE SELECTOR TO THE ALREADY DIALED TWR FREQ AND TRANSMITTED: '(FLT ID) HOLDING SHORT 26R.' SUBSEQUENT TAXI TO THE GATE WAS NORMAL. ALL 3 CREW MEMBERS WERE CONCERNED THAT WE MAY HAVE LANDED WITHOUT LNDG CLRNC. YET ALL 3 FELT THEY HAD HEARD (AND HAD ACKNOWLEDGED) A 'CLRED TO LAND' CLRNC. THE S/O COMMENTED THAT, 'IF TWR NEEDED TO TALK TO US, HE COULD HAVE HAD APCH TELL US.' AFTER BLOCKING, CREW CALLED TWR ON LANDLINE. TWR SAID, 'YOU WERE CLRED TO LAND. YOU MAY NOT HAVE HEART IT, BUT YOU WERE CLRED.' TROUBLING THINGS: THIS WAS AN EXPERIENCED CREW. THE CAPT HAS OVER 30 YRS WITH THIS CARRIER, THE F/O 25, 6 YRS IN THAT SEAT. THE S/O HAD ONLY 2 OR 3 YRS EXPERIENCE, BUT WAS UNUSUALLY COMPETENT AT MONITORING THE OPERATION AND NOT AT ALL SHY ABOUT SPEAKING OUT IF HE SAW ANYTHING WRONG. SO HOW DID ALL 3 OF US NOT REALIZE WE WERE LISTENING TO APCH CTL ALL THE WAY TO LNDG? DID WE ALL 'FEEL' WE HEARD A LNDG CLRNC BECAUSE APCH ISSUED IT, OR BECAUSE THAT'S WHAT WE WANTED TO BELIEVE? CONTRIBUTING FACTORS: FATIGUE. THIS WAS THE END OF A LONG 3RD DAY OF A 4 DAY TRIP. BOTH THE CAPT AND F/O HAD COMMENDED THAT THEY HAD GOTTEN LITTLE SLEEP ON THE SHORT LAYOVER. EXPERIENCE AND WORKLOAD: WHILE OBVIOUSLY COMPETENT AND SKILLFUL, THE CAPT WAS NEW-IN-TYPE, AND HAD DEMONSTRATED A TENDENCY TO 'GET BEHIND' WHILE TRYING TO OPERATE THE FOREIGN FLT GUIDANCE SYSTEM. THIS WAS HIS FIRST LINE TRIP -- HE FLEW EVERY LEG. AS A RESULT, THE F/O WAS SPENDING MORE THAN USUAL ATTN TO MONITORING THE FLT PARAMETERS AND FLT GUIDANCE SYSTEM SETTINGS. CUES AND PSYCHOLOGICAL INPUTS. THE F/O HAD PRIMARY RESPONSIBILITY FOR ATC COM. COULD THE ACT OF DIALING THE TWR FREQ IN THE DUAL TUNING HEAD, COMBINED WITH THE NOT-TOO-USUAL DIALOGUE BETWEEN HIM AND APCH (ABOUT RWY NEEDS) HAVE INFLUENCED HIS PERCEPTION OF WHERE HE WAS IN THE COM CHAIN OF EVENTS? NORMALLY, PASSING THE OUTER MARKER, LOCATOR IS A CUE HERE -- BUT THOUGH THE LOCATOR WAS TUNED AND IDENTIFIED ON THIS APCH, NO ONE NOTICED THE OUTER. THE 'MARKER' SWITCH WAS NOT ON, SO NO AURAL SIGNAL WAS HEARD. THE BLUE LIGHT AND ADF NEEDLE SWING WENT UNNOTICED. TO WHAT EXTENT WAS THIS DUE TO EVERYONE'S PREOCCUPATION WITH MONITORING THE ACFT'S PHYSICAL FLT PARAMETERS?
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.