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|
Attributes | |
ACN | 1318293 |
Time | |
Date | 201512 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.TRACON |
State Reference | US |
Aircraft 1 | |
Make Model Name | Citation Excel (C560XL) |
Operating Under FAR Part | Part 91 |
Flight Phase | Landing |
Route In Use | Visual Approach |
Flight Plan | IFR |
Person 1 | |
Function | First Officer Pilot Not Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) Flight Crew Instrument Flight Crew Multiengine Flight Crew Flight Instructor |
Experience | Flight Crew Last 90 Days 23 Flight Crew Total 7379 Flight Crew Type 651 |
Events | |
Anomaly | Deviation - Procedural Clearance Deviation - Procedural Published Material / Policy Deviation - Track / Heading All Types Ground Incursion Runway |
Narrative:
We setup for a RNAV approach; arriving from the north-north west. During our descent we broke out of the overcast above 3;000 feet. I looked to my right; saw an airport with a runway orientated in the correct direction and expected length. I incorrectly reported the airport (the wrong one)in sight. The PIC said he was going to do a visual approach and asked me to cancel IFR. Communications with approach control took several tries to get confirmation of cancellation. I then returned to my working on checklist items. I made a comment to the captain that we appeared to be a little high. He called for gear and flaps. I believe he also extended the speed brakes. I was working on checklist items and radio calls and I failed to monitor the aircraft's position on the multi function display (mfd) in relation to the line drawn from the final approach fix to our intended destination. I also remember making several attempt to turn on the PAPI with no luck. I completed all checklist items on short final and then focused my attention on the airspeed indicator. I failed to notice on final our mfd would have showed us 2 miles right of final and 4 miles short of the intended airport. We landed. Pure luck provided us with a runway that was long enough (4;000 feet) and the slope was in the correct direction to safely stop. This could of easily turned into an accident.this incident was caused by me and the pilot flying's (PF) human errors. When I misidentified the airport I started the ball rolling towards this incident. Multiple clues were missed that should have prevented this incident. Navigation displays were present that showed us off course. We suddenly found ourselves above the desired approach profile with no apparent cause. The PAPI would not illuminate. I was time compressed to get the checklist done for no apparent reason. There are several external/latent factors that could have contributed to the incident.-fatigue- this was the 6th leg of a 7 leg day (eastern time). The day began by awakening at xa:00 (body clock) xb:00 local for a xc:00 show for a xd:00 takeoff. The day before consisted of a xa:30 awakening for a xd:00 departure (central time) with a 12 hour duty day. I gauged my fatigue level at the time before the incident as tired but not exhausted.-sops-our company SOP's contain no standard callouts. I believe standard call out would have reduced workload and increased our awareness of an unusual situation in development. (Time compressed/rushed calls cause red flags with well developed SOP's)-checklists-besides lack of standard callouts; our checklists contain redundant/non safety related items. Our approach and landing checklist checks flap position 4 times form the final approach fix inboard (the aircraft also has an emergency ground proximity warning system (egpws) that warns of incorrect flap position). This diverts attention from the task at hand. -Safety culture-since the incident has happened I have learned of 5 other occasions where our company came close to landing at the wrong airport. None of these incidents were reported in the safety management system. Had they been reported or we had heeded the NTSB warnings after other operators landed at incorrect airports we may have been able to correct our checklist and standard call out problems. Active preventive or predictive risk analysis may have trapped these human errors.
Original NASA ASRS Text
Title: A corporate pilot reported the circumstances that led to landing at the incorrect airport after cancellation of instrument flight plan.
Narrative: We setup for a RNAV approach; arriving from the North-north west. During our descent we broke out of the overcast above 3;000 feet. I looked to my right; saw an airport with a runway orientated in the correct direction and expected length. I incorrectly reported the airport (the wrong one)in sight. The PIC said he was going to do a visual approach and asked me to cancel IFR. Communications with Approach control took several tries to get confirmation of cancellation. I then returned to my working on checklist items. I made a comment to the Captain that we appeared to be a little high. He called for gear and flaps. I believe he also extended the speed brakes. I was working on checklist items and radio calls and I failed to monitor the aircraft's position on the Multi Function Display (MFD) in relation to the line drawn from the final approach fix to our intended destination. I also remember making several attempt to turn on the PAPI with no luck. I completed all checklist items on short final and then focused my attention on the airspeed indicator. I failed to notice on final our MFD would have showed us 2 miles right of final and 4 miles short of the intended airport. We landed. Pure luck provided us with a runway that was long enough (4;000 feet) and the slope was in the correct direction to safely stop. This could of easily turned into an accident.This incident was caused by me and the Pilot Flying's (PF) human errors. When I misidentified the airport I started the ball rolling towards this incident. Multiple clues were missed that should have prevented this incident. Navigation displays were present that showed us off course. We suddenly found ourselves above the desired approach profile with no apparent cause. The PAPI would not illuminate. I was time compressed to get the checklist done for no apparent reason. There are several external/latent factors that could have contributed to the incident.-Fatigue- This was the 6th leg of a 7 leg day (Eastern Time). The day began by awakening at XA:00 (Body Clock) XB:00 local for a XC:00 show for a XD:00 takeoff. The day before consisted of a XA:30 awakening for a XD:00 departure (Central Time) with a 12 hour duty day. I gauged my fatigue level at the time before the incident as tired but not exhausted.-SOPs-Our company SOP's contain no standard callouts. I believe standard call out would have reduced workload and increased our awareness of an unusual situation in development. (Time compressed/rushed calls cause red flags with well developed SOP's)-Checklists-Besides lack of standard callouts; our checklists contain redundant/non safety related items. Our approach and landing checklist checks flap position 4 times form the final approach fix inboard (The aircraft also has an Emergency Ground Proximity Warning System (EGPWS) that warns of incorrect flap position). This diverts attention from the task at hand. -Safety Culture-Since the incident has happened I have learned of 5 other occasions where our company came close to landing at the wrong airport. None of these incidents were reported in the Safety Management System. Had they been reported or we had heeded the NTSB warnings after other operators landed at incorrect airports we may have been able to correct our checklist and standard call out problems. Active preventive or predictive risk analysis may have trapped these human errors.
Data retrieved from NASA's ASRS site 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.