Narrative:

Writing has always been a challenge for me but that isn't why this report is so late. I find writing a report particularly hard. While it appears to be a great idea and I whole heartedly endorse it; it remains very difficult to confess a failure in performance. I wonder if there is a way to make the report more inviting and less intimidating. Even if the only thing that can be done is for all who read these; keep the fact that confession is a very difficult thing to do and to exercise the awareness of that particular human component. What follows is my confession. It seems one mistake often leads to others. That certainly happened this last flight of a four-day trip. I was blessed with a good crew. Two flight attendants that are both competent and pleasant to work with. My first officer has been with the company for a year and is everything an airline could hope for. His work ethic; knowledge; communication skills and relationship with the aircraft are top notch. He is more than a pilot; he's a student of aviation. Still; we managed to forget to go from flaps 30 to flaps 45 on final approach and once the error was discovered; we failed to go around. We landed without a problem but that doesn't excuse such mistakes. I was alerted to the problem by the GPWS saying; 'too low; terrain. Too low; terrain.' this didn't make sense to either one of us since we had the runway in sight at 12 o'clock with the PAPI showing two white and two red. The localizer and glide slope also indicated that everything was fine. I wish it had said; 'too low; flaps.' that was why it went off and that would have pointed our minds in the direction of the actual problem rather than worrying about running into something or GPS problems. We were at the threshold and very close to the flare before I figured out we had flaps 30 and announced it. My first officer said; 'flaps 45' and I selected it. I did consider a go around but opted to continue the landing since we were so close to the flare on a runway that is very long. I don't wish to rationalize bad behavior as that's a slippery slope to building bad habits. But that decision to land might have been preferable to going around. As I said; we were very close to landing. A go around at that moment might have involved greater risk not because we were so low; we train to go around at the last second like that in the simulator. Rather; I think the earlier mistake indicated a new found ability to make errors. I can't speak for my first officer but I was starting to feel a little run down and I think he might have been too. I'll return to this later but first I'd like to look at how we got into this mess in the first place. I'd gotten the ATIS and we had briefed a visual backed up by the ILS to a different runway when we were told to descend via the STAR to that runway. I'd mentioned during the brief that it was quiet and that we might be offered a longer runway. My first officer agreed to accept that if it was offered. It had been rainy for a few days but the air was clear and clean as we descended. ATIS advised a very light wind out of the southeast. Aloft it was a different story; the wind was quite strong out of the south and the autopilot had to hold a wind correction of 5 to 10 degrees to track the course. As hoped for; we were offered the longer runway. We were cleared direct to the IAF and instructed to cross at or above 4000 and to maintain 210 knots to a 10 mile final. We were already doing 210 so my first officer selected 4000 while I put the runway in the FMS and selected direct IAF. As we approached the IAF he selected heading sync; heading mode; green needles and approach mode. I think the combination of a very shallow intercept angle and a decreasing crosswind as we descended caused us to parallel the approach course without LOC2 becoming active. I told him you need to use the heading bug to make a small left turn to get on the localizer. He did and LOC2 became active. Unfortunately; we were slightly above the glide slope. My first officer started adescent at a rate between 1500 and 2000 feet per minute to catch the glide slope from above. That can take a while as the glide slope is 'falling away' from the plane as you descend to catch it. He called for gear down to get ready to land and presumably to increase drag. We were going too fast to select flaps 30 and he didn't call for that. I'm not certain but I think he had the thrust levers about 1/2 inch to 1 inch above flight idle. I believe that's a common error when trying to go down and slow down. We had been instructed to maintain 170 knots or greater to a 5 mile final which took care of itself in our descent to the glide slope. As we caught the glide slope we slowed and flaps 30 was called for and selected. During all this we were handed off to tower and cleared to land. I don't know how we skipped the flaps 45 on the before landing checklist callout or the stable at 1000 ft but we did. We had a lot going on in a short period of time and skipped the things we've done every flight for many years.there are a number of things that lead to this event. I can't speak for my first officer but I think we were both running a little low on energy. Combining that with the instruction to 'keep your speed up' and the runway change; created the opportunity for the unthinkable. It's been very difficult for me to confess this in this very public forum. It feels like I am opening myself up to some severe repercussions. I do; however; have a few ideas to reduce the risk of this happening in the future. First; calling for the gear without calling for flaps 30 makes the call for flaps 30 in the near future feel like you've accomplished flaps 45. That is the action that normally happens a short time after calling for gear down. Perhaps a policy of saying; 'gear down; flaps 30; bug 165' (as if it were one word) only when the speed allows the extension of flaps 30 would help. We use the gear to slow down sometimes and I hesitate to recommend taking that tool out of the toolkit but it should be considered. Second; I think we've gotten away from making standard callouts to get configured. This might be a result of operating in the real world. ATC often asks pilots to keep the speed up. We were instructed to maintain 210 to a 10 mile final and 170 to a 5 mile final. While this can be an engaging challenge when you're operating at 100%; if anything goes even slightly wrong like getting above the glide slope; or if it's late at night and your energy level is starting to wind down; meeting the challenge to keep the speed up can lead to trouble. I also see a lot of first officer's bugging 165 while doing 190 to 200; then slowing to flaps 30 speed and calling for flaps 30. This might be a result of bugging vt when flaps 20 is selected. Perhaps bugging 180 at the extension of flaps 20 would help. 180 mirrors the 'flaps 30; bug 165' call in that it's 5 knots below the next flap speed and; it is a safe change to make since 180 is greater than the minimum maneuvering speed for the maximum landing weight at flaps 20. Ultimately; rededicating ourselves to sticking to the 'script' spelled out in the cfm can only help. Third; fatigue is a tough problem. Sometimes you know you're getting tired but often fatigue sneaks up on you with little warning. I think the FAA has given us good rules to keep fatigue from being a problem and that the airline has implemented policies and programs that go above and beyond the regulations. Still; it sneaks into the cockpit occasionally and when it does; it seems to be at busy times. I wouldn't say that I was fatigued when this happened nor when we shut down the aircraft and went home. But; it was late in the day and the end of a four day trip. I don't know how to prevent this but continuing efforts on this front will be important.

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Original NASA ASRS Text

Title: CRJ-900 Captain reported receiving a GPWS warning for improper flap configuration on final approach. The crew selected the correct flap selection and landed safely.

Narrative: Writing has always been a challenge for me but that isn't why this report is so late. I find writing a report particularly hard. While it appears to be a great idea and I whole heartedly endorse it; it remains very difficult to confess a failure in performance. I wonder if there is a way to make the report more inviting and less intimidating. Even if the only thing that can be done is for all who read these; keep the fact that confession is a very difficult thing to do and to exercise the awareness of that particular human component. What follows is my confession. It seems one mistake often leads to others. That certainly happened this last flight of a four-day trip. I was blessed with a good crew. Two flight attendants that are both competent and pleasant to work with. My first officer has been with the company for a year and is everything an airline could hope for. His work ethic; knowledge; communication skills and relationship with the aircraft are top notch. He is more than a pilot; he's a student of aviation. Still; we managed to forget to go from flaps 30 to flaps 45 on final approach and once the error was discovered; we failed to go around. We landed without a problem but that doesn't excuse such mistakes. I was alerted to the problem by the GPWS saying; 'Too low; terrain. Too low; terrain.' This didn't make sense to either one of us since we had the runway in sight at 12 o'clock with the PAPI showing two white and two red. The localizer and glide slope also indicated that everything was fine. I wish it had said; 'Too low; flaps.' That was why it went off and that would have pointed our minds in the direction of the actual problem rather than worrying about running into something or GPS problems. We were at the threshold and very close to the flare before I figured out we had flaps 30 and announced it. My FO said; 'Flaps 45' and I selected it. I did consider a go around but opted to continue the landing since we were so close to the flare on a runway that is very long. I don't wish to rationalize bad behavior as that's a slippery slope to building bad habits. But that decision to land might have been preferable to going around. As I said; we were very close to landing. A go around at that moment might have involved greater risk not because we were so low; we train to go around at the last second like that in the simulator. Rather; I think the earlier mistake indicated a new found ability to make errors. I can't speak for my FO but I was starting to feel a little run down and I think he might have been too. I'll return to this later but first I'd like to look at how we got into this mess in the first place. I'd gotten the ATIS and we had briefed a visual backed up by the ILS to a different runway when we were told to descend via the STAR to that runway. I'd mentioned during the brief that it was quiet and that we might be offered a longer runway. My FO agreed to accept that if it was offered. It had been rainy for a few days but the air was clear and clean as we descended. ATIS advised a very light wind out of the southeast. Aloft it was a different story; the wind was quite strong out of the south and the autopilot had to hold a wind correction of 5 to 10 degrees to track the course. As hoped for; we were offered the longer runway. We were cleared direct to the IAF and instructed to cross at or above 4000 and to maintain 210 knots to a 10 mile final. We were already doing 210 so my FO selected 4000 while I put the runway in the FMS and selected direct IAF. As we approached the IAF he selected heading sync; heading mode; green needles and approach mode. I think the combination of a very shallow intercept angle and a decreasing crosswind as we descended caused us to parallel the approach course without LOC2 becoming active. I told him you need to use the heading bug to make a small left turn to get on the localizer. He did and LOC2 became active. Unfortunately; we were slightly above the glide slope. My FO started adescent at a rate between 1500 and 2000 feet per minute to catch the glide slope from above. That can take a while as the glide slope is 'falling away' from the plane as you descend to catch it. He called for gear down to get ready to land and presumably to increase drag. We were going too fast to select flaps 30 and he didn't call for that. I'm not certain but I think he had the thrust levers about 1/2 inch to 1 inch above flight idle. I believe that's a common error when trying to go down and slow down. We had been instructed to maintain 170 knots or greater to a 5 mile final which took care of itself in our descent to the glide slope. As we caught the glide slope we slowed and flaps 30 was called for and selected. During all this we were handed off to Tower and cleared to land. I don't know how we skipped the flaps 45 on the Before Landing Checklist callout or the Stable at 1000 ft but we did. We had a lot going on in a short period of time and skipped the things we've done every flight for many years.There are a number of things that lead to this event. I can't speak for my FO but I think we were both running a little low on energy. Combining that with the instruction to 'keep your speed up' and the runway change; created the opportunity for the unthinkable. It's been very difficult for me to confess this in this very public forum. It feels like I am opening myself up to some severe repercussions. I do; however; have a few ideas to reduce the risk of this happening in the future. First; calling for the gear without calling for flaps 30 makes the call for flaps 30 in the near future feel like you've accomplished flaps 45. That is the action that normally happens a short time after calling for gear down. Perhaps a policy of saying; 'Gear down; flaps 30; bug 165' (as if it were one word) only when the speed allows the extension of flaps 30 would help. We use the gear to slow down sometimes and I hesitate to recommend taking that tool out of the toolkit but it should be considered. Second; I think we've gotten away from making standard callouts to get configured. This might be a result of operating in the real world. ATC often asks pilots to keep the speed up. We were instructed to maintain 210 to a 10 mile final and 170 to a 5 mile final. While this can be an engaging challenge when you're operating at 100%; if anything goes even slightly wrong like getting above the glide slope; or if it's late at night and your energy level is starting to wind down; meeting the challenge to keep the speed up can lead to trouble. I also see a lot of FO's bugging 165 while doing 190 to 200; then slowing to flaps 30 speed and calling for flaps 30. This might be a result of bugging Vt when flaps 20 is selected. Perhaps bugging 180 at the extension of flaps 20 would help. 180 mirrors the 'flaps 30; bug 165' call in that it's 5 knots below the next flap speed and; it is a safe change to make since 180 is greater than the minimum maneuvering speed for the maximum landing weight at flaps 20. Ultimately; rededicating ourselves to sticking to the 'script' spelled out in the CFM can only help. Third; fatigue is a tough problem. Sometimes you know you're getting tired but often fatigue sneaks up on you with little warning. I think the FAA has given us good rules to keep fatigue from being a problem and that the airline has implemented policies and programs that go above and beyond the regulations. Still; it sneaks into the cockpit occasionally and when it does; it seems to be at busy times. I wouldn't say that I was fatigued when this happened nor when we shut down the aircraft and went home. But; it was late in the day and the end of a four day trip. I don't know how to prevent this but continuing efforts on this front will be important.

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.