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|
Attributes | |
ACN | 163791 |
Time | |
Date | 199011 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : oak |
State Reference | CA |
Altitude | msl bound lower : 3000 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : oak |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport |
Flight Phase | descent other |
Route In Use | approach : visual enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : atp pilot : commercial |
Experience | flight time last 90 days : 200 flight time total : 3800 flight time type : 880 |
ASRS Report | 163791 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : far non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Aircraft was heading westbound for an anticipated visibility approach to oak. Cockpit crew indicated to the controller that we could navigation direct to the OM and asked for said clearance. Approach cleared us to 'maintain heading, descend to 4000',' and, 'proceed direct to the OM.' first officer was flying. Approach asked crew if field was in sight. Air crew mistook highway 580 going over the oakland foothills for the san mateo bridge. Utilizing what we thought was 'the bridge' as a visibility cue, we called the field in sight. Approach then cleared the aircraft to cross oak 6 DME at or below 2000', and cleared us for the visibility. As we got closer to the 'san mateo bridge,' we realized that this was not correct. We then made a second mistake, thinking highway 580 was actually the dumbarton bridge. Thinking us now south of the airport (first officer's radios were tuned to the ILS; i.e., no point), first officer turned aircraft 'toward' the field. At this point approach control asked air crew if they still had the field. We stated that we had lost the field, and approach then told us to maintain 3000' and turn left to 180 degrees. As we leveled off the GPWS sounded. Once we commenced our turn at 3000' we realized our error. We had mistaken highway 580 as it ran through the oakland hills for, first, the san mateo bridge, and then later, for the dumbarton bridge. The oak hills looked like the south.F. Bay. A contributing factors was that the crew had flown this same evolution 14 times prior to this episode in the previous 30 day period. Complacency was a major contributing factor, with the fact that this was the last flight of the air crew for the night, as well as for the month.
Original NASA ASRS Text
Title: ACR LGT CONTROLLED FLT TOWARD TERRAIN. GPWS ACTIVATED AS ACFT COMPLIED WITH APCH CTLR'S CLRNC TO CLIMB.
Narrative: ACFT WAS HDG WBND FOR AN ANTICIPATED VIS APCH TO OAK. COCKPIT CREW INDICATED TO THE CTLR THAT WE COULD NAV DIRECT TO THE OM AND ASKED FOR SAID CLRNC. APCH CLRED US TO 'MAINTAIN HDG, DSND TO 4000',' AND, 'PROCEED DIRECT TO THE OM.' F/O WAS FLYING. APCH ASKED CREW IF FIELD WAS IN SIGHT. AIR CREW MISTOOK HWY 580 GOING OVER THE OAKLAND FOOTHILLS FOR THE SAN MATEO BRIDGE. UTILIZING WHAT WE THOUGHT WAS 'THE BRIDGE' AS A VIS CUE, WE CALLED THE FIELD IN SIGHT. APCH THEN CLRED THE ACFT TO CROSS OAK 6 DME AT OR BELOW 2000', AND CLRED US FOR THE VIS. AS WE GOT CLOSER TO THE 'SAN MATEO BRIDGE,' WE REALIZED THAT THIS WAS NOT CORRECT. WE THEN MADE A SECOND MISTAKE, THINKING HWY 580 WAS ACTUALLY THE DUMBARTON BRIDGE. THINKING US NOW S OF THE ARPT (F/O'S RADIOS WERE TUNED TO THE ILS; I.E., NO POINT), F/O TURNED ACFT 'TOWARD' THE FIELD. AT THIS POINT APCH CTL ASKED AIR CREW IF THEY STILL HAD THE FIELD. WE STATED THAT WE HAD LOST THE FIELD, AND APCH THEN TOLD US TO MAINTAIN 3000' AND TURN LEFT TO 180 DEGS. AS WE LEVELED OFF THE GPWS SOUNDED. ONCE WE COMMENCED OUR TURN AT 3000' WE REALIZED OUR ERROR. WE HAD MISTAKEN HWY 580 AS IT RAN THROUGH THE OAKLAND HILLS FOR, FIRST, THE SAN MATEO BRIDGE, AND THEN LATER, FOR THE DUMBARTON BRIDGE. THE OAK HILLS LOOKED LIKE THE S.F. BAY. A CONTRIBUTING FACTORS WAS THAT THE CREW HAD FLOWN THIS SAME EVOLUTION 14 TIMES PRIOR TO THIS EPISODE IN THE PREVIOUS 30 DAY PERIOD. COMPLACENCY WAS A MAJOR CONTRIBUTING FACTOR, WITH THE FACT THAT THIS WAS THE LAST FLT OF THE AIR CREW FOR THE NIGHT, AS WELL AS FOR THE MONTH.
Data retrieved from NASA's ASRS site as of July 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.