37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 191942 |
Time | |
Date | 199110 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : orh |
State Reference | MA |
Altitude | agl bound lower : 0 agl bound upper : 2500 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : bdl tower : orh |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent : approach descent other landing other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 7800 flight time type : 1500 |
ASRS Report | 191942 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 5000 flight time type : 900 |
ASRS Report | 191945 |
Events | |
Anomaly | incursion : landing without clearance non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Cleared on approach to orh, we were advised by approach control (bdl, I think) to contact orh tower at the OM. Since orh has no radar, this would be the first direct contact with orh ATC. The first officer switched over to orh tower, but did not call, as we were not yet at the marker. As it turned out, due to several factors, contact was not made with tower until after landing. I spoke later with the tower controller. She advised me that since there was no traffic conflict, she chose not to initiate a call to us when she saw us on short final, as she knew how busy we would be negotiating a night landing on a short, wet runway with a gusty crosswind. I believe this was a wise move on her part. I also believe several contributing factors led to this mistake. First and foremost was fatigue. This approach and landing was my 7TH of the day, and due to previous delays I had been on duty in excess of 15 hours. I was very tired. Second was the WX. A cold front was passing through the area, and along with low ceilings and rain, there was moderate to severe turbulence all through the approach with a gusty crosswind at touchdown. Though the radio call should have been made by my first officer, he was monitoring my approach very closely due to the WX conditions and our tiredness. I should have reminded him to make the call, but was very busy and did not think of it. Perhaps the most direct causal factor was that of our habit patterns. Most of our operations are conducted at airports with approach control at the field. We get used to the situation of approach advising the flight to contact tower, and the assumption is to do it now. The frequency change and radio call are done at one time and as one function. At orh, due to an apparent gap in bdl's radar coverage, we were advised to call orh tower upon reaching the OM, i.e., 'later'. The frequency change was made but the radio call -- now a separate function -- got lost this time. I have thought a lot over the last few days about how this situation could have been avoided. Other than the obvious solutions of better situational awareness, etc, the only other suggestion I can offer is for the tower controller to make a 'wake-up' call if the aircraft has not called in by the time approach has advised that the aircraft should be over the marker. Supplemental information from acn 191945: WX was reported as 1200 overcast visibility 7 mi with light rain. Both captain and I thought tower closed at XA00. Bradley approach was vectoring us for approach at approximately 12 mi were told to contact the orh tower. Asked if still open and was advised it was for another 5 mins (closed at XA30). Contacted the tower and was asked to report marker. Prior to marker we encountered turbulence and wind shear, and moderate rain. When passing marker we noted its passage with cockpit callout, but did not notify tower. We continued approach breaking out at about 500 ft still in turbulence and landed. After landing tower controller said 'well I guess you made it...how about this...clear to land taxi to the gate.' then she closed orh tower. Factors that contributed are many: 1) had just taken a 2 hour delay in phl due to ATC congestion at the airport. 2) this was the last flight of what turned out to be a 15:04 hour duty day. 3) WX at orh was nowhere near VFR as reported. 4) our initial confusion thinking that we would need to treat our approach procedure as if this was uncontrolled field for radio calls (thought tower closed). Callback conversation with reporter revealed the following information: reporter participated in structured callback for runway incursion study. Thinks that when changing radio frequency they should call new ATC facility at that time so that ATC will know which frequency to find them on if needed. Since no other traffic was involved he believes tower controller was right in not calling them on short final. Says that better coordination between bdl and orh would have alerted orh tower to fact that aircraft was being changed to tower frequency.
Original NASA ASRS Text
Title: ACR LNDG WITHOUT CLRNC.
Narrative: CLRED ON APCH TO ORH, WE WERE ADVISED BY APCH CTL (BDL, I THINK) TO CONTACT ORH TWR AT THE OM. SINCE ORH HAS NO RADAR, THIS WOULD BE THE FIRST DIRECT CONTACT WITH ORH ATC. THE FO SWITCHED OVER TO ORH TWR, BUT DID NOT CALL, AS WE WERE NOT YET AT THE MARKER. AS IT TURNED OUT, DUE TO SEVERAL FACTORS, CONTACT WAS NOT MADE WITH TWR UNTIL AFTER LNDG. I SPOKE LATER WITH THE TWR CTLR. SHE ADVISED ME THAT SINCE THERE WAS NO TFC CONFLICT, SHE CHOSE NOT TO INITIATE A CALL TO US WHEN SHE SAW US ON SHORT FINAL, AS SHE KNEW HOW BUSY WE WOULD BE NEGOTIATING A NIGHT LNDG ON A SHORT, WET RWY WITH A GUSTY XWIND. I BELIEVE THIS WAS A WISE MOVE ON HER PART. I ALSO BELIEVE SEVERAL CONTRIBUTING FACTORS LED TO THIS MISTAKE. FIRST AND FOREMOST WAS FATIGUE. THIS APCH AND LNDG WAS MY 7TH OF THE DAY, AND DUE TO PREVIOUS DELAYS I HAD BEEN ON DUTY IN EXCESS OF 15 HRS. I WAS VERY TIRED. SECOND WAS THE WX. A COLD FRONT WAS PASSING THROUGH THE AREA, AND ALONG WITH LOW CEILINGS AND RAIN, THERE WAS MODERATE TO SEVERE TURB ALL THROUGH THE APCH WITH A GUSTY XWIND AT TOUCHDOWN. THOUGH THE RADIO CALL SHOULD HAVE BEEN MADE BY MY FO, HE WAS MONITORING MY APCH VERY CLOSELY DUE TO THE WX CONDITIONS AND OUR TIREDNESS. I SHOULD HAVE REMINDED HIM TO MAKE THE CALL, BUT WAS VERY BUSY AND DID NOT THINK OF IT. PERHAPS THE MOST DIRECT CAUSAL FACTOR WAS THAT OF OUR HABIT PATTERNS. MOST OF OUR OPS ARE CONDUCTED AT ARPTS WITH APCH CTL AT THE FIELD. WE GET USED TO THE SITUATION OF APCH ADVISING THE FLT TO CONTACT TWR, AND THE ASSUMPTION IS TO DO IT NOW. THE FREQ CHANGE AND RADIO CALL ARE DONE AT ONE TIME AND AS ONE FUNCTION. AT ORH, DUE TO AN APPARENT GAP IN BDL'S RADAR COVERAGE, WE WERE ADVISED TO CALL ORH TWR UPON REACHING THE OM, I.E., 'LATER'. THE FREQ CHANGE WAS MADE BUT THE RADIO CALL -- NOW A SEPARATE FUNCTION -- GOT LOST THIS TIME. I HAVE THOUGHT A LOT OVER THE LAST FEW DAYS ABOUT HOW THIS SITUATION COULD HAVE BEEN AVOIDED. OTHER THAN THE OBVIOUS SOLUTIONS OF BETTER SITUATIONAL AWARENESS, ETC, THE ONLY OTHER SUGGESTION I CAN OFFER IS FOR THE TWR CTLR TO MAKE A 'WAKE-UP' CALL IF THE ACFT HAS NOT CALLED IN BY THE TIME APCH HAS ADVISED THAT THE ACFT SHOULD BE OVER THE MARKER. SUPPLEMENTAL INFO FROM ACN 191945: WX WAS RPTED AS 1200 OVCST VISIBILITY 7 MI WITH LIGHT RAIN. BOTH CAPT AND I THOUGHT TWR CLOSED AT XA00. BRADLEY APCH WAS VECTORING US FOR APCH AT APPROX 12 MI WERE TOLD TO CONTACT THE ORH TWR. ASKED IF STILL OPEN AND WAS ADVISED IT WAS FOR ANOTHER 5 MINS (CLOSED AT XA30). CONTACTED THE TWR AND WAS ASKED TO RPT MARKER. PRIOR TO MARKER WE ENCOUNTERED TURB AND WIND SHEAR, AND MODERATE RAIN. WHEN PASSING MARKER WE NOTED ITS PASSAGE WITH COCKPIT CALLOUT, BUT DID NOT NOTIFY TWR. WE CONTINUED APCH BREAKING OUT AT ABOUT 500 FT STILL IN TURB AND LANDED. AFTER LNDG TWR CTLR SAID 'WELL I GUESS YOU MADE IT...HOW ABOUT THIS...CLR TO LAND TAXI TO THE GATE.' THEN SHE CLOSED ORH TWR. FACTORS THAT CONTRIBUTED ARE MANY: 1) HAD JUST TAKEN A 2 HR DELAY IN PHL DUE TO ATC CONGESTION AT THE ARPT. 2) THIS WAS THE LAST FLT OF WHAT TURNED OUT TO BE A 15:04 HR DUTY DAY. 3) WX AT ORH WAS NOWHERE NEAR VFR AS RPTED. 4) OUR INITIAL CONFUSION THINKING THAT WE WOULD NEED TO TREAT OUR APCH PROC AS IF THIS WAS UNCTLED FIELD FOR RADIO CALLS (THOUGHT TWR CLOSED). CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR PARTICIPATED IN STRUCTURED CALLBACK FOR RWY INCURSION STUDY. THINKS THAT WHEN CHANGING RADIO FREQ THEY SHOULD CALL NEW ATC FACILITY AT THAT TIME SO THAT ATC WILL KNOW WHICH FREQ TO FIND THEM ON IF NEEDED. SINCE NO OTHER TFC WAS INVOLVED HE BELIEVES TWR CTLR WAS RIGHT IN NOT CALLING THEM ON SHORT FINAL. SAYS THAT BETTER COORD BTWN BDL AND ORH WOULD HAVE ALERTED ORH TWR TO FACT THAT ACFT WAS BEING CHANGED TO TWR FREQ.
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.