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|
Attributes | |
ACN | 197525 |
Time | |
Date | 199112 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : pit |
State Reference | PA |
Altitude | msl bound lower : 5000 msl bound upper : 5000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : pit |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent : approach descent other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 160 flight time total : 8500 flight time type : 6300 |
ASRS Report | 197525 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 10000 flight time type : 3000 |
ASRS Report | 197867 |
Events | |
Anomaly | conflict : airborne less severe non adherence : clearance non adherence : required legal separation other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera |
Resolutory Action | other |
Consequence | Other |
Miss Distance | horizontal : 6000 vertical : 900 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On approach to pittsburgh on air carrier X from grr, I copied that we were being vectored for approach to 28L at pit. I briefed the 28L approach and dialed in ILS frequency 108.9. About 12 mi out on right base to final we were given a vector to intercept final and were cleared for the approach to runway 28R. I did not hear the runway assignment change and believed we were still making an approach to runway 28L. The copilot was still tuned to the VOR and was unaware that I was lining up for the wrong runway. As I intercepted the localizer I was descending through 5200 ft and the TCASII TA went off followed by an RA to stop descent. At about the same time approach control told us to turn right, maintain 5000 ft and check ILS frequency for the right runway 28R. Realizing my error I leveled at 5000 ft, turned right, and put the correct ILS frequency in. I then looked out and saw air carrier Y below us on approach to 28L. The rest of the approach was uneventful. This traffic conflict would have been avoided if I had been more alert to the runway assignment. If my copilot had backed up the approach by selecting ILS on his side with the correct ILS frequency or if he had checked the frequency that I had selected. This could have resulted in a dangerous near miss/collision. Fortunately the TCASII worked as advertised and approach control detected the error. Supplemental information from acn 197867: flight conditions on top are VMC. Last leg of a 3 day trip. Vectors being given for ILS to pit runway 28R. Localizer frequency 111.7. Captain briefs approach to 28L (108.7) and I did not catch the error in his briefing as I was busy with other duties on the radio with maintenance. The briefing was given when we first heard ATIS about 40 mi out at 10000+ ft. During the initial part of approach captain on localizer 108.7 and I am on VOR 112.0 for DME. Approximately 10 mi out our TCASII computer gives a TA and we note on radar that an aircraft is near but 1000 ft below. We immediately level off at 5000 ft to check for visual contact when ATC called and alerted us that we were on approach to the left side (28L) when we should be on the right side (28R). We changed to 111.7 and continued on into pit. ATC did not warn of any traffic in area that we were in conflict with nor did they request evasive action. We saw no other aircraft until established on 28R localizer. Another aircraft was on approach to 28L but well clear. I believe this incident would not have happened if human factors and workload had been better managed. Attentiveness to briefings on approach, especially where parallel approachs are being conducted, is most important. Briefing should be conducted by PF when workload of PNF permits his full attention. Once again heavy workload in a high traffic environment was a factor. In this case 108.7 and 111.7, plus 28L/28R could be missed by a listener if he does not pay attention to what is being said. Actively listen to prevent a 'hearback' problem. Confirm that the instructions have been received and understood. Don't have your mind set on what you expect to hear.
Original NASA ASRS Text
Title: ACR X MADE WRONG RWY APCH HAD LTSS FROM ACR Y. PLTDEV. TCASII TA RA EVASIVE ACTION TAKEN.
Narrative: ON APCH TO PITTSBURGH ON ACR X FROM GRR, I COPIED THAT WE WERE BEING VECTORED FOR APCH TO 28L AT PIT. I BRIEFED THE 28L APCH AND DIALED IN ILS FREQ 108.9. ABOUT 12 MI OUT ON R BASE TO FINAL WE WERE GIVEN A VECTOR TO INTERCEPT FINAL AND WERE CLRED FOR THE APCH TO RWY 28R. I DID NOT HEAR THE RWY ASSIGNMENT CHANGE AND BELIEVED WE WERE STILL MAKING AN APCH TO RWY 28L. THE COPLT WAS STILL TUNED TO THE VOR AND WAS UNAWARE THAT I WAS LINING UP FOR THE WRONG RWY. AS I INTERCEPTED THE LOC I WAS DSNDING THROUGH 5200 FT AND THE TCASII TA WENT OFF FOLLOWED BY AN RA TO STOP DSCNT. AT ABOUT THE SAME TIME APCH CTL TOLD US TO TURN R, MAINTAIN 5000 FT AND CHK ILS FREQ FOR THE RIGHT RWY 28R. REALIZING MY ERROR I LEVELED AT 5000 FT, TURNED R, AND PUT THE CORRECT ILS FREQ IN. I THEN LOOKED OUT AND SAW ACR Y BELOW US ON APCH TO 28L. THE REST OF THE APCH WAS UNEVENTFUL. THIS TFC CONFLICT WOULD HAVE BEEN AVOIDED IF I HAD BEEN MORE ALERT TO THE RWY ASSIGNMENT. IF MY COPLT HAD BACKED UP THE APCH BY SELECTING ILS ON HIS SIDE WITH THE CORRECT ILS FREQ OR IF HE HAD CHKED THE FREQ THAT I HAD SELECTED. THIS COULD HAVE RESULTED IN A DANGEROUS NEAR MISS/COLLISION. FORTUNATELY THE TCASII WORKED AS ADVERTISED AND APCH CTL DETECTED THE ERROR. SUPPLEMENTAL INFO FROM ACN 197867: FLT CONDITIONS ON TOP ARE VMC. LAST LEG OF A 3 DAY TRIP. VECTORS BEING GIVEN FOR ILS TO PIT RWY 28R. LOC FREQ 111.7. CAPT BRIEFS APCH TO 28L (108.7) AND I DID NOT CATCH THE ERROR IN HIS BRIEFING AS I WAS BUSY WITH OTHER DUTIES ON THE RADIO WITH MAINT. THE BRIEFING WAS GIVEN WHEN WE FIRST HEARD ATIS ABOUT 40 MI OUT AT 10000+ FT. DURING THE INITIAL PART OF APCH CAPT ON LOC 108.7 AND I AM ON VOR 112.0 FOR DME. APPROX 10 MI OUT OUR TCASII COMPUTER GIVES A TA AND WE NOTE ON RADAR THAT AN ACFT IS NEAR BUT 1000 FT BELOW. WE IMMEDIATELY LEVEL OFF AT 5000 FT TO CHK FOR VISUAL CONTACT WHEN ATC CALLED AND ALERTED US THAT WE WERE ON APCH TO THE L SIDE (28L) WHEN WE SHOULD BE ON THE R SIDE (28R). WE CHANGED TO 111.7 AND CONTINUED ON INTO PIT. ATC DID NOT WARN OF ANY TFC IN AREA THAT WE WERE IN CONFLICT WITH NOR DID THEY REQUEST EVASIVE ACTION. WE SAW NO OTHER ACFT UNTIL ESTABLISHED ON 28R LOC. ANOTHER ACFT WAS ON APCH TO 28L BUT WELL CLR. I BELIEVE THIS INCIDENT WOULD NOT HAVE HAPPENED IF HUMAN FACTORS AND WORKLOAD HAD BEEN BETTER MANAGED. ATTENTIVENESS TO BRIEFINGS ON APCH, ESPECIALLY WHERE PARALLEL APCHS ARE BEING CONDUCTED, IS MOST IMPORTANT. BRIEFING SHOULD BE CONDUCTED BY PF WHEN WORKLOAD OF PNF PERMITS HIS FULL ATTN. ONCE AGAIN HVY WORKLOAD IN A HIGH TFC ENVIRONMENT WAS A FACTOR. IN THIS CASE 108.7 AND 111.7, PLUS 28L/28R COULD BE MISSED BY A LISTENER IF HE DOES NOT PAY ATTN TO WHAT IS BEING SAID. ACTIVELY LISTEN TO PREVENT A 'HEARBACK' PROBLEM. CONFIRM THAT THE INSTRUCTIONS HAVE BEEN RECEIVED AND UNDERSTOOD. DON'T HAVE YOUR MIND SET ON WHAT YOU EXPECT TO HEAR.
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.