37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 201029 |
Time | |
Date | 199202 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : sfo |
State Reference | CA |
Altitude | agl bound lower : 4000 agl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : oak tower : sfo tracon : den |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | descent : approach |
Route In Use | approach : straight in approach : visual |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | descent : approach |
Route In Use | approach : visual approach : straight in |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 13000 flight time type : 900 |
ASRS Report | 200970 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : undershoot conflict : airborne less severe non adherence : clearance other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | flight crew : took evasive action flight crew : returned to intended course or assigned course |
Consequence | Other |
Miss Distance | horizontal : 3000 vertical : 500 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Inter Facility Coordination Failure Pilot Deviation |
Narrative:
Air carrier X had planned an ILS to runway 19L and had armed the localizer for capture. About 1-2 mins before TA we were reclred for visual to runway 19R. Both of us failed to remember to deselect the runway 19L localizer and proceeded to line up for runway 19L. Shortly thereafter the TA/RA sounded and we immediately asked for confirmation on runway to which we were cleared. Tower controller confirmed runway 19R and indicated we had traffic behind us and below. We had pulled up on response to the RA and then pulled over to align with runway 19R. Supplemental information from acn 200970. While on intercept heading for ILS runway 19L, TRACON reclred us for visual runway 19R. I misinterpreted clearance for visual runway 19L and continued to intercept and fly localizer. While descending 1500 ft above GS, we got TCASII TA followed by RA. I initiated climb then level off while captain advised tower and asked for confirmation of runway. We subsequently side stepped to 19R and completed normal approach and landing. Tower advised traffic for 19L that we were above and ahead. They reported us in sight 'high.' it is easy to overlook a subtle clearance change in the busy approach environment '1000 ft' call out is supposed to break this chain, but that would have been to late under these circumstances. I will develop a personal habit to resolve this ambiguity at localizer/centerline intercept.
Original NASA ASRS Text
Title: ACR X APCH TO WRONG RWY RECEIVED TCASII TA RA CLB EVASIVE ACTION TAKEN HAD CONFLICT WITH ACFT Y.
Narrative: ACR X HAD PLANNED AN ILS TO RWY 19L AND HAD ARMED THE LOC FOR CAPTURE. ABOUT 1-2 MINS BEFORE TA WE WERE RECLRED FOR VISUAL TO RWY 19R. BOTH OF US FAILED TO REMEMBER TO DESELECT THE RWY 19L LOC AND PROCEEDED TO LINE UP FOR RWY 19L. SHORTLY THEREAFTER THE TA/RA SOUNDED AND WE IMMEDIATELY ASKED FOR CONFIRMATION ON RWY TO WHICH WE WERE CLRED. TWR CTLR CONFIRMED RWY 19R AND INDICATED WE HAD TFC BEHIND US AND BELOW. WE HAD PULLED UP ON RESPONSE TO THE RA AND THEN PULLED OVER TO ALIGN WITH RWY 19R. SUPPLEMENTAL INFO FROM ACN 200970. WHILE ON INTERCEPT HDG FOR ILS RWY 19L, TRACON RECLRED US FOR VISUAL RWY 19R. I MISINTERPRETED CLRNC FOR VISUAL RWY 19L AND CONTINUED TO INTERCEPT AND FLY LOC. WHILE DSNDING 1500 FT ABOVE GS, WE GOT TCASII TA FOLLOWED BY RA. I INITIATED CLB THEN LEVEL OFF WHILE CAPT ADVISED TWR AND ASKED FOR CONFIRMATION OF RWY. WE SUBSEQUENTLY SIDE STEPPED TO 19R AND COMPLETED NORMAL APCH AND LNDG. TWR ADVISED TFC FOR 19L THAT WE WERE ABOVE AND AHEAD. THEY RPTED US IN SIGHT 'HIGH.' IT IS EASY TO OVERLOOK A SUBTLE CLRNC CHANGE IN THE BUSY APCH ENVIRONMENT '1000 FT' CALL OUT IS SUPPOSED TO BREAK THIS CHAIN, BUT THAT WOULD HAVE BEEN TO LATE UNDER THESE CIRCUMSTANCES. I WILL DEVELOP A PERSONAL HABIT TO RESOLVE THIS AMBIGUITY AT LOC/CTRLINE INTERCEPT.
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.