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Attributes | |
ACN | 308050 |
Time | |
Date | 199506 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : adq |
State Reference | AK |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | IMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | artcc : zny |
Operator | other |
Make Model Name | Hercules (C-130) |
Operating Under FAR Part | other : other |
Flight Phase | landing other |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : military |
Function | flight crew : captain oversight : pic |
Qualification | pilot : military |
Experience | flight time last 90 days : 70 flight time total : 7000 flight time type : 3900 |
ASRS Report | 308050 |
Person 2 | |
Affiliation | government : military |
Function | flight crew : first officer |
Qualification | pilot : military |
Events | |
Anomaly | incursion : landing without clearance non adherence : published procedure non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
WX on departure from adq was reported VFR, but ceiling and visibility in the departure and approach corridor was marginal -- approximately 1000 ft and 2 mi. Flight to eilson was uneventful. While transferring the helicopter crews at eilson with engines running, I swapped seats with the copilot so that I could fly the return leg from the left seat. Departure from eilson and cruise back to vicinity of kodiak was uneventful. About 5 NM north of the arc for the ILS/DME 2 special approach to adq, zan advised that we were not yet clear for the approach because kodiak tower was handling a special VFR arrival. Almost immediately after turning on the arc, though, we were cleared for the approach and began descent and confign. Because I plan to retire from the service in the near future to pursue an airline career, I'm trying to reshape my habit patterns to civilian operating practices, and so I briefed the crew that we would put the gear down and complete the pre-landing checklist at the final approach fix. Normal center of gravity practice is to have all checklists completed in the vicinity of the approach gate. The copilot (PNF) called tower when we departed the arc. Tower asked him to report the final approach fix so that the lights could be on full, and the copilot acknowledged. At final approach fix I called for gear down and checklist. I had my hands full flying the ILS because of wind on final on the tail at 25 KTS and a 10 KT crosswind at the field. We broke out at minimums of 300 ft ceiling, visibility approximately 1 1/2 SM. I could barely see the runway because the lights weren't on. I didn't think anything about this at the time. We completed the landing and were cleared to taxi back to base parking. When I arrived at base operations, I was asked by the duty officer to call the tower. The tower operator stated that we had landed without clearance. I was quite surprised, but on reflection don't remember hearing the copilot make the final approach fix call. I was task saturated with flying and didn't back him up on communications duties. I debriefed the copilot, navigator, and radio operator (any of whom could have caught this omission) on this incident as an illustration of how cockpit resource management and backing each other up could have prevented this occurrence. I think this incident was caused by a change to the crew's normal routine of getting the aircraft fully configured and all checklists completed prior to the arrival at the approach gate. Busy with the gear and checklist at the final approach fix, the copilot forgot the call. Busy with the flying, I didn't catch the omission. I'm going back to the unofficial routine of getting the aircraft configured and having all checklists done well prior to the final approach fix. In this way I'll have more attention left to back up the crew before becoming task saturated with a difficult instrument approach procedure. Callback conversation with reporter revealed the following information: this reporter was flying a united states coast guard HC130-H on a search support mission when the incident occurred. He said that the trouble began when he changed from the standard procedures to a practice that he had seen an air carrier flight crew use in order to 'try it out' so he would be ready for an airline career when he retired. Later, after talking the event over with his crew and the tower controller and the standards department, he decided that he would in the future use standard procedures wherever or whatever they were at the current organization.
Original NASA ASRS Text
Title: UNAUTH LNDG -- MIL PLT LANDS WITHOUT CLRNC.
Narrative: WX ON DEP FROM ADQ WAS RPTED VFR, BUT CEILING AND VISIBILITY IN THE DEP AND APCH CORRIDOR WAS MARGINAL -- APPROX 1000 FT AND 2 MI. FLT TO EILSON WAS UNEVENTFUL. WHILE TRANSFERRING THE HELI CREWS AT EILSON WITH ENGS RUNNING, I SWAPPED SEATS WITH THE COPLT SO THAT I COULD FLY THE RETURN LEG FROM THE L SEAT. DEP FROM EILSON AND CRUISE BACK TO VICINITY OF KODIAK WAS UNEVENTFUL. ABOUT 5 NM N OF THE ARC FOR THE ILS/DME 2 SPECIAL APCH TO ADQ, ZAN ADVISED THAT WE WERE NOT YET CLR FOR THE APCH BECAUSE KODIAK TWR WAS HANDLING A SPECIAL VFR ARR. ALMOST IMMEDIATELY AFTER TURNING ON THE ARC, THOUGH, WE WERE CLRED FOR THE APCH AND BEGAN DSCNT AND CONFIGN. BECAUSE I PLAN TO RETIRE FROM THE SVC IN THE NEAR FUTURE TO PURSUE AN AIRLINE CAREER, I'M TRYING TO RESHAPE MY HABIT PATTERNS TO CIVILIAN OPERATING PRACTICES, AND SO I BRIEFED THE CREW THAT WE WOULD PUT THE GEAR DOWN AND COMPLETE THE PRE-LNDG CHKLIST AT THE FINAL APCH FIX. NORMAL CTR OF GRAVITY PRACTICE IS TO HAVE ALL CHKLISTS COMPLETED IN THE VICINITY OF THE APCH GATE. THE COPLT (PNF) CALLED TWR WHEN WE DEPARTED THE ARC. TWR ASKED HIM TO RPT THE FINAL APCH FIX SO THAT THE LIGHTS COULD BE ON FULL, AND THE COPLT ACKNOWLEDGED. AT FINAL APCH FIX I CALLED FOR GEAR DOWN AND CHKLIST. I HAD MY HANDS FULL FLYING THE ILS BECAUSE OF WIND ON FINAL ON THE TAIL AT 25 KTS AND A 10 KT XWIND AT THE FIELD. WE BROKE OUT AT MINIMUMS OF 300 FT CEILING, VISIBILITY APPROX 1 1/2 SM. I COULD BARELY SEE THE RWY BECAUSE THE LIGHTS WEREN'T ON. I DIDN'T THINK ANYTHING ABOUT THIS AT THE TIME. WE COMPLETED THE LNDG AND WERE CLRED TO TAXI BACK TO BASE PARKING. WHEN I ARRIVED AT BASE OPS, I WAS ASKED BY THE DUTY OFFICER TO CALL THE TWR. THE TWR OPERATOR STATED THAT WE HAD LANDED WITHOUT CLRNC. I WAS QUITE SURPRISED, BUT ON REFLECTION DON'T REMEMBER HEARING THE COPLT MAKE THE FINAL APCH FIX CALL. I WAS TASK SATURATED WITH FLYING AND DIDN'T BACK HIM UP ON COMS DUTIES. I DEBRIEFED THE COPLT, NAVIGATOR, AND RADIO OPERATOR (ANY OF WHOM COULD HAVE CAUGHT THIS OMISSION) ON THIS INCIDENT AS AN ILLUSTRATION OF HOW COCKPIT RESOURCE MGMNT AND BACKING EACH OTHER UP COULD HAVE PREVENTED THIS OCCURRENCE. I THINK THIS INCIDENT WAS CAUSED BY A CHANGE TO THE CREW'S NORMAL ROUTINE OF GETTING THE ACFT FULLY CONFIGURED AND ALL CHKLISTS COMPLETED PRIOR TO THE ARR AT THE APCH GATE. BUSY WITH THE GEAR AND CHKLIST AT THE FINAL APCH FIX, THE COPLT FORGOT THE CALL. BUSY WITH THE FLYING, I DIDN'T CATCH THE OMISSION. I'M GOING BACK TO THE UNOFFICIAL ROUTINE OF GETTING THE ACFT CONFIGURED AND HAVING ALL CHKLISTS DONE WELL PRIOR TO THE FINAL APCH FIX. IN THIS WAY I'LL HAVE MORE ATTN LEFT TO BACK UP THE CREW BEFORE BECOMING TASK SATURATED WITH A DIFFICULT INST APCH PROC. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THIS RPTR WAS FLYING A UNITED STATES COAST GUARD HC130-H ON A SEARCH SUPPORT MISSION WHEN THE INCIDENT OCCURRED. HE SAID THAT THE TROUBLE BEGAN WHEN HE CHANGED FROM THE STANDARD PROCS TO A PRACTICE THAT HE HAD SEEN AN ACR FLC USE IN ORDER TO 'TRY IT OUT' SO HE WOULD BE READY FOR AN AIRLINE CAREER WHEN HE RETIRED. LATER, AFTER TALKING THE EVENT OVER WITH HIS CREW AND THE TWR CTLR AND THE STANDARDS DEPT, HE DECIDED THAT HE WOULD IN THE FUTURE USE STANDARD PROCS WHEREVER OR WHATEVER THEY WERE AT THE CURRENT ORGANIZATION.
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.