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Attributes | |
ACN | 415429 |
Time | |
Date | 199809 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : lax airport : lax |
State Reference | CA |
Altitude | msl bound lower : 4000 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : lax tower : lax |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent : approach descent other |
Route In Use | approach : visual arrival other arrival star : star |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 15000 flight time type : 250 |
ASRS Report | 415429 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Inter Facility Coordination Failure other |
Narrative:
En route from ewr to lax, ZLA changed en route clearance 'after pgs VORTAC, J128 to lax.' set up in CDU, the clearance changed back to 'direct civet, civet arrival.' prior to civet, reclred for 'mitts arrival, cleared direct snrkl intersection, snrkl at or above 12000 ft.' had to type in snrkl to CDU, as it did not come up when selecting mitts arrival, also had to put in altitude restr at snrkl. Not sure if they cleared us to descend via the mitts arrival (15 mi from mitts) and finally got confirmation to descend via arrival 3 mi from mitts and we had to use speed brakes and vertical speed mode to get down in time. Cleared initially for ILS runway 24R, set in CDU and ILS frequencys. First officer had been advised to have approach plate ready for runway 24L. Rebriefed ILS for runway 24R versus runway 25L, the initial runway for the original civet arrival. About 6 mi from lax, approach asked if we had the field in sight. We replied 'affirmative' and he reclred us for the 'visual approach to runway 24L (versus runway 24R) and to contact lax tower.' when first officer set in tower frequency, he set 135.9 versus 133.9 and did not call them as soon as possible. As the captain had asked for the ILS frequency to be set in for runway 24L, first officer could not change the ILS frequency in the head, as 'approach' mode had already been selected for runway 24R. First officer reset runway 24L in CDU and was then able to dial in ILS frequency for runway 24L. Captain was hand flying after the clearance was changed from runway 24R to runway 24L, using raw data on ADI and HSI. After first officer retuned ILS to runway 24L, neither pilot had flight director data. Captain continued to hand fly the approach under visual conditions, and at 700-800 ft AGL, we spotted an aircraft on runway 24L. The first officer asked the captain if we were cleared to land and the captain replied affirmative (hearing cleared for the approach, and switch to tower, and with all of the other distrs, focused on the approach and thought we had been cleared to land). On the landing roll, we commented on how quiet it was, and after clearing the runway and switching to ground control, the first officer noticed 135.9 had been set versus 133.9. Ground gave us taxi instructions to the gate with no comments. We called the tower supervisor to clear up the situation. His reaction to the statement was that it was a coordination problem between TRACON and the tower, adding that he did not contact us until 2 NM from the runway, as if he was unaware that we were not on frequency. We did not admit to him that we had not heard the landing clearance, and he made no further comments on the matter. We briefly discussed why lax always seems to give multiple approach and runway changes, and he answered that they land aircraft on the inside runways -- occasionally, to help out with spacing of aircraft for approach control. 2 experienced crew members landed without a clearance from the tower due to all of the workload and distrs listed above. Automation is good only to a point. When it becomes cumbersome, then raw data and basic aviation skills take preference. Recommendations: keep approach and runway changes to a minimum. Ensure at 1000 ft AGL (500 ft AGL minimum) that landing clearance has been received. It might not be a bad idea to put it on the landing checklist, as basic as that may seem (in this case it may have helped). Avoid CDU changes at low altitudes that could prove to be distracting.
Original NASA ASRS Text
Title: LGT ACR ACFT IS CLRED FROM ONE STAR TO ANOTHER, THEN WITHIN 10 MI OF LNDG, IS AGAIN RECLRED FOR ANOTHER APCH, LNDG ON A PARALLEL RWY. PLT CONCERNED WITH INCREASED COCKPIT WORKLOAD CAUSED BY RWY CHANGES AND THE ACCOMPANYING AUTOMATION INPUTS.
Narrative: ENRTE FROM EWR TO LAX, ZLA CHANGED ENRTE CLRNC 'AFTER PGS VORTAC, J128 TO LAX.' SET UP IN CDU, THE CLRNC CHANGED BACK TO 'DIRECT CIVET, CIVET ARR.' PRIOR TO CIVET, RECLRED FOR 'MITTS ARR, CLRED DIRECT SNRKL INTXN, SNRKL AT OR ABOVE 12000 FT.' HAD TO TYPE IN SNRKL TO CDU, AS IT DID NOT COME UP WHEN SELECTING MITTS ARR, ALSO HAD TO PUT IN ALT RESTR AT SNRKL. NOT SURE IF THEY CLRED US TO DSND VIA THE MITTS ARR (15 MI FROM MITTS) AND FINALLY GOT CONFIRMATION TO DSND VIA ARR 3 MI FROM MITTS AND WE HAD TO USE SPD BRAKES AND VERT SPD MODE TO GET DOWN IN TIME. CLRED INITIALLY FOR ILS RWY 24R, SET IN CDU AND ILS FREQS. FO HAD BEEN ADVISED TO HAVE APCH PLATE READY FOR RWY 24L. REBRIEFED ILS FOR RWY 24R VERSUS RWY 25L, THE INITIAL RWY FOR THE ORIGINAL CIVET ARR. ABOUT 6 MI FROM LAX, APCH ASKED IF WE HAD THE FIELD IN SIGHT. WE REPLIED 'AFFIRMATIVE' AND HE RECLRED US FOR THE 'VISUAL APCH TO RWY 24L (VERSUS RWY 24R) AND TO CONTACT LAX TWR.' WHEN FO SET IN TWR FREQ, HE SET 135.9 VERSUS 133.9 AND DID NOT CALL THEM ASAP. AS THE CAPT HAD ASKED FOR THE ILS FREQ TO BE SET IN FOR RWY 24L, FO COULD NOT CHANGE THE ILS FREQ IN THE HEAD, AS 'APCH' MODE HAD ALREADY BEEN SELECTED FOR RWY 24R. FO RESET RWY 24L IN CDU AND WAS THEN ABLE TO DIAL IN ILS FREQ FOR RWY 24L. CAPT WAS HAND FLYING AFTER THE CLRNC WAS CHANGED FROM RWY 24R TO RWY 24L, USING RAW DATA ON ADI AND HSI. AFTER FO RETUNED ILS TO RWY 24L, NEITHER PLT HAD FLT DIRECTOR DATA. CAPT CONTINUED TO HAND FLY THE APCH UNDER VISUAL CONDITIONS, AND AT 700-800 FT AGL, WE SPOTTED AN ACFT ON RWY 24L. THE FO ASKED THE CAPT IF WE WERE CLRED TO LAND AND THE CAPT REPLIED AFFIRMATIVE (HEARING CLRED FOR THE APCH, AND SWITCH TO TWR, AND WITH ALL OF THE OTHER DISTRS, FOCUSED ON THE APCH AND THOUGHT WE HAD BEEN CLRED TO LAND). ON THE LNDG ROLL, WE COMMENTED ON HOW QUIET IT WAS, AND AFTER CLRING THE RWY AND SWITCHING TO GND CTL, THE FO NOTICED 135.9 HAD BEEN SET VERSUS 133.9. GND GAVE US TAXI INSTRUCTIONS TO THE GATE WITH NO COMMENTS. WE CALLED THE TWR SUPVR TO CLR UP THE SIT. HIS REACTION TO THE STATEMENT WAS THAT IT WAS A COORD PROB BTWN TRACON AND THE TWR, ADDING THAT HE DID NOT CONTACT US UNTIL 2 NM FROM THE RWY, AS IF HE WAS UNAWARE THAT WE WERE NOT ON FREQ. WE DID NOT ADMIT TO HIM THAT WE HAD NOT HEARD THE LNDG CLRNC, AND HE MADE NO FURTHER COMMENTS ON THE MATTER. WE BRIEFLY DISCUSSED WHY LAX ALWAYS SEEMS TO GIVE MULTIPLE APCH AND RWY CHANGES, AND HE ANSWERED THAT THEY LAND ACFT ON THE INSIDE RWYS -- OCCASIONALLY, TO HELP OUT WITH SPACING OF ACFT FOR APCH CTL. 2 EXPERIENCED CREW MEMBERS LANDED WITHOUT A CLRNC FROM THE TWR DUE TO ALL OF THE WORKLOAD AND DISTRS LISTED ABOVE. AUTOMATION IS GOOD ONLY TO A POINT. WHEN IT BECOMES CUMBERSOME, THEN RAW DATA AND BASIC AVIATION SKILLS TAKE PREFERENCE. RECOMMENDATIONS: KEEP APCH AND RWY CHANGES TO A MINIMUM. ENSURE AT 1000 FT AGL (500 FT AGL MINIMUM) THAT LNDG CLRNC HAS BEEN RECEIVED. IT MIGHT NOT BE A BAD IDEA TO PUT IT ON THE LNDG CHKLIST, AS BASIC AS THAT MAY SEEM (IN THIS CASE IT MAY HAVE HELPED). AVOID CDU CHANGES AT LOW ALTS THAT COULD PROVE TO BE DISTRACTING.
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.