Narrative:

Initial contact with lax approach control told us to expect ILS runway 25R with mudde 4 arrival. Captain (PNF) inserted the mudde 4 arrival while the first officer got his charts. Approximately 4 NM east of mudde (14000 ft), we switched to the second approach controller, who told us to fly present heading (230 degrees) to intercept localizer runway 24L, expect ILS runway 24L, runway 24L GS OTS. At that time, I (PNF) inserted ILS runway 24L and briefed the first officer on the approach, calling out initial altitudes MDA (with airspeed out - 580 ft), missed approach procedure, MSA, localizer identify inbound. I manually inserted localizer identify/inbound course and selected localizer only approach on the navigation/rad page. We were cleared for approach and first officer descended to 2200 ft approximately 6 NM prior to romen. After he leveled off, approach control told us to contact tower at romen, cleared for approach. At that time I looked at the navigation display which showed FF24L and not romen, so I looked at the approach plate to confirm where romen was and noticed I hadn't set time to missed approach. I started to set it and told the first officer to set minimums (580 ft) and by the time I figured the missed approach time we were descending out of 1500 ft and I figured it was too late. After looking out for the runway, I decided we were too low and told the first officer to stop his descent at about the same time ATC asked us what our altitude was. We had not yet crossed romen and were still talking to approach. He told us the altitude restr was 2200 ft at romen -- we were approximately 900 ft. He asked us if we could make it from there and I asked for missed approach instructions. He asked if we were IMC and I told him we were VMC. We flew according to his missed approach instructions and continued around for landing at lax. The human factors involved in this incident are as follows: 1) the last min runway change rushed both of us and consequently the approach was not thoroughly briefed nor understood. The fact that the approach was changed from an ILS to a localizer only (GS was OTS) compounded the issue. There is more to brief in terms of technique when flying a non precision approach. 2) effective communication broke down. Both of us got absorbed in our own little worlds of 'preparation' and stopped communicating. Every 'incident' I have been involved in, however minor, has been a result of at least 1 person not saying what was on his mind. I should have asked the first officer what his intended technique/action would be after romen (ie, to either use vertical speed or level change to MDA). 3) there was no xchk. I didn't realize until the controller gave us the frequency change at romen that 'romen' was defined on the FMS and navigation displays as FF149 with a hand altitude of 2200 ft. Also, when I told the first officer to set MDA, I should have said 'preselect' and he should have corrected me and reminded me that we were to cross romen at 2200 ft. 4) finally, the distraction in the cockpit caused by a lack of a good brief. At the time I should have been xchking the first officer's position and altitude, I was concerned with time to missed approach, finding romen, the turnoff point on the runway and the fact that I considered the first officer slow in catching up and minding the store. The 2 contributing factors that I think are necessary to bring up are the fact that we were both tired, not from excessive duty times, but from the simple fact of changing from daytime duty period to nighttime duty period. Also, lax's really bad habit of last min runway changes.

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Original NASA ASRS Text

Title: AFTER LAST MIN CLOSE IN APCH CHANGE, HVT CREW CROSS FAF 1300 FT LOW PRIOR TO MISSED APCH AT LAX.

Narrative: INITIAL CONTACT WITH LAX APCH CTL TOLD US TO EXPECT ILS RWY 25R WITH MUDDE 4 ARR. CAPT (PNF) INSERTED THE MUDDE 4 ARR WHILE THE FO GOT HIS CHARTS. APPROX 4 NM E OF MUDDE (14000 FT), WE SWITCHED TO THE SECOND APCH CTLR, WHO TOLD US TO FLY PRESENT HDG (230 DEGS) TO INTERCEPT LOC RWY 24L, EXPECT ILS RWY 24L, RWY 24L GS OTS. AT THAT TIME, I (PNF) INSERTED ILS RWY 24L AND BRIEFED THE FO ON THE APCH, CALLING OUT INITIAL ALTS MDA (WITH AIRSPD OUT - 580 FT), MISSED APCH PROC, MSA, LOC IDENT INBOUND. I MANUALLY INSERTED LOC IDENT/INBOUND COURSE AND SELECTED LOC ONLY APCH ON THE NAV/RAD PAGE. WE WERE CLRED FOR APCH AND FO DSNDED TO 2200 FT APPROX 6 NM PRIOR TO ROMEN. AFTER HE LEVELED OFF, APCH CTL TOLD US TO CONTACT TWR AT ROMEN, CLRED FOR APCH. AT THAT TIME I LOOKED AT THE NAV DISPLAY WHICH SHOWED FF24L AND NOT ROMEN, SO I LOOKED AT THE APCH PLATE TO CONFIRM WHERE ROMEN WAS AND NOTICED I HADN'T SET TIME TO MISSED APCH. I STARTED TO SET IT AND TOLD THE FO TO SET MINIMUMS (580 FT) AND BY THE TIME I FIGURED THE MISSED APCH TIME WE WERE DSNDING OUT OF 1500 FT AND I FIGURED IT WAS TOO LATE. AFTER LOOKING OUT FOR THE RWY, I DECIDED WE WERE TOO LOW AND TOLD THE FO TO STOP HIS DSCNT AT ABOUT THE SAME TIME ATC ASKED US WHAT OUR ALT WAS. WE HAD NOT YET CROSSED ROMEN AND WERE STILL TALKING TO APCH. HE TOLD US THE ALT RESTR WAS 2200 FT AT ROMEN -- WE WERE APPROX 900 FT. HE ASKED US IF WE COULD MAKE IT FROM THERE AND I ASKED FOR MISSED APCH INSTRUCTIONS. HE ASKED IF WE WERE IMC AND I TOLD HIM WE WERE VMC. WE FLEW ACCORDING TO HIS MISSED APCH INSTRUCTIONS AND CONTINUED AROUND FOR LNDG AT LAX. THE HUMAN FACTORS INVOLVED IN THIS INCIDENT ARE AS FOLLOWS: 1) THE LAST MIN RWY CHANGE RUSHED BOTH OF US AND CONSEQUENTLY THE APCH WAS NOT THOROUGHLY BRIEFED NOR UNDERSTOOD. THE FACT THAT THE APCH WAS CHANGED FROM AN ILS TO A LOC ONLY (GS WAS OTS) COMPOUNDED THE ISSUE. THERE IS MORE TO BRIEF IN TERMS OF TECHNIQUE WHEN FLYING A NON PRECISION APCH. 2) EFFECTIVE COM BROKE DOWN. BOTH OF US GOT ABSORBED IN OUR OWN LITTLE WORLDS OF 'PREPARATION' AND STOPPED COMMUNICATING. EVERY 'INCIDENT' I HAVE BEEN INVOLVED IN, HOWEVER MINOR, HAS BEEN A RESULT OF AT LEAST 1 PERSON NOT SAYING WHAT WAS ON HIS MIND. I SHOULD HAVE ASKED THE FO WHAT HIS INTENDED TECHNIQUE/ACTION WOULD BE AFTER ROMEN (IE, TO EITHER USE VERT SPD OR LEVEL CHANGE TO MDA). 3) THERE WAS NO XCHK. I DIDN'T REALIZE UNTIL THE CTLR GAVE US THE FREQ CHANGE AT ROMEN THAT 'ROMEN' WAS DEFINED ON THE FMS AND NAV DISPLAYS AS FF149 WITH A HAND ALT OF 2200 FT. ALSO, WHEN I TOLD THE FO TO SET MDA, I SHOULD HAVE SAID 'PRESELECT' AND HE SHOULD HAVE CORRECTED ME AND REMINDED ME THAT WE WERE TO CROSS ROMEN AT 2200 FT. 4) FINALLY, THE DISTR IN THE COCKPIT CAUSED BY A LACK OF A GOOD BRIEF. AT THE TIME I SHOULD HAVE BEEN XCHKING THE FO'S POS AND ALT, I WAS CONCERNED WITH TIME TO MISSED APCH, FINDING ROMEN, THE TURNOFF POINT ON THE RWY AND THE FACT THAT I CONSIDERED THE FO SLOW IN CATCHING UP AND MINDING THE STORE. THE 2 CONTRIBUTING FACTORS THAT I THINK ARE NECESSARY TO BRING UP ARE THE FACT THAT WE WERE BOTH TIRED, NOT FROM EXCESSIVE DUTY TIMES, BUT FROM THE SIMPLE FACT OF CHANGING FROM DAYTIME DUTY PERIOD TO NIGHTTIME DUTY PERIOD. ALSO, LAX'S REALLY BAD HABIT OF LAST MIN RWY CHANGES.

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.