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Attributes | |
ACN | 488646 |
Time | |
Date | 200010 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : atl.airport |
State Reference | GA |
Altitude | msl single value : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : atl.tracon tower : afw.tower |
Operator | common carrier : air carrier |
Make Model Name | Brasilia EMB-120 All Series |
Operating Under FAR Part | Part 119 |
Navigation In Use | other Other |
Flight Phase | descent : approach descent : intermediate altitude |
Route In Use | approach : visual |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : atl.tracon |
Operator | common carrier : air carrier |
Make Model Name | DC-9 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 3300 flight time type : 1800 |
ASRS Report | 488646 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : multi engine |
Events | |
Anomaly | non adherence : published procedure non adherence : company policies non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory flight crew : returned to intended or assigned course |
Consequence | other |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I (captain) was flying inbound to atl for visual to runway 26R. I reported traffic to follow and airport in sight. Localizer was selected, tuned, autoplt on heading and altitude mode. First officer was new to company with only 30 hours off of IOE and required frequent correction/monitoring by myself. Last clearance received was cleared visual runway 26R slow to 180 KIAS. First officer read back runway 27R. Controller corrected and added 'slow to 160 KIAS.' first officer did not read back 160 KIAS or catch runway error. I read back runway 26R, 160 KIAS. Approach then pointed out we had flown south of the runway 26R localizer and needed to correct. We corrected and landed uneventfully. I was quite shaken up by this event because I was completely unaware that I had crossed the final for 3 runways (runway 26R, runway 26L, and runway 27R) and was almost lined up for runway 27L on far south side of airport until the controller called us. I could not understand how I had gotten there. The last situation I was aware of was slowing to 160 KIAS, intercepting inbound, and following traffic. It was almost as if I had been in a trance or asleep for a few seconds. I thank my lucky stars the traffic was light and I did not collide with traffic to runway 27L. I think the following factors contributed to this incident: 1) fatigue: overnight scheduled for about 9 hours total rest. Long delay for transportation to hotel and I woke up at XA15 for XC30 duty I and could not go back to sleep. Also, I had been sick for 2 days prior to trip and had not rested well. 2) new first officer: a) first officer never spoke up as I blew through the final for our runway -- I suspect because he may not have noticed it or thought he was incorrect or was too timid. B) I was distraction from flying the aircraft due to the need to monitor and correct his actions simultaneously. 3) there were 2 DC9's simultaneously landing on parallel runways (runway 26R and runway 27L). I believe I may have idented the wrong DC9 and so misjudged my turn to final. What I should have done differently: 1) use autoplt approach mode instead of heading mode to help prevent missing the localizer. 2) prioritize -- I should have placed all emphasis on aircraft control and flying and let the PNF stumble on radio at that busy point in the approach and landing phase. 3) sleep better/more caffeine. 4) try to be even more encouraging to first officer's about speaking up.
Original NASA ASRS Text
Title: TRACK DEV ON A VISUAL APCH TO ATL, GA, WITH CRM AND FATIGUE ISSUES.
Narrative: I (CAPT) WAS FLYING INBOUND TO ATL FOR VISUAL TO RWY 26R. I RPTED TFC TO FOLLOW AND ARPT IN SIGHT. LOC WAS SELECTED, TUNED, AUTOPLT ON HDG AND ALT MODE. FO WAS NEW TO COMPANY WITH ONLY 30 HRS OFF OF IOE AND REQUIRED FREQUENT CORRECTION/MONITORING BY MYSELF. LAST CLRNC RECEIVED WAS CLRED VISUAL RWY 26R SLOW TO 180 KIAS. FO READ BACK RWY 27R. CTLR CORRECTED AND ADDED 'SLOW TO 160 KIAS.' FO DID NOT READ BACK 160 KIAS OR CATCH RWY ERROR. I READ BACK RWY 26R, 160 KIAS. APCH THEN POINTED OUT WE HAD FLOWN S OF THE RWY 26R LOC AND NEEDED TO CORRECT. WE CORRECTED AND LANDED UNEVENTFULLY. I WAS QUITE SHAKEN UP BY THIS EVENT BECAUSE I WAS COMPLETELY UNAWARE THAT I HAD CROSSED THE FINAL FOR 3 RWYS (RWY 26R, RWY 26L, AND RWY 27R) AND WAS ALMOST LINED UP FOR RWY 27L ON FAR S SIDE OF ARPT UNTIL THE CTLR CALLED US. I COULD NOT UNDERSTAND HOW I HAD GOTTEN THERE. THE LAST SIT I WAS AWARE OF WAS SLOWING TO 160 KIAS, INTERCEPTING INBOUND, AND FOLLOWING TFC. IT WAS ALMOST AS IF I HAD BEEN IN A TRANCE OR ASLEEP FOR A FEW SECONDS. I THANK MY LUCKY STARS THE TFC WAS LIGHT AND I DID NOT COLLIDE WITH TFC TO RWY 27L. I THINK THE FOLLOWING FACTORS CONTRIBUTED TO THIS INCIDENT: 1) FATIGUE: OVERNIGHT SCHEDULED FOR ABOUT 9 HRS TOTAL REST. LONG DELAY FOR TRANSPORTATION TO HOTEL AND I WOKE UP AT XA15 FOR XC30 DUTY I AND COULD NOT GO BACK TO SLEEP. ALSO, I HAD BEEN SICK FOR 2 DAYS PRIOR TO TRIP AND HAD NOT RESTED WELL. 2) NEW FO: A) FO NEVER SPOKE UP AS I BLEW THROUGH THE FINAL FOR OUR RWY -- I SUSPECT BECAUSE HE MAY NOT HAVE NOTICED IT OR THOUGHT HE WAS INCORRECT OR WAS TOO TIMID. B) I WAS DISTR FROM FLYING THE ACFT DUE TO THE NEED TO MONITOR AND CORRECT HIS ACTIONS SIMULTANEOUSLY. 3) THERE WERE 2 DC9'S SIMULTANEOUSLY LNDG ON PARALLEL RWYS (RWY 26R AND RWY 27L). I BELIEVE I MAY HAVE IDENTED THE WRONG DC9 AND SO MISJUDGED MY TURN TO FINAL. WHAT I SHOULD HAVE DONE DIFFERENTLY: 1) USE AUTOPLT APCH MODE INSTEAD OF HDG MODE TO HELP PREVENT MISSING THE LOC. 2) PRIORITIZE -- I SHOULD HAVE PLACED ALL EMPHASIS ON ACFT CTL AND FLYING AND LET THE PNF STUMBLE ON RADIO AT THAT BUSY POINT IN THE APCH AND LNDG PHASE. 3) SLEEP BETTER/MORE CAFFEINE. 4) TRY TO BE EVEN MORE ENCOURAGING TO FO'S ABOUT SPEAKING UP.
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.