Narrative:

This incident was the worst case of human factors and negative synergy that I have seen in my career. The accident chain was 1 link away from being complete on this flight. Our flight requested a straight-in runway 11 visual and had been cleared to runway 11 and to expedite descent to 3000 ft. Runway 29 was the active, but tower often approves opposite direction operations. Both the visual runway 29 and runway 11 were briefed for the approach. The straight-in was requested for 2 reasons: first, to make things easier on the PF/sic who was behind the airplane. Second, to expedite our arrival. The problem came into play on a 5 mi final. We were behind the profile for configuring when the PF made a turn off final to a 030 degree heading, which was towards the previous departure. At this time I asked what he was doing and approach asked our altitude. Nobody knew what the other parties in this situation were doing. The PF thought that the 030 degree vector given to our company aircraft was for us. I thought we were cleared for the approach (as did the PIC of our company and following us). Approach thought we were stopping at 3000 ft. We finally had to break off the approach and circle to runway 29. During the confusion, the thrust reversers arming was skipped on the checklist and the PF accidentally turned off the ground spoilers. Both of these items became obvious during the landing roll. This combined with the PF not extending the flight spoilers (per company operations) at touchdown (I had to reach around the throttle quadrant to deploy the spoilers) made for a very long ground roll and heavy braking. (Thrust reversers armed during the ground roll and deployed.) factors: 1) PF/sic: behind aircraft though very experienced in type. 2) PNF/PIC: approach and landing expectancy. 3) controller: controller change during our arrival. Nonstandard radio phraseology (both myself and company (aircraft Y) captain understood 'cleared' for runway 11 'visual.' what controller meant was 'proceed to runway 11 and expedite to 3000 ft.' 4) checklist: first 3 items of before landing checklist (#1 hydraulic 'B' pumps on, #2 thrust reversers arm, #3 annunciator recall) should be moved to the approach checklist. They are too critical to be delayed to the before landing checklist. 5) different aircraft: our crews fly 3 different types of jet aircraft during any given week, which disrupts flow patterns and procedures.

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Original NASA ASRS Text

Title: AN APCH IS ABANDONED WHEN MULTIPLE FACTORS COME TOGETHER TO RAISE THE CONFUSION FACTOR OF ALL PARTIES INVOLVED MAKING IT THE MOST PRUDENT COURSE OF ACTION.

Narrative: THIS INCIDENT WAS THE WORST CASE OF HUMAN FACTORS AND NEGATIVE SYNERGY THAT I HAVE SEEN IN MY CAREER. THE ACCIDENT CHAIN WAS 1 LINK AWAY FROM BEING COMPLETE ON THIS FLT. OUR FLT REQUESTED A STRAIGHT-IN RWY 11 VISUAL AND HAD BEEN CLRED TO RWY 11 AND TO EXPEDITE DSCNT TO 3000 FT. RWY 29 WAS THE ACTIVE, BUT TWR OFTEN APPROVES OPPOSITE DIRECTION OPS. BOTH THE VISUAL RWY 29 AND RWY 11 WERE BRIEFED FOR THE APCH. THE STRAIGHT-IN WAS REQUESTED FOR 2 REASONS: FIRST, TO MAKE THINGS EASIER ON THE PF/SIC WHO WAS BEHIND THE AIRPLANE. SECOND, TO EXPEDITE OUR ARR. THE PROB CAME INTO PLAY ON A 5 MI FINAL. WE WERE BEHIND THE PROFILE FOR CONFIGURING WHEN THE PF MADE A TURN OFF FINAL TO A 030 DEG HDG, WHICH WAS TOWARDS THE PREVIOUS DEP. AT THIS TIME I ASKED WHAT HE WAS DOING AND APCH ASKED OUR ALT. NOBODY KNEW WHAT THE OTHER PARTIES IN THIS SIT WERE DOING. THE PF THOUGHT THAT THE 030 DEG VECTOR GIVEN TO OUR COMPANY ACFT WAS FOR US. I THOUGHT WE WERE CLRED FOR THE APCH (AS DID THE PIC OF OUR COMPANY AND FOLLOWING US). APCH THOUGHT WE WERE STOPPING AT 3000 FT. WE FINALLY HAD TO BREAK OFF THE APCH AND CIRCLE TO RWY 29. DURING THE CONFUSION, THE THRUST REVERSERS ARMING WAS SKIPPED ON THE CHKLIST AND THE PF ACCIDENTALLY TURNED OFF THE GND SPOILERS. BOTH OF THESE ITEMS BECAME OBVIOUS DURING THE LNDG ROLL. THIS COMBINED WITH THE PF NOT EXTENDING THE FLT SPOILERS (PER COMPANY OPS) AT TOUCHDOWN (I HAD TO REACH AROUND THE THROTTLE QUADRANT TO DEPLOY THE SPOILERS) MADE FOR A VERY LONG GND ROLL AND HVY BRAKING. (THRUST REVERSERS ARMED DURING THE GND ROLL AND DEPLOYED.) FACTORS: 1) PF/SIC: BEHIND ACFT THOUGH VERY EXPERIENCED IN TYPE. 2) PNF/PIC: APCH AND LNDG EXPECTANCY. 3) CTLR: CTLR CHANGE DURING OUR ARR. NONSTANDARD RADIO PHRASEOLOGY (BOTH MYSELF AND COMPANY (ACFT Y) CAPT UNDERSTOOD 'CLRED' FOR RWY 11 'VISUAL.' WHAT CTLR MEANT WAS 'PROCEED TO RWY 11 AND EXPEDITE TO 3000 FT.' 4) CHKLIST: FIRST 3 ITEMS OF BEFORE LNDG CHKLIST (#1 HYD 'B' PUMPS ON, #2 THRUST REVERSERS ARM, #3 ANNUNCIATOR RECALL) SHOULD BE MOVED TO THE APCH CHKLIST. THEY ARE TOO CRITICAL TO BE DELAYED TO THE BEFORE LNDG CHKLIST. 5) DIFFERENT ACFT: OUR CREWS FLY 3 DIFFERENT TYPES OF JET ACFT DURING ANY GIVEN WK, WHICH DISRUPTS FLOW PATTERNS AND PROCS.

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.