37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 558965 |
Time | |
Date | 200208 |
Day | Wed |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : bos.airport |
State Reference | MA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : bos.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 123 flight time total : 5000 flight time type : 140 |
ASRS Report | 558965 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : private pilot : multi engine pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 12000 flight time type : 3500 |
ASRS Report | 558050 |
Events | |
Anomaly | incursion : landing without clearance non adherence : far non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Talking to bos approach, being sequenced in and finally got approach clearance for ILS runway 27 bos, maintain 170 KTS till ripit (6.5 mi). Approach controller busy with other aircraft and never told us to switch to tower. We did not catch it due to the following listed distrs: the 'B' autoplt was engaged with the captain flying the approach. This is unusual as the 'B' approach gets its data from the first officer's instruments. The captain elected to do this after a number of abnormal roll inputs had been abruptly entered by the 'a' autoplt earlier in the flight. He tried 'a' again during the initial approach and excess transient rolls continued. Therefore, he switched to autoplt 'B.' he switched back to 'a' to make the approach legal with him flying but the erratic rolls continued which was very disconcerting at low altitude. The captain called for the before lng checklist while monitoring autoplt a's performance, which was erratic. We completed the checklist and he finally disconnected the autoplt completely and hand flew the approach. At this point he stated that he has not landed in over a month, so I should back him up closely. We are at about 2 1/2 mi with other traffic still on the runway. While watching the other traffic, I noticed that the captain was holding unusual amounts of right wing down aileron and then taking it out, putting back in, and taking it out. The reported winds were light with little crosswind component for so much aileron. I was concerned as I began to wonder whether this could be a control problem with the aircraft somehow related to the abnormal roll tendencies of the 'a' autoplt, or was the captain really rusty from not flying recently? (I have never flown with him before and he is extremely junior at the company.) as I was watching his aileron inputs, I remembered that there was a gripe in the aircraft logbook about fuel gauge inaccuracies. I looked down and noticed there was a 400 pound fuel split indicated on the gauges, but I don't know whether they were accurate due to the gripe in the book. We were at 500 ft and the traffic on the runway was clearing at the end. We were almost there -- in the flare and finally touchdown. I thought to myself, 'I'm glad that is over.' as we rolled to the turnoff, I began my flow and wondered why the tower was not talking to us. I looked down and realized we didn't switch to the tower frequency. I immediately threw the xfer switch as tower was dialed in the standby position. Tower called us and cleared us to cross the other runway and contact ground. Nothing more was said. In summary, I believe that many distrs led to this loss of situational awareness. Primarily the concern for the flyability or airworthiness of the aircraft. Also, the concern for the captain's lack of experience and recency, the fuel split, poor communications with approach due to volume of traffic, tight sequencing with traffic ahead, and a relatively short notice to change from the runway 22 to runway 27 approach all contributed to basically being task saturated. Supplemental information from acn 558050: copilot missed the '1000 ft, cleared to land' required call. I also missed the omission. ZBW never said a word to us, and we didn't advertise the error. I, (captain) just came off an extended leave 30+ days. This was the first leg since my break.
Original NASA ASRS Text
Title: B737-200 FLT CREW LANDED AT BOS WITHOUT A CLRNC.
Narrative: TALKING TO BOS APCH, BEING SEQUENCED IN AND FINALLY GOT APCH CLRNC FOR ILS RWY 27 BOS, MAINTAIN 170 KTS TILL RIPIT (6.5 MI). APCH CTLR BUSY WITH OTHER ACFT AND NEVER TOLD US TO SWITCH TO TWR. WE DID NOT CATCH IT DUE TO THE FOLLOWING LISTED DISTRS: THE 'B' AUTOPLT WAS ENGAGED WITH THE CAPT FLYING THE APCH. THIS IS UNUSUAL AS THE 'B' APCH GETS ITS DATA FROM THE FO'S INSTS. THE CAPT ELECTED TO DO THIS AFTER A NUMBER OF ABNORMAL ROLL INPUTS HAD BEEN ABRUPTLY ENTERED BY THE 'A' AUTOPLT EARLIER IN THE FLT. HE TRIED 'A' AGAIN DURING THE INITIAL APCH AND EXCESS TRANSIENT ROLLS CONTINUED. THEREFORE, HE SWITCHED TO AUTOPLT 'B.' HE SWITCHED BACK TO 'A' TO MAKE THE APCH LEGAL WITH HIM FLYING BUT THE ERRATIC ROLLS CONTINUED WHICH WAS VERY DISCONCERTING AT LOW ALT. THE CAPT CALLED FOR THE BEFORE LNG CHKLIST WHILE MONITORING AUTOPLT A'S PERFORMANCE, WHICH WAS ERRATIC. WE COMPLETED THE CHKLIST AND HE FINALLY DISCONNECTED THE AUTOPLT COMPLETELY AND HAND FLEW THE APCH. AT THIS POINT HE STATED THAT HE HAS NOT LANDED IN OVER A MONTH, SO I SHOULD BACK HIM UP CLOSELY. WE ARE AT ABOUT 2 1/2 MI WITH OTHER TFC STILL ON THE RWY. WHILE WATCHING THE OTHER TFC, I NOTICED THAT THE CAPT WAS HOLDING UNUSUAL AMOUNTS OF R WING DOWN AILERON AND THEN TAKING IT OUT, PUTTING BACK IN, AND TAKING IT OUT. THE RPTED WINDS WERE LIGHT WITH LITTLE XWIND COMPONENT FOR SO MUCH AILERON. I WAS CONCERNED AS I BEGAN TO WONDER WHETHER THIS COULD BE A CTL PROB WITH THE ACFT SOMEHOW RELATED TO THE ABNORMAL ROLL TENDENCIES OF THE 'A' AUTOPLT, OR WAS THE CAPT REALLY RUSTY FROM NOT FLYING RECENTLY? (I HAVE NEVER FLOWN WITH HIM BEFORE AND HE IS EXTREMELY JUNIOR AT THE COMPANY.) AS I WAS WATCHING HIS AILERON INPUTS, I REMEMBERED THAT THERE WAS A GRIPE IN THE ACFT LOGBOOK ABOUT FUEL GAUGE INACCURACIES. I LOOKED DOWN AND NOTICED THERE WAS A 400 LB FUEL SPLIT INDICATED ON THE GAUGES, BUT I DON'T KNOW WHETHER THEY WERE ACCURATE DUE TO THE GRIPE IN THE BOOK. WE WERE AT 500 FT AND THE TFC ON THE RWY WAS CLRING AT THE END. WE WERE ALMOST THERE -- IN THE FLARE AND FINALLY TOUCHDOWN. I THOUGHT TO MYSELF, 'I'M GLAD THAT IS OVER.' AS WE ROLLED TO THE TURNOFF, I BEGAN MY FLOW AND WONDERED WHY THE TWR WAS NOT TALKING TO US. I LOOKED DOWN AND REALIZED WE DIDN'T SWITCH TO THE TWR FREQ. I IMMEDIATELY THREW THE XFER SWITCH AS TWR WAS DIALED IN THE STANDBY POS. TWR CALLED US AND CLRED US TO CROSS THE OTHER RWY AND CONTACT GND. NOTHING MORE WAS SAID. IN SUMMARY, I BELIEVE THAT MANY DISTRS LED TO THIS LOSS OF SITUATIONAL AWARENESS. PRIMARILY THE CONCERN FOR THE FLYABILITY OR AIRWORTHINESS OF THE ACFT. ALSO, THE CONCERN FOR THE CAPT'S LACK OF EXPERIENCE AND RECENCY, THE FUEL SPLIT, POOR COMS WITH APCH DUE TO VOLUME OF TFC, TIGHT SEQUENCING WITH TFC AHEAD, AND A RELATIVELY SHORT NOTICE TO CHANGE FROM THE RWY 22 TO RWY 27 APCH ALL CONTRIBUTED TO BASICALLY BEING TASK SATURATED. SUPPLEMENTAL INFO FROM ACN 558050: COPLT MISSED THE '1000 FT, CLRED TO LAND' REQUIRED CALL. I ALSO MISSED THE OMISSION. ZBW NEVER SAID A WORD TO US, AND WE DIDN'T ADVERTISE THE ERROR. I, (CAPT) JUST CAME OFF AN EXTENDED LEAVE 30+ DAYS. THIS WAS THE FIRST LEG SINCE MY BREAK.
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.