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Attributes | |
ACN | 586114 |
Time | |
Date | 200306 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : lax.airport |
State Reference | CA |
Altitude | msl single value : 2200 |
Environment | |
Flight Conditions | VMC |
Weather Elements | other |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 24r |
Flight Phase | descent : approach |
Route In Use | approach : visual arrival : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : sct.tracon |
Operator | common carrier : air carrier |
Make Model Name | Brasilia EMB-120 All Series |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 24r |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 586114 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 586115 |
Events | |
Anomaly | conflict : airborne less severe non adherence : far non adherence : clearance non adherence : company policies other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : returned to intended or assigned course |
Supplementary | |
Problem Areas | Aircraft Airspace Structure Environmental Factor Flight Crew Human Performance Weather |
Primary Problem | Environmental Factor |
Narrative:
I was captain and PNF on flight ZZZ-lax. This was the 4TH flight of the day, 4TH aircraft of the day, 4TH set of flight attendants of the day, third day of flying for myself and the 4TH day of flying for the first officer. We were 1 hour late out of ZZZ due to airplane change/connect. Aircraft was speed limited due to flap/slat indication problem. Normal flight and rteing to lax. We were cleared for a visual approach to follow a commuter aircraft 3 NM ahead, turning a 5 NM final to runway 24R lax. A few clouds were in the area of the approach end of runway 24. We turned a normal base at approximately 6 NM, 180 KTS, runway 24R, and traffic ahead was in sight. The first officer said he would square the turn to final somewhat to increase the spacing on the aircraft ahead. The ILS frequency was tuned for runway 24R and VOR/localizer selected on the MCP. I observed the first officer begin the turn to final. During the turn to final, the first officer called for flaps 15, gear down final descent check, slowed to 160 KTS. As I set flaps, gear, made 2500 ft call, checked altimeters, received the call to switch to tower, finished checklist, I was head inside the cockpit. When I looked up, I saw we had overshot final for runway 24R. I called for the first officer to immediately correct to the right. As we were turning to correct, approach control called and gave us a heading of 270 degrees to the right. I acknowledged the call, and said we were correcting. The first officer made an appropriate correction to runway 24R. Normal, stabilized approach and landing followed. In debriefing the incident, the first officer said that the few clouds in the area of runway 24R were a factor in leading to disorientation, and a subsequent reduction in bank angle during the turn to final. Additional factors that may have contributed to this incident: 1) distraction by myself during a critical phase of flight during the turn to final. 2) failure by the PF to recognize disorientation during the turn to final. 3) failure to use all tools available, (localizer, flight director, map display) to verify our position. 4) failure to prioritize tasks and backup the PF during a critical phase of flight. 5) WX in the area of the runway as well as low light conditions at dusk, and haze. 6) approach/runway lighting not in use. 7) no PAPI/VASI installed at lax. 8) fatigue by the pilots due to multiple 4-LEG days, aircraft changes, crew changes, delay on last leg of last day. Note: as an lax-based pilot, I have flown hundreds of these same approachs under the same or similar conditions without incident. The haze, flying into the sun and marine layer are constant companions to pilots flying into lax. High traffic counts and the congested visual approach environment make lax a challenging location. I strongly advocate for lax to use their approach lighting system on a high visibility setting, even during VFR conditions, to help pilots maintain a strong sense of orientation to the runway in use during all phases of operation. I also strongly advocate for the installation of a PAPI/VASI system at lax for the previous reasons. Supplemental information from acn 586115: during my intercept of the ILS course, I became task saturated and overshot the final approach course. As I glanced in the cockpit to check flap speeds, lower the gear, and level off the altitude, I saw that I was aligned with the runway 25L approach course. I quickly applied bank to correct my alignment. At no time did I feel that any aircraft was in danger, nor was any aircraft told to break out.
Original NASA ASRS Text
Title: FLT CREW OF B733 BECAME DISORIENTED DURING TURN TO VISUAL FINAL RWY 25R (OR RWY 24R, DEPENDING ON WHICH RPT IS CORRECT) AT LAX WHEN VISIBILITY WAS COMPROMISED BY HAZE AND AFTERNOON SUN. PNF WAS OCCUPIED WITH NUMEROUS DUTIES, AND BOTH PLTS WERE FATIGUED.
Narrative: I WAS CAPT AND PNF ON FLT ZZZ-LAX. THIS WAS THE 4TH FLT OF THE DAY, 4TH ACFT OF THE DAY, 4TH SET OF FLT ATTENDANTS OF THE DAY, THIRD DAY OF FLYING FOR MYSELF AND THE 4TH DAY OF FLYING FOR THE FO. WE WERE 1 HR LATE OUT OF ZZZ DUE TO AIRPLANE CHANGE/CONNECT. ACFT WAS SPD LIMITED DUE TO FLAP/SLAT INDICATION PROB. NORMAL FLT AND RTEING TO LAX. WE WERE CLRED FOR A VISUAL APCH TO FOLLOW A COMMUTER ACFT 3 NM AHEAD, TURNING A 5 NM FINAL TO RWY 24R LAX. A FEW CLOUDS WERE IN THE AREA OF THE APCH END OF RWY 24. WE TURNED A NORMAL BASE AT APPROX 6 NM, 180 KTS, RWY 24R, AND TFC AHEAD WAS IN SIGHT. THE FO SAID HE WOULD SQUARE THE TURN TO FINAL SOMEWHAT TO INCREASE THE SPACING ON THE ACFT AHEAD. THE ILS FREQ WAS TUNED FOR RWY 24R AND VOR/LOC SELECTED ON THE MCP. I OBSERVED THE FO BEGIN THE TURN TO FINAL. DURING THE TURN TO FINAL, THE FO CALLED FOR FLAPS 15, GEAR DOWN FINAL DSCNT CHK, SLOWED TO 160 KTS. AS I SET FLAPS, GEAR, MADE 2500 FT CALL, CHKED ALTIMETERS, RECEIVED THE CALL TO SWITCH TO TWR, FINISHED CHKLIST, I WAS HEAD INSIDE THE COCKPIT. WHEN I LOOKED UP, I SAW WE HAD OVERSHOT FINAL FOR RWY 24R. I CALLED FOR THE FO TO IMMEDIATELY CORRECT TO THE R. AS WE WERE TURNING TO CORRECT, APCH CTL CALLED AND GAVE US A HDG OF 270 DEGS TO THE R. I ACKNOWLEDGED THE CALL, AND SAID WE WERE CORRECTING. THE FO MADE AN APPROPRIATE CORRECTION TO RWY 24R. NORMAL, STABILIZED APCH AND LNDG FOLLOWED. IN DEBRIEFING THE INCIDENT, THE FO SAID THAT THE FEW CLOUDS IN THE AREA OF RWY 24R WERE A FACTOR IN LEADING TO DISORIENTATION, AND A SUBSEQUENT REDUCTION IN BANK ANGLE DURING THE TURN TO FINAL. ADDITIONAL FACTORS THAT MAY HAVE CONTRIBUTED TO THIS INCIDENT: 1) DISTR BY MYSELF DURING A CRITICAL PHASE OF FLT DURING THE TURN TO FINAL. 2) FAILURE BY THE PF TO RECOGNIZE DISORIENTATION DURING THE TURN TO FINAL. 3) FAILURE TO USE ALL TOOLS AVAILABLE, (LOC, FLT DIRECTOR, MAP DISPLAY) TO VERIFY OUR POS. 4) FAILURE TO PRIORITIZE TASKS AND BACKUP THE PF DURING A CRITICAL PHASE OF FLT. 5) WX IN THE AREA OF THE RWY AS WELL AS LOW LIGHT CONDITIONS AT DUSK, AND HAZE. 6) APCH/RWY LIGHTING NOT IN USE. 7) NO PAPI/VASI INSTALLED AT LAX. 8) FATIGUE BY THE PLTS DUE TO MULTIPLE 4-LEG DAYS, ACFT CHANGES, CREW CHANGES, DELAY ON LAST LEG OF LAST DAY. NOTE: AS AN LAX-BASED PLT, I HAVE FLOWN HUNDREDS OF THESE SAME APCHS UNDER THE SAME OR SIMILAR CONDITIONS WITHOUT INCIDENT. THE HAZE, FLYING INTO THE SUN AND MARINE LAYER ARE CONSTANT COMPANIONS TO PLTS FLYING INTO LAX. HIGH TFC COUNTS AND THE CONGESTED VISUAL APCH ENVIRONMENT MAKE LAX A CHALLENGING LOCATION. I STRONGLY ADVOCATE FOR LAX TO USE THEIR APCH LIGHTING SYS ON A HIGH VISIBILITY SETTING, EVEN DURING VFR CONDITIONS, TO HELP PLTS MAINTAIN A STRONG SENSE OF ORIENTATION TO THE RWY IN USE DURING ALL PHASES OF OPERATION. I ALSO STRONGLY ADVOCATE FOR THE INSTALLATION OF A PAPI/VASI SYS AT LAX FOR THE PREVIOUS REASONS. SUPPLEMENTAL INFO FROM ACN 586115: DURING MY INTERCEPT OF THE ILS COURSE, I BECAME TASK SATURATED AND OVERSHOT THE FINAL APCH COURSE. AS I GLANCED IN THE COCKPIT TO CHK FLAP SPDS, LOWER THE GEAR, AND LEVEL OFF THE ALT, I SAW THAT I WAS ALIGNED WITH THE RWY 25L APCH COURSE. I QUICKLY APPLIED BANK TO CORRECT MY ALIGNMENT. AT NO TIME DID I FEEL THAT ANY ACFT WAS IN DANGER, NOR WAS ANY ACFT TOLD TO BREAK OUT.
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.