 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Flight crew of A319, task saturated by an unexpected slam dunk type of visual approach, landing without clearance at las.
| Attributes | |
| ACN | 599649 |
| Time | |
| Date | 200311 |
| Day | Sat |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : las.airport |
| State Reference | NV |
| Altitude | agl single value : 0 |
| Environment | |
| Flight Conditions | IMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tower : las.tower |
| Operator | common carrier : air carrier |
| Make Model Name | A319 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | landing : roll |
| Route In Use | approach : visual |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : multi engine pilot : atp |
| Experience | flight time last 90 days : 200 flight time total : 9150 flight time type : 3775 |
| ASRS Report | 599649 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : commercial pilot : multi engine pilot : instrument pilot : atp |
| Experience | flight time last 90 days : 165 flight time total : 10001 flight time type : 619 |
| ASRS Report | 599964 |
| Events | |
| Anomaly | incursion : landing without clearance non adherence : company policies non adherence : far other anomaly |
| Independent Detector | other flight crewa |
| Resolutory Action | none taken : detected after the fact |
| Supplementary | |
| Problem Areas | Environmental Factor Flight Crew Human Performance Aircraft ATC Human Performance |
| Primary Problem | Flight Crew Human Performance |
Narrative:
This was the final leg of a long day of flying (jfk-lax-las, approximately 7 hours 15 mins of block flight time). We were vectored off of the kepec 1 RNAV arrival, for a close approach/visual to runway 25L at lax. The aircraft was high on the approach profile, and the PF and I faced a high workload period -- configuring the aircraft, modifying the level of aircraft automation (clearing waypoints in the mcdu, changing settings on the FCU/flight director setup), running the landing checklist, making proper altitude callouts, and visually scanning for traffic. As the approach progressed, the captain and I became engrossed in a discussion about an incorrect 'ground speed mini' calculation on our airspeed indicators. (Ground speed mini is an energy management feature used by A319/A320 on final approach.) the landing proceeded normally, until I realized during the landing rollout that the #1 radio had not been switched to the tower frequency. We may have made our landing without a clearance. We switched immediately to the tower frequency and checked in while rolling out and clearing the runway. Without further comment, the tower controller issued a taxi clearance and frequency change to ramp control. Though surprised at my oversight, I can honestly say there was no reckless intent on my part or on the part of the captain. In my opinion, a period of high workload, a momentary fixation/omission with an unexpected indication on flight instruments, and a certain component of fatigue resulted in not changing radio frequencys in a timely manner. Even the captain was unaware of what had occurred, claiming his focus was more on aircraft flight path/control and making a stabilized approach. Our own 'reminder' procedures used to confirm receipt of a landing clearance failed due to distraction, fixation/omission, and fatigue. Perhaps a more standardized method (ie, an added item in a landing checklist) to confirm receipt of a landing clearance could prevent future mishaps like this one.
Original NASA ASRS Text
Title: FLT CREW OF A319, TASK SATURATED BY AN UNEXPECTED SLAM DUNK TYPE OF VISUAL APCH, LWOC AT LAS.
Narrative: THIS WAS THE FINAL LEG OF A LONG DAY OF FLYING (JFK-LAX-LAS, APPROX 7 HRS 15 MINS OF BLOCK FLT TIME). WE WERE VECTORED OFF OF THE KEPEC 1 RNAV ARR, FOR A CLOSE APCH/VISUAL TO RWY 25L AT LAX. THE ACFT WAS HIGH ON THE APCH PROFILE, AND THE PF AND I FACED A HIGH WORKLOAD PERIOD -- CONFIGURING THE ACFT, MODIFYING THE LEVEL OF ACFT AUTOMATION (CLRING WAYPOINTS IN THE MCDU, CHANGING SETTINGS ON THE FCU/FLT DIRECTOR SETUP), RUNNING THE LNDG CHKLIST, MAKING PROPER ALT CALLOUTS, AND VISUALLY SCANNING FOR TFC. AS THE APCH PROGRESSED, THE CAPT AND I BECAME ENGROSSED IN A DISCUSSION ABOUT AN INCORRECT 'GND SPD MINI' CALCULATION ON OUR AIRSPD INDICATORS. (GND SPD MINI IS AN ENERGY MGMNT FEATURE USED BY A319/A320 ON FINAL APCH.) THE LNDG PROCEEDED NORMALLY, UNTIL I REALIZED DURING THE LNDG ROLLOUT THAT THE #1 RADIO HAD NOT BEEN SWITCHED TO THE TWR FREQ. WE MAY HAVE MADE OUR LNDG WITHOUT A CLRNC. WE SWITCHED IMMEDIATELY TO THE TWR FREQ AND CHKED IN WHILE ROLLING OUT AND CLRING THE RWY. WITHOUT FURTHER COMMENT, THE TWR CTLR ISSUED A TAXI CLRNC AND FREQ CHANGE TO RAMP CTL. THOUGH SURPRISED AT MY OVERSIGHT, I CAN HONESTLY SAY THERE WAS NO RECKLESS INTENT ON MY PART OR ON THE PART OF THE CAPT. IN MY OPINION, A PERIOD OF HIGH WORKLOAD, A MOMENTARY FIXATION/OMISSION WITH AN UNEXPECTED INDICATION ON FLT INSTS, AND A CERTAIN COMPONENT OF FATIGUE RESULTED IN NOT CHANGING RADIO FREQS IN A TIMELY MANNER. EVEN THE CAPT WAS UNAWARE OF WHAT HAD OCCURRED, CLAIMING HIS FOCUS WAS MORE ON ACFT FLT PATH/CTL AND MAKING A STABILIZED APCH. OUR OWN 'REMINDER' PROCS USED TO CONFIRM RECEIPT OF A LNDG CLRNC FAILED DUE TO DISTR, FIXATION/OMISSION, AND FATIGUE. PERHAPS A MORE STANDARDIZED METHOD (IE, AN ADDED ITEM IN A LNDG CHKLIST) TO CONFIRM RECEIPT OF A LNDG CLRNC COULD PREVENT FUTURE MISHAPS LIKE THIS ONE.
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.