37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 615009 |
Time | |
Date | 200404 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sfo.airport |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 500 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tower : sfo.tower |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach descent : intermediate altitude |
Route In Use | approach : charted visual approach : visual arrival other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 12000 flight time type : 6000 |
ASRS Report | 615009 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 50 flight time total : 17000 flight time type : 50 |
ASRS Report | 615010 |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : voice alert activated other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Big sur two arrival into sfo -- anticipated and received tip toe visual to runway 28L. Thoroughly briefed (30 degree flap) visual and ILS to runway 28L. In descent from 5000 ft altitude restr at menlo were given approach controller (frequency) change. New controller changed clearance to quiet bridge visual runway 28R, gave us parallel traffic at 9 O'clock position, and pressed us to call the traffic, bridge, and runway in sight. Scrambling to comply, I lost situational awareness as I set up first officer for approach. Back in loop realized descent was not fast enough and (temporarily) put first officer to 40 degree flaps to get down. On GS meant to return to 30 degree flap, but selected 25 degrees. Realized error when voice alert activated. Speed was adequate for 25 degree flap landing and had first officer continue now stabilized approach to a proper touchdown. Problems: first officer new to airplane requiring maximum supervision. Demanding visual approach complicated by last min change by controller. My judgement accepting new approach that overtasked me. (I was verbally flying the approach as I set up the first officer as I monitored parallel traffic as I handle the radios. Even with veteran first officer we would have been challenged, but could have adequately handled the approach.) my judgement accepting, albeit a safe landing, one that was not within SOP. A go around would have created its own problems, but was the proper response.
Original NASA ASRS Text
Title: B737 CREW LANDED WITH 25 DEG FLAPS INSTEAD OF THE INTENDED 30 DEG FLAPS.
Narrative: BIG SUR TWO ARR INTO SFO -- ANTICIPATED AND RECEIVED TIP TOE VISUAL TO RWY 28L. THOROUGHLY BRIEFED (30 DEG FLAP) VISUAL AND ILS TO RWY 28L. IN DSCNT FROM 5000 FT ALT RESTR AT MENLO WERE GIVEN APCH CTLR (FREQ) CHANGE. NEW CTLR CHANGED CLRNC TO QUIET BRIDGE VISUAL RWY 28R, GAVE US PARALLEL TFC AT 9 O'CLOCK POS, AND PRESSED US TO CALL THE TFC, BRIDGE, AND RWY IN SIGHT. SCRAMBLING TO COMPLY, I LOST SITUATIONAL AWARENESS AS I SET UP FO FOR APCH. BACK IN LOOP REALIZED DSCNT WAS NOT FAST ENOUGH AND (TEMPORARILY) PUT FO TO 40 DEG FLAPS TO GET DOWN. ON GS MEANT TO RETURN TO 30 DEG FLAP, BUT SELECTED 25 DEGS. REALIZED ERROR WHEN VOICE ALERT ACTIVATED. SPD WAS ADEQUATE FOR 25 DEG FLAP LNDG AND HAD FO CONTINUE NOW STABILIZED APCH TO A PROPER TOUCHDOWN. PROBS: FO NEW TO AIRPLANE REQUIRING MAX SUPERVISION. DEMANDING VISUAL APCH COMPLICATED BY LAST MIN CHANGE BY CTLR. MY JUDGEMENT ACCEPTING NEW APCH THAT OVERTASKED ME. (I WAS VERBALLY FLYING THE APCH AS I SET UP THE FO AS I MONITORED PARALLEL TFC AS I HANDLE THE RADIOS. EVEN WITH VETERAN FO WE WOULD HAVE BEEN CHALLENGED, BUT COULD HAVE ADEQUATELY HANDLED THE APCH.) MY JUDGEMENT ACCEPTING, ALBEIT A SAFE LNDG, ONE THAT WAS NOT WITHIN SOP. A GAR WOULD HAVE CREATED ITS OWN PROBS, BUT WAS THE PROPER RESPONSE.
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.