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|
Attributes | |
ACN | 616460 |
Time | |
Date | 200405 |
Day | Sat |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : mdw.airport |
State Reference | IL |
Altitude | agl bound lower : 0 agl bound upper : 1000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : mdw.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach landing : roll |
Route In Use | approach : visual |
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 : 18000 flight time type : 13000 |
ASRS Report | 616460 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : multi engine |
Experience | flight time last 90 days : 130 flight time total : 5500 flight time type : 1800 |
ASRS Report | 616444 |
Events | |
Anomaly | incursion : runway inflight encounter : weather non adherence : company policies non adherence : clearance non adherence : far non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Weather Company Airport |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Neither of us had slept well the night before. He had a sore neck and my room had been next to the maid's utility room where the noise started at XA30. We were glad that this was the last and easiest day of our trip. We were scheduled for 4 legs and 8 hours of duty. That all changed when we arrived at the airport and operations informed us that our flight was running 3-4 hours late. There were multiple lines of thunderstorms moving through ZZZ. We were finally released from gate hold 6 hours later and departed for ZZZ. There were still thunderstorms on the arrival and we were the pathfinders for the arrs from the south. I was hoping that our flight to our next city and back to ZZZ would be stubbed so that we could get back on schedule to mdw but, no such luck. We flew the next leg almost full both ways. Flying back to ZZZ we both realized we were tired, but there was a plane full of people that needed us to get them to mdw. On our flight to mdw, I mentioned to my first officer that he had the cockpit pretty cold. He said he thought that would help keep us awake and alert. We got a direct clearance to mdw and a crossing restr to cross 20 mi east of mdw at 10000 ft. This seemed a little strange, but hey, it was late at night and there wasn't much traffic. Mdw ATIS showed gusty winds and the ILS to runway 4R circle to runway 13C. I briefed the approach, but we both agreed that we would probably get the visual to runway 13C and set the ILS in our radios and set the inbound course. I was still using LNAV to the fix when we were handed off to approach and they cleared us to 6000 ft, at about 10 mi northeast of mdw. We called the airport and were cleared for the visual to runway 13C. At 5 mi north and descending through 5000 ft, we were handed off to the tower and they cleared us to land on runway 13C. We were still a little high and I didn't want to go too far toward ohare airspace, so I decided to configure on speed to flaps 40 degrees and keep a 4 mi pattern. I continued to descend on the base and just prior to turning final, I noticed my HSI selector was still on navigation, so I flipped it up to monitor the ILS. I also realized we hadn't run the 'before landing' checklist, so we completed it. As I turned on final, I checked that we were on GS and since I was still a little north of the extended centerline, the localizer was not centered. I rolled out on final, made my 1000 ft calls. (We were configured, on speed, and GS. I transitioned to the VASI and made a smooth touchdown on the 1000 ft marker.) after moderate use of brakes and thrust reverse, we were cleared by tower to exit the runway and taxi to the gate. The first officer said that operations might have us wait out because our gate was occupied. I thought, at this late hour? We cleared the end of the concourse and could see our gate was open. We taxied into the gate, deplaned, and ran our checklist. The airplane was handed off to maintenance and we were finally done. Then came the message to call the tower. The tower controller was almost apologetic when he asked if I realized that we had landed on runway 13L. I was shocked. I said, 'no are you sure?' my first officer and I couldn't believe it. We had landed on the wrong runway. I spent many sleepless hours reflecting on the events leading up to our arrival. How could we both have made this mistake? The following facts became apparent. We were a tired crew on the last leg home after a long day filled with lengthy delays and bad WX. In the last 20 yrs, I had flown into mdw a thousand times before without any problems, but I had never flown a visual approach to runway 13C at night from that direction. I accepted a clearance that kept us high and tight and I got busy trying to configure and descend while keeping the aircraft close to the airport. Yes, we had briefed the ILS backup and our radios were set, but I was slow to set my HSI switch and my attention got diverted outside flying the approach. Supplemental information from acn 616444: we configured and descended making left traffic to runway 13C visual. We both had the ILS runway 13C dialed in. I reminded the captain about the before landing checklist and accomplished it prior to the 1000 ft call, sticking to stabilized approach criteria. Mdw tower cleared us to land and my captain finished turning final onto the runway lights. (As he was doing this, I noticed the localizer moving towards center and then began to pay more attention to his GS and descent.) I called him 1 DOT high and then he noticed his navigation was still in LNAV position. He corrected the switch position and corrected his descent and we made a nice landing with minimal braking with a turn off at the end. Tower was looking for us and wanted us to call them. Tower informed us that we had actually landed on the left runway and not the center. They wanted us to be aware of this and be more careful. The tower had informed us there was no harm done and it would be like that phone call and incident never happened. The biggest contributing factors to this would have to be, in my opinion, fatigue, shooting an approach not used too often, and a bit of complacency.
Original NASA ASRS Text
Title: B733 FLT CREW MAKES WRONG RWY APCH AND LNDG DURING A NIGHT OP AT MDW, IL.
Narrative: NEITHER OF US HAD SLEPT WELL THE NIGHT BEFORE. HE HAD A SORE NECK AND MY ROOM HAD BEEN NEXT TO THE MAID'S UTILITY ROOM WHERE THE NOISE STARTED AT XA30. WE WERE GLAD THAT THIS WAS THE LAST AND EASIEST DAY OF OUR TRIP. WE WERE SCHEDULED FOR 4 LEGS AND 8 HRS OF DUTY. THAT ALL CHANGED WHEN WE ARRIVED AT THE ARPT AND OPS INFORMED US THAT OUR FLT WAS RUNNING 3-4 HRS LATE. THERE WERE MULTIPLE LINES OF TSTMS MOVING THROUGH ZZZ. WE WERE FINALLY RELEASED FROM GATE HOLD 6 HRS LATER AND DEPARTED FOR ZZZ. THERE WERE STILL TSTMS ON THE ARR AND WE WERE THE PATHFINDERS FOR THE ARRS FROM THE S. I WAS HOPING THAT OUR FLT TO OUR NEXT CITY AND BACK TO ZZZ WOULD BE STUBBED SO THAT WE COULD GET BACK ON SCHEDULE TO MDW BUT, NO SUCH LUCK. WE FLEW THE NEXT LEG ALMOST FULL BOTH WAYS. FLYING BACK TO ZZZ WE BOTH REALIZED WE WERE TIRED, BUT THERE WAS A PLANE FULL OF PEOPLE THAT NEEDED US TO GET THEM TO MDW. ON OUR FLT TO MDW, I MENTIONED TO MY FO THAT HE HAD THE COCKPIT PRETTY COLD. HE SAID HE THOUGHT THAT WOULD HELP KEEP US AWAKE AND ALERT. WE GOT A DIRECT CLRNC TO MDW AND A XING RESTR TO CROSS 20 MI E OF MDW AT 10000 FT. THIS SEEMED A LITTLE STRANGE, BUT HEY, IT WAS LATE AT NIGHT AND THERE WASN'T MUCH TFC. MDW ATIS SHOWED GUSTY WINDS AND THE ILS TO RWY 4R CIRCLE TO RWY 13C. I BRIEFED THE APCH, BUT WE BOTH AGREED THAT WE WOULD PROBABLY GET THE VISUAL TO RWY 13C AND SET THE ILS IN OUR RADIOS AND SET THE INBOUND COURSE. I WAS STILL USING LNAV TO THE FIX WHEN WE WERE HANDED OFF TO APCH AND THEY CLRED US TO 6000 FT, AT ABOUT 10 MI NE OF MDW. WE CALLED THE ARPT AND WERE CLRED FOR THE VISUAL TO RWY 13C. AT 5 MI N AND DSNDING THROUGH 5000 FT, WE WERE HANDED OFF TO THE TWR AND THEY CLRED US TO LAND ON RWY 13C. WE WERE STILL A LITTLE HIGH AND I DIDN'T WANT TO GO TOO FAR TOWARD OHARE AIRSPACE, SO I DECIDED TO CONFIGURE ON SPD TO FLAPS 40 DEGS AND KEEP A 4 MI PATTERN. I CONTINUED TO DSND ON THE BASE AND JUST PRIOR TO TURNING FINAL, I NOTICED MY HSI SELECTOR WAS STILL ON NAV, SO I FLIPPED IT UP TO MONITOR THE ILS. I ALSO REALIZED WE HADN'T RUN THE 'BEFORE LNDG' CHKLIST, SO WE COMPLETED IT. AS I TURNED ON FINAL, I CHKED THAT WE WERE ON GS AND SINCE I WAS STILL A LITTLE N OF THE EXTENDED CTRLINE, THE LOC WAS NOT CTRED. I ROLLED OUT ON FINAL, MADE MY 1000 FT CALLS. (WE WERE CONFIGURED, ON SPD, AND GS. I TRANSITIONED TO THE VASI AND MADE A SMOOTH TOUCHDOWN ON THE 1000 FT MARKER.) AFTER MODERATE USE OF BRAKES AND THRUST REVERSE, WE WERE CLRED BY TWR TO EXIT THE RWY AND TAXI TO THE GATE. THE FO SAID THAT OPS MIGHT HAVE US WAIT OUT BECAUSE OUR GATE WAS OCCUPIED. I THOUGHT, AT THIS LATE HR? WE CLRED THE END OF THE CONCOURSE AND COULD SEE OUR GATE WAS OPEN. WE TAXIED INTO THE GATE, DEPLANED, AND RAN OUR CHKLIST. THE AIRPLANE WAS HANDED OFF TO MAINT AND WE WERE FINALLY DONE. THEN CAME THE MESSAGE TO CALL THE TWR. THE TWR CTLR WAS ALMOST APOLOGETIC WHEN HE ASKED IF I REALIZED THAT WE HAD LANDED ON RWY 13L. I WAS SHOCKED. I SAID, 'NO ARE YOU SURE?' MY FO AND I COULDN'T BELIEVE IT. WE HAD LANDED ON THE WRONG RWY. I SPENT MANY SLEEPLESS HRS REFLECTING ON THE EVENTS LEADING UP TO OUR ARR. HOW COULD WE BOTH HAVE MADE THIS MISTAKE? THE FOLLOWING FACTS BECAME APPARENT. WE WERE A TIRED CREW ON THE LAST LEG HOME AFTER A LONG DAY FILLED WITH LENGTHY DELAYS AND BAD WX. IN THE LAST 20 YRS, I HAD FLOWN INTO MDW A THOUSAND TIMES BEFORE WITHOUT ANY PROBS, BUT I HAD NEVER FLOWN A VISUAL APCH TO RWY 13C AT NIGHT FROM THAT DIRECTION. I ACCEPTED A CLRNC THAT KEPT US HIGH AND TIGHT AND I GOT BUSY TRYING TO CONFIGURE AND DSND WHILE KEEPING THE ACFT CLOSE TO THE ARPT. YES, WE HAD BRIEFED THE ILS BACKUP AND OUR RADIOS WERE SET, BUT I WAS SLOW TO SET MY HSI SWITCH AND MY ATTN GOT DIVERTED OUTSIDE FLYING THE APCH. SUPPLEMENTAL INFO FROM ACN 616444: WE CONFIGURED AND DSNDED MAKING L TFC TO RWY 13C VISUAL. WE BOTH HAD THE ILS RWY 13C DIALED IN. I REMINDED THE CAPT ABOUT THE BEFORE LNDG CHKLIST AND ACCOMPLISHED IT PRIOR TO THE 1000 FT CALL, STICKING TO STABILIZED APCH CRITERIA. MDW TWR CLRED US TO LAND AND MY CAPT FINISHED TURNING FINAL ONTO THE RWY LIGHTS. (AS HE WAS DOING THIS, I NOTICED THE LOC MOVING TOWARDS CTR AND THEN BEGAN TO PAY MORE ATTN TO HIS GS AND DSCNT.) I CALLED HIM 1 DOT HIGH AND THEN HE NOTICED HIS NAV WAS STILL IN LNAV POS. HE CORRECTED THE SWITCH POS AND CORRECTED HIS DSCNT AND WE MADE A NICE LNDG WITH MINIMAL BRAKING WITH A TURN OFF AT THE END. TWR WAS LOOKING FOR US AND WANTED US TO CALL THEM. TWR INFORMED US THAT WE HAD ACTUALLY LANDED ON THE L RWY AND NOT THE CTR. THEY WANTED US TO BE AWARE OF THIS AND BE MORE CAREFUL. THE TWR HAD INFORMED US THERE WAS NO HARM DONE AND IT WOULD BE LIKE THAT PHONE CALL AND INCIDENT NEVER HAPPENED. THE BIGGEST CONTRIBUTING FACTORS TO THIS WOULD HAVE TO BE, IN MY OPINION, FATIGUE, SHOOTING AN APCH NOT USED TOO OFTEN, AND A BIT OF COMPLACENCY.
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.