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|
Attributes | |
ACN | 677896 |
Time | |
Date | 200511 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : egkk.airport |
State Reference | FO |
Altitude | agl single value : 1000 |
Environment | |
Flight Conditions | VMC VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : egkk.tower |
Operator | common carrier : air carrier |
Make Model Name | B767-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach |
Flight Plan | IFR |
Aircraft 2 | |
Route In Use | approach : visual |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : relief pilot oversight : pic |
Qualification | pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 230 flight time total : 15000 flight time type : 3500 |
ASRS Report | 677896 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 20000 flight time type : 1000 |
ASRS Report | 677619 |
Events | |
Anomaly | non adherence : company policies non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | controller : issued alert flight crew : regained aircraft control |
Consequence | faa : investigated other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
Flight to egkk on visual approach to runway 26L; at about 1000 ft AGL; had flaps 20 degrees and captain (PF) called for 'gear down; landing checklist.' captain (PF) called for 'flaps 30 degrees;' first officer commented something about the 'landing gear.' london tower called about the same time; advising our landing gear was retracted. And we simultaneously get an audio warning 'too low gear; too low flaps?' we advise egkk we are aware; captain called for the landing gear again (or he at least called for the checklist at 1000 ft and the gear was overlooked) and the gear was extended somewhere between 500-350 ft. Landing flaps (30 degrees) were extended; checklist completed and we accomplished a normal landing that was uneventful. From my perspective; as the so; the problem arose due to fatigue and exhaustion. Contributing factors: air carrier nonstandard policy of providing for adequate crew rest (both before a trip and en route). To the best of my recollection; the problem was discovered: via the checklist; automation; and tower observation. I had been awake for nearly 24 hours at the time of this event. I don't recall taking a crew break. At my seniority; we don't always dispatch with a third pilot. Consequently; I don't routinely retire to the cabin (crew rest seat) because half the time it's not available. I can't overemphasize enough what a hindrance or liability air carrier's nonstandard practice of flying with/without the third pilot is. The approach was thoroughly briefed by the PF. I remember what I thought might have been some unnecessary speed assignments by egkk approach. However; after the captain called for the 'landing checklist;' I relaxed a bit (my fault); and didn't follow the line-by-line execution (to include gear) of the checklist. Callback conversation with reporter revealed the following information: reporter stated that the british aeronautical auths notified the FAA and the air carrier about this incident. The reporter's contribution to this event was fatigue and having been told very recently by a check airman that the relief officer had no place responding to checklists. This led the reporter to be less vigilant. The end result of this event was the FAA is not taking enforcement action; but the air carrier gave the pilots 2 weeks off without pay. Supplemental information from acn 677619: flight XXX inbound to london's gatwick airport. I was flying on visual approach; called for landing checklist at about 1000 ft AGL had flaps 20 degrees out. Called for flaps 30 degrees. The first officer missed the call for gear down. At about same time the control tower called to say our gear was not down. We advised the tower that we were aware; lowered gear not less than 500 ft AGL; landed normal. Having flown all night from ZZZ to lgw we missed the gear call; all else was normal. I will now do checklist earlier when fatigued.
Original NASA ASRS Text
Title: A FATIGUED B767-200 CREW LOWERED THE LNDG GEAR AT 1000 FT ON APCH TO EGKK FOLLOWING AN ALL NIGHT INTL FLT.
Narrative: FLT TO EGKK ON VISUAL APCH TO RWY 26L; AT ABOUT 1000 FT AGL; HAD FLAPS 20 DEGS AND CAPT (PF) CALLED FOR 'GEAR DOWN; LNDG CHKLIST.' CAPT (PF) CALLED FOR 'FLAPS 30 DEGS;' FO COMMENTED SOMETHING ABOUT THE 'LNDG GEAR.' LONDON TWR CALLED ABOUT THE SAME TIME; ADVISING OUR LNDG GEAR WAS RETRACTED. AND WE SIMULTANEOUSLY GET AN AUDIO WARNING 'TOO LOW GEAR; TOO LOW FLAPS?' WE ADVISE EGKK WE ARE AWARE; CAPT CALLED FOR THE LNDG GEAR AGAIN (OR HE AT LEAST CALLED FOR THE CHKLIST AT 1000 FT AND THE GEAR WAS OVERLOOKED) AND THE GEAR WAS EXTENDED SOMEWHERE BTWN 500-350 FT. LNDG FLAPS (30 DEGS) WERE EXTENDED; CHKLIST COMPLETED AND WE ACCOMPLISHED A NORMAL LNDG THAT WAS UNEVENTFUL. FROM MY PERSPECTIVE; AS THE SO; THE PROB AROSE DUE TO FATIGUE AND EXHAUSTION. CONTRIBUTING FACTORS: ACR NONSTANDARD POLICY OF PROVIDING FOR ADEQUATE CREW REST (BOTH BEFORE A TRIP AND ENRTE). TO THE BEST OF MY RECOLLECTION; THE PROB WAS DISCOVERED: VIA THE CHKLIST; AUTOMATION; AND TWR OBSERVATION. I HAD BEEN AWAKE FOR NEARLY 24 HRS AT THE TIME OF THIS EVENT. I DON'T RECALL TAKING A CREW BREAK. AT MY SENIORITY; WE DON'T ALWAYS DISPATCH WITH A THIRD PLT. CONSEQUENTLY; I DON'T ROUTINELY RETIRE TO THE CABIN (CREW REST SEAT) BECAUSE HALF THE TIME IT'S NOT AVAILABLE. I CAN'T OVEREMPHASIZE ENOUGH WHAT A HINDRANCE OR LIABILITY ACR'S NONSTANDARD PRACTICE OF FLYING WITH/WITHOUT THE THIRD PLT IS. THE APCH WAS THOROUGHLY BRIEFED BY THE PF. I REMEMBER WHAT I THOUGHT MIGHT HAVE BEEN SOME UNNECESSARY SPD ASSIGNMENTS BY EGKK APCH. HOWEVER; AFTER THE CAPT CALLED FOR THE 'LNDG CHKLIST;' I RELAXED A BIT (MY FAULT); AND DIDN'T FOLLOW THE LINE-BY-LINE EXECUTION (TO INCLUDE GEAR) OF THE CHKLIST. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THE BRITISH AERONAUTICAL AUTHS NOTIFIED THE FAA AND THE ACR ABOUT THIS INCIDENT. THE RPTR'S CONTRIBUTION TO THIS EVENT WAS FATIGUE AND HAVING BEEN TOLD VERY RECENTLY BY A CHK AIRMAN THAT THE RELIEF OFFICER HAD NO PLACE RESPONDING TO CHKLISTS. THIS LED THE RPTR TO BE LESS VIGILANT. THE END RESULT OF THIS EVENT WAS THE FAA IS NOT TAKING ENFORCEMENT ACTION; BUT THE ACR GAVE THE PLTS 2 WKS OFF WITHOUT PAY. SUPPLEMENTAL INFO FROM ACN 677619: FLT XXX INBOUND TO LONDON'S GATWICK ARPT. I WAS FLYING ON VISUAL APCH; CALLED FOR LNDG CHKLIST AT ABOUT 1000 FT AGL HAD FLAPS 20 DEGS OUT. CALLED FOR FLAPS 30 DEGS. THE FO MISSED THE CALL FOR GEAR DOWN. AT ABOUT SAME TIME THE CTL TWR CALLED TO SAY OUR GEAR WAS NOT DOWN. WE ADVISED THE TWR THAT WE WERE AWARE; LOWERED GEAR NOT LESS THAN 500 FT AGL; LANDED NORMAL. HAVING FLOWN ALL NIGHT FROM ZZZ TO LGW WE MISSED THE GEAR CALL; ALL ELSE WAS NORMAL. I WILL NOW DO CHKLIST EARLIER WHEN FATIGUED.
Data retrieved from NASA's ASRS site as of January 2009 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.