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Attributes | |
ACN | 690264 |
Time | |
Date | 200603 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : clt.airport |
State Reference | NC |
Altitude | agl single value : 1000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : clt.tracon tower : dfw.tower |
Operator | general aviation : personal |
Make Model Name | Citation Excel |
Operating Under FAR Part | Part 91 |
Navigation In Use | ils localizer only : 18l other |
Flight Phase | descent : approach |
Route In Use | approach : visual |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : clt.tracon |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 75 flight time total : 6000 flight time type : 75 |
ASRS Report | 690264 |
Person 2 | |
Affiliation | other |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 75 flight time total : 6000 flight time type : 200 |
ASRS Report | 690213 |
Events | |
Anomaly | conflict : airborne less severe non adherence : clearance other spatial deviation |
Independent Detector | other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued advisory flight crew : returned to original clearance |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 6600 vertical : 100 |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
The PNF set up the FMS and navigation frequencys for an ILS approach to runway 23 as a backup to a visual landing. The approach was briefed and runway 23 environment was talked about to include the length; direction of turnoff and possible taxiway. On downwind; the approach controller called our traffic that we would be following at our 10 O' clock position approximately 2 mi. Both myself and the PNF picked up our traffic visually and told the controller we had our traffic in sight. We were cleared for a l-hand; descending turn to follow our traffic with instructions not to go below 4000 ft before 11 mi from the field and asked to slow turn. I lined up on runway 23 using my ILS information as backup and configured the aircraft with flaps approach and gear down to slow to approximately 160 KTS for spacing. At approximately 7-8 mi out we were asked by approach if we would like a runway change to runway 18L. After discussing it with my copilot; we decided to accept the runway change because the taxi to the FBO would be less complicated. We accepted the change and I made a r-hand turn to approximately 270 degrees to set up for a left base to runway 18L. We were also told that there would be 1 aircraft departing from runway 18L prior to our landing. When I rolled out of my turn and looked up; I immediately saw a white concrete runway that I idented as runway 18L. I also saw an aircraft taxiing onto the runway which is what I expected given what I had been told by approach. We were switched to tower and I continued my left base for the runway. As I continued my approach; I noticed in my peripheral vision as I looked inside at the instrument panel that the PNF was heads down changing the approach in the FMS from the ILS to runway 23 to the ILS to runway 18L to provide me added backup guidance for my landing. At approximately 500-700 ft and 3 mi from the runway on the left base runway; tower called and told me to make an immediate l-hand turn. My reaction was to look left and as I did I realized I had just passed runway 18L and was on a left base for runway 18R. When the call was made; the PNF looked up from the FMS and immediately called 'we're cleared to land on runway 18L; 18L.' I continued my l-hand turn and made a normal landing on runway 18L. On taxi to the FBO we were asked to call TRACON when we shut down. I made the phone call and explained my mistake. The controller subsequently called me back and said that he was going to file an incident report because we had come within 1.1 mi lateral separation and 100 ft vertical separation of a regional airliner and that the airliner was asked to break out to help maintain lateral separation as I turned left back to runway 18L. Dominoes -- let me say up front that I was clearly wrong in my actions. I accepted the runway change to runway 18L and misidented runway 18R for runway 18L. The following is my best analysis of the events that occurred that put myself and another experienced pilot in a position to be preparing to land on the wrong runway. 1) when the initial runway change was given; I made an immediate right turn to set myself up for a base to runway 18. During this turn; I looked at my instruments to monitor angle of bank and rate of descent in the turn. When I looked back out to where I expected to see the runway; I immediately saw a runway in front of me that I assumed was runway 18L. A runway diagram shows that runway 18R extends approximately 1400 ft beyond runway 18L at the approach end of the runways. 2) the second visual cue that helped me to pick up runway 18R first was the fact that it is a white concrete whereas runway 18L is a black asphalt. With the VMC conditions at the time; runway 18R stood out and was the first thing I picked up when I looked out. I obviously made the wrong assumption that both runways would be the same color and that I would pick up the other runway as I got closer. 3) the last visual cue that convinced me that I had the correct runway was the aircraft taking the runway when I first acquired it visually. Since I had been told there was one to depart before I arrived; that visual picture made sense to me and further convinced me I was going to the correct runway. At that point my focus became the end of that runway and the aircraft departing. The rest of the airport environment faded to the backgnd of my focus.4) the last domino was my not requiring the PNF to re-brief the landing since the runway had changed and to visually verify my intent to land on the runway I had idented as runway 18L. Instead; I allowed him to continue to work on putting in an approach I didn't need because of the visual conditions thus rendering him ineffective in identing the mistake I had made in misidenting runway 18R as runway 18L and as my intended point of landing. Root cause: poor CRM on my part. After 30 yrs of flying; to include 22 in the military; I would love nothing more than to say this was caused by something other than myself. It is hard to admit that with my experience level; the sophistication of the aircraft I was flying; and the existing VMC conditions; I could make so basic an error. However; no matter how I slice the apple it comes down to my not running the cockpit correctly when the runway change was made. I should have required the PNF to re-brief the runway environment I was going to see for landing and to visually verify the correct runway as we normally do as a matter of routine. Because of my misguided comfort level in having idented the correct runway for landing; I allowed the PNF to continue to work on putting an approach in the FMS that I didn't need when he should have been heads up and eyes out during this critical phase of the flight. Had I required my copilot to re-brief the landing environment or merely told him to not worry about putting in an approach that I didn't need and to stay outside the aircraft; I am convinced he would have immediately picked up my error and we would have corrected it long before I crossed the extended centerline for runway 18L. This is especially frustrating given the fact that I recently got my type rating in this aircraft and was shown an excellent film on CRM that addressed this exact issue. Heads down activity working on loading approachs into an FMS in the close-in runway environment instead of remaining heads up and working as a crew to ensure the aircraft is landed safely where it was cleared to land. Recommendations: I wish this were a unique problem that had a new and unique solution. However; it does not. It is the age old problem of not running a cockpit correctly and allowing things to transpire that are not helpful to the safety of the aircraft. I would recommend continued emphasis on when to program the FMS and when not to. The PNF and I had discussed it on many occasions and both concluded unnecessary use of the 'box' close in shouldn't happen. However; it did. And it did because I allowed it to happen and the PNF was confident in my abilities to properly identify a runway under VMC conditions.
Original NASA ASRS Text
Title: CITATION CE560XL FLT CREW WHILE MANEUVERING FOR LNDG TO PARALLEL RWYS; OVERSHOOTS THE CTRLINE; CAUSING ANOTHER ACFT TO GO AROUND.
Narrative: THE PNF SET UP THE FMS AND NAV FREQS FOR AN ILS APCH TO RWY 23 AS A BACKUP TO A VISUAL LNDG. THE APCH WAS BRIEFED AND RWY 23 ENVIRONMENT WAS TALKED ABOUT TO INCLUDE THE LENGTH; DIRECTION OF TURNOFF AND POSSIBLE TXWY. ON DOWNWIND; THE APCH CTLR CALLED OUR TFC THAT WE WOULD BE FOLLOWING AT OUR 10 O' CLOCK POS APPROX 2 MI. BOTH MYSELF AND THE PNF PICKED UP OUR TFC VISUALLY AND TOLD THE CTLR WE HAD OUR TFC IN SIGHT. WE WERE CLRED FOR A L-HAND; DSNDING TURN TO FOLLOW OUR TFC WITH INSTRUCTIONS NOT TO GO BELOW 4000 FT BEFORE 11 MI FROM THE FIELD AND ASKED TO SLOW TURN. I LINED UP ON RWY 23 USING MY ILS INFO AS BACKUP AND CONFIGURED THE ACFT WITH FLAPS APCH AND GEAR DOWN TO SLOW TO APPROX 160 KTS FOR SPACING. AT APPROX 7-8 MI OUT WE WERE ASKED BY APCH IF WE WOULD LIKE A RWY CHANGE TO RWY 18L. AFTER DISCUSSING IT WITH MY COPLT; WE DECIDED TO ACCEPT THE RWY CHANGE BECAUSE THE TAXI TO THE FBO WOULD BE LESS COMPLICATED. WE ACCEPTED THE CHANGE AND I MADE A R-HAND TURN TO APPROX 270 DEGS TO SET UP FOR A L BASE TO RWY 18L. WE WERE ALSO TOLD THAT THERE WOULD BE 1 ACFT DEPARTING FROM RWY 18L PRIOR TO OUR LNDG. WHEN I ROLLED OUT OF MY TURN AND LOOKED UP; I IMMEDIATELY SAW A WHITE CONCRETE RWY THAT I IDENTED AS RWY 18L. I ALSO SAW AN ACFT TAXIING ONTO THE RWY WHICH IS WHAT I EXPECTED GIVEN WHAT I HAD BEEN TOLD BY APCH. WE WERE SWITCHED TO TWR AND I CONTINUED MY L BASE FOR THE RWY. AS I CONTINUED MY APCH; I NOTICED IN MY PERIPHERAL VISION AS I LOOKED INSIDE AT THE INST PANEL THAT THE PNF WAS HEADS DOWN CHANGING THE APCH IN THE FMS FROM THE ILS TO RWY 23 TO THE ILS TO RWY 18L TO PROVIDE ME ADDED BACKUP GUIDANCE FOR MY LNDG. AT APPROX 500-700 FT AND 3 MI FROM THE RWY ON THE L BASE RWY; TWR CALLED AND TOLD ME TO MAKE AN IMMEDIATE L-HAND TURN. MY REACTION WAS TO LOOK L AND AS I DID I REALIZED I HAD JUST PASSED RWY 18L AND WAS ON A L BASE FOR RWY 18R. WHEN THE CALL WAS MADE; THE PNF LOOKED UP FROM THE FMS AND IMMEDIATELY CALLED 'WE'RE CLRED TO LAND ON RWY 18L; 18L.' I CONTINUED MY L-HAND TURN AND MADE A NORMAL LNDG ON RWY 18L. ON TAXI TO THE FBO WE WERE ASKED TO CALL TRACON WHEN WE SHUT DOWN. I MADE THE PHONE CALL AND EXPLAINED MY MISTAKE. THE CTLR SUBSEQUENTLY CALLED ME BACK AND SAID THAT HE WAS GOING TO FILE AN INCIDENT RPT BECAUSE WE HAD COME WITHIN 1.1 MI LATERAL SEPARATION AND 100 FT VERT SEPARATION OF A REGIONAL AIRLINER AND THAT THE AIRLINER WAS ASKED TO BREAK OUT TO HELP MAINTAIN LATERAL SEPARATION AS I TURNED L BACK TO RWY 18L. DOMINOES -- LET ME SAY UP FRONT THAT I WAS CLRLY WRONG IN MY ACTIONS. I ACCEPTED THE RWY CHANGE TO RWY 18L AND MISIDENTED RWY 18R FOR RWY 18L. THE FOLLOWING IS MY BEST ANALYSIS OF THE EVENTS THAT OCCURRED THAT PUT MYSELF AND ANOTHER EXPERIENCED PLT IN A POS TO BE PREPARING TO LAND ON THE WRONG RWY. 1) WHEN THE INITIAL RWY CHANGE WAS GIVEN; I MADE AN IMMEDIATE R TURN TO SET MYSELF UP FOR A BASE TO RWY 18. DURING THIS TURN; I LOOKED AT MY INSTS TO MONITOR ANGLE OF BANK AND RATE OF DSCNT IN THE TURN. WHEN I LOOKED BACK OUT TO WHERE I EXPECTED TO SEE THE RWY; I IMMEDIATELY SAW A RWY IN FRONT OF ME THAT I ASSUMED WAS RWY 18L. A RWY DIAGRAM SHOWS THAT RWY 18R EXTENDS APPROX 1400 FT BEYOND RWY 18L AT THE APCH END OF THE RWYS. 2) THE SECOND VISUAL CUE THAT HELPED ME TO PICK UP RWY 18R FIRST WAS THE FACT THAT IT IS A WHITE CONCRETE WHEREAS RWY 18L IS A BLACK ASPHALT. WITH THE VMC CONDITIONS AT THE TIME; RWY 18R STOOD OUT AND WAS THE FIRST THING I PICKED UP WHEN I LOOKED OUT. I OBVIOUSLY MADE THE WRONG ASSUMPTION THAT BOTH RWYS WOULD BE THE SAME COLOR AND THAT I WOULD PICK UP THE OTHER RWY AS I GOT CLOSER. 3) THE LAST VISUAL CUE THAT CONVINCED ME THAT I HAD THE CORRECT RWY WAS THE ACFT TAKING THE RWY WHEN I FIRST ACQUIRED IT VISUALLY. SINCE I HAD BEEN TOLD THERE WAS ONE TO DEPART BEFORE I ARRIVED; THAT VISUAL PICTURE MADE SENSE TO ME AND FURTHER CONVINCED ME I WAS GOING TO THE CORRECT RWY. AT THAT POINT MY FOCUS BECAME THE END OF THAT RWY AND THE ACFT DEPARTING. THE REST OF THE ARPT ENVIRONMENT FADED TO THE BACKGND OF MY FOCUS.4) THE LAST DOMINO WAS MY NOT REQUIRING THE PNF TO RE-BRIEF THE LNDG SINCE THE RWY HAD CHANGED AND TO VISUALLY VERIFY MY INTENT TO LAND ON THE RWY I HAD IDENTED AS RWY 18L. INSTEAD; I ALLOWED HIM TO CONTINUE TO WORK ON PUTTING IN AN APCH I DIDN'T NEED BECAUSE OF THE VISUAL CONDITIONS THUS RENDERING HIM INEFFECTIVE IN IDENTING THE MISTAKE I HAD MADE IN MISIDENTING RWY 18R AS RWY 18L AND AS MY INTENDED POINT OF LNDG. ROOT CAUSE: POOR CRM ON MY PART. AFTER 30 YRS OF FLYING; TO INCLUDE 22 IN THE MIL; I WOULD LOVE NOTHING MORE THAN TO SAY THIS WAS CAUSED BY SOMETHING OTHER THAN MYSELF. IT IS HARD TO ADMIT THAT WITH MY EXPERIENCE LEVEL; THE SOPHISTICATION OF THE ACFT I WAS FLYING; AND THE EXISTING VMC CONDITIONS; I COULD MAKE SO BASIC AN ERROR. HOWEVER; NO MATTER HOW I SLICE THE APPLE IT COMES DOWN TO MY NOT RUNNING THE COCKPIT CORRECTLY WHEN THE RWY CHANGE WAS MADE. I SHOULD HAVE REQUIRED THE PNF TO RE-BRIEF THE RWY ENVIRONMENT I WAS GOING TO SEE FOR LNDG AND TO VISUALLY VERIFY THE CORRECT RWY AS WE NORMALLY DO AS A MATTER OF ROUTINE. BECAUSE OF MY MISGUIDED COMFORT LEVEL IN HAVING IDENTED THE CORRECT RWY FOR LNDG; I ALLOWED THE PNF TO CONTINUE TO WORK ON PUTTING AN APCH IN THE FMS THAT I DIDN'T NEED WHEN HE SHOULD HAVE BEEN HEADS UP AND EYES OUT DURING THIS CRITICAL PHASE OF THE FLT. HAD I REQUIRED MY COPLT TO RE-BRIEF THE LNDG ENVIRONMENT OR MERELY TOLD HIM TO NOT WORRY ABOUT PUTTING IN AN APCH THAT I DIDN'T NEED AND TO STAY OUTSIDE THE ACFT; I AM CONVINCED HE WOULD HAVE IMMEDIATELY PICKED UP MY ERROR AND WE WOULD HAVE CORRECTED IT LONG BEFORE I CROSSED THE EXTENDED CTRLINE FOR RWY 18L. THIS IS ESPECIALLY FRUSTRATING GIVEN THE FACT THAT I RECENTLY GOT MY TYPE RATING IN THIS ACFT AND WAS SHOWN AN EXCELLENT FILM ON CRM THAT ADDRESSED THIS EXACT ISSUE. HEADS DOWN ACTIVITY WORKING ON LOADING APCHS INTO AN FMS IN THE CLOSE-IN RWY ENVIRONMENT INSTEAD OF REMAINING HEADS UP AND WORKING AS A CREW TO ENSURE THE ACFT IS LANDED SAFELY WHERE IT WAS CLRED TO LAND. RECOMMENDATIONS: I WISH THIS WERE A UNIQUE PROB THAT HAD A NEW AND UNIQUE SOLUTION. HOWEVER; IT DOES NOT. IT IS THE AGE OLD PROB OF NOT RUNNING A COCKPIT CORRECTLY AND ALLOWING THINGS TO TRANSPIRE THAT ARE NOT HELPFUL TO THE SAFETY OF THE ACFT. I WOULD RECOMMEND CONTINUED EMPHASIS ON WHEN TO PROGRAM THE FMS AND WHEN NOT TO. THE PNF AND I HAD DISCUSSED IT ON MANY OCCASIONS AND BOTH CONCLUDED UNNECESSARY USE OF THE 'BOX' CLOSE IN SHOULDN'T HAPPEN. HOWEVER; IT DID. AND IT DID BECAUSE I ALLOWED IT TO HAPPEN AND THE PNF WAS CONFIDENT IN MY ABILITIES TO PROPERLY IDENT A RWY UNDER VMC CONDITIONS.
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.