Narrative:

I am manager airline safety investigation. Attached are excerpts from the investigation report into an incident involving one of our aircraft following the offset localizer approach into runway 22R at jfk. Several safety issues were idented with regard to the crew lack of situational awareness during the approach; some of which pertained to the layout of approach information on commercial charts and to the jfk airport poor lighting facilities for runway 22R. At the time of the occurrence; the crew was not aware that the localizer was offset and they believed that the crab attitude of the aircraft was due to the crosswind. As the aircraft continued on localizer; crossed the runway centerline and continued descending to the left of the runway; it became apparent to the crew that there was something wrong and they initiated a go around. Contributing to the crew lack of awareness was the narrower side-lighted runway and the lack of centerline lighting; which likely altered the crew ht perception. We have contacted commercial chart company and informed them of the issue regarding the information layout on approach chart. They have responded and will attempt to make editorial changes in the layout to alleviate the issue. Of note is that there is no mention of offset localizer anywhere on the FAA chart for runway 22R. We do not know if other operators encounter similar problems at jfk. However; we feel that this is a serious issue which warrants further action. This report is submitted with the view of stimulating further action by the FAA to implement necessary improvements to runway lighting for runway 22L at jfk and chart information layout regarding offset localizer approach in general. Air carrier was a scheduled freighter flight to jfk. The 2 cockpit crew comprised a captain (PF) and an first officer (PNF). There was also a positioning captain and first officer on board; who were both present in the cockpit at the time of the incident. The flight was uneventful. Due to the WX conditions forecast for jfk; the planned high landing weight; and the captain's lack of familiarity with jfk; the crew spent a great deal of time in the cruise planning and preparing for the arrival and landing. The descent was uneventful and the aircraft was vectored onto a left downwind for runway 22L; for which the captain had briefed an autoland. Around 4000 ft on descent and on base for runway 22L; ATC changed the runway clearance and vectored the crew to a base for runway 22R which has an offset localizer and is therefore not autoland approved. The captain requested the first officer to select the new approach and runway in the FMS. The captain re-briefed for the new approach and that he would leave the automation in for as long as possible. The actual WX was worse than the taf and the ATIS; with 1.5 SM visibility in rain; cloud base approximately 400 ft; moderate rain and very gusty wind. The aircraft broke out of cloud around 400 ft with the runway lighting visible but faint appearing in the right windshield and with the extended centerline to the left of the aircraft; as expected by the crew. The aircraft was stable and on the ILS profile for the whole approach. At minima (250 ft RA) the captain called 'land' and left the autoplt engaged. Around 180 ft RA the aircraft crossed over the extended runway centerline from right to left. As the aircraft continued and crossed to the left of the centerline; the first officer called 'centerline drifting right;' or words to that effect. There was no positive change to the aircraft's trajectory and; approximately 2-3 seconds later; at around 100 ft RA; as the left hand runway edge lights passed to the right side of the cockpit; both positioning crew in the jumpseats called 'go around.' a further 2-3 seconds passed before the captain initiated a go around. The aircraft reached a minimum altitude of 24 ft RA during the go around. On climb out the aircraft was reclred to (the original) runway 22L. The aircraft was radar vectored around to runway 22L onto which a successful autoland approach was conducted. This report includes recommendations with regard to improving the runway and approach facilities and the presentation of data for the destination airport; the flight crew command training and pairing; the crew briefing procedures for runway changes; and the fleet standardization of landing callouts and autoplt disconnect ht. The approach was conducted at night; inpoor visibility to a narrow runway with no centerline lighting; approach lighting or touchdown zone lighting; as well as no PAPI or VASI. However; the pilot was correct in identing several factors that could produce visual illusions on the approach. These included the narrow runway potentially giving the illusions of being high on profile; poor visibility giving the illusion of the runway being further away than it is; and the windscreen wipers being on; which can draw the focal attention inwards and thus make the runway appear further away than it is. Further; the lack of guidance lighting impede the pilot from gaining the correct perception and situational awareness. The lack of centerline lighting has previously been shown to increase the difficulty in judging runway lateral positioning. The approach chart used by the crew was new york ILS runway 22R. This was the appropriate chart. Due to the layout of the chart it is not obvious that the localizer is offset. Offset localizer textbox is located to the southeast of the runway complex; in the shoreline shading. Due to the pattern of the coastline shading and its proximity to the missed approach information; it may have been difficult to identify the offset localizer textbox; particularly during night operations. Recommendations: 1) the FAA improves the runway lighting and approach guidance visual aids for jfk runway 22R. This should include ensuring that runway centerline lighting is available and the addition of touchdown zone and approach lighting; 2) the FAA provide commercial chart company with the necessary offset localizer information for inclusion into the runway 22R ILS approach chart; 3) commercial chart company improve the chart layout for jfk runway 22R ILS to ensure that the offset localizer information is highlighted. Consideration should be given to adding the offset localizer information into the ILS identify box and moving the offset localizer box to a more conspicuous location.

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Original NASA ASRS Text

Title: A FLT SAFETY MGR SUGGESTS SAFETY IMPROVEMENTS FOR THE JFK ILS RWY 22R FOLLOWING AN ACR B747-400 CREW'S LOW VISUAL MISSED APCH BECAUSE THE OFFSET APCH COURSE; WIND; AND LACK OF RWY LIGHTS.

Narrative: I AM MGR AIRLINE SAFETY INVESTIGATION. ATTACHED ARE EXCERPTS FROM THE INVESTIGATION RPT INTO AN INCIDENT INVOLVING ONE OF OUR ACFT FOLLOWING THE OFFSET LOC APCH INTO RWY 22R AT JFK. SEVERAL SAFETY ISSUES WERE IDENTED WITH REGARD TO THE CREW LACK OF SITUATIONAL AWARENESS DURING THE APCH; SOME OF WHICH PERTAINED TO THE LAYOUT OF APCH INFO ON COMMERCIAL CHARTS AND TO THE JFK ARPT POOR LIGHTING FACILITIES FOR RWY 22R. AT THE TIME OF THE OCCURRENCE; THE CREW WAS NOT AWARE THAT THE LOC WAS OFFSET AND THEY BELIEVED THAT THE CRAB ATTITUDE OF THE ACFT WAS DUE TO THE XWIND. AS THE ACFT CONTINUED ON LOC; CROSSED THE RWY CTRLINE AND CONTINUED DSNDING TO THE L OF THE RWY; IT BECAME APPARENT TO THE CREW THAT THERE WAS SOMETHING WRONG AND THEY INITIATED A GAR. CONTRIBUTING TO THE CREW LACK OF AWARENESS WAS THE NARROWER SIDE-LIGHTED RWY AND THE LACK OF CTRLINE LIGHTING; WHICH LIKELY ALTERED THE CREW HT PERCEPTION. WE HAVE CONTACTED COMMERCIAL CHART COMPANY AND INFORMED THEM OF THE ISSUE REGARDING THE INFO LAYOUT ON APCH CHART. THEY HAVE RESPONDED AND WILL ATTEMPT TO MAKE EDITORIAL CHANGES IN THE LAYOUT TO ALLEVIATE THE ISSUE. OF NOTE IS THAT THERE IS NO MENTION OF OFFSET LOC ANYWHERE ON THE FAA CHART FOR RWY 22R. WE DO NOT KNOW IF OTHER OPERATORS ENCOUNTER SIMILAR PROBS AT JFK. HOWEVER; WE FEEL THAT THIS IS A SERIOUS ISSUE WHICH WARRANTS FURTHER ACTION. THIS RPT IS SUBMITTED WITH THE VIEW OF STIMULATING FURTHER ACTION BY THE FAA TO IMPLEMENT NECESSARY IMPROVEMENTS TO RWY LIGHTING FOR RWY 22L AT JFK AND CHART INFO LAYOUT REGARDING OFFSET LOC APCH IN GENERAL. ACR WAS A SCHEDULED FREIGHTER FLT TO JFK. THE 2 COCKPIT CREW COMPRISED A CAPT (PF) AND AN FO (PNF). THERE WAS ALSO A POSITIONING CAPT AND FO ON BOARD; WHO WERE BOTH PRESENT IN THE COCKPIT AT THE TIME OF THE INCIDENT. THE FLT WAS UNEVENTFUL. DUE TO THE WX CONDITIONS FORECAST FOR JFK; THE PLANNED HIGH LNDG WT; AND THE CAPT'S LACK OF FAMILIARITY WITH JFK; THE CREW SPENT A GREAT DEAL OF TIME IN THE CRUISE PLANNING AND PREPARING FOR THE ARR AND LNDG. THE DSCNT WAS UNEVENTFUL AND THE ACFT WAS VECTORED ONTO A L DOWNWIND FOR RWY 22L; FOR WHICH THE CAPT HAD BRIEFED AN AUTOLAND. AROUND 4000 FT ON DSCNT AND ON BASE FOR RWY 22L; ATC CHANGED THE RWY CLRNC AND VECTORED THE CREW TO A BASE FOR RWY 22R WHICH HAS AN OFFSET LOC AND IS THEREFORE NOT AUTOLAND APPROVED. THE CAPT REQUESTED THE FO TO SELECT THE NEW APCH AND RWY IN THE FMS. THE CAPT RE-BRIEFED FOR THE NEW APCH AND THAT HE WOULD LEAVE THE AUTOMATION IN FOR AS LONG AS POSSIBLE. THE ACTUAL WX WAS WORSE THAN THE TAF AND THE ATIS; WITH 1.5 SM VISIBILITY IN RAIN; CLOUD BASE APPROX 400 FT; MODERATE RAIN AND VERY GUSTY WIND. THE ACFT BROKE OUT OF CLOUD AROUND 400 FT WITH THE RWY LIGHTING VISIBLE BUT FAINT APPEARING IN THE R WINDSHIELD AND WITH THE EXTENDED CTRLINE TO THE L OF THE ACFT; AS EXPECTED BY THE CREW. THE ACFT WAS STABLE AND ON THE ILS PROFILE FOR THE WHOLE APCH. AT MINIMA (250 FT RA) THE CAPT CALLED 'LAND' AND LEFT THE AUTOPLT ENGAGED. AROUND 180 FT RA THE ACFT CROSSED OVER THE EXTENDED RWY CTRLINE FROM R TO L. AS THE ACFT CONTINUED AND CROSSED TO THE L OF THE CTRLINE; THE FO CALLED 'CTRLINE DRIFTING R;' OR WORDS TO THAT EFFECT. THERE WAS NO POSITIVE CHANGE TO THE ACFT'S TRAJECTORY AND; APPROX 2-3 SECONDS LATER; AT AROUND 100 FT RA; AS THE L HAND RWY EDGE LIGHTS PASSED TO THE R SIDE OF THE COCKPIT; BOTH POSITIONING CREW IN THE JUMPSEATS CALLED 'GAR.' A FURTHER 2-3 SECONDS PASSED BEFORE THE CAPT INITIATED A GAR. THE ACFT REACHED A MINIMUM ALT OF 24 FT RA DURING THE GAR. ON CLBOUT THE ACFT WAS RECLRED TO (THE ORIGINAL) RWY 22L. THE ACFT WAS RADAR VECTORED AROUND TO RWY 22L ONTO WHICH A SUCCESSFUL AUTOLAND APCH WAS CONDUCTED. THIS RPT INCLUDES RECOMMENDATIONS WITH REGARD TO IMPROVING THE RWY AND APCH FACILITIES AND THE PRESENTATION OF DATA FOR THE DEST ARPT; THE FLT CREW COMMAND TRAINING AND PAIRING; THE CREW BRIEFING PROCS FOR RWY CHANGES; AND THE FLEET STANDARDIZATION OF LNDG CALLOUTS AND AUTOPLT DISCONNECT HT. THE APCH WAS CONDUCTED AT NIGHT; INPOOR VISIBILITY TO A NARROW RWY WITH NO CTRLINE LIGHTING; APCH LIGHTING OR TOUCHDOWN ZONE LIGHTING; AS WELL AS NO PAPI OR VASI. HOWEVER; THE PLT WAS CORRECT IN IDENTING SEVERAL FACTORS THAT COULD PRODUCE VISUAL ILLUSIONS ON THE APCH. THESE INCLUDED THE NARROW RWY POTENTIALLY GIVING THE ILLUSIONS OF BEING HIGH ON PROFILE; POOR VISIBILITY GIVING THE ILLUSION OF THE RWY BEING FURTHER AWAY THAN IT IS; AND THE WINDSCREEN WIPERS BEING ON; WHICH CAN DRAW THE FOCAL ATTN INWARDS AND THUS MAKE THE RWY APPEAR FURTHER AWAY THAN IT IS. FURTHER; THE LACK OF GUIDANCE LIGHTING IMPEDE THE PLT FROM GAINING THE CORRECT PERCEPTION AND SITUATIONAL AWARENESS. THE LACK OF CTRLINE LIGHTING HAS PREVIOUSLY BEEN SHOWN TO INCREASE THE DIFFICULTY IN JUDGING RWY LATERAL POSITIONING. THE APCH CHART USED BY THE CREW WAS NEW YORK ILS RWY 22R. THIS WAS THE APPROPRIATE CHART. DUE TO THE LAYOUT OF THE CHART IT IS NOT OBVIOUS THAT THE LOC IS OFFSET. OFFSET LOC TEXTBOX IS LOCATED TO THE SE OF THE RWY COMPLEX; IN THE SHORELINE SHADING. DUE TO THE PATTERN OF THE COASTLINE SHADING AND ITS PROX TO THE MISSED APCH INFO; IT MAY HAVE BEEN DIFFICULT TO IDENT THE OFFSET LOC TEXTBOX; PARTICULARLY DURING NIGHT OPS. RECOMMENDATIONS: 1) THE FAA IMPROVES THE RWY LIGHTING AND APCH GUIDANCE VISUAL AIDS FOR JFK RWY 22R. THIS SHOULD INCLUDE ENSURING THAT RWY CTRLINE LIGHTING IS AVAILABLE AND THE ADDITION OF TOUCHDOWN ZONE AND APCH LIGHTING; 2) THE FAA PROVIDE COMMERCIAL CHART COMPANY WITH THE NECESSARY OFFSET LOC INFO FOR INCLUSION INTO THE RWY 22R ILS APCH CHART; 3) COMMERCIAL CHART COMPANY IMPROVE THE CHART LAYOUT FOR JFK RWY 22R ILS TO ENSURE THAT THE OFFSET LOC INFO IS HIGHLIGHTED. CONSIDERATION SHOULD BE GIVEN TO ADDING THE OFFSET LOC INFO INTO THE ILS IDENT BOX AND MOVING THE OFFSET LOC BOX TO A MORE CONSPICUOUS LOCATION.

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.