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|
Attributes | |
ACN | 732426 |
Time | |
Date | 200703 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : atl.airport |
State Reference | GA |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet 200 ER&LR |
Operating Under FAR Part | Part 121 |
Flight Phase | landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 732426 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | incursion : landing without clearance non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
I was working a 4 day that started off as a 'pm' pairing and mid-trip switched to an 'am' and then again on the last day became a 'pm.' I am a line holder and was on my 14TH modification with multiple aircraft swaps; crews; and types changes between the CL65 and CL65. Although I was working my 5TH unscheduled roundtrip the company had called me over 10 times in the last 4 days informing of schedule changes due to lack of capts. I know my pairing had been modified over 14 times because it was on mod 'north' and because I had fielded over 10 phone calls with crew scheduling. It was very apparent that crew scheduling was in crisis mode trying to cover trips. The first officer I was paired with was very complacent. Immediately after pushback I found myself correcting him on improper standardization. Once airborne I was again scrambling to watch him and the aircraft. He was in my opinion one of our weaker first officer's; acting outside of our SOP's in almost every phase of the flight. It was clearly a situation that had potential for error and I failed to recognize the scenario. His verbiage; flows; and callouts were all foreign to me; and I found myself constantly correcting him to the point that it became a big distraction. Twice I called for 'before landing checks' to his complete non-responsiveness; it was as if he was somewhere else. On short final I noticed a green light in the ATC tower at atlanta hartsfield tower aimed at our aircraft. On rollout as I called for 'after landing checks' I noticed the landing light confign was still indicating that we were only cleared for the approach. I also noticed my first officer scrambling for a ground frequency; when I queried him on what was going on he seemed confused and unresponsive. I noticed that approach control frequencys were still displayed and that I could hear atl approach still being broadcast. I also do not recall ever being handed off to tower. It was my belief that we landed atl on approach control with no verbal authority/authorized only a visual authority/authorized from the atl tower. On rollout I noticed I had never switched the landing nose light on; a system I use for myself to determine that we are cleared to land. Additionally; the green light gun was still pointed at our aircraft. Once we contacted ground I called for 'after landing checks.' when we got to the gate and completed our 'shutdown checks' I debriefed the situation. No one from tower ever asked us to call them; so I am uncertain as to exactly what happened; however I explained to the first officer that I take full responsibility for what had happened; but also had a lengthy discussion with him about his repeated failures to exercise SOP's during normal operations. I encouraged him to get back in the books to learn his callouts; flows; and procedures so as not to be a distraction to the other crew member; but rather a participant in the flight. I take 100% blame of this failure to properly communicate with atlanta tower; if in fact that is what happened. However; I was tired and too complacent from being overworked by the company's failures to properly staff the airline. Multiple crews; swaps; schedule changes; all add up; and I am embarrassed by this mistake and will make every attempt in the future to ensure that it does not happen again. I worry however that if this is happening to me; what other mistakes are being made by other crews who too are being overworked by schedules that may be legal; but are not safe and reasonable; by modifications that are never ending; by ACARS almost every 3 flts informing someone to call scheduling because of changes. Perhaps it is time the FAA get involved because I am worried that because of our schedules and management's failure to hear the pilot group's repeated requests for help a fatigue related accident is in our future.
Original NASA ASRS Text
Title: CL65-200 CAPTAIN REPORTS LANDING AT ATL WITHOUT CLEARANCE AFTER FO FAILS TO CALL THE TOWER PRIOR TO LANDING. THERE HAD BEEN MANY SCHEDULE CHANGES PRIOR TO THIS INCIDENT AND THE CREW WAS QUITE FATIGUED.
Narrative: I WAS WORKING A 4 DAY THAT STARTED OFF AS A 'PM' PAIRING AND MID-TRIP SWITCHED TO AN 'AM' AND THEN AGAIN ON THE LAST DAY BECAME A 'PM.' I AM A LINE HOLDER AND WAS ON MY 14TH MODIFICATION WITH MULTIPLE ACFT SWAPS; CREWS; AND TYPES CHANGES BTWN THE CL65 AND CL65. ALTHOUGH I WAS WORKING MY 5TH UNSCHEDULED ROUNDTRIP THE COMPANY HAD CALLED ME OVER 10 TIMES IN THE LAST 4 DAYS INFORMING OF SCHEDULE CHANGES DUE TO LACK OF CAPTS. I KNOW MY PAIRING HAD BEEN MODIFIED OVER 14 TIMES BECAUSE IT WAS ON MOD 'N' AND BECAUSE I HAD FIELDED OVER 10 PHONE CALLS WITH CREW SCHEDULING. IT WAS VERY APPARENT THAT CREW SCHEDULING WAS IN CRISIS MODE TRYING TO COVER TRIPS. THE FO I WAS PAIRED WITH WAS VERY COMPLACENT. IMMEDIATELY AFTER PUSHBACK I FOUND MYSELF CORRECTING HIM ON IMPROPER STANDARDIZATION. ONCE AIRBORNE I WAS AGAIN SCRAMBLING TO WATCH HIM AND THE ACFT. HE WAS IN MY OPINION ONE OF OUR WEAKER FO'S; ACTING OUTSIDE OF OUR SOP'S IN ALMOST EVERY PHASE OF THE FLT. IT WAS CLRLY A SITUATION THAT HAD POTENTIAL FOR ERROR AND I FAILED TO RECOGNIZE THE SCENARIO. HIS VERBIAGE; FLOWS; AND CALLOUTS WERE ALL FOREIGN TO ME; AND I FOUND MYSELF CONSTANTLY CORRECTING HIM TO THE POINT THAT IT BECAME A BIG DISTR. TWICE I CALLED FOR 'BEFORE LNDG CHKS' TO HIS COMPLETE NON-RESPONSIVENESS; IT WAS AS IF HE WAS SOMEWHERE ELSE. ON SHORT FINAL I NOTICED A GREEN LIGHT IN THE ATC TWR AT ATLANTA HARTSFIELD TWR AIMED AT OUR ACFT. ON ROLLOUT AS I CALLED FOR 'AFTER LNDG CHKS' I NOTICED THE LNDG LIGHT CONFIGN WAS STILL INDICATING THAT WE WERE ONLY CLRED FOR THE APCH. I ALSO NOTICED MY FO SCRAMBLING FOR A GND FREQ; WHEN I QUERIED HIM ON WHAT WAS GOING ON HE SEEMED CONFUSED AND UNRESPONSIVE. I NOTICED THAT APCH CTL FREQS WERE STILL DISPLAYED AND THAT I COULD HEAR ATL APCH STILL BEING BROADCAST. I ALSO DO NOT RECALL EVER BEING HANDED OFF TO TWR. IT WAS MY BELIEF THAT WE LANDED ATL ON APCH CTL WITH NO VERBAL AUTH ONLY A VISUAL AUTH FROM THE ATL TWR. ON ROLLOUT I NOTICED I HAD NEVER SWITCHED THE LNDG NOSE LIGHT ON; A SYS I USE FOR MYSELF TO DETERMINE THAT WE ARE CLRED TO LAND. ADDITIONALLY; THE GREEN LIGHT GUN WAS STILL POINTED AT OUR ACFT. ONCE WE CONTACTED GND I CALLED FOR 'AFTER LNDG CHKS.' WHEN WE GOT TO THE GATE AND COMPLETED OUR 'SHUTDOWN CHKS' I DEBRIEFED THE SITUATION. NO ONE FROM TWR EVER ASKED US TO CALL THEM; SO I AM UNCERTAIN AS TO EXACTLY WHAT HAPPENED; HOWEVER I EXPLAINED TO THE FO THAT I TAKE FULL RESPONSIBILITY FOR WHAT HAD HAPPENED; BUT ALSO HAD A LENGTHY DISCUSSION WITH HIM ABOUT HIS REPEATED FAILURES TO EXERCISE SOP'S DURING NORMAL OPS. I ENCOURAGED HIM TO GET BACK IN THE BOOKS TO LEARN HIS CALLOUTS; FLOWS; AND PROCS SO AS NOT TO BE A DISTR TO THE OTHER CREW MEMBER; BUT RATHER A PARTICIPANT IN THE FLT. I TAKE 100% BLAME OF THIS FAILURE TO PROPERLY COMMUNICATE WITH ATLANTA TWR; IF IN FACT THAT IS WHAT HAPPENED. HOWEVER; I WAS TIRED AND TOO COMPLACENT FROM BEING OVERWORKED BY THE COMPANY'S FAILURES TO PROPERLY STAFF THE AIRLINE. MULTIPLE CREWS; SWAPS; SCHEDULE CHANGES; ALL ADD UP; AND I AM EMBARRASSED BY THIS MISTAKE AND WILL MAKE EVERY ATTEMPT IN THE FUTURE TO ENSURE THAT IT DOES NOT HAPPEN AGAIN. I WORRY HOWEVER THAT IF THIS IS HAPPENING TO ME; WHAT OTHER MISTAKES ARE BEING MADE BY OTHER CREWS WHO TOO ARE BEING OVERWORKED BY SCHEDULES THAT MAY BE LEGAL; BUT ARE NOT SAFE AND REASONABLE; BY MODIFICATIONS THAT ARE NEVER ENDING; BY ACARS ALMOST EVERY 3 FLTS INFORMING SOMEONE TO CALL SCHEDULING BECAUSE OF CHANGES. PERHAPS IT IS TIME THE FAA GET INVOLVED BECAUSE I AM WORRIED THAT BECAUSE OF OUR SCHEDULES AND MGMNT'S FAILURE TO HEAR THE PLT GROUP'S REPEATED REQUESTS FOR HELP A FATIGUE RELATED ACCIDENT IS IN OUR FUTURE.
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.