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|
Attributes | |
ACN | 768884 |
Time | |
Date | 200801 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : mia.airport |
State Reference | FL |
Altitude | msl single value : 1500 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Thunderstorm Rain |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : mia.tracon |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 9 |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision arrival star : flipr |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 768884 |
Person 2 | |
Affiliation | government : faa |
Function | controller : approach |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Supplementary | |
Problem Areas | ATC Human Performance Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
During descent on the flipr arrival to mia; we had to deviate to the southwest off the RNAV track for towering cumulus; with occasional lightning cloud to cloud. We received clearance to do so initially; and then the approach controller commented that we should have shared further deviation with him; which was prevented due to frequency congestion. We were told to expect the ILS runway 8R to mia initially; and then after the deviation and vectors; were descended to 1500 ft MSL and given the final vector to join the ILS runway 8R. Apparently due to high workload the final turn onto the approach included clearance for the ILS runway 9 at mia instead and my first officer inadvertently only read back 'cleared for the ILS approach.' due to the high workload and configuring for the approach; I neglected to ask the first officer to confirm cleared for the ILS runway 8R; with approach control. We were xferred to the tower and on initial contact it became apparent that the controller was concerned that we were not lining up with the ILS runway 9. He asked us why we weren't and then my first officer responded that we were intercepting the ILS runway 8R as was our cleared approach. Then the controller asked if we had runway 8R in sight; which we did; and then he said; 'cleared to land runway 8R!' we landed uneventfully and had fallen victim to an unexpected clearance without proper readback or detection. None of the 3 pilots including myself remember hearing the actual ILS approach clearance detail. Symptoms of tired minds up all night; early in the morning. Lesson learned; and to take nothing for granted on an 'expect' basis.
Original NASA ASRS Text
Title: B767 FLT CREW REPORTS NOT HEARING CHANGE FROM ILS 8R TO ILS 9 AT MIA; CITING FATIGUE. LCL CTLR SUBSEQUENTLY CLEARS FLIGHT TO LAND RWY 8R.
Narrative: DURING DSCNT ON THE FLIPR ARR TO MIA; WE HAD TO DEVIATE TO THE SW OFF THE RNAV TRACK FOR TOWERING CUMULUS; WITH OCCASIONAL LIGHTNING CLOUD TO CLOUD. WE RECEIVED CLRNC TO DO SO INITIALLY; AND THEN THE APCH CTLR COMMENTED THAT WE SHOULD HAVE SHARED FURTHER DEV WITH HIM; WHICH WAS PREVENTED DUE TO FREQ CONGESTION. WE WERE TOLD TO EXPECT THE ILS RWY 8R TO MIA INITIALLY; AND THEN AFTER THE DEV AND VECTORS; WERE DSNDED TO 1500 FT MSL AND GIVEN THE FINAL VECTOR TO JOIN THE ILS RWY 8R. APPARENTLY DUE TO HIGH WORKLOAD THE FINAL TURN ONTO THE APCH INCLUDED CLRNC FOR THE ILS RWY 9 AT MIA INSTEAD AND MY FO INADVERTENTLY ONLY READ BACK 'CLRED FOR THE ILS APCH.' DUE TO THE HIGH WORKLOAD AND CONFIGURING FOR THE APCH; I NEGLECTED TO ASK THE FO TO CONFIRM CLRED FOR THE ILS RWY 8R; WITH APCH CTL. WE WERE XFERRED TO THE TWR AND ON INITIAL CONTACT IT BECAME APPARENT THAT THE CTLR WAS CONCERNED THAT WE WERE NOT LINING UP WITH THE ILS RWY 9. HE ASKED US WHY WE WEREN'T AND THEN MY FO RESPONDED THAT WE WERE INTERCEPTING THE ILS RWY 8R AS WAS OUR CLRED APCH. THEN THE CTLR ASKED IF WE HAD RWY 8R IN SIGHT; WHICH WE DID; AND THEN HE SAID; 'CLRED TO LAND RWY 8R!' WE LANDED UNEVENTFULLY AND HAD FALLEN VICTIM TO AN UNEXPECTED CLRNC WITHOUT PROPER READBACK OR DETECTION. NONE OF THE 3 PLTS INCLUDING MYSELF REMEMBER HEARING THE ACTUAL ILS APCH CLRNC DETAIL. SYMPTOMS OF TIRED MINDS UP ALL NIGHT; EARLY IN THE MORNING. LESSON LEARNED; AND TO TAKE NOTHING FOR GRANTED ON AN 'EXPECT' BASIS.
Data retrieved from NASA's ASRS site as of May 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.