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Attributes | |
ACN | 796690 |
Time | |
Date | 200807 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 2500 |
Environment | |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : zzz.tracon tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : xxl |
Route In Use | approach : instrument precision arrival star : n/s |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 154 flight time type : 1420 |
ASRS Report | 796690 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 174 flight time type : 7000 |
ASRS Report | 796818 |
Events | |
Anomaly | airspace violation : entry conflict : airborne less severe inflight encounter : weather non adherence : clearance non adherence : company policies non adherence : far other spatial deviation |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance flight crew : exited penetrated airspace flight crew : took evasive action |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Narrative:
Arrived ZZZ via STAR arrival. Flew downwind from VOR after being told to expect ILS xxl sidestep runway xxr. On downwind and approximately 2 mi past abeam the numbers; ATC advised us of traffic we would be following on final for runway xxr. I spotted the traffic. The captain (PF) saw that traffic also and we called it in sight. PF began configuring and extended the downwind until ATC asked us to turn base. We turned base and PF asked me if I could see the airport. I stated I could not. He then said he could see the airport. At no time during the rest of the flight did he say if he could also see the traffic we were following. We were cleared to follow the aircraft in sight for the visual runway xxr. While configuring the airplane for landing and still on base leg; approach called over the radio to warn us that we had flown through final and to immediately turn toward the airport. The controller asked us if we had the airport in sight. The captain told me again he did as we immediately corrected north to intercept final for runway xxr. We reported ZZZ in sight to ATC. I then advised the captain that I could still not see runway xxr. Visibility was poor with the sun low in the sky (or setting). On approximately a 6 mi final I could see all 4 runways and verify that we were on final for runway xxr. We landed normally. After parking; we were advised over the phone that we had come too close to an aircraft on final for the south complex at ZZZ. The CRM between the captain and I during the entire trip was excellent. We had flown an FAA cockpit observer on the first day of the trip and he commented on how well we worked together. This incident took place on the last day of the trip. It happened in a very; very short amount of time and during a task-intensive phase. I stated clearly to the captain that I could not identify runway 24R visually for most of the approach. His tone and attitude were very confident as he continued to state that 'it's ok; I have the airport in sight.' it appears that he misidented runways xx for runways yy and flew through both runway xxl and xxr final approachs. ATC promptly advised us of the error. As we turned base leg from final; I was very task saturated. I was looking for the airport; monitoring airspeed for confign and talking to ATC. Although we had the ILS for runway xxl set up; and it may be easy to ask why I did not notice that we had flown through that course using the CDI; the truth is that I was very busy. My primary focus was looking outside the aircraft to find the airport visually because that is the approach we had been cleared for. ATIS was reporting 8 mi and scattered clouds over the airport. The sun at XA00 pm is at a very bad angle for seeing airport when the marine layer is over the airport. But this comes as a surprise when the airport is very easy to see on downwind abeam midfield at 7000 ft. It is very common during everyday operations to report the field in sight and accept a visual clearance with only 1 pilot able to see the runway. Capts do it all the time on downwind for las runway 25L; for example. In this instance; I could have more aggressively stated that I did not see the runway since I was very concerned with helping the PF intercept the correct final; but once again time and task management were an issue. My opinion; there is nothing I have seen at air carrier flight operations that causes me more concern than capts that take over decision making in the cockpit entirely by themselves. In this specific case at ZZZ; the PF/captain thought he saw the correct runway; but seemed to feel no obligation to seek out my opinion as to whether or not we were intercepting the correct final. This is what visual approachs combined with poor WX and a very short period (base leg at ZZZ) will do to a captain (or any PF) who is otherwise outstanding at CRM. Supplemental information from acn 796818: in the base turn I realized that the airport was not in sight; but it appeared that I could follow the preceding traffic to the airport. About the time we should have started our turn to final; I asked for flaps 15 degree setting off gear horn. I visually went inside to troubleshoot the gear thinking that it had been lowered during the downwind to base turn.when I went outside again I was unable to see the preceding aircraft but located the runways. Unfortunately what I saw was runway xyl and xyr. The aircraft heading was 90 degrees off runway course when I noticed the xxl localizer start to swing. I immediately turned right to correct my mistake. In the turn I saw the approach lights and PAPI's which were just starting to come into view from under the marine layer as we descended onto profile. We made a visual approach to runway xyr. Contributing factors: 1) it appeared visual approach would be no problem from abeam the airport. 2) thin marine layer that prevented us from seeing the runways from above profile. 3) several ATC communications coincided with callouts and cockpit communications. I believe this led to the gear not being lowered. A second call came while trying to resolve the gear horn. 4) non-standard approachs to ILS xxr. Tunnel vision set in as I became task saturated. Although I am very familiar with ZZZ and its surroundings; I didn't pick up on clues that should have helped me locate the correct runway. The appropriate course of action would have been a go around.
Original NASA ASRS Text
Title: A B737 CREW REPORTS A CRM ERROR WHEN THE FO REPORTED THAT HE DID NOT HAVE THE RWY IN SIGHT FOR A VISUAL. THE CAPT REPORTED HE SAW THE RWY BUT HE HAD THE WRONG RWY. A LOSS OF SEPARATION RESULTED.
Narrative: ARRIVED ZZZ VIA STAR ARR. FLEW DOWNWIND FROM VOR AFTER BEING TOLD TO EXPECT ILS XXL SIDESTEP RWY XXR. ON DOWNWIND AND APPROX 2 MI PAST ABEAM THE NUMBERS; ATC ADVISED US OF TFC WE WOULD BE FOLLOWING ON FINAL FOR RWY XXR. I SPOTTED THE TFC. THE CAPT (PF) SAW THAT TFC ALSO AND WE CALLED IT IN SIGHT. PF BEGAN CONFIGURING AND EXTENDED THE DOWNWIND UNTIL ATC ASKED US TO TURN BASE. WE TURNED BASE AND PF ASKED ME IF I COULD SEE THE ARPT. I STATED I COULD NOT. HE THEN SAID HE COULD SEE THE ARPT. AT NO TIME DURING THE REST OF THE FLT DID HE SAY IF HE COULD ALSO SEE THE TFC WE WERE FOLLOWING. WE WERE CLRED TO FOLLOW THE ACFT IN SIGHT FOR THE VISUAL RWY XXR. WHILE CONFIGURING THE AIRPLANE FOR LNDG AND STILL ON BASE LEG; APCH CALLED OVER THE RADIO TO WARN US THAT WE HAD FLOWN THROUGH FINAL AND TO IMMEDIATELY TURN TOWARD THE ARPT. THE CTLR ASKED US IF WE HAD THE ARPT IN SIGHT. THE CAPT TOLD ME AGAIN HE DID AS WE IMMEDIATELY CORRECTED N TO INTERCEPT FINAL FOR RWY XXR. WE RPTED ZZZ IN SIGHT TO ATC. I THEN ADVISED THE CAPT THAT I COULD STILL NOT SEE RWY XXR. VISIBILITY WAS POOR WITH THE SUN LOW IN THE SKY (OR SETTING). ON APPROX A 6 MI FINAL I COULD SEE ALL 4 RWYS AND VERIFY THAT WE WERE ON FINAL FOR RWY XXR. WE LANDED NORMALLY. AFTER PARKING; WE WERE ADVISED OVER THE PHONE THAT WE HAD COME TOO CLOSE TO AN ACFT ON FINAL FOR THE S COMPLEX AT ZZZ. THE CRM BTWN THE CAPT AND I DURING THE ENTIRE TRIP WAS EXCELLENT. WE HAD FLOWN AN FAA COCKPIT OBSERVER ON THE FIRST DAY OF THE TRIP AND HE COMMENTED ON HOW WELL WE WORKED TOGETHER. THIS INCIDENT TOOK PLACE ON THE LAST DAY OF THE TRIP. IT HAPPENED IN A VERY; VERY SHORT AMOUNT OF TIME AND DURING A TASK-INTENSIVE PHASE. I STATED CLRLY TO THE CAPT THAT I COULD NOT IDENT RWY 24R VISUALLY FOR MOST OF THE APCH. HIS TONE AND ATTITUDE WERE VERY CONFIDENT AS HE CONTINUED TO STATE THAT 'IT'S OK; I HAVE THE ARPT IN SIGHT.' IT APPEARS THAT HE MISIDENTED RWYS XX FOR RWYS YY AND FLEW THROUGH BOTH RWY XXL AND XXR FINAL APCHS. ATC PROMPTLY ADVISED US OF THE ERROR. AS WE TURNED BASE LEG FROM FINAL; I WAS VERY TASK SATURATED. I WAS LOOKING FOR THE ARPT; MONITORING AIRSPD FOR CONFIGN AND TALKING TO ATC. ALTHOUGH WE HAD THE ILS FOR RWY XXL SET UP; AND IT MAY BE EASY TO ASK WHY I DID NOT NOTICE THAT WE HAD FLOWN THROUGH THAT COURSE USING THE CDI; THE TRUTH IS THAT I WAS VERY BUSY. MY PRIMARY FOCUS WAS LOOKING OUTSIDE THE ACFT TO FIND THE ARPT VISUALLY BECAUSE THAT IS THE APCH WE HAD BEEN CLRED FOR. ATIS WAS RPTING 8 MI AND SCATTERED CLOUDS OVER THE ARPT. THE SUN AT XA00 PM IS AT A VERY BAD ANGLE FOR SEEING ARPT WHEN THE MARINE LAYER IS OVER THE ARPT. BUT THIS COMES AS A SURPRISE WHEN THE ARPT IS VERY EASY TO SEE ON DOWNWIND ABEAM MIDFIELD AT 7000 FT. IT IS VERY COMMON DURING EVERYDAY OPS TO RPT THE FIELD IN SIGHT AND ACCEPT A VISUAL CLRNC WITH ONLY 1 PLT ABLE TO SEE THE RWY. CAPTS DO IT ALL THE TIME ON DOWNWIND FOR LAS RWY 25L; FOR EXAMPLE. IN THIS INSTANCE; I COULD HAVE MORE AGGRESSIVELY STATED THAT I DID NOT SEE THE RWY SINCE I WAS VERY CONCERNED WITH HELPING THE PF INTERCEPT THE CORRECT FINAL; BUT ONCE AGAIN TIME AND TASK MGMNT WERE AN ISSUE. MY OPINION; THERE IS NOTHING I HAVE SEEN AT ACR FLT OPS THAT CAUSES ME MORE CONCERN THAN CAPTS THAT TAKE OVER DECISION MAKING IN THE COCKPIT ENTIRELY BY THEMSELVES. IN THIS SPECIFIC CASE AT ZZZ; THE PF/CAPT THOUGHT HE SAW THE CORRECT RWY; BUT SEEMED TO FEEL NO OBLIGATION TO SEEK OUT MY OPINION AS TO WHETHER OR NOT WE WERE INTERCEPTING THE CORRECT FINAL. THIS IS WHAT VISUAL APCHS COMBINED WITH POOR WX AND A VERY SHORT PERIOD (BASE LEG AT ZZZ) WILL DO TO A CAPT (OR ANY PF) WHO IS OTHERWISE OUTSTANDING AT CRM. SUPPLEMENTAL INFO FROM ACN 796818: IN THE BASE TURN I REALIZED THAT THE ARPT WAS NOT IN SIGHT; BUT IT APPEARED THAT I COULD FOLLOW THE PRECEDING TFC TO THE ARPT. ABOUT THE TIME WE SHOULD HAVE STARTED OUR TURN TO FINAL; I ASKED FOR FLAPS 15 DEG SETTING OFF GEAR HORN. I VISUALLY WENT INSIDE TO TROUBLESHOOT THE GEAR THINKING THAT IT HAD BEEN LOWERED DURING THE DOWNWIND TO BASE TURN.WHEN I WENT OUTSIDE AGAIN I WAS UNABLE TO SEE THE PRECEDING ACFT BUT LOCATED THE RWYS. UNFORTUNATELY WHAT I SAW WAS RWY XYL AND XYR. THE ACFT HDG WAS 90 DEGS OFF RWY COURSE WHEN I NOTICED THE XXL LOC START TO SWING. I IMMEDIATELY TURNED R TO CORRECT MY MISTAKE. IN THE TURN I SAW THE APCH LIGHTS AND PAPI'S WHICH WERE JUST STARTING TO COME INTO VIEW FROM UNDER THE MARINE LAYER AS WE DSNDED ONTO PROFILE. WE MADE A VISUAL APCH TO RWY XYR. CONTRIBUTING FACTORS: 1) IT APPEARED VISUAL APCH WOULD BE NO PROB FROM ABEAM THE ARPT. 2) THIN MARINE LAYER THAT PREVENTED US FROM SEEING THE RWYS FROM ABOVE PROFILE. 3) SEVERAL ATC COMS COINCIDED WITH CALLOUTS AND COCKPIT COMS. I BELIEVE THIS LED TO THE GEAR NOT BEING LOWERED. A SECOND CALL CAME WHILE TRYING TO RESOLVE THE GEAR HORN. 4) NON-STANDARD APCHS TO ILS XXR. TUNNEL VISION SET IN AS I BECAME TASK SATURATED. ALTHOUGH I AM VERY FAMILIAR WITH ZZZ AND ITS SURROUNDINGS; I DIDN'T PICK UP ON CLUES THAT SHOULD HAVE HELPED ME LOCATE THE CORRECT RWY. THE APPROPRIATE COURSE OF ACTION WOULD HAVE BEEN A GAR.
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.