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|
Attributes | |
ACN | 813454 |
Time | |
Date | 200811 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 1500 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 180 flight time total : 19000 flight time type : 5950 |
ASRS Report | 813545 |
Events | |
Anomaly | other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Supplementary | |
Problem Areas | Maintenance Human Performance Company Flight Crew Human Performance |
Primary Problem | Ambiguous |
Narrative:
I arrived at operations 30 mins early for XA45 pm show; was notified at XA15 pm that flight was delayed until XG10 pm departure. Aircraft inbound. Hung around operations; unable to sleep. Boarded aircraft with mechanics in cockpit. Late write-ups. Vertical speed wheel changed and CDU changed. Maintenance called back due to CDU's not working right. Lengthy discussions and more swaps. Finally pushed at XH35 pm. Flight uneventful. Approaching ZZZ at cruise briefed arrival for ILS at ZZZ. Discussed night landing; dark; no moon; terrain issues. (Neither of us had landed there at night.) autoplt approach to be used; 'leave engaged for approach.' scattered cloud layers with VFR at airport. Right crosswind 15 KTS. During descent discussed tower closed; make reports on CTAF. Approach vectored us to intercept final just outside FAF. Thin wispy layer of clouds till just inside marker. No runway lights on. Pitch black and no ground lights in vicinity of runway and airport for ground-plane orientation. Stated that runway lights not on and called for manual activation. Not on right away and I got impatient; I clicked for the lights but inadvertently disconnected the autoplt. With double click; no aural warning. We were VFR; saw aircraft nose dip; (should have been in trim with autoplt) and slight roll left. Corrected sink and turned back right to increase crab. It was disorienting until runway lights came on during adjustments. I was over controling the path corrections; and adjusting back to centerline VFR. Got brief GS annunciations and made adjustments. (Still over controling somewhat.) descent to runway; touchdown and rollout uneventful. Debriefed with first officer after arrival on events; mistakes. We were both confused initially on sight picture and getting lights on and why autoplt came off. On ground I pieced together how I had hit disconnect in hurry to get lights on and find airport and runway. Analyzing: error in not thinking of tower being closed and needing manual control of lights for final. Over controling the corrections made; causing more corrections to the corrections! I recognized the disorientation from no area lights; runway lights and crab. My slow reactions and confusion. At no point did I fear for the outcome. I do fly all-nighters willingly and never struggle with drowsiness. I do normally brief that we acknowledge we have been up all night and to keep things simple. I was alert during the flight. I don't think I was that tired. I wasn't in the mindset of 'this is an all-nighter;' we were a late flight. I have never experienced these effects of fatigue; (slowed thinking and reactions); to this degree. These; coupled with some confusion and mis-direction were really an eye opener. I will not underestimate the effects of fatigue again. I had; of course made no adjustments in the day's activities; or sleep pattern for the unexpected all-nighter. I remember I was a little less-than-enthusiastic about heading to work. (Not like me) 'after just doing the 1 day fly/DH turn -- 13 hour day' the day before.
Original NASA ASRS Text
Title: A B757 PILOT DESCRIBES THE MENTAL CONFUSION AND PHYSICAL ACTION ERRORS DURING A NIGHT APPROACH AS A RESULT OF FATIGUE. THERE WAS LONG DELAY PRIOR TO THIS ALL-NIGHT FLIGHT THAT WAS SUPPOSED TO BE A DAYLIGHT FLIGHT.
Narrative: I ARRIVED AT OPS 30 MINS EARLY FOR XA45 PM SHOW; WAS NOTIFIED AT XA15 PM THAT FLT WAS DELAYED UNTIL XG10 PM DEP. ACFT INBOUND. HUNG AROUND OPS; UNABLE TO SLEEP. BOARDED ACFT WITH MECHS IN COCKPIT. LATE WRITE-UPS. VERT SPD WHEEL CHANGED AND CDU CHANGED. MAINT CALLED BACK DUE TO CDU'S NOT WORKING RIGHT. LENGTHY DISCUSSIONS AND MORE SWAPS. FINALLY PUSHED AT XH35 PM. FLT UNEVENTFUL. APCHING ZZZ AT CRUISE BRIEFED ARR FOR ILS AT ZZZ. DISCUSSED NIGHT LNDG; DARK; NO MOON; TERRAIN ISSUES. (NEITHER OF US HAD LANDED THERE AT NIGHT.) AUTOPLT APCH TO BE USED; 'LEAVE ENGAGED FOR APCH.' SCATTERED CLOUD LAYERS WITH VFR AT ARPT. R XWIND 15 KTS. DURING DSCNT DISCUSSED TWR CLOSED; MAKE RPTS ON CTAF. APCH VECTORED US TO INTERCEPT FINAL JUST OUTSIDE FAF. THIN WISPY LAYER OF CLOUDS TILL JUST INSIDE MARKER. NO RWY LIGHTS ON. PITCH BLACK AND NO GND LIGHTS IN VICINITY OF RWY AND ARPT FOR GND-PLANE ORIENTATION. STATED THAT RWY LIGHTS NOT ON AND CALLED FOR MANUAL ACTIVATION. NOT ON RIGHT AWAY AND I GOT IMPATIENT; I CLICKED FOR THE LIGHTS BUT INADVERTENTLY DISCONNECTED THE AUTOPLT. WITH DOUBLE CLICK; NO AURAL WARNING. WE WERE VFR; SAW ACFT NOSE DIP; (SHOULD HAVE BEEN IN TRIM WITH AUTOPLT) AND SLIGHT ROLL L. CORRECTED SINK AND TURNED BACK R TO INCREASE CRAB. IT WAS DISORIENTING UNTIL RWY LIGHTS CAME ON DURING ADJUSTMENTS. I WAS OVER CTLING THE PATH CORRECTIONS; AND ADJUSTING BACK TO CTRLINE VFR. GOT BRIEF GS ANNUNCIATIONS AND MADE ADJUSTMENTS. (STILL OVER CTLING SOMEWHAT.) DSCNT TO RWY; TOUCHDOWN AND ROLLOUT UNEVENTFUL. DEBRIEFED WITH FO AFTER ARR ON EVENTS; MISTAKES. WE WERE BOTH CONFUSED INITIALLY ON SIGHT PICTURE AND GETTING LIGHTS ON AND WHY AUTOPLT CAME OFF. ON GND I PIECED TOGETHER HOW I HAD HIT DISCONNECT IN HURRY TO GET LIGHTS ON AND FIND ARPT AND RWY. ANALYZING: ERROR IN NOT THINKING OF TWR BEING CLOSED AND NEEDING MANUAL CTL OF LIGHTS FOR FINAL. OVER CTLING THE CORRECTIONS MADE; CAUSING MORE CORRECTIONS TO THE CORRECTIONS! I RECOGNIZED THE DISORIENTATION FROM NO AREA LIGHTS; RWY LIGHTS AND CRAB. MY SLOW REACTIONS AND CONFUSION. AT NO POINT DID I FEAR FOR THE OUTCOME. I DO FLY ALL-NIGHTERS WILLINGLY AND NEVER STRUGGLE WITH DROWSINESS. I DO NORMALLY BRIEF THAT WE ACKNOWLEDGE WE HAVE BEEN UP ALL NIGHT AND TO KEEP THINGS SIMPLE. I WAS ALERT DURING THE FLT. I DON'T THINK I WAS THAT TIRED. I WASN'T IN THE MINDSET OF 'THIS IS AN ALL-NIGHTER;' WE WERE A LATE FLT. I HAVE NEVER EXPERIENCED THESE EFFECTS OF FATIGUE; (SLOWED THINKING AND REACTIONS); TO THIS DEGREE. THESE; COUPLED WITH SOME CONFUSION AND MIS-DIRECTION WERE REALLY AN EYE OPENER. I WILL NOT UNDERESTIMATE THE EFFECTS OF FATIGUE AGAIN. I HAD; OF COURSE MADE NO ADJUSTMENTS IN THE DAY'S ACTIVITIES; OR SLEEP PATTERN FOR THE UNEXPECTED ALL-NIGHTER. I REMEMBER I WAS A LITTLE LESS-THAN-ENTHUSIASTIC ABOUT HEADING TO WORK. (NOT LIKE ME) 'AFTER JUST DOING THE 1 DAY FLY/DH TURN -- 13 HR DAY' THE DAY BEFORE.
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.