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|
Attributes | |
ACN | 81555 |
Time | |
Date | 198802 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : sfo |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | descent : approach landing other |
Route In Use | approach : visual |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | descent : approach landing other |
Route In Use | approach : visual |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 3000 flight time type : 1000 |
ASRS Report | 81555 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 13500 flight time type : 1100 |
ASRS Report | 81609 |
Events | |
Anomaly | incursion : landing without clearance non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
While in contact with bay approach upon arriving at sfo, we were given a traffic advisory at 9 O'clock, 5 mi, an medium large transport Y. After calling 'visual' on the traffic, we were clrd for the quiet bridge approach to runway 28R 'with the traffic in sight.' I commented to the captain that we were level with and converging with the traffic, and were then given additional traffic 1 O'clock at 1 1/2 mi wbound altitude unknown. At that point we were approximately 8000' altitude and descending. I made and called visual contact on a low flying light aircraft crossing under our nose about 3000-4000' below us. Meanwhile we continued to merge with the traffic at 9 O'clock who was shooting a visual to 28L, and I commented that it was a (company name) scheme with (name) painted on it. We continued on collision bearing until we were 500-700' exactly line abreast--where we stayed throughout the approach and landing. The captain commented that it was probably very disconcerting for the passenger to see us so close--as it was to us. We were so caught up in watching medium large transport Y, looking for other traffic and flying the quiet bridge approach that we did not hear any call for us to change to tower frequency. I presume that we landed on 28R at ksfo west/O clearance from the tower to land. The first contact that we made with tower was at taxiway east holding short of runway 28L, at which time tower clrd us to cross runway 28L and contact ground. We crossed and contacted west/O further comment. We had just finished 3 legs from pittsburgh, had to deice and flew for over 7 hours just prior to this incident. That coupled with our preoccupation with finding and maintaining sep from the traffic and approach not prompting us to contact tower (or us not hearing it) caused this incident. Supplemental information from acn 81609: visual contact with the medium large transport Y was acknowledged, and I was clrd for a visual approach to runway 28R, to maintain visual sep from the medium large transport Y traffic approaching runway 28L. My first officer was looking for the issued crossing traffic below us and also completing the final landing checklist. I do not recall receiving a frequency change to sfo tower. My flight and the medium large transport Y approaching runway 28L converged over the san mateo bridge at 1900', each aligned with the extended centerline of our respective runways. The speed and glide paths of both aircraft were compatible from the bridge to T/D on our respective runways. I would estimate that the horizontal sep between the 2 aircraft from the bridge to the runways was 500'. The aircraft which I followed to runway 28R, an large transport, landed approximately 4 mi ahead of me, and was not a factor. The close proximity of the other aircraft throughout the final approach and landing was apparently enough of a distraction to me that I did not verify contact with sfo tower, or verify clearance to land. I instructed my first officer to switch to sfo tower frequency. Shortly thereafter, I was clrd to cross runway 28L and to contact ground control when clear. No corrective actions were taken, as the landing had already been completed. In my judgement, the entire approach and landing was a safe operation conducted on speed and on profile with adequate sep from the preceeding aircraft. The majority of my attention during the approach was focused on flying the aircraft, ensuring adequate sep from the parallel traffic and ensuring that all prelndg checks had been completed. The abnormality was the close proximity of the aircraft on the parallel approach. The only other factor affecting the quality of human performance would be the last 2 communications with oak approach control. The first communication contained an altitude change, airspeed change, conflicting traffic advisory and other approach traffic advisory, all of which required crew action, one of which diverted crew attention. The second communication contained the visual approach clearance. As I have stated, to my recollection, neither communication contained a frequency change to sfo tower. Although this does no alleviate my responsibility, I feel it contributed to the situation.
Original NASA ASRS Text
Title: MLG ON PARALLEL VISUAL SIDE-BY-SIDE APCH LANDED WITHOUT CLRNC FROM TWR. FLT CREW NOT HAPPY WITH CHARTED VISUAL APCH PROC OR ATC TECHNIQUE OF ALIGNING ACFT SIDE-BY-SIDE ON PARALLEL APCH PATHS. FLT CREW ALSO OBJECTS TO THE TASK LOAD VOLUME REQUIRED BY ATC PROC OF VECTORING ACFT ONTO APCH.
Narrative: WHILE IN CONTACT WITH BAY APCH UPON ARRIVING AT SFO, WE WERE GIVEN A TFC ADVISORY AT 9 O'CLOCK, 5 MI, AN MLG Y. AFTER CALLING 'VISUAL' ON THE TFC, WE WERE CLRD FOR THE QUIET BRIDGE APCH TO RWY 28R 'WITH THE TFC IN SIGHT.' I COMMENTED TO THE CAPT THAT WE WERE LEVEL WITH AND CONVERGING WITH THE TFC, AND WERE THEN GIVEN ADDITIONAL TFC 1 O'CLOCK AT 1 1/2 MI WBOUND ALT UNKNOWN. AT THAT POINT WE WERE APPROX 8000' ALT AND DSNDING. I MADE AND CALLED VISUAL CONTACT ON A LOW FLYING LIGHT ACFT XING UNDER OUR NOSE ABOUT 3000-4000' BELOW US. MEANWHILE WE CONTINUED TO MERGE WITH THE TFC AT 9 O'CLOCK WHO WAS SHOOTING A VISUAL TO 28L, AND I COMMENTED THAT IT WAS A (COMPANY NAME) SCHEME WITH (NAME) PAINTED ON IT. WE CONTINUED ON COLLISION BEARING UNTIL WE WERE 500-700' EXACTLY LINE ABREAST--WHERE WE STAYED THROUGHOUT THE APCH AND LNDG. THE CAPT COMMENTED THAT IT WAS PROBABLY VERY DISCONCERTING FOR THE PAX TO SEE US SO CLOSE--AS IT WAS TO US. WE WERE SO CAUGHT UP IN WATCHING MLG Y, LOOKING FOR OTHER TFC AND FLYING THE QUIET BRIDGE APCH THAT WE DID NOT HEAR ANY CALL FOR US TO CHANGE TO TWR FREQ. I PRESUME THAT WE LANDED ON 28R AT KSFO W/O CLRNC FROM THE TWR TO LAND. THE FIRST CONTACT THAT WE MADE WITH TWR WAS AT TXWY E HOLDING SHORT OF RWY 28L, AT WHICH TIME TWR CLRD US TO CROSS RWY 28L AND CONTACT GND. WE CROSSED AND CONTACTED W/O FURTHER COMMENT. WE HAD JUST FINISHED 3 LEGS FROM PITTSBURGH, HAD TO DEICE AND FLEW FOR OVER 7 HRS JUST PRIOR TO THIS INCIDENT. THAT COUPLED WITH OUR PREOCCUPATION WITH FINDING AND MAINTAINING SEP FROM THE TFC AND APCH NOT PROMPTING US TO CONTACT TWR (OR US NOT HEARING IT) CAUSED THIS INCIDENT. SUPPLEMENTAL INFORMATION FROM ACN 81609: VISUAL CONTACT WITH THE MLG Y WAS ACKNOWLEDGED, AND I WAS CLRD FOR A VISUAL APCH TO RWY 28R, TO MAINTAIN VISUAL SEP FROM THE MLG Y TFC APCHING RWY 28L. MY F/O WAS LOOKING FOR THE ISSUED XING TFC BELOW US AND ALSO COMPLETING THE FINAL LNDG CHKLIST. I DO NOT RECALL RECEIVING A FREQ CHANGE TO SFO TWR. MY FLT AND THE MLG Y APCHING RWY 28L CONVERGED OVER THE SAN MATEO BRIDGE AT 1900', EACH ALIGNED WITH THE EXTENDED CENTERLINE OF OUR RESPECTIVE RWYS. THE SPD AND GLIDE PATHS OF BOTH ACFT WERE COMPATIBLE FROM THE BRIDGE TO T/D ON OUR RESPECTIVE RWYS. I WOULD ESTIMATE THAT THE HORIZ SEP BTWN THE 2 ACFT FROM THE BRIDGE TO THE RWYS WAS 500'. THE ACFT WHICH I FOLLOWED TO RWY 28R, AN LGT, LANDED APPROX 4 MI AHEAD OF ME, AND WAS NOT A FACTOR. THE CLOSE PROX OF THE OTHER ACFT THROUGHOUT THE FINAL APCH AND LNDG WAS APPARENTLY ENOUGH OF A DISTR TO ME THAT I DID NOT VERIFY CONTACT WITH SFO TWR, OR VERIFY CLRNC TO LAND. I INSTRUCTED MY F/O TO SWITCH TO SFO TWR FREQ. SHORTLY THEREAFTER, I WAS CLRD TO CROSS RWY 28L AND TO CONTACT GND CTL WHEN CLR. NO CORRECTIVE ACTIONS WERE TAKEN, AS THE LNDG HAD ALREADY BEEN COMPLETED. IN MY JUDGEMENT, THE ENTIRE APCH AND LNDG WAS A SAFE OPERATION CONDUCTED ON SPD AND ON PROFILE WITH ADEQUATE SEP FROM THE PRECEEDING ACFT. THE MAJORITY OF MY ATTN DURING THE APCH WAS FOCUSED ON FLYING THE ACFT, ENSURING ADEQUATE SEP FROM THE PARALLEL TFC AND ENSURING THAT ALL PRELNDG CHKS HAD BEEN COMPLETED. THE ABNORMALITY WAS THE CLOSE PROX OF THE ACFT ON THE PARALLEL APCH. THE ONLY OTHER FACTOR AFFECTING THE QUALITY OF HUMAN PERFORMANCE WOULD BE THE LAST 2 COMS WITH OAK APCH CTL. THE FIRST COM CONTAINED AN ALT CHANGE, AIRSPD CHANGE, CONFLICTING TFC ADVISORY AND OTHER APCH TFC ADVISORY, ALL OF WHICH REQUIRED CREW ACTION, ONE OF WHICH DIVERTED CREW ATTN. THE SECOND COM CONTAINED THE VISUAL APCH CLRNC. AS I HAVE STATED, TO MY RECOLLECTION, NEITHER COM CONTAINED A FREQ CHANGE TO SFO TWR. ALTHOUGH THIS DOES NO ALLEVIATE MY RESPONSIBILITY, I FEEL IT CONTRIBUTED TO THE SITUATION.
Data retrieved from NASA's ASRS site as of August 2007 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.