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|
Attributes | |
ACN | 94168 |
Time | |
Date | 198809 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : lax |
State Reference | CA |
Altitude | msl bound lower : 1500 msl bound upper : 5000 |
Environment | |
Flight Conditions | Marginal |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : lax tower : lax |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | descent : approach descent other landing : go around |
Route In Use | approach : visual |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 4000 flight time type : 1500 |
ASRS Report | 94168 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | incursion : landing without clearance non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The initial approach started as a 24-25 profile descent from the northwest. On downwind, north of the field, the initial confusion arose when I thought I heard, 'expect 24R,' and the first officer flight engineer understood 25R. Approach then said, 'slow to 160, turn to 160 degree,' and, 'did we have traffic that he wanted us to follow for runway 25'? We didn't have the traffic. He gave us another turn to 230 degree and delayed our descent waiting for us to call the traffic. In the meantime, we had confirmed 25R and I had configured hoping to still make it down. When cleared the visual, the controller said something to the effect that he had probably turned us too tight. We said we'd try to make it. At 1000 to 1500' AGL, I broke off the approach and went around because we were too steep. The go around was uneventful. We were then vectored south of the field on downwind for runway 25L. At 8-10 due on downwind at 5000' MSL, approach asked if we had company widebody transport at 10 O'clock. We did not. After a short time, we called the widebody transport in sight and on his response, I thought we were cleared the visual behind the widebody transport and started my turn. In the turn, the controller asked us if we had an small transport on the nose southbound for a turn into 25R. We had an aircraft but couldn't identify if he was an small transport. The controller said maintain 3000' until small transport in sight. By this time, we said we had the traffic, but it looked like an mdt or an mdt. We described him as just forward and to the right. He was lined up for 25R, we were lined up for 25L by this time. We were then cleared to continue the visual approach and cleared to land. The rest of the approach seemed to proceed normally until after landing when approach sent us to tower frequency. None of us had caught the fact that we were not on tower frequency, and I feel reasonably sure we should have been. When we switched to tower, he didn't question our landing clearance and, so, I assumed it had been passed on approach frequency, as we had confirmed in the cockpit at 1000' AGL prior to landing. After landing, I called to the supervisor at TRACON and he said they had turned us way too tight on the first approach. However, he said we were not cleared the visual approach when we turned from downwind to final for the second approach. I obviously thought we were, but couldn't remember the exact conversation. He also questioned whether we had descended below 3000' assigned prior to calling the commuter traffic turning in for 25R. I explained we had not and the confusion over what type of aircraft he actually was. We discussed what we had learned in terms of communication and visual apches, and he said he felt the situation was settled. I think confusion is the key word here. I haven't been into lax as a captain before and the copilot had never been there as a crew member. The initial confusion with the assigned runway on the 1ST approach carried over to the 2ND approach and led to a breakdown in crew coordination as evidenced by the misunderstood visual approach clearance and landing on approach frequency. I sensed this after the go around and called for the entire approach and landing checklist and slowed to 190 on downwind to slow things down and regroup. There were numerous radio calls made by us that were not answered at this time due to traffic saturation which added to the confusion. With all the traffic being called out, I honestly focused on flying the jet and looking outside, perhaps too much so. With all the confusion, the first officer and flight engineer either misunderstood the clearance also, or were so far behind that they didn't catch it or question it. In the future, when I sense this confusion, I intend to question the controller more closely. I also intend to be more selective in the use of the visual approach. Most importantly, I'm going to specifically brief crew coordination from the standpoint of the need to question one another if any confusion in the cockpit should arise.
Original NASA ASRS Text
Title: ACR LGT FLT CREW MADE GO AROUND WHEN TOO HIGH ON VISUAL APCH. STARTED VISUAL APCH BEFORE CLEARED AND THEN LANDED WITHOUT CONTACTING TWR.
Narrative: THE INITIAL APCH STARTED AS A 24-25 PROFILE DSCNT FROM THE NW. ON DOWNWIND, N OF THE FIELD, THE INITIAL CONFUSION AROSE WHEN I THOUGHT I HEARD, 'EXPECT 24R,' AND THE FO FE UNDERSTOOD 25R. APCH THEN SAID, 'SLOW TO 160, TURN TO 160 DEG,' AND, 'DID WE HAVE TFC THAT HE WANTED US TO FOLLOW FOR RWY 25'? WE DIDN'T HAVE THE TFC. HE GAVE US ANOTHER TURN TO 230 DEG AND DELAYED OUR DSCNT WAITING FOR US TO CALL THE TFC. IN THE MEANTIME, WE HAD CONFIRMED 25R AND I HAD CONFIGURED HOPING TO STILL MAKE IT DOWN. WHEN CLRED THE VISUAL, THE CTLR SAID SOMETHING TO THE EFFECT THAT HE HAD PROBABLY TURNED US TOO TIGHT. WE SAID WE'D TRY TO MAKE IT. AT 1000 TO 1500' AGL, I BROKE OFF THE APCH AND WENT AROUND BECAUSE WE WERE TOO STEEP. THE GO AROUND WAS UNEVENTFUL. WE WERE THEN VECTORED S OF THE FIELD ON DOWNWIND FOR RWY 25L. AT 8-10 DUE ON DOWNWIND AT 5000' MSL, APCH ASKED IF WE HAD COMPANY WDB AT 10 O'CLOCK. WE DID NOT. AFTER A SHORT TIME, WE CALLED THE WDB IN SIGHT AND ON HIS RESPONSE, I THOUGHT WE WERE CLRED THE VISUAL BEHIND THE WDB AND STARTED MY TURN. IN THE TURN, THE CTLR ASKED US IF WE HAD AN SMT ON THE NOSE SBND FOR A TURN INTO 25R. WE HAD AN ACFT BUT COULDN'T IDENTIFY IF HE WAS AN SMT. THE CTLR SAID MAINTAIN 3000' UNTIL SMT IN SIGHT. BY THIS TIME, WE SAID WE HAD THE TFC, BUT IT LOOKED LIKE AN MDT OR AN MDT. WE DESCRIBED HIM AS JUST FORWARD AND TO THE RIGHT. HE WAS LINED UP FOR 25R, WE WERE LINED UP FOR 25L BY THIS TIME. WE WERE THEN CLRED TO CONTINUE THE VISUAL APCH AND CLRED TO LAND. THE REST OF THE APCH SEEMED TO PROCEED NORMALLY UNTIL AFTER LNDG WHEN APCH SENT US TO TWR FREQ. NONE OF US HAD CAUGHT THE FACT THAT WE WERE NOT ON TWR FREQ, AND I FEEL REASONABLY SURE WE SHOULD HAVE BEEN. WHEN WE SWITCHED TO TWR, HE DIDN'T QUESTION OUR LNDG CLRNC AND, SO, I ASSUMED IT HAD BEEN PASSED ON APCH FREQ, AS WE HAD CONFIRMED IN THE COCKPIT AT 1000' AGL PRIOR TO LNDG. AFTER LNDG, I CALLED TO THE SUPVR AT TRACON AND HE SAID THEY HAD TURNED US WAY TOO TIGHT ON THE FIRST APCH. HOWEVER, HE SAID WE WERE NOT CLRED THE VISUAL APCH WHEN WE TURNED FROM DOWNWIND TO FINAL FOR THE SECOND APCH. I OBVIOUSLY THOUGHT WE WERE, BUT COULDN'T REMEMBER THE EXACT CONVERSATION. HE ALSO QUESTIONED WHETHER WE HAD DSNDED BELOW 3000' ASSIGNED PRIOR TO CALLING THE COMMUTER TFC TURNING IN FOR 25R. I EXPLAINED WE HAD NOT AND THE CONFUSION OVER WHAT TYPE OF ACFT HE ACTUALLY WAS. WE DISCUSSED WHAT WE HAD LEARNED IN TERMS OF COM AND VISUAL APCHES, AND HE SAID HE FELT THE SITUATION WAS SETTLED. I THINK CONFUSION IS THE KEY WORD HERE. I HAVEN'T BEEN INTO LAX AS A CAPT BEFORE AND THE COPLT HAD NEVER BEEN THERE AS A CREW MEMBER. THE INITIAL CONFUSION WITH THE ASSIGNED RWY ON THE 1ST APCH CARRIED OVER TO THE 2ND APCH AND LED TO A BREAKDOWN IN CREW COORD AS EVIDENCED BY THE MISUNDERSTOOD VISUAL APCH CLRNC AND LNDG ON APCH FREQ. I SENSED THIS AFTER THE GO AROUND AND CALLED FOR THE ENTIRE APCH AND LNDG CHKLIST AND SLOWED TO 190 ON DOWNWIND TO SLOW THINGS DOWN AND REGROUP. THERE WERE NUMEROUS RADIO CALLS MADE BY US THAT WERE NOT ANSWERED AT THIS TIME DUE TO TFC SATURATION WHICH ADDED TO THE CONFUSION. WITH ALL THE TFC BEING CALLED OUT, I HONESTLY FOCUSED ON FLYING THE JET AND LOOKING OUTSIDE, PERHAPS TOO MUCH SO. WITH ALL THE CONFUSION, THE FO AND FE EITHER MISUNDERSTOOD THE CLRNC ALSO, OR WERE SO FAR BEHIND THAT THEY DIDN'T CATCH IT OR QUESTION IT. IN THE FUTURE, WHEN I SENSE THIS CONFUSION, I INTEND TO QUESTION THE CTLR MORE CLOSELY. I ALSO INTEND TO BE MORE SELECTIVE IN THE USE OF THE VISUAL APCH. MOST IMPORTANTLY, I'M GOING TO SPECIFICALLY BRIEF CREW COORD FROM THE STANDPOINT OF THE NEED TO QUESTION ONE ANOTHER IF ANY CONFUSION IN THE COCKPIT SHOULD ARISE.
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.