37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 945092 |
Time | |
Date | 201104 |
Local Time Of Day | 0001-0600 |
Place | |
Locale Reference | SGES.Airport |
State Reference | FO |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Make Model Name | MD-11 |
Operating Under FAR Part | Part 121 |
Flight Phase | Landing |
Route In Use | Visual Approach |
Flight Plan | IFR |
Person 1 | |
Function | Relief Pilot Pilot Not Flying |
Qualification | Flight Crew Flight Engineer Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Total 9000 |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy Flight Deck / Cabin / Aircraft Event Other / Unknown Ground Event / Encounter Loss Of Aircraft Control Ground Event / Encounter Ground Strike - Aircraft Ground Event / Encounter Object Ground Excursion Runway |
Narrative:
The flight proceeded through cruise and descent normal operations. First officer was pilot flying and captain was pilot not flying. Cleared ILS 23 to sges; sky clear; wind calm; visibility 3;000m due to patchy fog 21/21 1013hp. We had visual contact with runway from less then 10 miles during descent on the arrival. Approach begins at 2;800; airport elevation about 846 ft; runway 23 11;154 ft landing distance available; 148 ft wide; low intensity runway lights and PAPI. The IAF is AGL NDB located 6.8 miles from the runway and we had clear visual contact with the airport and runway from beyond this point. There was some fog over the first portion of the runway but it was thin and the lights were clearly visible through it at all times. First officer elected to hand fly the approach I believe disconnected the autopilot at about 2;800 ft. I do not recall what the aircraft configuration was. I believe landing configuration and landing checklist complete. Approach was mostly normal with slight deviations on glideslope and localizer. At some point below 1;000 ft the first officer drifted slightly right of localizer. The captain told the first officer to keep an eye on the instruments. At some point about 100 ft AGL (my eyes were now outside the aircraft) aircraft began to drift left of localizer. I called out 'get the back on the (expletive deleted) centerline'. I believe there was some correction but very shortly thereafter the left wing dipped and the nose pulled left. Almost simultaneous with touchdown I called out; 'captain! Take it; take it'. Captain said; 'I got it; I got it'. First officer's hands were still on yoke and throttles. CAWS height above ground callouts had been closer together than what I would consider normal. The first officer had controls at touchdown and the captain took over after we were on the ground. I know that the correct inputs to correct back to centerline were not being applied the last 50 ft by the first officer. Aircraft touched down slightly left of centerline but not aligned with the runway and from my perspective it appeared that the first officer froze and stopped flying the aircraft. We exited the left side of the runway to the point that the left main and center gear were in the grass. I felt the left main gear impact and I believe we immediately got the 'tire failure' warning but cannot be sure exactly when. We veered hard right and were back on the runway tracking down the middle. I selected configuration status page and announced 'we blew tire number 5' followed by 'brake temps normal' and continued to monitor tires and brakes on configuration page. When we slowed to taxi speed there was not any noticeable vibration; I consulted QRH (nothing for warning on landing) and the captain elected to continue to taxi to parking. Taxi to parking [was] normal. Upon post flight inspection found tire #5 blown; damage to #1 tire; and damage to left inboard flap track fairing.beyond the hard facts of what happened I would like to state for the record a few other things which I believe ultimately contributed to this event [are] the first officer [and] fatigue. This was only my second flight since being signed off of initial operating experience. The previous flight involved three legs on which I was also paired with this captain. Prior to this flight I had never met the first officer and knew nothing about him. I began to question his judgment within 3 minutes of arriving in operations and his CRM skills within another 5 minutes. I picked up the paperwork and began to review the load plan and weight and balance forms. I noticed immediately that the tail number did not match the flight number and destination and that neither the top weights on the form nor the ZFW cg (zero fuel weight center of gravity) were plotted. I brought this to his attention and he said we could probably just change the tail number. I objected saying that was the load master's job and insisted it be taken in to operations. They guys in operations said he would get the load master. We took the forms to the work table and he announced (did not ask; announced) he would fly the leg to sges. That would make me the relief pilot and as such directly responsible for the weight and balance and performance computations. Nonetheless; he began to fill out the top of the form. I informed him that as I was the relief pilot it was my responsibility to perform that task. He muttered something about me being the new guy to which I responded that I had my job; he had his job; and the captain had his job and that they would both have an opportunity to check my work. Shortly thereafter a load master arrived. I showed him the problems and he immediately inquired who had begun to fill out the top of the form to which I responded that the first officer had. He stated very clearly that that was not the pilot's job; it was the responsibility of the load master and that in fact it was the wrong weight and balance for our tail. He took the weight and balance and returned a few minutes later with a corrected one which the first officer also took (again; not his responsibility) and reviewed and declared correct. I took it and immediately saw that the bow was for 4 people and that we had 5 onboard. I pointed this out to the load master and he ultimately returned with a weight and balance that was properly filled in. It was at this point that I took captain aside and asked him if he had ever flown with the first officer (he had not) and I informed him of my opinion that he (first officer) had already demonstrated to me that he had neither good judgment nor CRM skills and that he was arrogant. During the next few hours first officer's behavior did nothing but reinforce my opinion. He briefed us on how strictly he enforced sterile cockpit and broke sterile cockpit within ten seconds of beginning pushback and repeatedly during taxi. He said he intended to hand fly the aircraft all the way up to cruise at which point the captain and I stated that we would be in rvsm airspace by then and that the autopilot needed to be engaged prior to that. He jumped in on radio calls; and called '1;000 below' before giving the pilot not flying the opportunity to call it. During cruise captain went in the back and requested I sit in the left seat as the pilot not flying. First officer replied to radio calls before I could even key the mike and until I finally had enough and said something he would take the clipboard with the master flight plan and do the fuel scores. Again; this is the job of the pilot not flying. I told him that I would appreciate being able to do my job but his excuse was that he was bored and needed something to do. At some point he reached over and began setting the barometer. Altitude for the approach we anticipated on the captain's ecp. During cruise he told me to request a climb to FL330 from our current 310. He didn't discuss it; he just told me to do it. I asked him why he wanted to climb since our optimum was showing FL295 and there was not any difference in the wind either. He gave me some incorrect explanation about fuel burn. I asked him what exactly he thought optimum altitude meant and why he thought he knew better than the airplane did about where it was. First officer has an arrogant; aggressive personality and based on my direct observation of his interpersonal communication; leadership; and decision making skills (or lack thereof) absolutely no CRM skills. He possesses a strong self confidence from which I can find no rational source. He complained that he had been passed over for promotion and wondered aloud why and what he could do about it. He quotes (often mis-quotes) minutiae from the manuals but consistently misses large operational considerations such as the fact that they often use meters not feet or miles in south america. He will argue the smallest points and I found him to be generally disagreeable; easily bewildered and overall unpleasant to be around. It has come to myattention that there are company captains who will not allow this first officer to fly the airplane. If this is the case I am astonished that in a company of this size this first officer was not weeded out prior to this. If it is true that this first officer is a known weak link and the company did nothing to remove him from flight status I have a real reason to be upset with the company. This first officer almost cost me my life and the company an airplane.there can be little question that fatigue played a role in this event. After all; it occurred early in the morning when the normal person is in his deepest sleep; and after an eight hour flight. Now some of this can be placed on the FAA for allowing part 121 supplemental carriers to operate the way they do; namely; no real rest requirements. Under part 121 flag and domestic there is a 24 hour look back during which a pilot must have received a regulatory rest period. The rest must be continuous; uninterrupted and prospective (known in advance). These requirements do not exist under 121 supplemental and our company has no policy in place that puts any further restriction on rest; flight; or duty times. The FAA is not solely culpable. In my opinion our company shares a large portion of the blame for its pilots potentially being fatigued. On a daily basis the predicted departure times for flights can change by 12 hours or more. It is almost impossible to predict with any reasonable accuracy when we should be resting for flights. We go on rest; awake and await notification for a flight. Often it is just around the time you're ready for a nap when the phone call comes. I do not recall how late this flight departed but with no hard scheduled departure times we play a constant guessing game with when and how much to sleep. In addition to the failure to produce or stick to a realistic flight schedule; it is my opinion that the ability to operate 12 hours of flight time within 24 hours due to carrying a relief pilot provides very little benefit to the pilot when there exist no adequate crew rest facilities. If our aircraft had real rest facilities; or even rudimentary bunks we could actually get some real rest enroute and if proper crew rest schedules are applied we could always be assured of two rested pilots at the controls.conclusion: in my opinion the blame for this event rests almost exclusively on first officer's inability to control the aircraft throughout the landing phase of flight. What role his poor judgment; personality and lack of CRM and the fatigue level of the operating flight crew is speculative; ambiguous and difficult to assign. I will offer you this. I am skeptical that his deficiencies can be resolved by additional training. Good judgment can not be trained into a pilot and arrogance can not be trained out.
Original NASA ASRS Text
Title: An MD-11 Relief Pilot addressed shortcomings in flight crew CRM; SOP and flying skills which resulted in an excursion from the landing runway after touchdown following a poorly stabilized approach.
Narrative: The flight proceeded through cruise and descent normal operations. First Officer was pilot flying and Captain was pilot not flying. Cleared ILS 23 to SGES; sky clear; wind calm; visibility 3;000m due to patchy fog 21/21 1013hp. We had visual contact with runway from less then 10 miles during descent on the arrival. Approach begins at 2;800; airport elevation about 846 FT; Runway 23 11;154 FT landing distance available; 148 FT wide; low intensity runway lights and PAPI. The IAF is AGL NDB located 6.8 miles from the runway and we had clear visual contact with the airport and runway from beyond this point. There was some fog over the first portion of the runway but it was thin and the lights were clearly visible through it at all times. First Officer elected to hand fly the approach I believe disconnected the autopilot at about 2;800 FT. I do not recall what the aircraft configuration was. I believe landing configuration and Landing Checklist complete. Approach was mostly normal with slight deviations on glideslope and localizer. At some point below 1;000 FT the First Officer drifted slightly right of localizer. The Captain told the First Officer to keep an eye on the instruments. At some point about 100 FT AGL (my eyes were now outside the aircraft) aircraft began to drift left of localizer. I called out 'get the back on the (expletive deleted) centerline'. I believe there was some correction but very shortly thereafter the left wing dipped and the nose pulled left. Almost simultaneous with touchdown I called out; 'Captain! Take it; take it'. Captain said; 'I got it; I got it'. First Officer's hands were still on yoke and throttles. CAWS height above ground callouts had been closer together than what I would consider normal. The First Officer had controls at touchdown and the Captain took over after we were on the ground. I know that the correct inputs to correct back to centerline were not being applied the last 50 FT by the First Officer. Aircraft touched down slightly left of centerline but not aligned with the runway and from my perspective it appeared that the First Officer froze and stopped flying the aircraft. We exited the left side of the runway to the point that the left main and center gear were in the grass. I felt the left main gear impact and I believe we immediately got the 'Tire Failure' warning but cannot be sure exactly when. We veered hard right and were back on the runway tracking down the middle. I selected CONFIG status page and announced 'we blew tire number 5' followed by 'brake temps normal' and continued to monitor tires and brakes on CONFIG page. When we slowed to taxi speed there was not any noticeable vibration; I consulted QRH (nothing for warning on landing) and the Captain elected to continue to taxi to parking. Taxi to parking [was] normal. Upon post flight inspection found tire #5 blown; damage to #1 tire; and damage to left inboard flap track fairing.Beyond the hard facts of what happened I would like to state for the record a few other things which I believe ultimately contributed to this event [are] the First Officer [and] fatigue. This was only my second flight since being signed off of Initial Operating Experience. The previous flight involved three legs on which I was also paired with this Captain. Prior to this flight I had never met the First Officer and knew nothing about him. I began to question his judgment within 3 minutes of arriving in Operations and his CRM skills within another 5 minutes. I picked up the paperwork and began to review the load plan and weight and balance forms. I noticed immediately that the tail number did not match the flight number and destination and that neither the top weights on the form nor the ZFW CG (Zero Fuel Weight Center of Gravity) were plotted. I brought this to his attention and he said we could probably just change the tail number. I objected saying that was the Load Master's job and insisted it be taken in to Operations. They guys in Operations said he would get the Load Master. We took the forms to the work table and he announced (did not ask; announced) he would fly the leg to SGES. That would make me the Relief Pilot and as such directly responsible for the weight and balance and performance computations. Nonetheless; he began to fill out the top of the form. I informed him that as I was the Relief Pilot it was my responsibility to perform that task. He muttered something about me being the new guy to which I responded that I had my job; he had his job; and the Captain had his job and that they would both have an opportunity to check my work. Shortly thereafter a Load Master arrived. I showed him the problems and he immediately inquired who had begun to fill out the top of the form to which I responded that the First Officer had. He stated very clearly that that was not the pilot's job; it was the responsibility of the Load Master and that in fact it was the wrong weight and balance for our tail. He took the weight and balance and returned a few minutes later with a corrected one which the First Officer also took (again; NOT his responsibility) and reviewed and declared correct. I took it and immediately saw that the BOW was for 4 people and that we had 5 onboard. I pointed this out to the Load Master and he ultimately returned with a weight and balance that was properly filled in. It was at this point that I took Captain aside and asked him if he had ever flown with the First Officer (he had not) and I informed him of my opinion that he (First Officer) had already demonstrated to me that he had neither good judgment nor CRM skills and that he was arrogant. During the next few hours First Officer's behavior did nothing but reinforce my opinion. He briefed us on how strictly he enforced sterile cockpit and broke sterile cockpit within ten seconds of beginning pushback and repeatedly during taxi. He said he intended to hand fly the aircraft all the way up to cruise at which point the Captain and I stated that we would be in RVSM airspace by then and that the autopilot needed to be engaged prior to that. He jumped in on radio calls; and called '1;000 below' before giving the pilot not flying the opportunity to call it. During cruise Captain went in the back and requested I sit in the left seat as the pilot not flying. First Officer replied to radio calls before I could even key the mike and until I finally had enough and said something he would take the clipboard with the master Flight Plan and do the fuel scores. Again; this is the job of the pilot not flying. I told him that I would appreciate being able to do my job but his excuse was that he was bored and needed something to do. At some point he reached over and began setting the barometer. Altitude for the approach we anticipated on the Captain's ECP. During cruise he told me to request a climb to FL330 from our current 310. He didn't discuss it; he just told me to do it. I asked him why he wanted to climb since our optimum was showing FL295 and there was not any difference in the wind either. He gave me some incorrect explanation about fuel burn. I asked him what exactly he thought Optimum Altitude meant and why he thought he knew better than the airplane did about where it was. First Officer has an arrogant; aggressive personality and based on my direct observation of his interpersonal communication; leadership; and decision making skills (or lack thereof) absolutely no CRM skills. He possesses a strong self confidence from which I can find no rational source. He complained that he had been passed over for promotion and wondered aloud why and what he could do about it. He quotes (often mis-quotes) minutiae from the manuals but consistently misses large operational considerations such as the fact that they often use meters not feet or miles in South America. He will argue the smallest points and I found him to be generally disagreeable; easily bewildered and overall unpleasant to be around. It has come to myattention that there are company Captains who will not allow this First Officer to fly the airplane. If this is the case I am astonished that in a Company of this size this First Officer was not weeded out prior to this. If it is true that this First Officer is a known weak link and the Company did nothing to remove him from flight status I have a real reason to be upset with the Company. This First Officer almost cost me my life and the Company an airplane.There can be little question that fatigue played a role in this event. After all; it occurred early in the morning when the normal person is in his deepest sleep; and after an eight hour flight. Now some of this can be placed on the FAA for allowing Part 121 Supplemental Carriers to operate the way they do; namely; no real rest requirements. Under part 121 Flag and Domestic there is a 24 hour look back during which a pilot must have received a regulatory rest period. The rest must be continuous; uninterrupted and prospective (known in advance). These requirements do not exist under 121 Supplemental and our Company has no policy in place that puts any further restriction on rest; flight; or duty times. The FAA is not solely culpable. In my opinion our Company shares a large portion of the blame for its pilots potentially being fatigued. On a daily basis the predicted departure times for flights can change by 12 hours or more. It is almost impossible to predict with any reasonable accuracy when we should be resting for flights. We go on rest; awake and await notification for a flight. Often it is just around the time you're ready for a nap when the phone call comes. I do not recall how late this flight departed but with no hard scheduled departure times we play a constant guessing game with when and how much to sleep. In addition to the failure to produce or stick to a realistic flight schedule; it is my opinion that the ability to operate 12 hours of flight time within 24 hours due to carrying a Relief Pilot provides very little benefit to the pilot when there exist no adequate crew rest facilities. If our aircraft had real rest facilities; or even rudimentary bunks we could actually get some real rest enroute and if proper crew rest schedules are applied we could always be assured of two rested pilots at the controls.Conclusion: In my opinion the blame for this event rests almost exclusively on First Officer's inability to control the aircraft throughout the landing phase of flight. What role his poor judgment; personality and lack of CRM and the fatigue level of the operating flight crew is speculative; ambiguous and difficult to assign. I will offer you this. I am skeptical that his deficiencies can be resolved by additional training. Good judgment can not be trained into a pilot and arrogance can not be trained out.
Data retrieved from NASA's ASRS site as of April 2012 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.