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|
Attributes | |
ACN | 96944 |
Time | |
Date | 198810 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sea |
State Reference | WA |
Altitude | agl bound lower : 0 agl bound upper : 3000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : sea tower : sea |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent : approach landing other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 150 flight time total : 4000 flight time type : 1000 |
ASRS Report | 96944 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 10000 flight time type : 7500 |
ASRS Report | 97010 |
Events | |
Anomaly | incursion : landing without clearance non adherence : far non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
Flight was flown by captain. The ILS runway 16R CAT ii approach was briefed. Sea approach issued the following clearance. 'Company identify, turn right heading 130, maintain at or above 3000' till anvil, cleared ILS 16R approach, tower at anvil.' I read back the clearance as follows. 'Company identify cleared ILS 16R approach, heading 130, at or above 3000' till anvil.' at that point I was tuned to sea VOR. The captain tuned to the ILS. We intercepted the localizer just outside anvil. I tuned and identified the ILS. The captain commanded gear down and I concluded the final descent checklist. We crossed parkk outer locator, captain announced target approach speed. At that point I was a bit distraction by the constant aural code of the OM. The marker switches were not silenced because of the need to hear the im to determine minimums for the approach. That distraction plus the total concentration I was devoting to the approach was enough to cause me to deviate from SOP and not contact tower. Holding short of 16L I advised. 'Holding short 16L.' the answer was, 'this is sea approach.' that was the first I realized my error. I immediately switched to tower and received clearance to cross 16L. Conclusion/solution. In analyzing this event, I must take full responsibility for not adhering to procedures, but I also feel that this is a weak spot in the approach clearance procedure. Throughout the entire flight, pilots are directed by ATC when to change frequency and the transfer is made immediately. Yet on some approachs, the final switch to tower is not commanded by ATC but is triggered by some other event. In this case the 11 DME fix off of sea ILS. During a period of high concentration and workload such as a CAT ii approach, the pilot might not 'key' into a passive frequency change device. That was my problem on this approach. My solution is, all frequency changes from approach to tower should be initiated as positive commands by approach control. 'Identify, contact tower 119.9.' this might not be a workable solution from the ATC viewpoint, but my mistake would have been avoided under such a procedure.
Original NASA ASRS Text
Title: ACR MLG UNAUTH LNDG AT SEA FROM CAT II APCH.
Narrative: FLT WAS FLOWN BY CAPT. THE ILS RWY 16R CAT II APCH WAS BRIEFED. SEA APCH ISSUED THE FOLLOWING CLRNC. 'COMPANY IDENT, TURN RIGHT HDG 130, MAINTAIN AT OR ABOVE 3000' TILL ANVIL, CLRED ILS 16R APCH, TWR AT ANVIL.' I READ BACK THE CLRNC AS FOLLOWS. 'COMPANY IDENT CLRED ILS 16R APCH, HDG 130, AT OR ABOVE 3000' TILL ANVIL.' AT THAT POINT I WAS TUNED TO SEA VOR. THE CAPT TUNED TO THE ILS. WE INTERCEPTED THE LOC JUST OUTSIDE ANVIL. I TUNED AND IDENTIFIED THE ILS. THE CAPT COMMANDED GEAR DOWN AND I CONCLUDED THE FINAL DSCNT CHKLIST. WE CROSSED PARKK OUTER LOCATOR, CAPT ANNOUNCED TARGET APCH SPD. AT THAT POINT I WAS A BIT DISTR BY THE CONSTANT AURAL CODE OF THE OM. THE MARKER SWITCHES WERE NOT SILENCED BECAUSE OF THE NEED TO HEAR THE IM TO DETERMINE MINIMUMS FOR THE APCH. THAT DISTR PLUS THE TOTAL CONCENTRATION I WAS DEVOTING TO THE APCH WAS ENOUGH TO CAUSE ME TO DEVIATE FROM SOP AND NOT CONTACT TWR. HOLDING SHORT OF 16L I ADVISED. 'HOLDING SHORT 16L.' THE ANSWER WAS, 'THIS IS SEA APCH.' THAT WAS THE FIRST I REALIZED MY ERROR. I IMMEDIATELY SWITCHED TO TWR AND RECEIVED CLRNC TO CROSS 16L. CONCLUSION/SOLUTION. IN ANALYZING THIS EVENT, I MUST TAKE FULL RESPONSIBILITY FOR NOT ADHERING TO PROCS, BUT I ALSO FEEL THAT THIS IS A WEAK SPOT IN THE APCH CLRNC PROC. THROUGHOUT THE ENTIRE FLT, PLTS ARE DIRECTED BY ATC WHEN TO CHANGE FREQ AND THE TRANSFER IS MADE IMMEDIATELY. YET ON SOME APCHS, THE FINAL SWITCH TO TWR IS NOT COMMANDED BY ATC BUT IS TRIGGERED BY SOME OTHER EVENT. IN THIS CASE THE 11 DME FIX OFF OF SEA ILS. DURING A PERIOD OF HIGH CONCENTRATION AND WORKLOAD SUCH AS A CAT II APCH, THE PLT MIGHT NOT 'KEY' INTO A PASSIVE FREQ CHANGE DEVICE. THAT WAS MY PROB ON THIS APCH. MY SOLUTION IS, ALL FREQ CHANGES FROM APCH TO TWR SHOULD BE INITIATED AS POSITIVE COMMANDS BY APCH CTL. 'IDENT, CONTACT TWR 119.9.' THIS MIGHT NOT BE A WORKABLE SOLUTION FROM THE ATC VIEWPOINT, BUT MY MISTAKE WOULD HAVE BEEN AVOIDED UNDER SUCH A PROC.
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.