What happened
On June 8, 2022, a Boeing 757-236, operating as FedEx flight 1170 with registration N949FD, was on approach to Tulsa International Airport (TUL) in Oklahoma. The flight had originated from Fort Worth Alliance Airport (AFW).
During the approach, the flight crew was cleared for a visual approach to runway 18L. While the crew was in visual meteorological conditions, they misidentified runway 18R as their intended landing surface. The first officer noted that the aircraft appeared low and that the Precision Approach Path Indicator (PAPI) lights indicated they were below the glidepath, but he did not alert the captain to the lateral deviation on the horizontal situation indicator (HSI).
The captain adjusted the descent rate based on the PAPI lights to align with what he perceived as the correct glidepath. At approximately 800 feet above ground level, the Runway Awareness and Advisory System (RAAS) issued an automated callout, "Approaching 18R." The crew did not acknowledge or recall this specific callout due to simultaneous cockpit communications.
The aircraft touched down on runway 18R at approximately 04:13. After the RAAS announced that 3,000 feet of runway remained, the captain realized the error, applied heavy braking, and eventually exited the runway at the final taxiway. There were no injuries and no damage to the aircraft.
The investigation
Investigators examined the flight data and cockpit voice recorder, which showed the crew's descent and the RAAS callouts. A simulator evaluation conducted by the NTSB's Operational Factors/Human Performance group demonstrated that during a visual approach to runway 18R, the cockpit displays (PFD and HUD) indicated the aircraft was off-course and below the glideslope, consistent with the incident.
The investigation also reviewed the crew's fatigue levels. The captain had been awake for approximately 15 hours and 30 minutes prior to the incident and had experienced significant sleep debt in the preceding days. The airline's fatigue risk management software had calculated a risk score for the pairing based on the assumption that the crew would take a 30-minute nap during their hub turn, an assumption the crew was not explicitly informed of.
Findings
- The flight crew misidentified runway 18R as runway 18L.
- The crew failed to correctly interpret visual and electronic indicators, such as the HSI deviation and the PAPI lights, which signaled they were misaligned.
- The crew's failure to recognize the error was likely influenced by plan continuation bias, where the crew remained committed to their established approach plan despite conflicting information.
- Cognitive function was likely degraded due to fatigue and working during a period of circadian low.
- The air traffic controller failed to monitor the aircraft after issuing the landing clearance, missing an opportunity to correct the runway misalignment.
- The tower controller's attention was diverted to providing taxi instructions to another aircraft.