AN LGT ACR CREW FAILED TO TUNE THEIR ILS RECEIVERS PROPERLY. HDG TRACK DEV.
Synopsis
AN LGT ACR CREW FAILED TO TUNE THEIR ILS RECEIVERS PROPERLY. HDG TRACK DEV.
Narrative
ON VECTORS FROM LAX APCH CTL FOR A CAT II ILS TO RWY 24R (LAX); WE WERE TALKING TO LAX APCH CTL. WHILE ON THE BASE LEG HDG; #1 VHF NAV RADIO WAS TUNED TO SMO (110.8) AND #2 VHF NAV WAS TUNED TO THE LOC (108.5). A FREQ CHANGE WAS GIVEN BY APCH CTL TO AN INCORRECT TWR FREQ. WHILE THE COPLT WAS SORTING OUT THE PROPER COM RADIO FREQ; THE CAPT REACHED OVER AND TUNED THE #2 NAV RADIO TO 110.8 (THE SMO VOR) RATHER THAN TUNING HIS OWN RADIO TO THE PROPER LOC FREQ (108.5). NOW BOTH NAV RADIOS WERE TUNED TO THE SMO VOR INSTEAD OF THE 24R LOC AND WE FLEW THROUGH THE LOC COURSE. LAX TWR (LCL) IMMEDIATELY REALIZED THAT WE HAD FLOWN THROUGH THE COURSE AND GAVE US A HDG TO CORRECT BACK. MEANWHILE; WE (THE CREW) REALIZED THE IMPROPER NAV FREQ AND TUNED THE PROPER ONE IN. AS A RESULT; WE WERE INSTRUCTED TO OVERFLY THE ARPT ON THE LOC SIGNAL AT 2000 FT AND RETURN TO APCH CTL FOR A SECOND APCH. I FIND IT IS VIRTUALLY IMPOSSIBLE TO READ THE LOC FREQ ON THE APCH PLATES WHILE LOOKING OVER THE CAPT AND COPLT'S SHOULDERS AT NIGHT IN THE WX. I HAD AN APCH PLATE OF MY OWN IN HAND AS A BACKUP. LAX APCH CTL DID NOT HELP THE SITUATION BY 1) VECTORING US IN SO TIGHT ON THE APCH IN SUCH AUSTERE WX CONDITIONS AND 2) GIVING THE WRONG TWR FREQ WHICH DISTRACTED THE COPLT DURING A CRITICAL PHASE OF THE APCH. I BELIEVE THIS SITUATION WAS CAUSED BY A SERIES OF HUMAN FACTORS BREAKDOWNS. FIRST; THE SMO VOR SHOULD HAVE A FREQ OF 112.0 OR HIGHER SO AS NOT TO CONFUSE IT WITH A LOC FREQ. SECOND; LAX APCH CTL SHOULD NOT GIVE TIGHT VECTORS TO FINAL IN POOR WX CONDITIONS UNLESS REQUESTED BY THE CREW. ALSO; STEPS SHOULD BE TAKEN TO INSURE PROPER RADIO FREQ HDOF; AND HDOFS TO TWR SHOULD PROBABLY NOT BE MADE WHILE AN ACFT IS IN THE PROCESS OF INTERCEPTING A FINAL APCH COURSE. THIRD; THE APCH PLATE PUBLISHER SHOULD MAKE THE LOC FREQ A MORE PROMINENT FEATURE ON CAT II ILS APCH PLATES. OTHERWISE; SO'S SHOULD CARRY A FULL SET OF APCH PLATES SO THEY CAN ADEQUATELY BACK UP THE PLT WHO IS FLYING. THIS INCIDENT COULD HAVE RESULTED IN DISASTER AND COULD HAVE BEEN AVOIDED HAD ANY ONE OF THE PRECEDING HUMAN FACTORS OBSTACLES BEEN REMOVED.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.