1995-02 · NASA ASRS report 298533
RWY EXCURSION AFTER A DESTABILIZED APCH. LNDG OVERSHOT.
IN DEBRIEFING AFTER THIS INCIDENT THE CAPT STATED HE WAS UNAWARE OF THE ACFT CONFIGN FROM 4000 FT TO 5000 FT AGL. WE WERE ON AN ILS COUPLED APCH WITH THE RWY IN SIGHT INDICATING 210 KIAS WITH SLATS EXTENDED; CAPT FLYING. AT ABOUT THE OM THE COPLT PUT HIS HAND ON THE FLAP HANDLE. IT IS NOT UNUSUAL FOR THIS CAPT TO DELAY GEAR EXTENSION IN CLR WX. THE COPLT AGAIN TRIED THE HAND ON FLAP HANDLE CUE AND ABOUT THAT TIME MISSED MAKING THE 1000 FT CALL. I BACKED HIM UP AND CALLED THAT WE WERE BELOW 1000 FT. THE COPLT THEN VERBALLY INQUIRED ABOUT THE FLAPS AND I BELIEVE START FLAP EXTENSION. AT 500 FT THE GPWS SOUNDED AND THE CAPT CALLED FOR GEAR DOWN. I COMPLETED THE LNDG CHKLIST. THE APCH WAS NOT STABILIZED BUT A LNDG WITH ENOUGH STOPPING DISTANCE SEEMED ASSURED. ON ROLL OUT THE INITIAL BRAKING EFFORT WAS INADEQUATE; THE LAST 500 FT OF RWY THOUGH DRY; PROVIDED LESS THAN FULL BRAKING AND LNDG ROLL STOPPED SLIGHTLY PAST THE RWY END. THIS INCIDENT DEMONSTRATES THE VALUE OF ADHERING TO SOP. OPERATING OUTSIDE THE BOUNDS OF SOP PLACED THIS CREW IN A GREY AREA ABOUT WHEN THE PREPARATION FOR LNDG SHOULD OCCUR. THIS PRODUCED HESITATION AND CAUSED THE SUBTLE INCAPACITATION OF THE CAPT TO GO UNDETECTED. SOP CALLED FOR A MISSED APCH TO BE EXECUTED. THE CAPT WAS ABSOLUTELY COMMITTED TO A LNDG AND I FELT THEN THAT CALLING FOR A MISSED APCH WOULD HAVE BEEN IGNORED AND WOULD MERELY ADD ANOTHER DISTR TO A CHAOTIC SIT. I'LL NEVER KNOW IF HE WOULD HAVE GONE AROUND THOUGH BECAUSE I DIDN'T ADVOCATE. I SHOULD HAVE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE ACFT WAS A DC-10. THE ACFT EXITED THE CONFINES OF THE RWY PROPER; ONTO THE MACADAM THAT IS NOT CLASSIFIED AS AN OVERRUN AS IT DOES NOT HAVE THE LOAD BEARING CAPACITY AS SUCH. THERE IS A ROW OF RWY END LIGHTS THAT SEPARATES THE 2 AREAS. THE ACFT RAN OVER THESE LIGHTS AND CUT THE TIRES BADLY ENOUGH SO THAT THEY HAD TO BE REPLACED. THE L GEAR WENT OFF THE L SIDE OF THE AREA. THE BRAKES WERE EXCESSIVELY HEATED AND STARTED A GRASS FIRE DURING THE EXIT/RETURN AND TURN AROUND MANEUVER. THE RPTR ISN'T SURE AS TO WHO CALLED THE EMER GND EQUIP OUT BUT ASSUMES IT WAS THE TWR CTLR. THE CFR EQUIP FOLLOWED THEM TO THE GATE; UNKNOWN TO THE FLC. THE CREW HAD NO IDEA THE BRAKES WERE THAT HOT AS THE DC-10 HAS NO TEMP SENSING GAUGES TO MONITOR BRAKE TEMPS. THE RPTR IS A RETIRED B-727 CAPT WHO ELECTED TO CONTINUE AS A SO. HE STATED THAT WHEN HE ASSUMED THE POS OF THE SO; HE VOWED THAT HE WOULD NOT ATTEMPT TO ACT AS A 'REAR SEAT CAPT' BUT ACT AS A BALANCED CREWMEMBER. HE FELT THAT IN THIS CASE HE OVER REACTED; IN THE WRONG DIRECTION. HE SAID THAT BOTH HE AND THE FO ARE BASICALLY QUIET TYPE INDIVIDUALS. THE CAPT IN THIS CASE WAS ONE THAT WAS 'DIFFICULT' TO WORK WITH. AS TO THE LACK OF COCKPIT RESOURCE MGMNT DISPLAYED (WHICH THE COMPANY HAS PLACED GREAT EMPHASIS ON IN TRAINING) HE SAID THAT HE STILL DOESN'T KNOW WHY THEIR COCKPIT RESOURCE MGMNT TRAINING FAILED THEM DURING THIS EVENT. THE ACR IS VERY CONCERNED OVER THIS INCIDENT FROM THE HUMAN FACTORS POINT OF VIEW AND IS FOLLOWING UP ON THIS EVENT WITH 'ENTHUSIASM.' THE FO AND RPTR ARE IN A CONTINUING 'DISCUSSION' WITH THE COMPANY OVER THIS INCIDENT. THE CAPT IS NOW RETIRED 'MEDICALLY.' RPTR SAID IT WAS NOT CONNECTED WITH THIS RPTED EVENT.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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