2001-11 · NASA ASRS report 530141
AN APCH IS ABANDONED WHEN MULTIPLE FACTORS COME TOGETHER TO RAISE THE CONFUSION FACTOR OF ALL PARTIES INVOLVED MAKING IT THE MOST PRUDENT COURSE OF ACTION.
THIS INCIDENT WAS THE WORST CASE OF HUMAN FACTORS AND NEGATIVE SYNERGY THAT I HAVE SEEN IN MY CAREER. THE ACCIDENT CHAIN WAS 1 LINK AWAY FROM BEING COMPLETE ON THIS FLT. OUR FLT REQUESTED A STRAIGHT-IN RWY 11 VISUAL AND HAD BEEN CLRED TO RWY 11 AND TO EXPEDITE DSCNT TO 3000 FT. RWY 29 WAS THE ACTIVE; BUT TWR OFTEN APPROVES OPPOSITE DIRECTION OPS. BOTH THE VISUAL RWY 29 AND RWY 11 WERE BRIEFED FOR THE APCH. THE STRAIGHT-IN WAS REQUESTED FOR 2 REASONS: FIRST; TO MAKE THINGS EASIER ON THE PF/SIC WHO WAS BEHIND THE AIRPLANE. SECOND; TO EXPEDITE OUR ARR. THE PROB CAME INTO PLAY ON A 5 MI FINAL. WE WERE BEHIND THE PROFILE FOR CONFIGURING WHEN THE PF MADE A TURN OFF FINAL TO A 030 DEG HDG; WHICH WAS TOWARDS THE PREVIOUS DEP. AT THIS TIME I ASKED WHAT HE WAS DOING AND APCH ASKED OUR ALT. NOBODY KNEW WHAT THE OTHER PARTIES IN THIS SIT WERE DOING. THE PF THOUGHT THAT THE 030 DEG VECTOR GIVEN TO OUR COMPANY ACFT WAS FOR US. I THOUGHT WE WERE CLRED FOR THE APCH (AS DID THE PIC OF OUR COMPANY AND FOLLOWING US). APCH THOUGHT WE WERE STOPPING AT 3000 FT. WE FINALLY HAD TO BREAK OFF THE APCH AND CIRCLE TO RWY 29. DURING THE CONFUSION; THE THRUST REVERSERS ARMING WAS SKIPPED ON THE CHKLIST AND THE PF ACCIDENTALLY TURNED OFF THE GND SPOILERS. BOTH OF THESE ITEMS BECAME OBVIOUS DURING THE LNDG ROLL. THIS COMBINED WITH THE PF NOT EXTENDING THE FLT SPOILERS (PER COMPANY OPS) AT TOUCHDOWN (I HAD TO REACH AROUND THE THROTTLE QUADRANT TO DEPLOY THE SPOILERS) MADE FOR A VERY LONG GND ROLL AND HVY BRAKING. (THRUST REVERSERS ARMED DURING THE GND ROLL AND DEPLOYED.) FACTORS: 1) PF/SIC: BEHIND ACFT THOUGH VERY EXPERIENCED IN TYPE. 2) PNF/PIC: APCH AND LNDG EXPECTANCY. 3) CTLR: CTLR CHANGE DURING OUR ARR. NONSTANDARD RADIO PHRASEOLOGY (BOTH MYSELF AND COMPANY (ACFT Y) CAPT UNDERSTOOD 'CLRED' FOR RWY 11 'VISUAL.' WHAT CTLR MEANT WAS 'PROCEED TO RWY 11 AND EXPEDITE TO 3000 FT.' 4) CHKLIST: FIRST 3 ITEMS OF BEFORE LNDG CHKLIST (#1 HYD 'B' PUMPS ON; #2 THRUST REVERSERS ARM; #3 ANNUNCIATOR RECALL) SHOULD BE MOVED TO THE APCH CHKLIST. THEY ARE TOO CRITICAL TO BE DELAYED TO THE BEFORE LNDG CHKLIST. 5) DIFFERENT ACFT: OUR CREWS FLY 3 DIFFERENT TYPES OF JET ACFT DURING ANY GIVEN WK; WHICH DISRUPTS FLOW PATTERNS AND PROCS.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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