A CE550B PIC'S RPT ON LNDG WITHOUT CLRNC AT IND; IN.
Synopsis
A CE550B PIC'S RPT ON LNDG WITHOUT CLRNC AT IND; IN.
Narrative
GIVEN VISUAL APCH (CLOSE IN WITHIN 5 MI) TO THE ARPT; HIGH ALT 5000 FT AGL; NECESSITATING HIGH WORKLOAD ENVIRONMENT FOR THE CREW TO BECOME STABILIZED FOR LNDG ON PARALLEL RWYS IN USE. AS PIC OBSERVING FO PERFORM VISUAL APCH; I WAS LED INTO A COMPLACENCY FROM FLYING WITH THIS FO FOR APPROX 2 YRS WITH NO INCIDENTS OR ACCIDENTS. THIS DUE PRIMARILY TO MY PRIOR EXPERIENCES WITH THIS FO WHOM I CONSIDER VERY COMPETENT; CONSCIENTIOUS AND ASSERTIVE. OUR FLT HAD PREVIOUSLY LANDED AT THIS ARPT AND SAME RWY ALIGNMENT RWY 23L/R EARLIER IN THE SAME DAY. AN UNUSUAL FREQ IN USE BY APCH CTL THAT IS VERY SIMILAR TO TWR FREQ. THIS LED ME TO BELIEVE I HAD SWITCHED TO TWR AND JUST DIDN'T RECALL. OUR COMPANY AND ITS GROWING DEPT OF PLTS DO NOT UTILIZE A SOP FOR VARIED FLT REGIMES WE ENCOUNTER. CONTRIBUTING FACTOR IN TERMS OF THIS WAS FO'S RESPONSE OF SELECTING HEADING BUG (HSI) TO LNDG RWY WHEN CLRED FOR VISUAL APCH WHEN I HAVE BEEN TRAINED TO SELECT IT ONLY AFTER I'VE BEEN CLRED TO LAND. (IN OUR RUSHED RESPONSE TO LAND I DIDN'T NOTICE FO MOVING THE BUG TO LNDG RWY. LOOKING JUST BEFORE THE FLARE GLANCING AT THE GEAR LIGHTS AND HEADING BUG ON LNDG RWY I ASSUMED ALL WAS SATISFACTORY.) FATIGUE I THINK BECAME ONE OF THE BIGGEST FACTORS. EARLY AM WAKEUP OF XA30 COUPLED WITH MULTIPLE LEGS AND 14+ HR DUTY DAY; NO ABILITY TO REST SIGNIFICANTLY DEGRADED MY SITUATIONAL AWARENESS AND THOUGHT PROCESSES. SINGLE CHKLIST IN ACFT THAT WAS RECENTLY ADOPTED FROM A NON-JET ENVIRONMENT DID NOT HAVE CONFIRM LNDG CLRNC ON IT IN A LNDG PHASE OF FLT. NO HDOF TO TWR BY APCH CTL WAS GIVEN TO US; AGAIN LULLING ME INTO A STATE OF WELL-BEING. (I FULLY REALIZE THIS DOES NOT ABSOLVE THE CREW FROM SWITCHING ON THEIR OWN.) FINALLY; A BREAKDOWN OF CRM BTWN THE CREW ESPECIALLY THE CAPT TO KEEP EACH OF US 'I THE LOOP.' TURNING OFF RWY TO PARALLEL TXWY; I GLANCED AT THE RADIO AND ASKED TO GO TO GND WHEN APCH RESPONDED YES GO TO GND. REALIZED THAT WE WERE STILL ON APCH FREQ AND DIDN'T GET A CLRNC TO LAND FROM TWR. (RWY WAS CLR WITH NO OTHER TFC ON IT.) CORRECT ACTIONS: NONE AT THE TIME; OTHER THAN REQUEST PERMISSION TO TAXI WHILE ON TXWY. AFTER SHUT DOWN; IMMEDIATELY CALLED IND TWR SUPVR TO DISCUSS SIT THAT JUST OCCURRED. FORTUNATELY FOR US; CTLR SAW US AND ISSUED ON THE TWR FREQ A 'CLRED TO LAND RWY 23R' AS STATED BY SUPVR ON THE TELEPHONE. DISCUSSION AND CORRECTIVE ACTION: AFTER MUCH THOUGHT; I'VE COME TO THE CONCLUSION THAT A PRIMARY BREAKDOWN OF MY SITUATIONAL AWARENESS THROUGH FATIGUE AND/OR COMPLACENCY CAUSED THIS INFRACTION. NEARING THE END OF 4 MONTHS OF BUSIER THAN NORMAL FLT SCHEDULES HAS TAKEN ITS TOLL ON ME PHYSICALLY AND MENTALLY. CONTRIBUTING; A NEW CHKLIST THAT OMITS CERTAIN ITEMS THAT I'VE BEEN UTILIZING FOR YRS IN THE SAME JET ACFT LED ME INTO A FUNDAMENTAL MISTAKE THAT EVEN MY PRIMARY FLT TRAINING DIDN'T HELP ME TO DISCOVER. IN THE FUTURE; I'LL STRICTLY ADHERE TO SOP'S FOR MYSELF AND CREW TO ENHANCE OUR PERFORMANCE THUS LIMITING EXPOSURE TO THESE TYPES OF FUNDAMENTAL MISTAKES. ESPECIALLY DURING A PORTION OF THE FLT THAT WE ARE RUSHING; I'LL DECLINE THE CLRNC IF I FEEL IT MINIMIZES SAFETY MARGINS. FINALLY; REALIZE THAT I'M NOT SUPERMAN; AND THAT I CAN BECOME THE WEAKEST LINK IN THE SAFETY CHAIN. IN THE FUTURE; I WILL BE MORE RESPONSIBLE FOR DETERMINING MY FITNESS FOR FLT AND IF TIRED I'LL BECOME EVEN MORE FOCUSED ON THE TASK AT HAND. I NOW REALIZE WHY FATIGUE IS SUCH AN INSIDIOUS THREAT STALKING ALL OF US; DEGRADING HUMAN PERFORMANCE VERY SUBTLETY UNTIL IT'S TOO LATE.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.