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A Monthly Safety Bulletin
from
The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
ASRS Recently Issued Alerts On…
BE55 landing gear incident
B777 main battery overheat
A fuel contamination incident
An approach frequency charting error
Oceanic Area Control Center clearance lead time incident
August-September 2002 Report Intake
Air Carrier / Air Taxi Pilots 4209
General Aviation Pilots 1499
Controllers 116
Cabin/Mechanics/Military/Other 286
TOTAL 6110
Number 277 October 2002
Some “Thoughts” on Safety
An ASRS report that appears in CALLBACK is meant to
stimulate thinking about aviation safety. The following
reports offer a few thoughts that might prompt us to
think twice when that ‘little voice’ says, “Something’s not
right”
A B757 pilot shows that even when we think we are
paying attention, the thinking process can be shortcircuited
by a preconceived notion.

Approach said, “Expect Runway 18R.” On short final I
thought I heard, “Cleared to land Runway 18R.” I asked
[Tower to] confirm clearance to land. Again, I thought he
said, “Cleared to land Runway 18R.” After landing, Tower
“He Thought I Said…”
A misunderstanding leads to an
unexpected reconfiguration, a look
of consternation, an unplanned
deceleration, an embarrassing
interrogation, and a resolve to
improve communication.

We were assigned FL 240 with clearance to cross INTXN
at 10,000 feet and 250 knots. At approximately 78 DME,
Center asked if we were going to be able to get down by
INTXN. The First Officer had started the descent [checklist]
and was responding to an ATC query. I stated (to the First
Officer), “We’re down,” as I had already started the descent.
The First Officer extended the landing gear at 23,000 feet
and 300+ knots. He thought I said, “Gear down.” We
attempted to raise the gear, but were unsuccessful until we
slowed below 250 knots. The First Officer informed ATC
that we were temporarily unable to maintain the assigned
speed of 310 knots. ATC asked if there was a problem...then
vectored us off track and then back to the Arrival. During
the vector, the gear retracted normally and we resumed
[our] assigned speed.
From the First Officer’s report:
While I was starting to run the descent checklist, I noticed
that we were a little high for our descent to INTXN…
Because we were high, ATC had told us to expedite our
descent, and I heard the Captain say, “Gear down.” I
quickly lowered the gear handle. After I had put the handle
down I realized that could not have been what the Captain
had asked for – and the look on his face confirmed it…
Upon reflection…I realize that I should not react so fast to
an order that is not a normal procedure. If I had questioned
the order first, then the Captain could have cleared up my
misunderstanding. CRM works if you use it.
“I Thought He Said…”
said both transmissions were, “Cleared to land Runway
18L.” [I] don’t know what to say. I just kept thinking
Runway 18R
In another “I thought he said” incident, a Tower controller
might have helped the involved pilot avoid a wrong
runway landing by mentioning a change of runway
assignments in the clearance.

At ten miles out, I [gave] my
position…[and] was told to enter a right
pattern to Runway 28. I was also told to
report the river, which is about three miles
out. I reported the river where I was told to
continue to Runway 28 and enter a right
downwind. When I got abeam Runway 20, I was cleared to
land Runway 20. I didn’t catch the difference in the two
runways. I was told twice to report Runway 28 and when
told Runway 20, I thought he said Runway 28. I landed on
Runway 28… The controller asked why I landed on
Runway 28 instead of Runway 20. I responded that I didn’t
realize that I had made that mistake.
“You are where your thoughts
have brought you.”
The pilot in our next report makes three references to
“thinking” about where he is going, but doesn’t appear to
be “hearing” any directions until the First Officer says,
“Stop!”

Tower told us to hold short of Runway 19L. The First
Officer acknowledged the call from Tower and confirmed
　
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