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difficult ATC instructions will require more vigilance.
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/
September 2007 Report Intake
Air Carrier/Air Taxi Pilots 2374
General Aviation Pilots 878
Controllers 103
Cabin/Mechanics/Military/Other 228
TOTAL 3583
ASRS Alerts Issued in September 2007
Subject of Alert No. of Alerts
Airport facility or procedure 1
Chart, publication, or nav database 1
Total 2
JFK Airport 10
ATL Airport 9
ORD Airport 9
MCO Airport 7
PHX Airport 6
A B737-300 First Officer describes a late runway change at
Las Vegas (LAS) and difficulty reprogramming the FMC.
■ Course deviation. I was flying to LAS. The ATIS as
copied by the Captain listed Runway 19 as the landing
runway. I set up the FMS for the SKEBR arrival Runway
19. We were then cleared to descend to CLARR at 13,000
feet on the SKEBR arrival for Runway 25. When I reset
the FMC for Runway 25, I ended up with overlapping
information on the flight route. By the time I got it sorted
out, I was past SKEBR and missed the turn to KEPEC.
ICAC Primary Problems
As part of the ASRS analysis of In-Close Approach Change
events, ASRS analysts assessed the principal contributors
to the incident. The ASRS analysts’ identified Flight Crew
Human Performance as the most frequently occurring
primary problem (197 incidents), followed by ATC Human
Performance (58 incidents). Figure 2 depicts the top eight
primary problem categories.
Figure 2. Top Eight Primary Problem Categories
Flight Crew Human Performance 197
ATC Human Performance 58
Ambiguous 29
Aircraft 11
Weather 5
Environmental Factor 3
Airport 2
ATC Facility 2
ICAC Contributing Factors
The ICAC report excerpts we’ve shared thus far reflect
a multiplicity of factors that contributed to the incidents
– flight crews “behind” the aircraft, divided attention in
the cockpit, FMS programming/reprogramming issues,
rushed flight crews, untimely ATC clearances, distraction,
and other factors. Figure 3 shows the top eleven categories
of contributing factors that were identified in the ICAC
analysis as reported by pilots. These categories were not
mutually exclusive, meaning that a single incident report
could reference multiple contributing factors.
A report from a B767 flight crew flying into San Francisco
(SFO) airport illustrates several of these factors, including
a late runway change, FMS reprogramming issues, and a
flight crew “behind” the aircraft.
■ Captain flying on autopilot inbound on FMS Bridge
Visual Runway 28R at 6,000 feet inside of ARCHI.
NORCAL [Northern California TRACON] gave us a
heading to now intercept Localizer Runway 28L and
descend to 5,000 feet. The Captain clicked off the autopilot
as I now worked the MCP and tried to find the new localizer
frequency and load the box, time permitting. Although it
335
was VFR, there was a cloud layer at 5,000 feet, so a visual
to the runway was not possible. We were kept high because
ATC wanted to cross an aircraft below us from the west
to Runway 28R for some reason switching us to Runway
28L. After finding and dialing in the Runway 28L localizer
frequency, I saw us descending at about 1,200 fpm through
5,100 feet and I called out ‘altitude.’ The hand-flying
Captain leveled off, but not before touching just below 300
feet low of 5,000 feet, at the same time overshooting slightly
the Runway 28L localizer course even though the MCP
was set up to both intercept the localizer and the altitude.
Corrections were made quickly and the controller never
mentioned it, but air carrier Y was passing in front of us and
just below us. I believe this problem wouldn’t have occurred
if the autopilot [had] been used throughout, and it would
have been helpful if the controller wouldn’t have crossed the
airplanes to opposite runways so late in the approach....
A CL65 landed on the wrong runway at DFW after a late
runway change, heads-down reprogramming of the FMS,
and other distractions.
■ We were cleared to land originally on Runway 18R, then
on downwind we were changed to Runway 17C. I was
inside the cockpit too much, changing the FMS, and the
speed bug was broken so I was fooling with that and talking
on the radio. I was the PNF, so I didn’t think to look outside
until short final, then it was too late. We landed on Runway
　
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