Narrative:

On the night of mar/xa/99, the copilot and I were both on day 5 or night 5 of 6 day on-call periods for reserve. At our air carrier, reserve is 24/7 which I feel contributed greatly to the following. We operated from sfo to lax. This flight I had been told, was to pick up an aircraft with bigger engines and continue to ord. The copilot was deadheading in from den as no sfo reserves were available. He was scheduled to arrive less than 30 mins before our scheduled departure. I was initially perturbed at this as it afforded no opportunity for a good briefing (something the air carrier preaches). At this time I had been up for 15 hours (short call for this flight providing no time for rest). Copilot had been up a similar amount. He arrived, introduced, and was confounded by additional leg, stating he was already tired. I was as well. We did a thorough briefing. I said 'we are both tired, let's be extremely careful -- watch each other, back each other up.' we got new release and WX for lax over ACARS. En route routine normal. We picked up los angeles ATIS and NOTAMS. Copilot briefed both -- no specific problems noted. ILS approach runway 25L and runway 24R in use. In the main body of the #1 NOTAMS (unrecognized) and at the end of #2 ATIS was #1 localizer inoperative and #2 localizer runway 25L OTS. We did not see this and were originally planned for runway 24R. Everyone getting visual approachs. Over santa monica we were reclred to a 110 degree heading to expect visual approach to runway 25L. I looked at main body of ATIS. ILS approach runway 24R and runway 25L in progress and asked the first officer to put it in the box, pointing at pedestal. The first officer tuned and idented runway 25L for backup to visual approach. (I assumed it was in FMC, but in reality it should not be necessary.) on approach, downwind, I noticed a swiftly approaching cloud deck and told first officer 'tell them this may not work visually.' no real response. Approach control was busy vectoring commuter preceding us. We got base turn about the time commuter said, 'this isn't going to work visually, no joy on the field.' I do not know what that aircraft did -- I think he went to the north complex. I said approach is 'losing the bubble' we are going to need the ILS. I felt confident -- we had briefed for this. Controller said 'intercept localizer runway 25L cleared for approach.' we had not picked up on the fact there was no operable localizer and were cleared for the ILS runway 25L. Obviously, we blew through the localizer and almost transgressed the north approach lanes. Compounding the problem, I thought the 'green line' was for runway 25L but it was runway 24R! Approach gave us vectors after I declared missed approach. We descended from 2500 ft to 2000 ft for the missed. Thank god! No TCASII -- no near miss, etc. I called the tower after routine missed approach and uneventful landing. ILS runway 25R sidestep runway 25L. They said 'no problem as far as they and approach control were concerned.' so why am I writing this then? 1) this could have resulted in a near miss or worse. 2) in my opinion, our air carrier's 24/7 reserve system contributed greatly. By the time we finished in ord. We had both been up for over 24 hours straight. 3) NOTAMS for domestic pilots should be more user friendly. Localizer OTS in the dark aircraft cockpit caused no 'bells' on first officer's part. It is ICAO. I would have missed it too. 4) last min runway change caused us to look at the main body of ATIS which clearly states ILS runway 25L in use. This is incredibly misleading. We were cleared for inoperative approach by approach control. In retrospect: 1) I should have obtained all necessary paperwork inside terminal and sat down with first officer. Not done it in dimly lit cockpit. 2) even though we did a very complete briefing, we missed vital information. I really do not know how, this was a real chain of events and approach control lost bubble at critical time for us. 3) confusing last min vectors to non-functioning approach confusing ATIS. 'ILS runway 25L approach in progress.' 4) we should probably both have turned down the trip for tired reasons. But then you get a call from chief pilot. Callback conversation with reporter revealed the following information: the reporter said that he and the first officer were rather fatigued, due to the way the reserve system functions,when they both arrived for their preflight duties. He emphasized that this situation is quite normal for reserve crews at every airline that he knows of and that this is the third airline in his career. This captain also repeated that both of the flight crew had been awake more than 24 hours by the time they had completed their flight assignment. The first officer was new to this aircraft and was unfamiliar with lax and during the descent copied the ATIS without realizing the significance of the localizer being inoperative and the runway 25L localizer being OTS since this was at the end of the ATIS text and there were visual approachs in progress at the time. The first officer also set up the approach to runway 24R instead of runway 25L as the captain expected thus misleading the captain who was using the course line display on the FMC as a reference for the distance to the localizer for runway 25L. The approach controller apparently did not realize that the localizer for runway 25L was OTS either, since the controller cleared them for the runway 25L ILS approach. The reporter said that the controller seemed confused when he announced that he was unable to receive the localizer and was initiating a go around. Later, when the reporter called the tower supervisor to discuss the approach and go around, the supervisor apparently told the captain that this was 'no big deal.' the reporter said that all of this probably could have been avoided if the trip, which was a costly error for the company, had been canceled or the flight crew had taken themselves off the line because of fatigue. He said that crew members usually do not do this because of fear of retribution from the airline management even though the general policy statement is against such retribution.

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Original NASA ASRS Text

Title: AN ACR B737-300 FLC EXECUTE A GAR AFTER BEING CLRED FOR AN ILS APCH TO A RWY WHOSE LOC WAS OTS. THERE WERE ALSO FATIGUE ISSUES AS WELL AS THE ATIS FORMAT INVOLVED IN THIS INCIDENT.

Narrative: ON THE NIGHT OF MAR/XA/99, THE COPLT AND I WERE BOTH ON DAY 5 OR NIGHT 5 OF 6 DAY ON-CALL PERIODS FOR RESERVE. AT OUR ACR, RESERVE IS 24/7 WHICH I FEEL CONTRIBUTED GREATLY TO THE FOLLOWING. WE OPERATED FROM SFO TO LAX. THIS FLT I HAD BEEN TOLD, WAS TO PICK UP AN ACFT WITH BIGGER ENGS AND CONTINUE TO ORD. THE COPLT WAS DEADHEADING IN FROM DEN AS NO SFO RESERVES WERE AVAILABLE. HE WAS SCHEDULED TO ARRIVE LESS THAN 30 MINS BEFORE OUR SCHEDULED DEP. I WAS INITIALLY PERTURBED AT THIS AS IT AFFORDED NO OPPORTUNITY FOR A GOOD BRIEFING (SOMETHING THE ACR PREACHES). AT THIS TIME I HAD BEEN UP FOR 15 HRS (SHORT CALL FOR THIS FLT PROVIDING NO TIME FOR REST). COPLT HAD BEEN UP A SIMILAR AMOUNT. HE ARRIVED, INTRODUCED, AND WAS CONFOUNDED BY ADDITIONAL LEG, STATING HE WAS ALREADY TIRED. I WAS AS WELL. WE DID A THOROUGH BRIEFING. I SAID 'WE ARE BOTH TIRED, LET'S BE EXTREMELY CAREFUL -- WATCH EACH OTHER, BACK EACH OTHER UP.' WE GOT NEW RELEASE AND WX FOR LAX OVER ACARS. ENRTE ROUTINE NORMAL. WE PICKED UP LOS ANGELES ATIS AND NOTAMS. COPLT BRIEFED BOTH -- NO SPECIFIC PROBS NOTED. ILS APCH RWY 25L AND RWY 24R IN USE. IN THE MAIN BODY OF THE #1 NOTAMS (UNRECOGNIZED) AND AT THE END OF #2 ATIS WAS #1 LOC INOP AND #2 LOC RWY 25L OTS. WE DID NOT SEE THIS AND WERE ORIGINALLY PLANNED FOR RWY 24R. EVERYONE GETTING VISUAL APCHS. OVER SANTA MONICA WE WERE RECLRED TO A 110 DEG HDG TO EXPECT VISUAL APCH TO RWY 25L. I LOOKED AT MAIN BODY OF ATIS. ILS APCH RWY 24R AND RWY 25L IN PROGRESS AND ASKED THE FO TO PUT IT IN THE BOX, POINTING AT PEDESTAL. THE FO TUNED AND IDENTED RWY 25L FOR BACKUP TO VISUAL APCH. (I ASSUMED IT WAS IN FMC, BUT IN REALITY IT SHOULD NOT BE NECESSARY.) ON APCH, DOWNWIND, I NOTICED A SWIFTLY APCHING CLOUD DECK AND TOLD FO 'TELL THEM THIS MAY NOT WORK VISUALLY.' NO REAL RESPONSE. APCH CTL WAS BUSY VECTORING COMMUTER PRECEDING US. WE GOT BASE TURN ABOUT THE TIME COMMUTER SAID, 'THIS ISN'T GOING TO WORK VISUALLY, NO JOY ON THE FIELD.' I DO NOT KNOW WHAT THAT ACFT DID -- I THINK HE WENT TO THE N COMPLEX. I SAID APCH IS 'LOSING THE BUBBLE' WE ARE GOING TO NEED THE ILS. I FELT CONFIDENT -- WE HAD BRIEFED FOR THIS. CTLR SAID 'INTERCEPT LOC RWY 25L CLRED FOR APCH.' WE HAD NOT PICKED UP ON THE FACT THERE WAS NO OPERABLE LOC AND WERE CLRED FOR THE ILS RWY 25L. OBVIOUSLY, WE BLEW THROUGH THE LOC AND ALMOST TRANSGRESSED THE N APCH LANES. COMPOUNDING THE PROB, I THOUGHT THE 'GREEN LINE' WAS FOR RWY 25L BUT IT WAS RWY 24R! APCH GAVE US VECTORS AFTER I DECLARED MISSED APCH. WE DSNDED FROM 2500 FT TO 2000 FT FOR THE MISSED. THANK GOD! NO TCASII -- NO NEAR MISS, ETC. I CALLED THE TWR AFTER ROUTINE MISSED APCH AND UNEVENTFUL LNDG. ILS RWY 25R SIDESTEP RWY 25L. THEY SAID 'NO PROB AS FAR AS THEY AND APCH CTL WERE CONCERNED.' SO WHY AM I WRITING THIS THEN? 1) THIS COULD HAVE RESULTED IN A NEAR MISS OR WORSE. 2) IN MY OPINION, OUR ACR'S 24/7 RESERVE SYS CONTRIBUTED GREATLY. BY THE TIME WE FINISHED IN ORD. WE HAD BOTH BEEN UP FOR OVER 24 HRS STRAIGHT. 3) NOTAMS FOR DOMESTIC PLTS SHOULD BE MORE USER FRIENDLY. LOC OTS IN THE DARK ACFT COCKPIT CAUSED NO 'BELLS' ON FO'S PART. IT IS ICAO. I WOULD HAVE MISSED IT TOO. 4) LAST MIN RWY CHANGE CAUSED US TO LOOK AT THE MAIN BODY OF ATIS WHICH CLRLY STATES ILS RWY 25L IN USE. THIS IS INCREDIBLY MISLEADING. WE WERE CLRED FOR INOP APCH BY APCH CTL. IN RETROSPECT: 1) I SHOULD HAVE OBTAINED ALL NECESSARY PAPERWORK INSIDE TERMINAL AND SAT DOWN WITH FO. NOT DONE IT IN DIMLY LIT COCKPIT. 2) EVEN THOUGH WE DID A VERY COMPLETE BRIEFING, WE MISSED VITAL INFO. I REALLY DO NOT KNOW HOW, THIS WAS A REAL CHAIN OF EVENTS AND APCH CTL LOST BUBBLE AT CRITICAL TIME FOR US. 3) CONFUSING LAST MIN VECTORS TO NON-FUNCTIONING APCH CONFUSING ATIS. 'ILS RWY 25L APCH IN PROGRESS.' 4) WE SHOULD PROBABLY BOTH HAVE TURNED DOWN THE TRIP FOR TIRED REASONS. BUT THEN YOU GET A CALL FROM CHIEF PLT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR SAID THAT HE AND THE FO WERE RATHER FATIGUED, DUE TO THE WAY THE RESERVE SYS FUNCTIONS,WHEN THEY BOTH ARRIVED FOR THEIR PREFLT DUTIES. HE EMPHASIZED THAT THIS SIT IS QUITE NORMAL FOR RESERVE CREWS AT EVERY AIRLINE THAT HE KNOWS OF AND THAT THIS IS THE THIRD AIRLINE IN HIS CAREER. THIS CAPT ALSO REPEATED THAT BOTH OF THE FLC HAD BEEN AWAKE MORE THAN 24 HRS BY THE TIME THEY HAD COMPLETED THEIR FLT ASSIGNMENT. THE FO WAS NEW TO THIS ACFT AND WAS UNFAMILIAR WITH LAX AND DURING THE DSCNT COPIED THE ATIS WITHOUT REALIZING THE SIGNIFICANCE OF THE LOC BEING INOP AND THE RWY 25L LOC BEING OTS SINCE THIS WAS AT THE END OF THE ATIS TEXT AND THERE WERE VISUAL APCHS IN PROGRESS AT THE TIME. THE FO ALSO SET UP THE APCH TO RWY 24R INSTEAD OF RWY 25L AS THE CAPT EXPECTED THUS MISLEADING THE CAPT WHO WAS USING THE COURSE LINE DISPLAY ON THE FMC AS A REF FOR THE DISTANCE TO THE LOC FOR RWY 25L. THE APCH CTLR APPARENTLY DID NOT REALIZE THAT THE LOC FOR RWY 25L WAS OTS EITHER, SINCE THE CTLR CLRED THEM FOR THE RWY 25L ILS APCH. THE RPTR SAID THAT THE CTLR SEEMED CONFUSED WHEN HE ANNOUNCED THAT HE WAS UNABLE TO RECEIVE THE LOC AND WAS INITIATING A GAR. LATER, WHEN THE RPTR CALLED THE TWR SUPVR TO DISCUSS THE APCH AND GAR, THE SUPVR APPARENTLY TOLD THE CAPT THAT THIS WAS 'NO BIG DEAL.' THE RPTR SAID THAT ALL OF THIS PROBABLY COULD HAVE BEEN AVOIDED IF THE TRIP, WHICH WAS A COSTLY ERROR FOR THE COMPANY, HAD BEEN CANCELED OR THE FLC HAD TAKEN THEMSELVES OFF THE LINE BECAUSE OF FATIGUE. HE SAID THAT CREW MEMBERS USUALLY DO NOT DO THIS BECAUSE OF FEAR OF RETRIBUTION FROM THE AIRLINE MGMNT EVEN THOUGH THE GENERAL POLICY STATEMENT IS AGAINST SUCH RETRIBUTION.

Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.