Narrative:

Given visual approach (close in within 5 mi) to the airport, high altitude 5000 ft AGL, necessitating high workload environment for the crew to become stabilized for landing on parallel runways in use. As PIC observing first officer perform visual approach, I was led into a complacency from flying with this first officer for approximately 2 yrs with no incidents or accidents. This due primarily to my prior experiences with this first officer whom I consider very competent, conscientious and assertive. Our flight had previously landed at this airport and same runway alignment runway 23L/right earlier in the same day. An unusual frequency in use by approach control that is very similar to tower frequency. This led me to believe I had switched to tower and just didn't recall. Our company and its growing department of pilots do not utilize a SOP for varied flight regimes we encounter. Contributing factor in terms of this was first officer's response of selecting heading bug (HSI) to landing runway when cleared for visual approach when I have been trained to select it only after I've been cleared to land. (In our rushed response to land I didn't notice first officer moving the bug to landing runway. Looking just before the flare glancing at the gear lights and heading bug on landing runway 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+ hour duty day, no ability to rest significantly degraded my situational awareness and thought processes. Single checklist in aircraft that was recently adopted from a non-jet environment did not have confirm landing clearance on it in a landing phase of flight. No handoff to tower by approach control 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 between the crew especially the captain to keep each of us 'I the loop.' turning off runway to parallel taxiway, I glanced at the radio and asked to go to ground when approach responded yes go to ground. Realized that we were still on approach frequency and didn't get a clearance to land from tower. (Runway was clear with no other traffic on it.) correct actions: none at the time, other than request permission to taxi while on taxiway. After shut down, immediately called ind tower supervisor to discuss situation that just occurred. Fortunately for us, controller saw us and issued on the tower frequency a 'cleared to land runway 23R' as stated by supervisor 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 flight schedules has taken its toll on me physically and mentally. Contributing, a new checklist that omits certain items that I've been utilizing for yrs in the same jet aircraft led me into a fundamental mistake that even my primary flight 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 flight that we are rushing, I'll decline the clearance 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 flight 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.

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Original NASA ASRS Text

Title: 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.

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.