C310 pilot on ILS approach to sba landing without clearance from tower.

Attributes
ACN	591576
Time
Date	200308
Day	Sun
Local Time Of Day	0601 To 1200
Place
Locale Reference	airport : sba.airport
State Reference	CA
Altitude	agl single value : 0
Environment
Flight Conditions	Mixed
Light	Daylight
Aircraft 1
Controlling Facilities	tower : sba.tower
Operator	general aviation : personal
Make Model Name	Cessna 310/T310C
Operating Under FAR Part	Part 91
Flight Phase	landing : roll
Flight Plan	IFR
Person 1
Affiliation	other
Function	flight crew : single pilot
Qualification	pilot : multi engine pilot : instrument
Experience	flight time last 90 days : 24.3 flight time total : 731.4 flight time type : 368.7
ASRS Report	591576
Person 2
Affiliation	government : faa
Function	controller : approach
Events
Anomaly	incursion : landing without clearance non adherence : far non adherence : published procedure
Independent Detector	other controllera other controllerb other flight crewa
Resolutory Action	none taken : detected after the fact
Consequence	faa : reviewed incident with flight crew
Supplementary
Problem Areas	ATC Human Performance Flight Crew Human Performance
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation Inter Facility Coordination Failure

Narrative:

En route to sba VFR, sba went IFR due to coastal stratus. I had been talking to santa barbara approach and asked for the ILS. I was vectored for a bit then cleared for the ILS 8 maintain 2000 ft till established. I never heard or never received a 'contact tower' instruction, and somehow in my concentration on flying the needles, did not question this or contact tower. I realized this after I contacted ground upon exiting the runway and ground asked why I hadn't complied with a tower instruction regarding exit. That's when I realized I had failed to contact tower. (This is the stuff of bad dreams!) chain of events: problem arose when either 1) approach failed to instruct me to contact tower, or 2) I missed the instruction (I certainly did not read back such an instruction) and 3) I failed to take the initiative to either question approach or contact tower without instruction. Discovered by: pilot (me) after landing. Corrective action: none -- communication error discovered after the event. Human performance considerations: perception: concentrating on ILS needles. Forgot to maintain communications discipline. Judgements, decisions: the problem was that there were no judgements or decisions in effect. Actions/inactions: though as PIC I believe I was entirely at fault, it might be thought that the tower would have been concerned that an airplane on long final wasn't communicating and checked back with approach which could have told me to contact tower. Not an 'acceptable' situation, only that it would be corrective. Factors affecting quality of human performance: happy with spot-on GS and localizer, I didn't even think about tower. This was a form of fixation, like starring at only 1 instrument instead of scanning, but instead my scan was fine, I just forgot to do the rest of the job. Lesson learned: contact tower on final! Philosophically: this was simple human error. But any error in procedure is always a wake-up call to be ever more alert and focused.

Original NASA ASRS Text

Title: C310 PLT ON ILS APCH TO SBA LWOC FROM TWR.

Narrative: ENRTE TO SBA VFR, SBA WENT IFR DUE TO COASTAL STRATUS. I HAD BEEN TALKING TO SANTA BARBARA APCH AND ASKED FOR THE ILS. I WAS VECTORED FOR A BIT THEN CLRED FOR THE ILS 8 MAINTAIN 2000 FT TILL ESTABLISHED. I NEVER HEARD OR NEVER RECEIVED A 'CONTACT TWR' INSTRUCTION, AND SOMEHOW IN MY CONCENTRATION ON FLYING THE NEEDLES, DID NOT QUESTION THIS OR CONTACT TWR. I REALIZED THIS AFTER I CONTACTED GND UPON EXITING THE RWY AND GND ASKED WHY I HADN'T COMPLIED WITH A TWR INSTRUCTION REGARDING EXIT. THAT'S WHEN I REALIZED I HAD FAILED TO CONTACT TWR. (THIS IS THE STUFF OF BAD DREAMS!) CHAIN OF EVENTS: PROB AROSE WHEN EITHER 1) APCH FAILED TO INSTRUCT ME TO CONTACT TWR, OR 2) I MISSED THE INSTRUCTION (I CERTAINLY DID NOT READ BACK SUCH AN INSTRUCTION) AND 3) I FAILED TO TAKE THE INITIATIVE TO EITHER QUESTION APCH OR CONTACT TWR WITHOUT INSTRUCTION. DISCOVERED BY: PLT (ME) AFTER LNDG. CORRECTIVE ACTION: NONE -- COM ERROR DISCOVERED AFTER THE EVENT. HUMAN PERFORMANCE CONSIDERATIONS: PERCEPTION: CONCENTRATING ON ILS NEEDLES. FORGOT TO MAINTAIN COMS DISCIPLINE. JUDGEMENTS, DECISIONS: THE PROB WAS THAT THERE WERE NO JUDGEMENTS OR DECISIONS IN EFFECT. ACTIONS/INACTIONS: THOUGH AS PIC I BELIEVE I WAS ENTIRELY AT FAULT, IT MIGHT BE THOUGHT THAT THE TWR WOULD HAVE BEEN CONCERNED THAT AN AIRPLANE ON LONG FINAL WASN'T COMMUNICATING AND CHKED BACK WITH APCH WHICH COULD HAVE TOLD ME TO CONTACT TWR. NOT AN 'ACCEPTABLE' SIT, ONLY THAT IT WOULD BE CORRECTIVE. FACTORS AFFECTING QUALITY OF HUMAN PERFORMANCE: HAPPY WITH SPOT-ON GS AND LOC, I DIDN'T EVEN THINK ABOUT TWR. THIS WAS A FORM OF FIXATION, LIKE STARRING AT ONLY 1 INST INSTEAD OF SCANNING, BUT INSTEAD MY SCAN WAS FINE, I JUST FORGOT TO DO THE REST OF THE JOB. LESSON LEARNED: CONTACT TWR ON FINAL! PHILOSOPHICALLY: THIS WAS SIMPLE HUMAN ERROR. BUT ANY ERROR IN PROC IS ALWAYS A WAKE-UP CALL TO BE EVER MORE ALERT AND FOCUSED.

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.