|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1801 To 2400|
|Locale Reference||airport : zzz.airport|
|Altitude||agl single value : 0|
|Operator||common carrier : charter|
|Make Model Name||Small Transport|
2 Turbojet Eng
|Operating Under FAR Part||Part 135|
|Flight Phase||landing : roll|
|Affiliation||company : charter|
|Function||flight crew : first officer|
|Qualification||pilot : multi engine|
pilot : instrument
pilot : commercial
pilot : atp
pilot : cfi
|Experience||flight time last 90 days : 75|
flight time total : 9500
flight time type : 300
|Anomaly||incursion : landing without clearance|
non adherence : far
|Independent Detector||other flight crewa|
|Resolutory Action||none taken : detected after the fact|
|Problem Areas||ATC Human Performance|
Flight Crew Human Performance
|Primary Problem||Flight Crew Human Performance|
The event occurred at the conclusion of a maximum length duty day; on the final leg flying to ZZZ. The captain began hand flying somewhere between 10000 ft and 6000 ft during the descent in order to get some hands-on time; as there were no passenger aboard. After being vectored to the final approach course; we were told by approach to 'maintain 2000 ft until established; cleared for the ILS runway 12R at ZZZ.' that statement by the controller prompted me to input the tower frequency into the standby position of the #1 radio which we were using at that time; fully expecting to be handed off to the tower controller momentarily. I stated to my partner that I had visual contact with both the runway and the VASI. We rolled briskly to the left in order to intercept the localizer and we overshot the rollout heading by about 20 degrees because the captain was pointing the aircraft toward where he believed the runway to be located. He then stated that he did not have a visual on the runway and that it was not in the location toward which he was looking and believed it to be located. I stated that the runway was at 1 O'clock position; the crosswind was (quickly) blowing us off course to the left of course (with a downwind heading); and that he should turn right to intercept. Immediately rolling back to the right; we intercepted shortly thereafter. I completed the before landing checklist and then made callouts. We landed; I deployed the lift dump; said 'my yoke;' called out 10 KT increments of speed until 60 KTS for thrust reverser stow; and we easily exited a high speed taxiway. As we crossed the hold line outbound from the runway; I reached toward the radio to switch to the ground frequency. Immediately; I realized and stated that 'we didn't call the tower!' at the same time my partner was stating 'the taxi light is not on; we didn't get a clearance to land!' (we do not turn on the taxi light on during an approach until we have received a clearance to land; and then the position of that switch becomes for us a confirmation that we have in fact received that clearance.) (the current ATIS had stated that ground and tower were combined on the tower frequency.) upon contacting tower; the gentleman asked 'are you ready to taxi?' I replied in the affirmative and gave our destination FBO. 'Taxiway C all the way to the main ramp' was his reply. As we taxied; I made a feeble attempt to look more innocent by transmitting 'tower; how do you read this radio?' he said '5 by 5; how me?' to which I replied 'perfect.' what a surprise -- landing without clearance has never happened to either one of us prior to this point! A contributing factor to this landing without clearance was the fact that we were not handed off by the approach controller to the tower controller. But that has happened to both of us before and we have always caught the error and corrected it before landing. The captain and myself work very well together as a team. We had even decided to take some time during our last stop to go get a real situation-down dinner before heading out once more. We agreed that the delay in getting home was acceptable because we had gone quite a while without eating; we were tired and a dinner break would help to refresh us before starting out again. We also did not want to get home late and be starving; compounded by sleep deprivation and a messed up sleep schedule the following day caused by eating too late at night. Both the captain and myself take pride in our work and we strive to be the best that we can be; realizing that neither one of us is perfect. We catch each other's mistakes and watch each other's backs; but both of us were totally caught off guard and totally surprised with this event even with professional conduct remaining throughout the whole time line. Being to the left of the localizer for a short period on the approach and the captain not seeing a runway where he thought it should be were also distrs; but nothing out of the ordinary or anything that we have not overcome previously. The only thing that we could figure out was that we must have been more tired than we thought ourselves to be. I did not realize how fatigued I was until I was driving home and all of the cars going the same way on the freeway were passing me. I believe that fatigue is an insidious form of debilitation because we are not able to see how much or even in what way it is actually affecting us. I am so very humbled by this event and it has made me more adamant about the importance of duty and rest periods and being proactive about taking care of myself and my partner both before and during a flight.
Original NASA ASRS Text
Title: SMALL JET FLT CREW REPORTS LANDING WITHOUT CLEARANCE AFTER VERY LONG DUTY DAY.
Narrative: THE EVENT OCCURRED AT THE CONCLUSION OF A MAX LENGTH DUTY DAY; ON THE FINAL LEG FLYING TO ZZZ. THE CAPT BEGAN HAND FLYING SOMEWHERE BTWN 10000 FT AND 6000 FT DURING THE DSCNT IN ORDER TO GET SOME HANDS-ON TIME; AS THERE WERE NO PAX ABOARD. AFTER BEING VECTORED TO THE FINAL APCH COURSE; WE WERE TOLD BY APCH TO 'MAINTAIN 2000 FT UNTIL ESTABLISHED; CLRED FOR THE ILS RWY 12R AT ZZZ.' THAT STATEMENT BY THE CTLR PROMPTED ME TO INPUT THE TWR FREQ INTO THE STANDBY POS OF THE #1 RADIO WHICH WE WERE USING AT THAT TIME; FULLY EXPECTING TO BE HANDED OFF TO THE TWR CTLR MOMENTARILY. I STATED TO MY PARTNER THAT I HAD VISUAL CONTACT WITH BOTH THE RWY AND THE VASI. WE ROLLED BRISKLY TO THE L IN ORDER TO INTERCEPT THE LOC AND WE OVERSHOT THE ROLLOUT HDG BY ABOUT 20 DEGS BECAUSE THE CAPT WAS POINTING THE ACFT TOWARD WHERE HE BELIEVED THE RWY TO BE LOCATED. HE THEN STATED THAT HE DID NOT HAVE A VISUAL ON THE RWY AND THAT IT WAS NOT IN THE LOCATION TOWARD WHICH HE WAS LOOKING AND BELIEVED IT TO BE LOCATED. I STATED THAT THE RWY WAS AT 1 O'CLOCK POS; THE XWIND WAS (QUICKLY) BLOWING US OFF COURSE TO THE L OF COURSE (WITH A DOWNWIND HDG); AND THAT HE SHOULD TURN R TO INTERCEPT. IMMEDIATELY ROLLING BACK TO THE R; WE INTERCEPTED SHORTLY THEREAFTER. I COMPLETED THE BEFORE LNDG CHKLIST AND THEN MADE CALLOUTS. WE LANDED; I DEPLOYED THE LIFT DUMP; SAID 'MY YOKE;' CALLED OUT 10 KT INCREMENTS OF SPD UNTIL 60 KTS FOR THRUST REVERSER STOW; AND WE EASILY EXITED A HIGH SPD TXWY. AS WE CROSSED THE HOLD LINE OUTBOUND FROM THE RWY; I REACHED TOWARD THE RADIO TO SWITCH TO THE GND FREQ. IMMEDIATELY; I REALIZED AND STATED THAT 'WE DIDN'T CALL THE TWR!' AT THE SAME TIME MY PARTNER WAS STATING 'THE TAXI LIGHT IS NOT ON; WE DIDN'T GET A CLRNC TO LAND!' (WE DO NOT TURN ON THE TAXI LIGHT ON DURING AN APCH UNTIL WE HAVE RECEIVED A CLRNC TO LAND; AND THEN THE POS OF THAT SWITCH BECOMES FOR US A CONFIRMATION THAT WE HAVE IN FACT RECEIVED THAT CLRNC.) (THE CURRENT ATIS HAD STATED THAT GND AND TWR WERE COMBINED ON THE TWR FREQ.) UPON CONTACTING TWR; THE GENTLEMAN ASKED 'ARE YOU READY TO TAXI?' I REPLIED IN THE AFFIRMATIVE AND GAVE OUR DEST FBO. 'TXWY C ALL THE WAY TO THE MAIN RAMP' WAS HIS REPLY. AS WE TAXIED; I MADE A FEEBLE ATTEMPT TO LOOK MORE INNOCENT BY XMITTING 'TWR; HOW DO YOU READ THIS RADIO?' HE SAID '5 BY 5; HOW ME?' TO WHICH I REPLIED 'PERFECT.' WHAT A SURPRISE -- LWOC HAS NEVER HAPPENED TO EITHER ONE OF US PRIOR TO THIS POINT! A CONTRIBUTING FACTOR TO THIS LWOC WAS THE FACT THAT WE WERE NOT HANDED OFF BY THE APCH CTLR TO THE TWR CTLR. BUT THAT HAS HAPPENED TO BOTH OF US BEFORE AND WE HAVE ALWAYS CAUGHT THE ERROR AND CORRECTED IT BEFORE LNDG. THE CAPT AND MYSELF WORK VERY WELL TOGETHER AS A TEAM. WE HAD EVEN DECIDED TO TAKE SOME TIME DURING OUR LAST STOP TO GO GET A REAL SIT-DOWN DINNER BEFORE HEADING OUT ONCE MORE. WE AGREED THAT THE DELAY IN GETTING HOME WAS ACCEPTABLE BECAUSE WE HAD GONE QUITE A WHILE WITHOUT EATING; WE WERE TIRED AND A DINNER BREAK WOULD HELP TO REFRESH US BEFORE STARTING OUT AGAIN. WE ALSO DID NOT WANT TO GET HOME LATE AND BE STARVING; COMPOUNDED BY SLEEP DEPRIVATION AND A MESSED UP SLEEP SCHEDULE THE FOLLOWING DAY CAUSED BY EATING TOO LATE AT NIGHT. BOTH THE CAPT AND MYSELF TAKE PRIDE IN OUR WORK AND WE STRIVE TO BE THE BEST THAT WE CAN BE; REALIZING THAT NEITHER ONE OF US IS PERFECT. WE CATCH EACH OTHER'S MISTAKES AND WATCH EACH OTHER'S BACKS; BUT BOTH OF US WERE TOTALLY CAUGHT OFF GUARD AND TOTALLY SURPRISED WITH THIS EVENT EVEN WITH PROFESSIONAL CONDUCT REMAINING THROUGHOUT THE WHOLE TIME LINE. BEING TO THE L OF THE LOC FOR A SHORT PERIOD ON THE APCH AND THE CAPT NOT SEEING A RWY WHERE HE THOUGHT IT SHOULD BE WERE ALSO DISTRS; BUT NOTHING OUT OF THE ORDINARY OR ANYTHING THAT WE HAVE NOT OVERCOME PREVIOUSLY. THE ONLY THING THAT WE COULD FIGURE OUT WAS THAT WE MUST HAVE BEEN MORE TIRED THAN WE THOUGHT OURSELVES TO BE. I DID NOT REALIZE HOW FATIGUED I WAS UNTIL I WAS DRIVING HOME AND ALL OF THE CARS GOING THE SAME WAY ON THE FREEWAY WERE PASSING ME. I BELIEVE THAT FATIGUE IS AN INSIDIOUS FORM OF DEBILITATION BECAUSE WE ARE NOT ABLE TO SEE HOW MUCH OR EVEN IN WHAT WAY IT IS ACTUALLY AFFECTING US. I AM SO VERY HUMBLED BY THIS EVENT AND IT HAS MADE ME MORE ADAMANT ABOUT THE IMPORTANCE OF DUTY AND REST PERIODS AND BEING PROACTIVE ABOUT TAKING CARE OF MYSELF AND MY PARTNER BOTH BEFORE AND DURING A FLT.
Data retrieved from NASA's ASRS site as of May 2009 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.