Fate of ATP pilot landing at wrong runway. A poll

Fate of ATP landing at wrong airport

  • No action, remain on duty

    Votes: 3 2.5%
  • Stern talking to. Remain on duty

    Votes: 18 14.8%
  • Letter of reprimand, additional landing training remain on duty

    Votes: 73 59.8%
  • Fired for cause

    Votes: 28 23.0%

  • Total voters
    122
do not use electronic means to back up visual approaches.
Clearly they should/could use "electronic means" before they start approach to decide if this is the right airport -specially that it is so easy. A chance spotting of runway is not a sufficient confirmation that this is the intended destination. Clearly some process of arriving at the decision - right/wrong airport is needed and I don't think they will be unfolding sectionals...
 
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What if the investigation shows flaws in SWA procedures (such as visual approach) or something such as a database error is uncovered, or a human factors event (fatigue, stress, etc) is a contributing factor?

SWA policy a contributing factor? That would never happen.....cough, Chicago Midway, ...cough....
 
SWA policy a contributing factor? That would never happen.....cough, Chicago Midway, ...cough....

Yep.

It's happened with other carriers, an incident or accident occurs and the investigation discovers an SOP is poorly written or doesn't adequately cover the situation. The company is then faced with a rewrite and retraining to correct it.

While in the CMO I worked several PD's (pilot deviations) of busted altitudes. These started happening with frequency. We discovered the standards department of the carrier had implemented a SOP that while climbing if a flight level was issued ( say through 10,000 feet to FL210) the crew was to set standard in the altimeter then, not wait until FL180.

You guessed it, they would set standard then get an intermediate level off (say 15,000). Then the altitude bust happens.

We "suggested" to the Standards to reevaluate their procedure to stop the PD's as well as mitigate a potential risk.
 
Just curious if the sim training at any company includes discovering that you are about to touch down on a runway that has unexpected numbers painted on it.

Seems to me that that should be done in the sim, since we're seeing that it happens in real life.
 
I"m running the exact same poll on a non-aviation forum, with the exact same wording(which is why I left out the FAA enforcement stuff here). The results over there are running #1, 7.2%. #2, 11.5%. #3, 42.3%. #4, 38.9% (rounding).

I thought it would be higher for firing outright, but not so. Some of the comments/questions are pretty interesting: 'Should they have just taken off and gone over to the other airport?' Not a bad idea, but I explained about the takeoff distance issue. 'I thought big planes have autopilot landing things.'
 
Just curious if the sim training at any company includes discovering that you are about to touch down on a runway that has unexpected numbers painted on it.

Seems to me that that should be done in the sim, since we're seeing that it happens in real life.

I've never seen that in any sim curriculum. I have seen rejected landings at touchdown in them.
 
Yep.

It's happened with other carriers, an incident or accident occurs and the investigation discovers an SOP is poorly written or doesn't adequately cover the situation. The company is then faced with a rewrite and retraining to correct it.

While in the CMO I worked several PD's (pilot deviations) of busted altitudes. These started happening with frequency. We discovered the standards department of the carrier had implemented a SOP that while climbing if a flight level was issued ( say through 10,000 feet to FL210) the crew was to set standard in the altimeter then, not wait until FL180.

You guessed it, they would set standard then get an intermediate level off (say 15,000). Then the altitude bust happens.

We "suggested" to the Standards to reevaluate their procedure to stop the PD's as well as mitigate a potential risk.

Is there not a FAR requirement saying a pilot needs to set the altimeter to the last known baro setting..:dunno:..

Does a company have the ability to alter FAR's to fit the mission..:dunno:

Seems to me if they could change the rules, they could then add lower landing minimums so they had less missed approaches and save on fuel and delays... It is the whole pandora box thingie..:idea:
 
Is there not a FAR requirement saying a pilot needs to set the altimeter to the last known baro setting..:dunno:..

Does a company have the ability to alter FAR's to fit the mission..:dunno:

Seems to me if they could change the rules, they could then add lower landing minimums so they had less missed approaches and save on fuel and delays... It is the whole pandora box thingie..:idea:

My understanding is that airline operations manuals have to be FAA-approved, but I don't know whether that covers this issue.
 
Is there not a FAR requirement saying a pilot needs to set the altimeter to the last known baro setting..:dunno:..

They were cleared to the flight levels. The altimeter setting in the flight levels is 29.92. That is by definition the flight levels.

Does a company have the ability to alter FAR's to fit the mission..:dunno:

A company has the ability to be stricter than the FARs. NEVER less restrictive.

Seems to me if they could change the rules, they could then add lower landing minimums so they had less missed approaches and save on fuel and delays... It is the whole pandora box thingie..:idea:

They can't change the rules unless it is MORE restrictive than the FARs.
 
Is there not a FAR requirement saying a pilot needs to set the altimeter to the last known baro setting..:dunno:..

Does a company have the ability to alter FAR's to fit the mission..:dunno:
How is that altering the FARs? Do you wait until the exact altitude to change? I know someone who does that. Most people lead it by some amount, sometimes by a lot. It doesn't really matter unless, as R&W points out, you get an intermediate level-off.
 
They were cleared to the flight levels. The altimeter setting in the flight levels is 29.92. That is by definition the flight levels.



A company has the ability to be stricter than the FARs. NEVER less restrictive.



They can't change the rules unless it is MORE restrictive than the FARs.


Yup... We change to 29.92 while passing through 17.5 on the way up and 18.5 on the way down... Even if you are cleared up to the FLs, the altimeter needs to be correct down low. IMHO.
 
How is that altering the FARs? Do you wait until the exact altitude to change? I know someone who does that. Most people lead it by some amount, sometimes by a lot. It doesn't really matter unless, as R&W points out, you get an intermediate level-off.

91.121 (a) 2
 
91.121 (a) 2
I guess you would be the guy that take it so literally that you would change it at the exact moment you cross 18,000'. But it doesn't really matter if you have already been cleared into the flight levels unless you get an intermediate level-off. I don't do it thousands of feet early (although I've seen people do it) but if I see a 17 on the altimeter going up or a 19 coming down I will usually change it then (unless cleared to FL180). In fact it's important to be careful coming down if you get cleared to 17,000' and the altimeter is low. You don't want to wait to long to reset it.
 
My understanding is that airline operations manuals have to be FAA-approved, but I don't know whether that covers this issue.

This is not a manual issue (altimeter change to standard) but an SOP, which may or may not be in a manual at some point.

Some times after long periods of time companies keep adding content and changing manuals to fit an operation. Different companies have different ways of dealing with this (my present carrier uses "FDIC" (flight deck crew information) memos as a way to communicate recent update and changes)

Supposedly when the new revision comes out for a manual these previous memos are to be added. Consequently as in any large operation things tend to fall through the cracks and sometimes get incorporated without further review.

The issue of the altimeter settings I was writing about came from Standards and was issued in a memo. We began seeing problems and when investigated found the source of said problems and had the company rethink their procedure.
 
I guess you would be the guy that take it so literally that you would change it at the exact moment you cross 18,000'. But it doesn't really matter if you have already been cleared into the flight levels unless you get an intermediate level-off. I don't do it thousands of feet early (although I've seen people do it) but if I see a 17 on the altimeter going up or a 19 coming down I will usually change it then (unless cleared to FL180). In fact it's important to be careful coming down if you get cleared to 17,000' and the altimeter is low. You don't want to wait to long to reset it.


In ICAO world if descending and the ATC issues the clearance "descend on QNH" from the flight levels then you can change your altimeter to QNH at that time.

My operator at the CMO also operated internationally and the standards people decided to use this procedure, albeit a bit "modified". They found out it didn't work. :rolleyes:
 
I guess you would be the guy that take it so literally that you would change it at the exact moment you cross 18,000'.

No, but the premise was that if they were at...say...5,000' and got cleared to FL350, the SOP was to reset the altimeter to 29.92 almost immediately. Then, if they got an intermediate level-off at...say...15,000' they'd regularly bust altitudes.

That, if accurate, would be a violation of the FARs, IMO. Emphasis on "if accurate".
 
No, but the premise was that if they were at...say...5,000' and got cleared to FL350, the SOP was to reset the altimeter to 29.92 almost immediately. Then, if they got an intermediate level-off at...say...15,000' they'd regularly bust altitudes.
I agree that is risky thing to do it that early as someone apparently found out, because there is a chance you might get an intermediate level-off. However I'll tell you that there is a wide variation in technique about when to change the altimeter, from a few thousand feet early to right on, but I've never seen it discussed and I never cared enough about it to bring it up to other people.
 
I agree that is risky thing to do it that early as someone apparently found out, because there is a chance you might get an intermediate level-off. However I'll tell you that there is a wide variation in technique about when to change the altimeter, from a few thousand feet early to right on, but I've never seen it discussed and I never cared enough about it to bring it up to other people.

My point in this is a procedure (SOP) that is adopted that initially sounds good but in reality creates another problem. These happen from time to time in air carrier operations and until something bad happens goes unnoticed.

This is why I advocated earlier to review SWA procedures and SOP's in regards to night visual approaches. Is there something that may have contributed? :dunno:
 
My point in this is a procedure (SOP) that is adopted that initially sounds good but in reality creates another problem. These happen from time to time in air carrier operations and until something bad happens goes unnoticed.
My responses were mostly to people who were wondering how such a procedure could be adopted since they think it is a violation of the FARs. I was just pointing out that most pilots don't change the altimeter right on the altitude and that the amount they lead it by differs. I've never heard of the procedure you describe, though.
 
My point in this is a procedure (SOP) that is adopted that initially sounds good but in reality creates another problem. These happen from time to time in air carrier operations and until something bad happens goes unnoticed.

In the case of company policy causing pilot deviations, does the crew get hung with the violation or does the company accept that responsibility?
 
In the case of company policy causing pilot deviations, does the crew get hung with the violation or does the company accept that responsibility?

PIC has the FINAL responsibility of the flight..... My money is on the PIC getting dinged with the offense...:yes: IMHO..
 
My responses were mostly to people who were wondering how such a procedure could be adopted since they think it is a violation of the FARs. I was just pointing out that most pilots don't change the altimeter right on the altitude and that the amount they lead it by differs. I've never heard of the procedure you describe, though.

Agreed.

Technically not a violation, just bad operating practice that could result in a violation.

Another one I was involved with years ago with a US carrier was the company issued a policy of "no additional fuel" to be carried. Previously when the crew received the weather and flight plans the Captain would add additional fuel (weather, delays, etc) to the predetermined flight plan load.

Company decided that carrying additional fuel was unnecessary given that the dispatcher has already accounted for such issues and that additional fuel meant additional fuel burn.

While on the surface this "seems" legit the pilot group (ALPA) countered it was excluding the Captain in the joint Captain/Dispatcher release provision of Part 121. When presented to the FAA they agreed, and the policy was rescinded.
 
In the case of company policy causing pilot deviations, does the crew get hung with the violation or does the company accept that responsibility?

If the company is proactive (they hold the operating certificate) then they will work out a solution with the FAA and right the situation.

In the altimeter situation I wrote we did not violate any flight crew members because the carrier admitted a flaw and quickly fixed the issue to the satisfaction of the FAA.
 
PIC has the FINAL responsibility of the flight..... My money is on the PIC getting dinged with the offense...:yes: IMHO..

While the PIC is the final authority he does have a responsibility to comply with company directives and manuals.

In a perfect world everything works perfectly. However we do not live in a perfect world and occasionally things go wrong. You have to admit over the years the air carriers in the US have made vast improvements (as demonstrated in their safety records) but they are very large organizations and very complex.

SMS (safety management systems) was introduced a few years ago as a means to identify risk and mitigate risk. If a company is properly using their SMS issues such as SOP's and procedures that are not properly written get discovered before implementation.
 
A number of years I was the PIC of a flight which overflew required maintenance. The maintenance department discovered it and self-disclosed to the FAA. No one got in trouble, in fact I never heard about it again, but we had to come up with a better method of releasing flights.
 
A number of years I was the PIC of a flight which overflew required maintenance. The maintenance department discovered it and self-disclosed to the FAA. No one got in trouble, in fact I never heard about it again, but we had to come up with a better method of releasing flights.


There is a BIG difference between flying a plane that didn't have "required maintenance done ( which you probably had no clue was not performed) and landing at the wrong airport.. ( which the PIC had total control over)... IMHO.....;)
 
There is a BIG difference between flying a plane that didn't have "required maintenance done ( which you probably had no clue was not performed) and landing at the wrong airport.. ( which the PIC had total control over)... IMHO.....;)

The thread drifted, Ben.
 
There is a BIG difference between flying a plane that didn't have "required maintenance done ( which you probably had no clue was not performed) and landing at the wrong airport.. ( which the PIC had total control over)... IMHO.....;)

You did post this...

PIC has the FINAL responsibility of the flight..... My money is on the PIC getting dinged with the offense...:yes: IMHO..

Does it matter what size the offense is? I thought we were taking about the pilots who had altitude deviations because of the company procedure anyway.
 
You did post this...



Does it matter what size the offense is? I thought we were taking about the pilots who had altitude deviations because of the company procedure anyway.


You are right......

I am outta here........:mad2::mad2::mad2:
 
There is a BIG difference between flying a plane that didn't have "required maintenance done ( which you probably had no clue was not performed) and landing at the wrong airport.. ( which the PIC had total control over)... IMHO.....;)


For sake of argument, what if it's discovered the FMS database had the wrong runway coordinates installed and the crew selected the runway for Branson but it was actually the other airport? And what "if" they had an SOP that stated "electronic backup of the landing runway is encouraged but not mandatory".

While there may have been reasons why he could have still avoided this mishap, do we still place all of the blame on the crew or do we use the acquired data and mitigate the risk?
 
For sake of argument, what if it's discovered the FMS database had the wrong runway coordinates installed and the crew selected the runway for Branson but it was actually the other airport? And what "if" they had an SOP that stated "electronic backup of the landing runway is encouraged but not mandatory".

While there may have been reasons why he could have still avoided this mishap, do we still place all of the blame on the crew or do we use the acquired data and mitigate the risk?

If the database is incorrect, that provides mitigation if not outright exoneration. However from the pilot's statement that doesn't appear to be the case. Sounds like they saw a set of lights and didn't pay further attention to the instrumentation.
 
From the NTSB:

On Jan 17th 2014 the NTSB reported that the aircraft was piloted by a captain with about 16,000 hours of flying experience and a first officer with about 25,000 hours of flying experience. The captain was on his first approach to Branson Airport, the first officer had flown into Branson one time before however in daylight. Air Traffic Control informed the crew they were 15nm from their destination, the crew advised they had the airfield in sight, and the air traffic controller cleared the flight for a visual approach to Branson's runway 14. The crew did not realize until after landing that they were at the wrong airport. The NTSB collected two hours of good recordings from the cockpit voice recorder and about 27 hours of data from the flight data recorder. In addition to the interviews with the two pilots the NTSB also talked to a Southwest Airlines dispatcher who was occupying the observer's seat. The crew reported they had programmed the approach into the flight management system, however then saw the airport beacon and runway lights that they identified as Branson Airport. They believed to be at Branson Airport until after touchdown when they applied heavy braking to stop the aircraft on the runway, then they radioed Branson Tower that they had landed at the wrong airport.

Graham Clark Airport features a runway 12/30 with 3738 feet/1140 meters length with only GPS/RNAV approach procedures published, Branson Airport features a runway 14/32 with 7140 feet/2175 meters length with an ILS approach to runway 32 and a GPS/RNAV approach to runway 14.

http://flightaware.com/live/flight/SWA4013/history/20140112/2145Z/KMDW/KBBG

Metars:
KBBG 130246Z 18015G28KT 10SM SCT250 14/M02 A2970=
KBBG 130152Z 17010KT 10SM FEW250 14/M02 A2971=
KBBG 130055Z 18011KT 10SM FEW250 15/M02 A2971=
KBBG 122347Z 15012G23KT 10SM FEW250 17/M02 A2970=
KBBG 122245Z 17008G16KT 10SM SKC 17/M03 A2971=
KBBG 122145Z 16013G19KT 10SM SKC 18/M03 A2972=
 
In ICAO world if descending and the ATC issues the clearance "descend on QNH" from the flight levels then you can change your altimeter to QNH at that time.
I spent a good bit of time going up and down between the QNH levels and Flight Levels in the military, and I never learned to do it any other way -- when cleared from a Flight Level down below the transition level, we always set the altimeters as soon as the descent was started, and did not wait to pass FL180 to do that. Maybe that was just the military, but I can think of a number of safety reasons why that's probably the best way to do it.
 
From the NTSB:

On Jan 17th 2014 the NTSB reported that the aircraft was piloted by a captain with about 16,000 hours of flying experience and a first officer with about 25,000 hours of flying experience. The captain was on his first approach to Branson Airport, the first officer had flown into Branson one time before however in daylight. Air Traffic Control informed the crew they were 15nm from their destination, the crew advised they had the airfield in sight, and the air traffic controller cleared the flight for a visual approach to Branson's runway 14. The crew did not realize until after landing that they were at the wrong airport. The NTSB collected two hours of good recordings from the cockpit voice recorder and about 27 hours of data from the flight data recorder. In addition to the interviews with the two pilots the NTSB also talked to a Southwest Airlines dispatcher who was occupying the observer's seat. The crew reported they had programmed the approach into the flight management system, however then saw the airport beacon and runway lights that they identified as Branson Airport. They believed to be at Branson Airport until after touchdown when they applied heavy braking to stop the aircraft on the runway, then they radioed Branson Tower that they had landed at the wrong airport.

Graham Clark Airport features a runway 12/30 with 3738 feet/1140 meters length with only GPS/RNAV approach procedures published, Airport features a runway 14/Branson32 with 7140 feet/2175 meters length with an ILS approach to runway 32 and a GPS/RNAV approach to runway 14.

http://flightaware.com/live/flight/SWA4013/history/20140112/2145Z/KMDW/KBBG

Metars:
KBBG 130246Z 18015G28KT 10SM SCT250 14/M02 A2970=
KBBG 130152Z 17010KT 10SM FEW250 14/M02 A2971=
KBBG 130055Z 18011KT 10SM FEW250 15/M02 A2971=
KBBG 122347Z 15012G23KT 10SM FEW250 17/M02 A2970=
KBBG 122245Z 17008G16KT 10SM SKC 17/M03 A2971=
KBBG 122145Z 16013G19KT 10SM SKC 18/M03 A2972=

Unless "someone" came out and pressure washed 12 off the runway and repainted 14 on it during their short flight from Chicago... That crew is toast......
 
A number of years I was the PIC of a flight which overflew required maintenance. The maintenance department discovered it and self-disclosed to the FAA. No one got in trouble, in fact I never heard about it again, but we had to come up with a better method of releasing flights.
There is a program for Part 121 carriers to set up a system in which self-disclosure of a violation the FAA did not hear about some other way first allows the carrier to fix the problem without FAA enforcement action against either the personnel or the operator. For more on the Aviation Safety Action Program (ASAP), see http://www.faa.gov/about/initiatives/asap/.
 
There is a program for Part 121 carriers to set up a system in which self-disclosure of a violation the FAA did not hear about some other way first allows the carrier to fix the problem without FAA enforcement action against either the personnel or the operator. For more on the Aviation Safety Action Program (ASAP), see http://www.faa.gov/about/initiatives/asap/.
But this was a Part 135 company. We don't have a formal ASAP program.
 
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