Fate of ATP pilot landing at wrong runway. A poll

[RotorAndWing]

Cause is rather interesting in this case, they went 'visual' with no 'visual' reference material. Had they had a sectional, Foreflight, WingX or similar they would have had access to 'visual' reference material. Either they should be provided this material or restricted to instrument procedures start to finish with no "expect the visual" approaches to be allowed.

The aircraft had FMS. If you are that unsure of a visual approach it can be configured by selecting the runway on the arrival page and "drawing" an extended centerline on the ND.

If you want more help you can simply create a few waypoints for a pattern entry and a base turn. You can even put constraints (altitude, speed) if you want to get real fancy.

 

[Henning]

The aircraft had FMS. If you are that unsure of a visual approach it can be configured by selecting the runway on the arrival page and "drawing" an extended centerline on the ND.

If you want more help you can simply create a few waypoints for a pattern entry and a base turn. You can even put constraints (altitude, speed) if you want to get real fancy.

Which basically makes it an instrument procedure doesn't it? Follow the instruments to the runway. The control of the plane itself is visual, but not the navigational procedure.

 

[RotorAndWing]

Which basically makes it an instrument procedure doesn't it?

No. You are setting reference points and cross checking visually.

Follow the instruments to the runway. The control of the plane itself is visual, but not the navigational procedure.

So if you have a SVT cockpit doing the same thing it's not a visual?

 

[Fearless Tower]

The airplane has an FMS. On the arrival page you can select runway and the approaches available to the runway. If no approach, then simple select the runway and it will display on the ND. Depending upon the FMS you can make a extended runway centerline on the ND for the runway.

Going back to the approach briefing it will be interesting to see if it was briefed and how they configured for the approach.

According to the NTSB update, it said they did have the correct airport loaded in the FMS.

 

[RotorAndWing]

According to the NTSB update, it said they did have the correct airport loaded in the FMS.

Yes. I'm interested in how they had it set up and how it was displayed. For me if I was turning final for an airport and the ND didn't have the runway in the correct position I would start trying to figure this out before proceeding.

Did they have an extended centerline or an approach loaded? What scale was the ND's set to?

 

[jonnyjetprop]

The correct answer is C. I'm sure the crew filled out an ASAP report. That will protect them from answer D.

The incident is a reminder that we are all a couple of links in the error chain from bad things happening. Be careful out there.

 

[Henning]

No. You are setting reference points and cross checking visually.

To me that makes it an instrument procedure. A visual procedure to me is out the window.

So if you have a SVT cockpit doing the same thing it's not a visual?

Correct, while SVT may display in a 'visual' format, it is still an instrument that does data interpretation and displays it in a 3D pictorial format. It may represent like out the window, but it is not.

 

[RotorAndWing]

To me that makes it an instrument procedure. A visual procedure to me is out the window.

Whatever. How is using available resources to increase situational awareness a bad thing?

Correct, while SVT may display in a 'visual' format, it is still an instrument that does data interpretation and displays it in a 3D pictorial format. It may represent like out the window, but it is not.

Again, situational awareness.

 

[Henning]

Whatever. How is using available resources to increase situational awareness a bad thing?




Again, situational awareness.

I don't think it's a bad thing, I think it's normal, my point is that they aren't given all the materials available to acquire a 'visual' situational awareness therefor shouldn't be issued or accept a visual approach. They shouldn't be transitioning from instruments until they are captured on the LOC&GS whether radio or RNAV based.

 

[RotorAndWing]

I don't think it's a bad thing, I think it's normal, my point is that they aren't given all the materials available to acquire a 'visual' situational awareness therefor shouldn't be issued or accept a visual approach. They shouldn't be transitioning from instruments until they are captured on the LOC&GS whether radio or RNAV based.

Whats the difference of that or having a runway and runway centerline superimposed on the ND using the FMS?

 

[Henning]

Whats the difference of that or having a runway and runway centerline superimposed on the ND using the FMS?

That works fine, for an instrument approach, but it does not provide them the "out the window" detail to see and compare to. If you don't know what you are looking at out the window, what good is the window? You should be on instruments until you know what you are looking at. They didn't know what they were looking at, they assumed, and they got it wrong.

 

[RotorAndWing]

That works fine, for an instrument approach, but it does not provide them the "out the window" detail to see and compare to. If you don't know what you are looking at out the window, what good is the window? You should be on instruments until you know what you are looking at. They didn't know what they were looking at, they assumed, and they got it wrong.

You're going around in circles now.

If a pilot is flying a visual and has the information in the FMS and displayed on the ND for situational awareness, he intercepts the runway centerline say at 5 miles, he lines up on the runway, runway heading is checked, the ND shows KXXX RNWY 14 next to the runway display and he looks out his window and sees the runway and landing aids (PAPI,VASI) verified against his airport diagram.

Visual approaches are done day in and day out in the 121 world, this is not a new procedure or seldom practiced procedure. Something has falling through the cracks here and it will be interesting when the facts come out to see where the failure points happened.

 

[Henning]

You're going around in circles now.

If a pilot is flying a visual and has the information in the FMS and displayed on the ND for situational awareness, he intercepts the runway centerline say at 5 miles, he lines up on the runway, runway heading is checked, the ND shows KXXX RNWY 14 next to the runway display and he looks out his window and sees the runway and landing aids (PAPI,VASI) verified against his airport diagram.

Visual approaches are done day in and day out in the 121 world, this is not a new procedure or seldom practiced procedure. Something has falling through the cracks here and it will be interesting when the facts come out to see where the failure points happened.

The failure from what I am reading from the pilot statements is that once they saw a runway all lit up and a beacon, they assumed that was their runway and never went back to the instruments to verify. My point is if they had a sectional, or an EFB version such as Foreflight or WingX, or an MFD style sectional display they would have had obvious information due to the lights on the ground that they were looking at the wrong airport. Clark is right there near the strip, Branson is out in the dark. If they had looked at a sectional representation when they briefed the approach, they would have know that was the wrong airport, it's dead obvious.

They did not have all the information available to them pertinent to that flight for visual operations.

 

[RotorAndWing]

The failure from what I am reading from the pilot statements is that once they saw a runway all lit up and a beacon, they assumed that was their runway and never went back to the instruments to verify.

No argument there.

My point is if they had a sectional, or an EFB version such as Foreflight or WingX, or an MFD style sectional display they would have had obvious information due to the lights on the ground that they were looking at the wrong airport.

They already had FMS with airport information, runway alignments, all available approaches with approach plates and airport diagrams (either paper or EFB ). Also area arrival charts.

If they didn't use these what makes you think they would dig out a sectional or another SI tool such as ForeFlight?

Clark is right there near the strip, Branson is out in the dark. If they had looked at a sectional representation when they briefed the approach, they would have know that was the wrong airport, it's dead obvious.

Maybe, maybe not.

They did not have all the information available to them pertinent to that flight for visual operations.

Yes they did, just not in the means you are accustomed to using.

 

[Henning]

No argument there.



They already had FMS with airport information, runway alignments, all available approaches with approach plates and airport diagrams (either paper or EFB). Also area arrival charts.

If they didn't use these what makes you think they would dig out a sectional or another SI tool such as ForeFlight?



Maybe, maybe not.



Yes they did, just not in the means you are accustomed to using.

I can't say they would dig it out, but if the same device has their approach plate to brief off, if they wouldn't bother to look at the rest of the info, that would make them even more negligent than they were here.

 

[RotorAndWing]

I can't say they would dig it out, but if the same device has their approach plate to brief off, if they wouldn't bother to look at the rest of the info, that would make them even more negligent than they were here.

I'll (better yet, the investigators) will decide negligence once all of the facts are in.

 

[Henning]

I'll (better yet, the investigators) will decide negligence once all of the facts are in.

All the facts are in, the report just hasn't been published yet. Since there was no crash and everyone is alive, the facts are simple to determine, especially when the pilots admitted "we ****ed up, we saw the lights and went there". The negligence is a given, they landed at the wrong airport. They did not blame faulty navigational equipment. Whether they had the FMS showing extended runways or whatever is just a matter of amount of negligence. Had they checked their visual approach against the FMS approach for Branson, they would have realized that they were heading to the wrong airport. The only real question is is there contributory negligence on the part of the company in it's establishment of procedure for visual approaches.

 

[RotorAndWing]

All the facts are in, the report just hasn't been published yet.

Which means the investigation is ongoing.

Since there was no crash and everyone is alive, the facts are simple to determine, especially when the pilots admitted "we ****ed up, we saw the lights and went there".

Very simplified, but missing key details.

The negligence is a given, they landed at the wrong airport.

Again you're trying to blanket the whole event with "negligence".

They did not blame faulty navigational equipment.

I wasn't aware you were privy to the inside of the investigation.

Whether they had the FMS showing extended runways or whatever is just a matter of amount of negligence.

Negligence or faulty procedures? What are the SWA SOP for a visual approach at night? Were they adhered too? Is there some room for interpretation contained within the SOP that could possibly lead a pilot into not following the procedure?

Had they checked their visual approach against the FMS approach for Branson, they would have realized that they were heading to the wrong airport.

Granted. The question now is why?

The only real question is is there contributory negligence on the part of the company in it's establishment of procedure for visual approaches.

Yep. That's why there is an ongoing investigation.


The easy part is just to point fingers, place blame, destroy two careers and move on. But that doesn't fix the root cause of the problem. Aviation Safety is about identifying risk and mitigating said risk.

If there is a procedural problem that needs to be analyzed and corrected. If there is a training problem again, analyzed and corrected.

Again, trained investigators are working the issues, I'll withhold judgement until the facts are out.

 

[taters]

I wonder what the SOP says on the visual approach for SWA ? In know what 121 says about them.
Keep in mind whatever the FAA signed off on as a SOP for Southwest is effectively an FAR, so they CAN be violated for failure to obey SOP at the least here.

 

[RotorAndWing]

I wonder what the SOP says on the visual approach for SWA ? In know what 121 says about them.
Keep in mind whatever the FAA signed off on as a SOP for Southwest is effectively an FAR, so they CAN be violated for failure to obey SOP at the least here.

FAA doesn't "sign off SOP's" per se. Typically SOP's are contained within the Flight Crew Training Manual or General Operations Manual which are FAA Approved.

However it's not uncommon to see SOP's put out via memo or other medium to the crew as a new procedure before being incorporated into a manual. My story a few post back about the climb and descend altimeter setting was an SOP that went wrong.

I haven't had time to get with a couple of friends flying for SWA to ask them what their procedure is for night visual approaches. I'm sure it's being scrutinized and no doubt that is going to change.

 

[Henning]

Which means the investigation is ongoing.



Very simplified, but missing key details.



Again you're trying to blanket the whole event with "negligence".



I wasn't aware you were privy to the inside of the investigation.



Negligence or faulty procedures? What are the SWA SOP for a visual approach at night? Were they adhered too? Is there some room for interpretation contained within the SOP that could possibly lead a pilot into not following the procedure?



Granted. The question now is why?



Yep. That's why there is an ongoing investigation.


The easy part is just to point fingers, place blame, destroy two careers and move on. But that doesn't fix the root cause of the problem. Aviation Safety is about identifying risk and mitigating said risk.

If there is a procedural problem that needs to be analyzed and corrected. If there is a training problem again, analyzed and corrected.

Again, trained investigators are working the issues, I'll withhold judgement until the facts are out.

I'm not advocating ruining these guys careers, but in the end, they carry the majority of the blame, and it is negligence by definition. They neglected to confirm they were heading to the correct runway. The published statements from them that I have read are clear admissions. I think that there is an inherent procedural error in the system by not providing the correct visual reference material regardless of the FMS data display and how it gets used whether they used that properly or not.

 

[RotorAndWing]

I'm not advocating ruining these guys careers, but in the end, they carry the majority of the blame, and it is negligence by definition. They neglected to confirm they were heading to the correct runway.

Again, what about the rest of the story? Start from before TOD when the arrival and approach were briefed. There are more facets to this than "they landed on the wrong runway". As with most incidents or accidents there is a chain, which links were broken and why?

The published statements from them that I have read are clear admissions.

Do you have a link to those "published statements"? I wasn't aware the interviews with the pilots have been released already.

I think that there is an inherent procedural error in the system by not providing the correct visual reference material regardless of the FMS data display and how it gets used whether they used that properly or not.

Since you obviously don't understand airline procedures with regards to visual approaches how can you claim a "procedural error"? And since airlines use visual approach procedures hundreds if not thousands a times a day (or night) how can it be a "procedural error" if their is only a .0001 percent failure rate?

 

[Henning]

Again, what about the rest of the story? Start from before TOD when the arrival and approach were briefed. There are more facets to this than "they landed on the wrong runway". As with most incidents or accidents there is a chain, which links were broken and why?



Do you have a link to those "published statements"? I wasn't aware the interviews with the pilots have been released already.



Since you obviously don't understand airline procedures with regards to visual approaches how can you claim a "procedural error"? And since airlines use visual approach procedures hundreds if not thousands a times a day (or night) how can it be a "procedural error" if their is only a .0001 percent failure rate?

How many errors does it take? We've had 2 in the last few months. They are equipped for instrument flight, had both those flights maintained instrument approaches they would have landed on the correct runways. How many "I almost did but caught it at the end" don't we hear about? I understand airline procedure well enough to know they are centered around and set up for IFR navigation procedure and do not carry VFR reference material. They shouldn't be navigating out of the window when they don't have the references to tell them what they are looking at, at least not until they have done several in day and night conditions. That was the point of failure, they didn't know what they were looking at but flew visual navigation.

 

[docmirror]

Does anyone think that a procedure at SWA tells the pilots to ignore their nav automation sources once they accept a visual? I guess we will see what we will see.

 

[Henning]

Does anyone think that a procedure at SWA tells the pilots to ignore their nav automation sources once they accept a visual? I guess we will see what we will see.

I seriously doubt it.

 

[RotorAndWing]

How many errors does it take? We've had 2 in the last few months.

Two out of how many thousands?? If we use that analogy then night VFR GA flying should be banned since the numbers are way higher to have an accident.

They are equipped for instrument flight, had both those flights maintained instrument approaches they would have landed on the correct runways.

Most of the world prohibits night visual approaches. Maybe the FAA should follow ICAO?

How many "I almost did but caught it at the end" don't we hear about? I understand airline procedure well enough to know they are centered around and set up for IFR navigation procedure and do not carry VFR reference material.

True.

They shouldn't be navigating out of the window when they don't have the references to tell them what they are looking at, at least not until they have done several in day and night conditions. That was the point of failure, they didn't know what they were looking at but flew visual navigation.

They did and a failure occurred. Again, let the facts come in and the investigation conclude before jumping to conclusions.

 

[Henning]

Two out of how many thousands?? If we use that analogy then night VFR GA flying should be banned since the numbers are way higher to have an accident.



Most of the world prohibits night visual approaches. Maybe the FAA should follow ICAO?



True.



They did and a failure occurred. Again, let the facts come in and the investigation conclude before jumping to conclusions.

From what I read only one had been into Branson and it was during the day. I think banning night visual approaches may be the eventual outcome, at least for commercial ops.

 

[RotorAndWing]

I think banning night visual approaches may be the eventual outcome, at least for commercial ops.

Again, 2 failures out of how many thousands? If the FAA is going to use this to ban night visual approaches then expect to see night GA ops (VFR) banned as well. Far more accidents with GA night VFR than air carrier ops.

Why not review the SWA (and AAC) SOP's and make appropriate changes? If SWA feels they have a problem with this airport then make it a "special use" airport.

Much better (and safer) solutions than banning operations.

 

[Fearless Tower]

Wonder what scale they had the display set to? If they had the right airport programmed into the FMS, but didn't adjust the scale of the display because they were both looking out the windows, it might not gave been as apparent that they were landing at the wrong one.

 

[RotorAndWing]

Wonder what scale they had the display set to? If they had the right airport programmed into the FMS, but didn't adjust the scale of the display because they were both looking out the windows, it might not gave been as apparent that they were landing at the wrong one.

Exactly.

 

[Dr. O]

I have no insider facts. I did notice one report that claimed there was a non pilot in the cockpit who is also suspended by SWA with reference to violations of the sterile cockpit rule.
I'm shocked, shocked I say, to not see endless speculation about his/her part in this morality play.
What is this board coming to. sheesh.

 

[Fearless Tower]

I have no insider facts. I did notice one report that claimed there was a non pilot in the cockpit who is also suspended by SWA with reference to violations of the sterile cockpit rule.
I'm shocked, shocked I say, to not see endless speculation about his/her part in this morality play.
What is this board coming to. sheesh.

Probably because the jumpseater was a company employee who was (most likely) legitimately occupying that seat.

 

[Palmpilot]

Again, 2 failures out of how many thousands? If the FAA is going to use this to ban night visual approaches then expect to see night GA ops (VFR) banned as well. Far more accidents with GA night VFR than air carrier ops...

That logc ignores the principle that paying passengers deserve a higher level of safety.

(I'm not saying that GA's problems with night VFR don't need attention, but I think the appropriate way to deal it would be better education of GA pilots on how to do it safely.)

 

[docmirror]

This still boils down to failure to meet absolute minimum acceptable standards or competence. We have another thread on here about incompetence, and we've all seen it. Not being able to do your job if you are in retail, or pump gas, or pour concrete doesn't get people killed. Aviation has been accurately described as not being a vocation that is competence-optional.

When you or I buy a ticket on an airliner, we expect - even demand that the pilots do their magic to get us to our destination without a mistake in between requiring a bus, or other ground method. Landing at the wrong airport is gross incompetence even one time, and should be grounds for termination. This isn't punishment for making a mistake, it's requiring that those who get the highest ratings, and are paid the big bucks to sit up in the pointy end do their diligence.

It's like I used to tell kids in my intermediate Algebra class when they would whine; 'but - wwwwwwwhhhhyyyyyyyyyyyyyy do I have to learn matrices and determinants?' and I would answer; 'because the next class, and the one after that which will lead to either med school, or eng school insure that we don't let incompetent people into those fields, and we don't have untrained people building bridges, and planes, and gas analyzers, and cutting into people, and flying planes, etc'.

When you strap on the hat with the silver braid, and you put on the coat with the epaulet stripes, you agree to a pact that you meet or exceed these minimum acceptable standards. One of those minimal standards is that when the plane lands, it is where you expect it to be, and not 6 miles away, at a local GA airport, while the pilot and co-pilot are sitting there with that jaw-drop look on their face. This keeps people from being killed and it's what I believe should be the way things are. If I screw up my job this bad, I fully expect to get fired on the spot, or after suitable investigation confirms my mistake.

 

[RotorAndWing]

That logc ignores the principle that paying passengers deserve a higher level of safety.

Granted. But the problem is being blown out of proportion. Commercial aviation in the US is safer today than 20 years ago. Given the total number of daily, monthly and yearly operations flown consider the level of safety being accomplished. Those passengers are receiving a higher level of safety, but unfortunately a crack happens. The job of the investigators is to find what caused this crack in the system and correct it to further increase that level of safety.

(I'm not saying that GA's problems with night VFR don't need attention, but I think the appropriate way to deal it would be better education of GA pilots on how to do it safely.)

Been tried but not working. The inherent problem with GA is that pilots are trained to a minimum standard then after receiving their license they no longer have to do anything for recurrency training or further education if they don't want to, and many do not.

 

[Palmpilot]

Granted. But the problem is being blown out of proportion. Commercial aviation in the US is safer today than 20 years ago. Given the total number of daily, monthly and yearly operations flown consider the level of safety being accomplished. Those passengers are receiving a higher level of safety, but unfortunately a crack happens. The job of the investigators is to find what caused this crack in the system and correct it to further increase that level of safety.

No argument here.

Been tried but not working.

I don't think it has been tried. When I was training for the private pilot certificate, I didn't receive instruction in strategies for night VFR obstacle avoidance. I figured that stuff out on my own.

 

[RotorAndWing]

No argument here.



I don't think it has been tried. When I was training for the private pilot certificate, I didn't receive instruction in strategies for night VFR obstacle avoidance. I figured that stuff out on my own.

Yep. Most countries prohibit night VFR or require special training and a rating for it, along with recurrency.

If the FAA followed suit and required the same level you would hear howling and moaning of how unfair it is.

So in the meantime............

 

[MachFly]

http://www.ntsb.gov/aviationquery/brief.aspx?ev_id=20140112X11328&key=1

NTSB Identification: DCA14IA037
Scheduled 14 CFR Part 121: Air Carrier operation of SOUTHWEST AIRLINES CO
Incident occurred Sunday, January 12, 2014 in Branson, MO
Aircraft: BOEING 737 7H4, registration: N272WN
Injuries: 131 Uninjured.
This is preliminary information, subject to change, and may contain errors. Any errors in this report will be corrected when the final report has been completed. NTSB investigators used data provided by various sources and may not have traveled in support of this investigation to prepare this aircraft incident report.​

On January 12, 2014, about 1810 local time, Southwest Airlines flight 4013, a Boeing 737-7H4, registration N272WN, mistakenly landed at M. Graham Clark Downtown Airport (KPLK), Branson, Missouri, which was 6 miles north of the intended destination, Branson Airport (KBBG), Branson, Missouri. The flight had been cleared to land on runway 14 at KBBG, which was 7,140 feet long, however, landed on runway 12 at KPLK, which was 3,738 feet long. There were no injuries to the 124 passengers and 7 crewmembers and the aircraft was not damaged. The aircraft was being operated under the provisions of 14 Code of Federal Regulations Part 121 as a regularly scheduled passenger flight from Chicago Midway International Airport (KMDW), Chicago, Illinois. Night visual meteorological conditions prevailed at the time.

 

[RotorAndWing]

So approximately how much time passes between the point where you move the levers forward and get a positive rate of climb?

In a large (transport) aircraft consider one more factor, kinetic energy. In a jet of say 120,000 pounds at landing weight on approach speed if the throttles are not pushed up to TOGA and the aircraft is pitched to about 12 degrees nose up it will start climbing due to the stored energy changing direction.

The thrust used for a stabilized approach (flaps landing and gear down) is already above 50% (typical) so the engines will respond faster than idle thrust to TOGA.

In the A320 I pull thrust off at about 20 feet above touchdown. As they are spooling down if I command TOGA the thrust comes back rapidly due to the higher idle. I may touch the runway on such a go around but it's momentary.

Hope that answers your question.

Found this for you in the A320 FCOM:

ENGINES ACCELERATION

When the pilot sets TOGA thrust for go-around, it takes some time for the engines to spool up due to
the acceleration capability of the high by pass ratio engines. Therefore, the pilot must be aware that
the aircraft will initially loose some altitude. This altitude loss will be greater if initial thrust is close to
idle and/or the aircraft speed is lower than VAPP.

Altitude loss following a go-around
​

 

[1600vw]

Rotor&Wing: You are so right.

I believe they call it being on the back side of the power curve. Once this happens you are landing.
This can happen in a piston engine too, but to a lesser degree.

Tony