What
Is Wrong?
 Among
other things, wrong is a word that describes something as being
out of normal working order or condition. When something "goes
wrong" with an aircraft component, a piece of equipment,
a schedule, a passenger, or the weather for example, that's
when aviation professionals rise to the occasion and fix what's
wrong or work around it. It's part of the job. Wrong
also describes a situation in which someone goes in an unintended
direction or makes an erroneous decision. The fix for that sort
of wrong can be a bit more challenging. Someone has to recognize
that something is amiss. Someone has to figure out what is
wrong.
The
people who submitted the following reports went in unintended
directions or made erroneous decisions, but they also did something
right. They shared their lessons so that the rest of us wouldn't
have to "go wrong."
Foreign
Exchange
Armed
with about 100 hours of experience, a sectional chart, and a
general idea of where to go, this pilot made a borderline decision
that led to some interesting inquiries.
I
departed [an airport in Washington State] for a direct flight
to another Washington airport. Forty minutes into the flight,
I noticed the right fuel gauge read almost zero.... I wondered
if I had a leak or a loose cap. I was close to my destination
so I continued. Then I started to question my exact location.
I couldn't make out landmarks that appeared on my sectional
chart.... I saw a large airport, turned west, and followed
the shoreline. Within a few minutes I found a smaller airport....
I circled the field attempting to see a name on the runway
or a hangar. Nothing.... I had fuel concerns. The sun had
already set. Every minute seemed like an hour and this airport
could be my destination. I made the appropriate calls, entered
the pattern, and landed. I taxied up to the first person I
could find, exchanged greetings, and asked him where we were.
He said, "ZZZ, [eh?]" I was in Canada! I checked
the fuel and flew back to the real destination. Five law enforcement/customs
vehicles arrived to welcome me to the U.S. Lots of questions,
explaining, and searches. It all ended with a photo session.
I
will put more effort into the planning phase of flights and
select landmarks that are easier to identify. I will make
better use of navigation aids and use "flight following."
Seeing
Is Believing
Armed
with over 15,000 hours of combined experience, advanced avionics,
and visual contact with the airport, this B737 flight crew believed
that they were headed for the right place. An alert air traffic
controller, however, noticed that something was wrong.
From
the Captain's report:
I
have often wondered how crews land at the wrong airport. Well,
now I know.... We were in and out of the clouds.... We were
told to expect the visual approach to Runway 19R at ZZZ....
The First Officer was flying and he was asking for lower.
I made the comment we had plenty of time, then all of a sudden
an airport appears in a break in the clouds. We called the
airport in sight. We were cleared for the visual approach
and were told to switch to the tower....We were cleared to
land. I remember thinking this doesn't look like nine miles,
but dismissed it because we had a runway in sight. We made
a turn through an opening in the clouds, maneuvered to final,
and had just lined up with the runway when the Tower Controller
said, "[Wrong Airport] is 12 o'clock, three miles. ZZZ
is one o'clock, nine miles. Do you have ZZZ in sight?"
We...looked out and saw the real ZZZ Airport in the distance
and called it in sight....
I
attribute this close call to several things. We could have
been more thorough in our brief.... I never verbalized the
fact that [Wrong Airport] was going to be in close proximity....
All radios, including ADF's were properly tuned, but ignored.
We were not able to see enough of the surrounding terrain
to properly orient ourselves visually. We did not have the
"big picture."
Lots
of lessons learned here. We were very lucky someone else was
looking out for us.
From
the First Officer's report (after receiving the alert from the
Tower Controller):
We
took a look at the MAP display and quickly confirmed our error....
Human
factors: Relying on my few remaining brain cells instead of
millions of dollars worth of navigation gear. After all, the
whole picture was right there in front of our faces.
Quiet!
Approach in Progress
Federal
Aviation Regulations Part 121.542 and Part 135.100 address the
importance of maintaining a sterile cockpit environment during
critical phases of flight. While there is no regulatory counterpart
in FAR Part 91, this PA32 pilot's report demonstrates why all
pilots should consider adopting the procedure. In small aircraft,
both pilots and passengers should not engage in any activity
during a critical phase of flight that could be a distraction
or otherwise interfere with the safe conduct of the flight.
I
was cleared for a visual, straight-in, Runway 21.... I located
the airport across a body of water and Runway 21 almost straight
ahead. Wondering why I had not received a hand-off to the
Tower, I tuned to ZZZ Tower and called on final.... Hearing
no response, I tried Ground Control. Still no response. I
landed and realized during the rollout that this was not ZZZ.
The runway was 23.... After explanations and paperwork, I
flew VFR to ZZZ, 15 miles away.
I
believe this event was a result of my not maintaining a sterile
cockpit environment, especially during the approach. I was
in deep conversation with a passenger. Because of this, I
missed any further calls from Approach Control, mistook the
picture of a similar airport environment, and didn't pay enough
attention to the unexplained silence during the attempts to
reach the Tower and Ground.
Wrong
Runway -
The Intersection Factor
In
the following reports, intersection takeoffs were a contributing
factor in departures from the wrong runway. At the end of a
runway there are usually prominent runway numbers painted on
the surface and the holding position signs indicate only one
runway direction (e.g. "27"). At taxiway/runway or
runway/runway, non-full length intersections, there are no surface
numbers and the hold position signs will indicate both runway
directions (e.g. "9-27"). Add in other factors such
as fatigue, weather, or distraction, and the possibility for
confusion at a runway intersection becomes a concern for everyone.
Right
Turn, Wrong Time
In the following
report, an ambiguous choice of words by the tower controller
and a pilot's failure to clarify the instructions contributed
to a wrong runway takeoff.
The
active runway was 17. Intersection takeoffs were being used.
I was at the Bravo intersection on Runway 17-35. From this
position a left turn would yield a 3,500-foot takeoff on Runway
17 and a right turn would yield a 3,500-foot takeoff on Runway
35. Tower said, "Turn right. Cleared for takeoff."
I read this back, turned right, and took off on Runway 35.
I
should have realized that they wanted me to takeoff on Runway
17 and turn right after takeoff. I am not sure that the tower
used standard terminology, but I have enough experience to
have realized that they wanted a right turn after takeoff.
I should have asked for clarification.
According
to the Controller's Handbook (7110.65P), the controller should,
"State the runway intersection when authorizing an aircraft
to taxi into position to hold or when clearing an aircraft for
takeoff from an intersection." The phraseology, "123
Alpha, cleared for takeoff, Runway 17 at Bravo, 3,500 feet available.
Turn right after takeoff," would have gone a long way toward
eliminating any confusion.
Heading
for Trouble
When flying
an aircraft with an unslaved directional gyro, the preferred
procedure is to place the aircraft on the correct runway and
then align the directional gyro to conform to the known runway
heading. Doing the opposite, that is, placing the aircraft on
the wrong runway and then trying to realign the earth with the
directional gyro, will not work. As this C210 pilot learned,
it also leads to more confusion after takeoff. This pilot's
conscientious analysis of the incident yields some sound advice
to keep the rest of us headed in the right direction.
I
received a clearance for departure on Runway 6R. After asking
for a progressive taxi clearance, I held short at the assigned
intersection and changed to Tower frequency. I was asked by
Tower to confirm that the remaining runway
from the intersection was sufficient. I shifted my attention
to the "shorter" end of the runway, confirmed that
it was sufficient, and was cleared into "position and
hold." Turning onto the runway, I aligned the directional
and held in position to await takeoff clearance. After a short
period, I was cleared for takeoff. On climb out, Tower advised
that I had departed on Runway 24L rather than Runway 6R and
I was told to turn to a specific heading. I immediately began
a steep turn to the assigned heading. About halfway through
the turn, the clearance was repeated, in such a way that I
assumed I was turning in the wrong direction. In my readback,
I confirmed the new direction of turn to the assigned heading.
Soon the controller, sounding more concerned, assigned a new
heading. I immediately turned to that heading and was flying
it when the controller repeated the assignment. I confirmed
that I was flying the assigned heading. At this point, the
controller advised an airliner on approach to Runway 6L that
a light aircraft was not listening to directions. Simultaneously,
I recognized that I must not have been flying the heading
that I thought I was flying. I determined that the directional
gyro was incorrectly set, reset the directional gyro, and
turned to the actual assigned heading.... I advised the controller
that I was now on the correct heading.... The remainder of
the flight was uneventful....
The
primary factors...: 1) failure to correctly set the directional
gyro (in spite of following a printed checklist).... 2) failure
to corroborate with available aids in the aircraft - airport
diagram on the moving map display. 3) failure to heed the
"inner voice" that recognized something was not
right as the takeoff roll began.
The
calm professionalism of the controller directly and significantly
contributed to the "containment" of this incident.
He issued instructions in a manner that did not compound the
stress inherent in dealing with what was clearly a major error....
An
Uneasy Departure
Fatigue
and complacency are two insidious factors that can sneak up
on the most experienced professionals. In this report, a B737
got about a 4,000-foot head start on a weary flight crew.
We
were cleared for takeoff from Runway 17 at Golf intersection.
As I was lining up for takeoff, the First Officer stated,
"This way," and pointed in the direction of Runway
35. I turned as he directed and commenced takeoff on Runway
35 from Golf. After takeoff, I realized that we took off from
the wrong runway. The First Officer asked for a vector to
join the airway. Tower replied, "Turn left and proceed
on course. (Pause) Everything all right?" The First Officer
replied, "Left on course," and "Yes."
In the midst of this we forgot to raise the gear until 4,000
feet. The rest of the flight continued without incident.
Contributing
factors: 1) Variable winds. We had landed on Runway 35 on
the previous leg. 2)...Cumulative fatigue. 3) The First Officer
was capable and conscientious, so I let my guard down. 4)
I did not act on the uneasy feeling I had after turning onto
Runway 35.
In
2004 the highest report intake in the history of the
Aviation Safety Reporting System was recorded -
37,752 reports.
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