Pilot Debrief

BOEING 767 near Atlanta Hartsfield Intl. Apt. (KATL), GA — 2009-10-19

Final reportOPS10IA001
Sign in to save
Date
2009-10-19
Location
Atlanta Hartsfield Intl. Apt. (KATL), GA, USA
Airport
KATL
Aircraft
BOEING 767
Registration
N185DN
Category
Airplane
Highest injury
None
Fatalities
0
Phase of flight
Approach

Probable cause

The flight crew’s failure to identify the correct landing surface due to fatigue. Contributing to the cause of the incident were (1) the flight crew’s decision to accept a late runway change, (2) the unavailability of the approach light system and the instrument landing system for the runway of intended landing, and (3) the combination of numerous taxiway signs and intermixing of light technologies on the taxiway.

Contributing factors

Contributing to the cause of the incident were (1) the flight crew’s decision to accept a late runway change, (2) the unavailability of the approach light system and the instrument landing system for the runway of intended landing, and (3) the combination of numerous taxiway signs and intermixing of light technologies on the taxiway.

NTSB narrative

During the flight one of the three required flight deck crew members became ill and was considered to be incapacitated. The remaining two crew members conducted the entire night flight without the benefit of a customary break period. Throughout the flight the crew made comments indicating that they were fatigued and identified fatigue as their highest threat for the approach, but did not discuss strategies to mitigate the consequences of fatigue. At the time of the incident, the crew had been on duty for about 12 hours and the captain had been awake for over 22 hours, while the first officer had been awake for at least 14 hours. During the descent and approach, the flight crew was assigned a number of runway changes; the last of which occurred near the final approach fix for runway 27L. While the flight was on final approach, the crew was offered and accepted a clearance to sidestep to runway 27R for landing. Although the flight crew had previously conducted an approach briefing for two different runways, they had not briefed the approach for runway 27R and were not aware that the approach light system and the instrument landing system (ILS) were not available to aid in identifying that runway. When the crew accepted the sidestep to runway 27R, the captain, who was the flying pilot, saw the precision approach path indicator and lined the airplane up on what he said were the brightest set of lights he could see. During the final approach, the first officer was preoccupied with attempting to tune and identify the ILS frequency for runway 27R. Just prior to the airplane touching down, the captain realized they were landing on a taxiway. The airplane landed on taxiway M, 200 feet north of, and parallel to, runway 27R. Postincident flight evaluations of the airport lighting indicated that there were a number of visual cues that could have misguided the captain to align with taxiway M instead of runway 27R while on final approach. These cues included numerous taxiways signs along the sides of taxiway M which, from the air, appeared to be white and could be perceived as runway edge lights. In addition, the blue light emitting diode (LED) lights used on the eastern end of taxiway M were perceived to be brighter than the adjacent incandescent lights on the airfield and the alternating yellow and green lights in the ILS critical area provided the appearance of a runway centerline. The postincident flight evaluations indicated that when the approach lights or the ILS for runway 27R were available and used, it was clearlyevident when the airplane was not aligned with the runway.

Analysis

Primary failure mode
Human factors
First missed decision gate
Crew did not conduct an additional briefing for runway 27R after last minute change.

NTSB coding

  • Wrong surface or wrong airport · Landing
  • Decision Making / Judgment
  • Impairment / Incapacitation

Evidence available

  • CVR
  • 21 docket documents
View NTSB final reportView NTSB docket

Docket documents21

Related mishaps