BOEING 767Delta Air Lines, Inc.
Atlanta Hartsfield Intl. Apt. (KATL), GA, USA · 2009-10-19·N185DN
What happened
NTSB summary, verbatimDuring 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.
Photographs
1the aircraft, and what the investigators foundProbable cause
the Board's determinationThe 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.
Occurrence sequence
3 stepsNTSB coding · CICTT taxonomy- 1 · EnrouteMedical event
- 2 · ApproachAirport occurrence
- 3 · LandingWrong surface or wrong airportdefining event
Findings
8 causal · 1 contributing- CAUSEPersonnel issues › Action/decision › Info processing/decision › Identification/recognition — Flight crew
- CAUSEPersonnel issues › Action/decision › Info processing/decision › Decision making/judgment — Flight crew
- CAUSEEnvironmental issues › Operating environment › Approach aid coverage/avail › Localizer — Availability of related info
- CAUSEEnvironmental issues › Operating environment › Approach aid coverage/avail › Approach lighting — Availability of related info
- CAUSEEnvironmental issues › Operating environment › Airport facilities/design › Taxiway lighting — Contributed to outcome
- CAUSEEnvironmental issues › Operating environment › Airport facilities/design › Taxiway markings/signage — Decision related to condition
- CAUSEPersonnel issues › Physical › Impairment/incapacitation › Illness/injury — Instructor/check pilot
- CAUSEPersonnel issues › Physical › Alertness/Fatigue — Flight crew
- FACTOREnvironmental issues › Operating environment › Radar services/coverage › Surface/taxi — Not specified
Safety recommendations
4 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Perform a technical review of Airport Surface Detection Equipment–Model X (ASDE-X) to determine if the capability exists systemwide to detect improper operations such as landings on taxiways.
tO THE FEDERAL AVIATION ADMINISTRATION: At those installation sites where the technical review recommended in Safety Recommendation A-11-12 determines it is feasible, implement modifications to Airport Surface Detection Equipment–Model X (ASDE-X) to detect improper operations, such as landings on taxiways, and provide alerts to air traffic controllers that these potential collision risks exist.
TO THE FEDERAL AVIATION ADMINISTRATION: Amend Federal Aviation Administration (FAA) Order 7210.3, “Facility Operation and Administration,” to direct that, at airports with air traffic control towers equipped with airport lighting control panels that do not provide direct indication of airport lighting intensities, the air traffic manager annually reviews and compares, with the airport operator, the preset selection settings configured in the tower lighting control system to verify that they comply with FAA requirements.
TO THE FEDERAL AVIATION ADMINISTRATION: Revise Advisory Circular 150/5345-56A, “Specification for L-890 Airport Lighting Control and Monitoring System (ALCMS)” to state that airport operators should inform air traffic managers of variances for, or modifications to, airfield lighting preset standards prescribed in Federal Aviation Administration requirements.
NTSB analysis
from the final reportDuring 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.