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"We are the protagonists of our stories called life, and there is no limit to how high we can fly."


PHD. MBA. MHS. Type rated on A350, A330, B777, B747-400, B747-200, B757, B767, B737, B727. International Airline Pilot / Author / Speaker. Dedicated to giving the gift of wings to anyone following their dreams. Supporting Aviation Safety through training, writing, and inspiration. Fighting for Aviation Safety and Airline Employee Advocacy. Safety Culture and SMS change agent.

Tuesday, January 14, 2014

Pilots Landing at the Wrong Airport...

They are doing it. The question is why? 


Two planes in the previous three months missed their intended destination and landed at the wrong airport. In October 2013 UPS hit a hill on their approach. July 2013 Asiana pilots crashed short of their runway with the autothrust off. All these events have a common factor:


Lack of Situational Awareness. 

Are pilots relying too heavily on automation for navigation? Those who get lulled into landing at the wrong airport, forgetting the many clues that might indicate they have made an error, may have been relying too heavily on their automatic aircraft for navigation. When it's gone, they get lost.

We have experienced four events in six months. All for the same reason—pilots not being able to manage the mission without assistance of the electronic magic.

If pilots were using their navigation systems and instruments, they should be able to make it to the correct airport. Therefore we can deduce that they were not. There are always traps and fatigue plays a huge role. But without basic navigation skills, we will see more of these miscalculated landings.


Lack of situational awareness was a key factor to the reason UPS hit the ground while on arrival in a perfectly good plane. This was also the reason Asiana pilots did not know their autothrust was disengaged and were low on arrival, ultimately crashing their B777.


Perhaps in training we need to focus not only on manipulation of flight controls with upset recovery at altitude and hand flying without the autothrust or glideslope, but we should revisit training those lost navigation skills and situational awareness.
The automated world might be making lazy navigators.


Challenges with automation is a central theme to Flight For Safety
 
In memory of passengers of AF447
 
GREAT NEWS!



Flight For Safety 
has been submitted!

Flight For Safety is an aviation thriller where fiction mirrors truth and each flight is a game of Russian roulette. Aircraft are crashing after computer failures, incidents are occurring worldwide, coming close to hull losses with mismanagement of aircraft navigation systems, and airline training programs are being cancelled. Aerodynamic skills are failing—new generation pilots have never learned them. But when Darby Bradshaw learns what is happening at her airline, she steps into a far-reaching conspiracy where she becomes the target.

BOOK IN HAND:

I will have my proof in "five" business days. Probably Monday the 20th. Once I approve, timing is in the hands of the printers and Amazon. Ebook will be complete Monday January 20th, too. I think everything will upload more quickly since this is my second book. I will keep you posted.

Wait until you see who endorsed Flight For Safety! This is exciting news. And the photo...my cover creator selected the winner. (It's not as large in the book and looks good.) Thank you all for your comments and suggestions.




Below is the photo I cropped to create the first picture. Size was an issue. Speaking of which...



Back to the issue...

Why do you think pilots are
landing at the wrong airports? 

 Darby Bradshaw knows!

Enjoy the Journey!
XO Karlene

48 comments:

  1. This is a tough question. These are professional pilots that have been flying for years and are well trained. I believe its a combination of fatigue and a lack of situational awareness. In the airplanes that have done it recently, they had the capability to display an extended centerline on their map displays. While places I've worked haven't made it company policy to do so, it is very common practice and I do it because it adds to situational awareness. I think it's important to use all of the tools available to you to combat threats like this. Things happen, the important thing is that nobody was hurt in either of these incidents, but there is a lot to be learned from them.

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    1. Yes, things happen. I just wonder if our using the automatic navigation as the end all ... that we forget how to confirm when we are cleared to land via the visual. The mind does strange things when it sees what it wants to see... and interprets something else. I've got a great example for this, and how easy it can happen. Will post soon. Thanks for your comment! And yes...fatigue is a huge issue.

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    2. I guess your point on "the mind does strange things" is quite interesting. I work recently on several projects with psychologists and neuroscientists on decision making projects an makes me wonder whether the manufacturers adequately human cognitive processes (especially under stress and anxiety) in developing new instruments (and automation systems)? Maybe one reason that they fail to trigger the pilot toward right/wrong decisions.

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    3. Mona, this is a great point! I wonder if we can get the manufacturers to start thinking something about this. One of my passions is human factors and how the mind works. Maybe we can work on this and provide suggestions. :)
      Thank you for your comment!

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    4. I have seen similar issues in other professionals, it isn't always solved by capacity building or experience. Cognitive reasoning in humans can be quite complex. Some more simplified research projects on decision making assume people make always "rational" decision but not always true. People also make irrational decisions especially under anxiety and stress and results in situations as you mentioned. We are currently recruiting a PhD students to work on issue of irrationality and decision making in medical context http://www.cognovo.eu/projects/irrationality-decision-making.php but the issue that you raise about pilots and decision (why an experienced pilot despite the equipments makes irrational decision that leads to accident can be another context to do such a project. I would guess there might be similarity and differences and can inform future decisions how to handle this...

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  2. I think you hit the issue right on the nose. Relying too much on technology has made people lazy and bad things happen when we get lazy. Congratulations on Flight For Safety getting so close!

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    1. Thank you so much Heather! As always a little snag this morning that is getting sorted out. But so close. Thank you for your support!!!

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  3. Karlene, as I think about this, another thing that really concerns me is the future of this. Every indication is that airplane manufacturers and airlines love automation and want us to use it. I think the culture is starting to change as we see incidents occurring with it, but as we continue to further automate airplanes will this issue get worse?

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    1. No kidding!! And look at today's post and tomorrow's post. It's all about the drones. Which will create more problems.

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  4. Karlene, you obviously know a lot more about this than I do...but why didn't these pilots notice that the runway designator was wrong? I know for sure that with the recent incident in Branson, while the runways at the two airports both run NW/SE, the one at KBBG is 14/32, and the one at KPLK is 12/30. Even if they couldn't really tell that the runway was way too short, surely they looked at the runway before landing on it and could have seen that the designator wasn't right.

    I also can't help but wonder if maybe airport designators should be painted above the runway designator, e.g "MDW / 04 / C" (not that anyone would mistake MDW for any of its neighbors).

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    1. Jeff, that's a great comment and thought. There are many clues that could have triggered they were at the wrong runway. But at night, at the point where they could have seen the designation if they were looking, they would have been looking down the runway for landing. They had no reason to doubt they were on the wrong one, until the end came too quickly.

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  5. Hi Karlene,

    In this case, I think I reliance on automation would have helped bring them right to the threshold in Branson. This looks like a good old fashioned case of looking out the window, accepting a visual and hand flying to the wrong piece of pavement.

    Back when I flew corporate jets, I always asked for a GPS approach when I was flying to unfamiliar airports after dark. One night, my first officer actually became annoyed with me since I was taking the extra time to fly the approach.

    "It's taking us further out of the way." He said as a beacon passed off our right wing.

    Then, we turned final... he was more annoyed because we weren't lined up with the runway.

    "That's because you're looking at the wrong airport." I finally told him. Lesson learned.

    Situational awareness and attention to detail is critical... Like noticing your arm is in a different position in the cropped and original photos above. ;)

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    1. Yes... if they would have "used" their automation that they have been so reliant upon. My point is... we are always using our automation for navigation that when it goes away... (intentionally because we kicked it off) we don't remember how to find the breadcrumbs to the right airport.

      Automation is a great thing. I'm just wondering if the reliance upon it is diminishing our skills.

      And i love those lessons learned. I learned a great one the other day, but need to get a photo to demonstrate. Then I'll write a post. Thank you so much for your comment!

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    2. We're on the same page. I understand what you're saying about dependence.

      But, sadly, I don't think it's a factor in this case. Pilots have been making this mistake long before the automation. I was just emphasizing a night landing to an unfamiliar airport is the perfect time to depend on it... to help avoid repeating past mistakes.

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    3. You're right...it is the perfect time. So I wonder why they weren't? That's the question. And those who never relied it.. yes, there will always be mistakes made. But there seems to be a correlation between all these incidents. You have to ask why with the technology on the plane they would do this? I don't have all answers...but we must figure out why so it won't happen again. And the only wait to do that is start throwing possible reasons into the mix. Thank you so much for your comments. Why do you think this happened?

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  6. One of the most basic and important things Robert has taught me, as I am sure the rest of his students, is that you have to know exactly where you are ALL of the time. Who would have thought that navigation, even its most BASIC concepts, could become a problem these days..?? But I whole heartedly agree with you that a lot of pilots lack training and have way too much automation dependency. (I need a verification on this - anyone?, however, I believe that it is mandated by the Korean Aviation Administration that automation is required for take offs and landings no matter what. Hence the Asiana T7 incident.)

    It's human nature to be addicted to things especially coffee and smoking. It's up to us to break these habits especially when these addictions interfere with the lives of the people who are paying pilots (directly or indirectly) to fly them safely to their destinations. Let's be thankful that this recent incident didn't cost any lives only inconvenienced a lot of people (to say the least.)

    Thank you for writing this post and I can not wait for FFS to be in my hands ready to devour. In the mean time, I might give FFC another review and do my write up on "Beach Music" Then it will be all FFS!

    Hope you are having a pleasant and productive day!!

    Jeremy

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    1. Thank you so much Jeremy! I am so excited to see a photo of you holding FFS. It's been a long time coming. And, I think you'll love it.

      This landing and using automation is an interesting situation. I have been spending days relearning math and feel brain dead. But it's enforcing that concept if you don't use it, you lose it.

      We want to use the automation, but it leaves the other side of the coin that when we don't, we get lost, or can't fly. None of this is coincidental.

      Definitely a challenge in the new world. And something I will have fun studying on how to fix while in school. If I can relearn math! lol

      Thanks for your comment!

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    2. Here's how to break dependence on technology: go rent a Cessna 152 (because it's the cheapest plane in the club) which only has 1 radio and 1 VOR, nothing else. Now that's old school! :-)

      Unfortunately this particular airplane doesn't have an ILS, GPS, or DME, so I wouldn't take it into IFR conditions. But it's good practice in VFR conditions with a sectional chart. And since we are now in a drought in California and haven't had any rain for months, we haven't had much IFR conditions lately.

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    3. Natasha, this is exactly what we all need to do!!! Keep those basics alive!!! Thank you so much for your comment and I have another idea too... coming soon. :)

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  7. I'm not exactly what to think of the issue, but the amount of incidents in commercial aviation recently has been frightening the public. I'm concerned that hefty regulations are coming our way if these problems can't be dealt with quickly.

    -Swayne

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    1. Swayne, you make an excellent point. Those regulations that come down when a problem exists and they don't know how to fix. This is not a regulation issue, but a training issue. I'm thinking!

      Thanks for your comment!

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  8. "Lack of Situational Awareness" has become the polite, PC term for not paying attention at critical times. Some of those accidents and others not cited happened with very senior, check pilots aboard. It is deeper and more serious - and I do not know the answers. However, I do see some research pending and an excellent topic for a dissertation beginning to develop. Do you? You write book; you publish book: I buy and read book. Almost two thirds of the way done and I cannot wait. Best wishes, -C.

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    1. I do see an excellent topic of research...and my mind is already going full speed in attempt to figure it out.

      Yes... I thought you would be excited. And tonight we had a little snag with a cover size, but getting sorted out. We may be delayed a day, but at this point there is nothing more I can do. :) Except study to make sure I get into school!

      Thank you so much for your comment and support!

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    2. Shortly after reading and responding I read a great new post by Chris Manno (JetHead's Blog) on this same subject. Chris wrote the non-PC details, much as my thinking, but he has the experience to validate his comments; I do not. I'm sure you've seen it. At the end of the week, all of the active crew bloggers share valuable thoughts and the common theme remains the same: Safety comes first. Thanks Karlene.
      Since you are this close to a real publication date, perhaps a week, maybe it is time to change the available title in the upper left "Order Here" box and begin accepting pre-publication orderes. I know you will when you can. I rarely buy 'signed' books, but you and a few other AV writers are the exception. I KNOW that it will be great; you know no other way. -C.
      P.S. Your action or that of others I don't know, but thank you for migrating to the numeric version of Captcha validation. It seems to serve the purpose and it is much easier on human eyes.

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    3. Hi Craig, All JetHead's comments are valid and make great points. And if we all did what we were supposed to, we would be safe. There comes that human factor issue and how easy it is to get sucked into doing something in error. I saw something very interesting and in light of this event...came up with a great idea! I have a fix and will be writing next week.

      The reason I haven't uploaded pre-orders are for two reasons. One... lack of time. I am so swamped. As soon as I get my GRE out of the way, giving myself two days to get caught up on life.

      But also, not sure the weight and shipping expense. I might just add shipping in this time... for international for sure. I've been selling books overseas for the occasional breakeven and loss. I'm going to get this figured out for sure! And will have those links up soon!

      As always... THANK YOU so very much!!!

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  9. Karlene,

    As a old school pilot who just learned new school technology, please take my comments with a grain of salt as I don't have enough experience to give a informed opinion.

    Yes fatigue makes lazy cowards of us all. Yes, we are all children of the magenta. And yes a lack of situational awareness is deadly. But for me, one of the biggest issues has been having too much information. With the glass, one can see the airspeed is three knots off or the altimeter is twenty feet low. The FMS shows a ground track of xxx and the VVI shows blah, blah, blah.

    I was taught the scan begins and ends with the ADI. But between that, the eyes are darting all over the place, gathering all the information while the mind is processing all the information. Crap, I am two knots slow, 100 feet high, descent rate is only 550 feet descent, the engines are at 82.3% N1 but it should be 83%, two degrees to the left and the cross track is R3, the pitch command bars want an additional degree left, one degree pitch down and there is a 7 knot tail wind. The FMAs are all green, LOC and GS still green, the AT is white but the THRST HOLD is green.

    With all this information, who has time to look out the stupid window? Who cares, looking out the window messes me up anyway.

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    1. Rob, you always make me smile. Here is your assignment... write how you feel right now. And in a year, let's see where you are.

      What's happening now is you have so much data coming in it's overwhelming. Soon... your brain will learn what you need and what you don't and you will automatically filter the don't need part out. That window will open and it will become second nature.

      And then someone will ask you how to do a holding pattern and you'll say... "where's the hold button?"

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    2. I hate to butt in here, but I think Capt. Akers got it just right and that he certainly knows how to drive his airplane safely. Essential information is, well Essential. Who among us has not suffered from Information Overload that requires the additional processing step of filtering the essential from the fluff. Thanks Captain! -C.

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    3. Oh, I know he's right. I remember the transition from steam to glass myself. It was a huge overload. After a while, it's not a big deal. I'm really curious when that point hits for him. I wish I would have kept track.

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    4. Karlene,

      Of course I will do exactly what you recommend. It will be a fun experiment to see how long until the light comes on.

      I appreciate the vote of confidence from Glen. The only remark I have is that I am now a former Captain. Due to inverse staffing at my company, I am back to wearing three bars, doing the walk around and pouring the coffee. But I am still blessed in all ways so all is well.

      Last night, I omitted one remark that is important to bring to the table. What was the pilot monitoring doing while the pilot flying was landing at the wrong airport?

      Maybe that should be the topic of conversation. Someone sitting next to the pilot flying allowed them to land at the wrong airport. That isn't cool.

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  10. Ok, I'll make a public confession. I got myself nearly lost one time flying to an airport that I've been to a few times during my flight training. The cause: outside the window is a mountain, the FMS gave me the impression that I'm further than I really am. What I failed to note is the "10" on the top center meant 10 miles to my destination. Which meant it's not on the other side of the mountain in front of me. I though of going to the airport on the other side of the said mountain; but, that's not where I was going that day. Good thing I had flight following and bothered to notify ATC that I'm climbing; his words were something along the lines of don't climb the airport should be right under your cowling. If I wasn't on flight following I would have been filing an ASRS report that day.

    As a software engineer, my theory on this matter is that the pilots believe that their automation knows as much as they do. Those computers need to be treated like primary students who just learned to do standard-rate turns. You wouldn't trust that student to have the wherewithal to aim some 50 feet in front of the numbers because a B737 is idling to the right of your runway waiting to take the parallel runway would you? So why trust that computer to not randomly give up controlling the aircraft because it freaked out for no apparent reason?

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    1. Keith, Thank you so much for sharing your experience. This falls into all of us have "almost" done something like this. We just had a wake up call from ATC, or realized last minute...etc.

      And I love the idea of treating the automation like a new student. When I was instructing my Guyanese students on the 757... first glass... I had to convince them that they were the pilots and there job was to make sure the automation was doing what they wanted to do. Not the other way around.

      Thank you so much for the great comment!

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  11. When I see things like that happening, I realize how fortunate I am for having flown as an ag-pilot and as a ferry pilot (mostly ferrying single engines, from USA to Brazil/Mercosur countries) in the early 90's. Nowadays I see some colleagues on the right seat of the bizjets I fly, who don't have a clue about the geography they are overflying and/or how far are they from T.o.D., without having it displayed somewhere on their MFD's. Definitely something has to change. Congratulations for your posting. Great discussion.

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    1. Thank you so much for your comments. This is the new world. While that extra data and information is great, we really need to have the foundation too. Thank you so much for joining the discussion.

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  12. Is the frequency actually increasing? Or has media coverage increased? Or has the frequency dramatically dropped with all of our technology that, when it does occur, it appears so prevalent in comparison? I am not convinced this is even an issue.

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    1. David, That is a great question! I think it could be an issue when the landings at the wrong airports involved accidents. There could have been a small plane in the pattern. They could have landed on a 2500 foot runway. Lots of "could ofs". Only for that reason is it a big deal.
      Someone sent me a list of wrong airport landings in the past. I might just post it next week. Thanks so much for your comment.

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    2. Am looking forward to your next book. Read the first and it was great.

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    3. Thank you so much! There was a David who left a comment on Amazon. But not sure if it was you. If not, would you mind leaving a comment? :)

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  13. Wow! Those guys surely must have had the name of the correct airport right on the magenta line and entered in the fmc, what where they thinking? Isnt the copilot supposed to check what the captain is doing, and vice-versa??
    Or maybe atc threw them for a loop and lost situational awarenes.
    I recently flew into SFO and man! The bay area is one of the most beautiful places ive ever seen. I can imagine the crew of Asiana mesmerized by the scenery and forgetting the A/T off.

    Even just a slight deviation from the flightplan can result disastrous. The Comair crash in KY. And UPS both resulted inderectly, from the active taxiway and runway respectively, being changed.
    Heck, some airliners have landed on taxiways, mistaken for runways.
    Thanks for hearing my contribution Karlene.
    NIGEL Z.

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    1. Nigel, they were certainly lucky. We don't always follow the magenta line into the airport. There is a point we transition to the outside. Why this happened, not sure. Apparently there was a jumpseater in the cockpit too.

      But you are so right about the landing on the taxi-ways... I know one very close to home...and I was on a flight where we were lined up for the wrong runway. That was a human factor nightmare.

      I really appreciate your contribution. When we all put our minds together, we will solve the problem. I have been so inspired by the comments, I think I've got a solution. :) To come soon.

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  14. I resume this to complacency. Here we go again.

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    1. I think you just said it all. Yep... here we go again!

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  15. Looking forward to reading Flight for Safety as soon as it hits the stores!

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    1. Thank you so much! Your comment was lost in moderation... and it's up! http://tinyurl.com/mjjkdon

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  16. This is a great admonition for all pilots, Karlene. Thank you!

    I learned to fly with "moving map technology" A.K.A. a sectional, pencil, and E6B before the existence of GPS. SA is a huge contributor for a successful conclusion to a flight.

    Years later, I now fly airplanes glass-equipped and yes... analog. 12" MFDs and 430/530 navigators have made getting around easier and I enjoy having 'em but, I force myself to remember and exercise the basics.

    I work at staying on the straight-n-narrow but, I'm a human capable of error and the dreaded "C" word, complacency. For safety's sake, we should be reminded.

    Thanks for the check! :)

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    1. Thank you so much for the comment. I think we all have a chance to fall into complacency mode. And... with that the door opens for that reality check. I think the concern are those students who never have the background that you do, to fall back on it in the future. A definite challenge for sure!

      We are all human. And with that comes mistakes. I think being proactive and thinking about what could happen, creates more of an awareness and diminishes the chances of it actually happening.

      Thank you so much for the comments.

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Thank you for your comment! If your comment doesn't appear immediately, it will after I land. Enjoy the journey!