C-17 landing at wrong airport - crew fatigue?

[Heathrow Harry]

The Air Force has concluded its investigation into an incident last July when a C-17 Globemaster III landed atteh wrong airport.

And the reasons for the mistake, according to a report that resulted from the Air Force investigation and published by the Tampa Bay Tribune, went beyond simple human error.

Rather than touching down at its intended destination — the MacDill Air Force Base (KMCF) in Tampa, Florida — the large cargo airplane landed at the Peter O Knight (KTPF) general aviation airport. KTPF is located about five miles northeast of KMCF on a similar albeit significantly smaller peninsula. The runway heading would have indicated to the pilots that they were approaching the right airport as both airports have the same Runway 4-22. However, it is surprising that the pilots of the heavy jet didn’t notice the difference in the runway lengths. KTPF’s runway is only about one third of the length of MacDill’s.

The report showed no record of who was in charge of the airplane, nor does it indicate whether any disciplinary action was taken against the crew, which was a part of the 305th Air Mobility Wing based in New Jersey. It does, however, state that in the days prior to the incident the crew “flew into complex airfields, dealt with multiple mission changes and flew long mission legs with several stops each day.”

The mission for the botched flight, which originated in Rome, had been changed several times before the final assignment of MacDill came about one hour before the Globemaster departed on July 20.

Several factors, including previous time zone changes, contributed to the pilot and copilot not operating at full mental capacity. The report stated that the pilot was acting at a 79 percent cognitive effectiveness and the copilot 89 percent. In comparison, a 0.08 percent blood alcohol level reduces the cognitive capacity to 70 percent.

A third crewmember, also a Globemaster pilot, assisted during the mid-air refueling -- a requirement for the flight that lasted nearly 12 hours. It appears that the three crewmembers were the only people onboard the C-17 capable of flying the airplane.

Fortunately the long flight ended in a safe landing at the 3,500-foot runway at KTPF, where the copilot was forced to apply “maximum effort braking” to get the airplane stopped in time. The final, short leg of the transoceanic flight was completed later the same day.

[Newforest2]

Previous thread. :)

http://www.pprune.org/military-aircrew/491076-c17-lands-wrong-3600-foot-runway.html

[AtomKraft]

These guys must have landed at McDill countless times- and been very aware of the presence of the 'other' airport.

Or not?

[S76Heavy]

When you're tired you tend to see what you expect to see, I suppose.

[avionimc]

And, runways are only a couple of miles apart, almost aligned, same final.

[SMT Member]

And, runways are only a couple of miles apart, almost aligned, same final.

And, KTPF is to the NE of McDill, which one suspects would make it the first runway to make visual contact with when arriving from Rome.

[Speed of Sound]

Same final yes, but when you have five miles left to run, you don't expect to see the runway half a mile below you. :-(

SoS

[Pontius Navigator]

Of course it has never happened before :)

Like Milltown is parallel with Lossie but 3.5 miles SE.

Or even Cottesmore and Wittering which are 10 miles apart.

These of course are both displaced horizontally but I am sure there are many other instances of aircraft landing short, possibly Easy Kirkby and Coningsby I seem to recollect (when the former was an emergency landing airfield at 6500ft).

[Tankertrashnav]

Air India Boeing 707 landing at Changi instead of Paya Lebar.

Javelin landing at Seletar instead of Tengah (both in 1967).

Four approximately North - South runways on small island like Singapore and this was inevitable.

[Willard Whyte]

At Lyneham we were always advised that an instrument approach tended to reduce the misidentification of airfields, particularly after longer crew duty days.

Knew someone who didn't get his B cat as a result of choosing a visual approach.

[Tiger_mate]

1979 and a USAF Bitburg based F15 Eagle (single seat) that had a nav computer failure landed at Wyton instead of Alconbury and even changed RT freq to Alconbury tower on roll out. The mother of all tails along these lines has to be the BA B747 that nearly landed on the A road alongside Heathrow. Nutts Corner got a few aircraft aiming for Aldergrove.

[Pontius Navigator]

At Lyneham

Ah Lyneham. In days of yore baby navs actually flew some sorties without screens (IIRC). Baby nav called forward to identify airfield pundit for the airfield to which he had navigated.

Identified .-.. .- as .... ...-

When asked if he was sure he was positive that it was Hullavington. Pilot duly landed, came to a stop, disembarked nav, and took off for base. He instructed ATC that baby nav be allowed to make his own, unassisted, return to base.

[WASALOADIE]

Mid 80's, Dan Air HS 748 landed at Langford Lodge In Northern Ireland instead of Aldergrove Airport.

Did Air Traffic Control not have an imput into the C17 incident? did they not query that they could not see the aircraft on finals?

[West Coast]

Fatigue perhaps, but other another contender would be complacency.

[VinRouge]

the two go hand in hand.

[con-pilot]

For those of us that have operated in and out of McDill, such a mistake as to confuse any runway in that area on a clear day, to McDill's, is totally mind boggling.

The runway at McDill is huge, I don't mean just long, but extremely wide as well.

I'm not saying the report is wrong or covering up something, but just WOW, how the hell could the crew make such a mistake, no matter how tired they are?

But, anything is possible I guess. :\

[Bellerophon]

...When you're tired you tend to see what you expect to see, I suppose...

... KTPF is to the NE of McDill, which one suspects would make it the first runway to make visual contact with when arriving from Rome...

...runways are only a couple of miles apart, almost aligned, same final....

There are reports in the Tampa press that the crew were aware of the proximity of Peter O Knight (KTPF) to MacDill (KMCF), and were trying to identify it in order to avoid the obvious trap.

However, there is yet another airfield, Tampa Executive (KVDF) some 8 miles to the NE of KTPF, which also has a short (4,200') runway aligned 05/23.

That makes it three airfields within 13 miles, all roughly in a straight line aligned NE/SW, all with runways aligned NE/SW, the first two of which (when approaching from the NE as this crew were) have short runways.

The reports go on to state - it is not clear on what basis or where they obtained their information - that the first airfield the crew saw was Tampa Executive which unfortunately they mis-identified as Peter O Knight, and therefore "knew" that the next airfield on track "must be" MacDill.

Whether this was the case or not I don't know, but looking at a map it does seem plausible and might offer a partial explanation as to how this incident came about.

It would be easy to laugh at a crew landing a C-17 on a 3,500' runway instead of the 11,421' runway they were expecting, but I suspect many of us, over the years, under the sort of pressure which this crew was under, may have come a bit closer to something similar than we would care to admit - even if it wasn't continued to a landing - and might have just a little sympathy for them. There but for the grace of God and all that!

Best Regards

Bellerophon

[VinRouge]

a skipper and I got quite low once in 5k vis on the way into Basrah, we had lined up on street lights "that must have been" the runway.

It wasnt until I picked up the Head down display showing us 3 miles offset did we realise there was something up...

Always flown FD coupled from then on to the final fix to prevent re-occurence, especially in doggers vis and on goggs. The fact we had flown 125 hours in the previous 30 days may have had a contributory factor...

[exeng]

The mother of all tails along these lines has to be the BA B747 that nearly landed on the A road alongside Heathrow

This aircraft (a 747-100 series) did not mistake the A4 for RWY 27R. They neither saw RW 27R or the A4.

They were attempting an autoland due to poor vis. The 747-100 series particularly had poor automatics (compared to more modern equipment these days) and the aircraft had to be 'nurtured' into a stable approach by positioning for a long final. They did not give the aircraft this opportunity and it never became stabilised on the localiser.

When it was apparent the aircraft was not stable a late go-around was executed, and while I would make no personal judgement of the crew, it would seem the go-around was poorly executed in that much less than full go-around EPR (1.41) was attained and insufficient nose up pitch was applied.

Worthy of note was the fact that the F/O was new to the fleet and had yet to carry out his 'all wx ops' training. Permission was granted by BA management to carry out an autoland despite the F/O's lack of training.

Also noteworthy was the fact that both the F/O and F/E were suffering from bad stomach upsets which they had apparently picked up in the slip at MRU. The F/O had sought medical advice and was given some medication to help. The F/E apparently did not seek medical advice but had used some of the medication given to the F/O.

The F/E never flew again and the Captain was demoted. He was also prosecuted by the CAA for reasons I have no time for here and sadly committed suicide some time later.

BA management stopped giving such permissions for autolands when crew member were unqualified. BA then undertook a major overhaul of the operational procedures to be used when operating low vis ops.


Regards
Exeng

[safetypee]

“It would be easy to laugh at a crew landing a C-17 on a 3,500' runway instead of the 11,421' runway they were expecting.”

Perhaps an example of ‘target fixation’ in using the HUD to assess the flight path intersecting the landing zone and not ‘seeing’ the actual runway length or surrounding cues?

[scarecrow450]

Vampire's landed at Sleap instead of Shawbury a few times, few years ago
a student pilot in his Cessna landed at Shawbury instead of Sleap

[Yellow Sun]

There are two types of pilot, those who have mis-identified an airfield and those who have yet to do so. I don't think I know of any pilot with significant experience who has not confused the identity of an airfield to some degree.

If you are fortunate the confusion is not critical, the error is quickly realised and corrected and you learn a valuable lesson. If you are unlucky the answer to the question "Do you think anyone noticed?" is a resounding "Yes!".

YS

Been there seen it, done it and watched others do it.

[BEagle]

...a student pilot in his Cessna landed at Shawbury instead of Sleap

Whereas in 1974, a Gnat QFI took control from his student (who was flying an actual weather diversion to Shawbury) - only to land at Sleap...:\

I don't think I know of any pilot with significant experience who has not confused the identity of an airfield to some degree.


Indeed so. Sorry, Withybush, it was me in 1976......:uhoh: But thanks for being good enough not to complain..:ok: Hope you liked the blue note!

[Two's in]

The reports go on to state - it is not clear on what basis or where they obtained their information - that the first airfield the crew saw was Tampa Executive which unfortunately they mis-identified as Peter O Knight, and therefore "knew" that the next airfield on track "must be" MacDill.

The trouble with that hypothesis is if you are over Tampa Exec, but think you are over Peter O Knight, then expect to see McDill on the nose you are heading exactly 180 degrees out from what you think you are. Peter O Knight is in the west side of Tampa Bay (a pretty substantial water feature), McDill is on the east side of Tampa Bay at the end of a prominent peninsular, Tampa Exec is landlocked in the junction of 2 major highways. Whatever anyone was doing in that cockpit, it didn't involve any use of a map or a compass.

[Danny42C]

S76Heavy (#4) and Yellow Sun (#22) have the right of it. It happens, it's happened before, it'll happen again.

Done it myself, no excuse, got four extra weekend SDOs from the Station Commander (full story some day on "Earning Pilot's Brevet in WWII" - if I live that long !)

[Fox3WheresMyBanana]

Leeming and Dishforth was another favourite, both 16/34, 10 miles down the road (A1) from each other)

I was joining at Leeming when a CFS JP (with the Chief Instructor on board, no less) called downwind and then finals

ATC "Don't have you visual, check you're not at Dishforth"

pause

(no callsign) "HOW embarrassing!"

[MightyGem]

It does, however, state that in the days prior to the incident the crew “flew into complex airfields, dealt with multiple mission changes and flew long mission legs with several stops each day.”

The mission for the botched flight, which originated in Rome, had been changed several times before the final assignment of MacDill came about one hour before the Globemaster departed on July 20.

Several factors, including previous time zone changes, contributed to the pilot and copilot not operating at full mental capacity. The report stated that the pilot was acting at a 79 percent cognitive effectiveness and the copilot 89 percent. In comparison, a 0.08 percent blood alcohol level reduces the cognitive capacity to 70 percent.
From a CRM Human Factors view, the above pretty much nails it I think, especially with the 12 hour flight home. Fatigue is insidious. It just creeps up on you without you noticing.

The report showed no record of who was in charge of the airplane, nor does it indicate whether any disciplinary action was taken against the crew,
Embarrassment at poor supervision perhaps.

[rlsbutler]

@tankertrashnav #9

You mention a Javelin landing at Seletar instead of Tengah in 1967.

As a Tengah habitue 1962-64, I wonder if the story is more complicated than for the other misident cases. I remember Seletar as being relatively small and old-fashioned. Current Seletar sites put the runway on 03/21, which is significantly different to Tengah's 18/36.

Is there a really interesting story to be told ?

best wishes

R

[Bellerophon]

Two's in

...if you are over Tampa Exec, but think you are over Peter O Knight, then expect to see McDill on the nose you are heading exactly 180 degrees out from what you think you are...

If you are over Tampa Executive airport, heading roughly South West (having approached from the North East) but think you are over Peter O Knight airport, then the airport that is now visible some 8 miles ahead and roughly on track - which is in fact Peter O Knight airport - could easily be mis-identified as MacDill AFB.


...Peter O Knight is in the west side of Tampa Bay...McDill is on the east side of Tampa Bay...

No, it isn't, have a look here (http://vfrmap.com/?type=vfrc&lat=27.915&lon=-82.449&zoom=9)

Peter O Knight airport is about 4 miles to the North East of MacDill AFB.

Tampa Executive airport is about 8 miles to the North East of Peter O Knight airport, and around 12 miles to the North East of MacDill AFB.

Is it possible that you also may just have mis-identified an airport?

Best Regards

Bellerophon

[ian16th]

A Lindholme station flight Anson was landed at Finningly circa 1955. The really embarrassed driver was the Lindholme Station Master! :uhoh:

[TyroPicard]

BOAC Comet at Juhu instead of Bombay (sic).

Woodford instead of Manchester ... similar runway direction .. USAF F111 does sunny Sunday airshow at EGCC .... Air France Caravelle seen going around and jinking right for Manch...

The list is endless...

[BOAC]

I am not in possession of all the factors in this 'fatigue'/tired incident, nor does it really matter which field is where or who has been where in the past. The very basic lesson this crew appear to have forgotten is when you feel completely knackered, either don't try a visual, let George take the strain, or if you do, back up the aids for the runway of choice. There really was no excuse I can see.

[ORAC]

A lot more common than you might think - The Legacy of Douglas Corrigan: "Wrong Way" Landings By Commercial Airliners (http://www.thirdamendment.com/wrongway.html)

[MightyGem]

when you feel completely knackered,
The trouble is, that when you feel completely knackered, you don't always think logically. Partly why a Colgan Air crew pulled back on the stick instead of pushing forward when the stall warning sounded, and subsequently crashed the aircraft.

[si.]

Leeming and Dishforth was another favourite, both 16/34, 10 miles down the
road (A1) from each other)





I was joining at Leeming when a CFS JP (with the Chief Instructor on board,
no less) called downwind and then finals





ATC "Don't have you visual, check you're not at Dishforth"





pause





(no callsign) "HOW embarrassing!"


Column back and power on for a short while, and you might just be able to blag it...:O

[BOAC]

when you feel completely knackered, you don't always think logically. - come on! You don't suddenly get 'completely knackered' - they were 12 hrs in transit. Let's try and make it a 'logical' step that when you know you are tired (and you will) you don't try fancy visuals into fields without backing up the aids - when you can - and they could.:ugh:

[West Coast]

That is a given, and I'm willing to wager electronic backup is part of their sop. The underlying question is why they did what they did.

[teeteringhead]

To add to the list, ISTR a VC-10 in 70/71 getting Sharjah and Dubai confused. Parallel runways a few miles apart and (in them days) not much else apart from the runways.

Can't remember whether it was BOAC, Gulf Air or CrabAir though ......

[edited to add:]

From the "Wrongway" link:

April 22, 1978 - A Maverick Air aircraft, bound for Tel Aviv, Israel (TLV), mistakenly lands at Beirut, Lebanon (BEY). See "Cargo Pilot Finds Wrong Airport," Washington Post, April 24, 1978.

... probably very lucky this mistake wasn't the other way round ........

As they say, I'm sure IDF would have "suitably counselled him on his error of judgement!" ;)

[Rocket2]

International flight checkers meet at Benson in the late 80's / early 90's cue foreign air force twin jet landing at Chalgrove, then does a rapid turn round to fly a couple of miles down the road to the correct place.

[Wensleydale]

However, it is surprising that the pilots of the heavy jet didn’t notice the
difference in the runway lengths. KTPF’s runway is only about one third of the
length of MacDill’s.



One would have thought that the Navigator would have said something....oh, just a minute.....

[BEagle]

One would have thought that the Navigator would have said something

"Would that be regular fries, sir?"

[Uncle Ginsters]

One would have thought that the Navigator would have said something

The 'navigator' certainly would have done - assuming they didn't programme the aircraft's flight plan to go to KTPF, then they would have had a whole raft of information displayed on both the MFDs and the Msn Computers telling them that there were still a few more miles to go.

The point about fatigue it is indeed insidious and, as some have said, these things have happened many times despite the raft of information available both in and out of the flight deck.

I think we're lucky not to have more - spare a thought for RAF crews operating with the same crew numbers as the KTPF incident on AeroMed flights (or at least Crew Duty Periods) of 24hrs or more on a fairly regular basis. :confused:

[Truck2005]

As a totally back seater in this thread, (ie an engineer), I enjoyed a landing in Cagliari instead of Deci:ugh::ugh:

[Q-SKI]

Mmm remember a Navy Sea King many years ago landing at Lasham at night instead of Odiham! The chat between them and the Air Traffic at Odiham was interesting to say the least!:ooh:

[Pontius Navigator]

.. USAF F111 does sunny Sunday airshow at EGCC ....

Where did that B52 do its display? Is wasn't at Fairford was it :)

[Wander00]

And the Cranwell Commandant who confused Cranwell and Barkston Heath in th early 60s

[rlsbutler]

And the Cranwell Commandant who confused Cranwell and Barkston Heath in th early 60s

Having been a Flight Cadet of the period and not having heard it before, I would need some solid witness statements to believe that one.

[glojo]

Bit of light relief,
I was once asked by the driver of a HUGE RAF low loader type lorry where the 'local' RAF base was.

At the time I was in Honiton, East Devon and this gentleman had driven down from Norfolk looking for RAF Honington!

I thought it hilarious but sadly the driver did not see the funny side of his error, I wonder what happened to him?