reducing "Crew-caused"
approach and landing
accidents 

Pilot-in-charge Monitored Approach

2007 KAL HUD taxyway landing Akita Japan

Brief account : 

The crew of the HUD-equipped B737-900 landed on the parallel taxyway after misidentitying it as the runway in a crosswind.   

Crew-related factors : 

In this event the Captain was using the autopilot to make a VOR approach. It was the Captain's first landing on this runway.  The weather included a crosswind from the right and intermittent rain.  Initially the F/O and then Captain confirmed the runway in sight from about 8 miles out. 

The Captain disconnected the autopilot at about 800ft, as the aircraft approached the MDA. The Captain continued to use the HUD overlaying the flight path vector on the what he thought was the runway. However in fact the VOR approach centreline was offset from the runway centreline by an amount similar to the drift angle, intersecting the runway centreline at about this point.  The aircraft appeared to be visually correctly aligned but with the taxyway which was 150m right of the runway. 

The pilots had discussed at several points whether they were in fact aligned with the correct surface as other elements (position of PAPI etc) were not as expected.  However the HUD guidance persuaded the Captain that all was well. 

The report noted that "it is considered possible that the captain had been preoccupied by the HUD display and did not make sufficient outside watching."   It also noted that " it is considered that the captain paid much of his attention to the HUD display, and did therefore not pay enough attention to the outside view. After the captain said, “I’ll make a landing there”, and changed from auto-pilot to manual operation, the first officer responded to captain’s remarks, such as “PAPI located far” or “a new runway”, however, it is considered that as the first officer started to pay attention to duty monitoring within the cockpit and hardly saw the outside, it is considered that he could not point out the mistake of the captain." 

This event illsutrates that even with advanced technology such as a HUD cannot prevent all visual misjudgements. But in this event the potential benefit from a change of procedure to PicMA is also relatively reduced. The fundamental problem arose at the point where the Captain would have taken control anyway, and the F/O was giving considerable attention to the instruments below DH. However,

1) in a more interactive approach briefing the pilots might have detected that the VOR centreline was not actually aligned with the runway;

2) the Captain would have had more opportunity to clarify in his own mind exactly what he was looking at;

3) in the same way he would have been able to speak directly to ATC rather than relaying requests via the F/O, for example to ask for example for the lighting to be turned up, which would have helped confirm what he was looking at.

Type: 
B737-900
Where: 
Akita Japan
Expected weather: 
Instrument
Pilot in charge: 
Capt
Early transition: 
No
Go-around : 
No
Damage: 
Minor or none
PicMA potential: 
Minor
Year: 
2007
Time: 
Day
Deterioration: 
No
Vert Guidance: 
None
Both Head Up: 
Yes
LoC: 
No
Operator: 
Korean
Fully prepared: 
Yes
Actual Weather: 
Wind
Autopilot : 
Y
CCAG: 
Normal