Fedex B752 at Tulsa on Jun 8th 2022, landed on wrong runway

Last Update: August 3, 2023 / 19:25:37 GMT/Zulu time

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Incident Facts

Date of incident
Jun 8, 2022

Classification
Incident

Airline
Fedex

Flight number
FX-1170

Departure
Fort Worth Alliance, United States

Destination
Tulsa, United States

Aircraft Registration
N949FD

Aircraft Type
Boeing 757-200

ICAO Type Designator
B752

A Fedex Federal Express Boeing 757-200 freighter, registration N949FD performing flight FX-1170 from Fort Worth Alliance,TX to Tulsa,OK (USA) with 2 crew, was cleared for a visual approach to and landing on runway 18L, however, lined up with runway 18R and continued for a landing on runway 18R. After the aircraft vacated the runway at the end, the crew informed tower they had landed on the wrong runway.

On Jul 8th 2022 the NTSB released their preliminary report and summarized the sequence of events (editorial note: the NTSB erroneously wrote runway 28L/28R a few times, no runways 28 exist at Tulsa):

According to the flight crew, the incident flight was the final leg on the 3rd night of a 5-night trip and had a scheduled departure time of 0330 CDT. The captain was pilot flying, and the first officer (FO) was pilot monitoring.

ADS-B data indicated that the incident airplane took off from AFW about 0332 CDT. The flight crew reported that the departure, takeoff and climb phases of the flight were normal. They climbed to FL310, briefed their expected approach to runway 18L and began their descent.

They obtained and reviewed automatic terminal information service (ATIS) information and set frequencies for the ILS runway 28L. The weather was instrument meteorological conditions (IMC) during the descent until they passed 10,000 ft. At the point they broke out of the clouds, they were on a 360-degree downwind vector and the FO had the airport beacon in sight. The controller then cleared the flight for the visual approach and landing on runway 18L. The FO correctly read back visual approach and landing clearance to runway 18L. The captain asked the FO to set an extended centerline on the flight management system (FMS). About 0413 CDT, the airplane landed on runway 28R, exited at taxiway L5 at the end of the runway, and notified the tower controller they had landed on the wrong runway.

All frequencies were combined in the TUL air traffic control tower at the time of the event. The controller reported clearing the aircraft for approach and landing in one call and did not become aware of the wrong runway landing until the crew reported it. The facility reported that traffic volume was light at the time of the incident. The control tower was located in between runway 18L and 18R which were approximately a mile apart.

On Feb 14th 2023 the NTSB opened their investigation docket.

On Aug 3rd 2023 the NTSB released their final report concluding the probable causes of the incident were:

The flight crew’s misidentification of the intended landing runway. Contributing to the incident were (1) the flight crew’s failure to perceive and correctly interpret visual and auditory indicators – including electronic guidance – that they were approaching the incorrect runway which was likely the result of a degradation in cognitive function brought on by working within their window of circadian low, increased workload, and fatigue, and (2) the air traffic controller’s failure to monitor the arriving flight after issuing a landing clearance.

The NTSB analysed:

As the Federal Express (FedEx) flight 1170 flight crew approached the Tulsa International Airport (TUL), they mis-identified runway 18R as runway 18L and continued their approach and landing on runway 18R. After touchdown and hearing the “3000 feet remaining” call from the automated runway awareness and advisory system (RAAS), the captain recognized they had landed on the incorrect runway, applied heavy braking and was able to exit the runway at the final taxiway.

Available Cues

As the flight was in visual meteorological conditions, there were available visual cues external to the airplane, to distinguish the runways from one another in their lighting, configurations, and the surrounding environments. These differences were all salient visual cues that should have enabled the flight crew to distinguish one runway from the other in visual meteorological conditions.

The flight deck provided both pilots with a primary flight display (PFD) and navigation display (ND), while only the captain had a heads up display (HUD) to aid in monitoring the progress of the flight. The first officer (FO) told investigators that the electronic glideslope on the PFDs and HUD which was set for 18L looked “normal” however he was concerned about their alignment with the visual glideslope (18R precision approach path indicator (PAPI)). The FO failed to realize that ultimately the airplane was showing “low” on the visual glideslope because of the parallel runways’ displaced thresholds.

Cognitive Phenomena

The flightdeck visual cues that were perceived by the flight crew were 1) the horizontal situation indicator (HSI) deviation bar being off to the left on the FO’s PFD; and 2) the captain’s HUD localizer being off to the left. It was FedEx policy to back up all approaches with the instrument landing system (ILS), however the flight crew appeared to discount the information their instruments were providing in favor of the view they had of the runway and understanding of their circumstances. The flight crew focused on their flightpath and decent rate for the runway they had already visually acquired, and the multiple visual cues that they were misaligned were not recognized.

Once they took manual control of the airplane and adjusted to the desired precision approach path, the flight crew proceeded with the landing without engaging in further confirming acts.

This behavior is consistent with the psychological phenomenon of plan continuation bias which is the unwillingness to deviate from a previously determined course of action, despite the arrival of circumstances precipitating the need for a change. Once a plan is committed to, it becomes increasingly difficult for stimuli or changing conditions to be recognized.

Plan continuation bias is exacerbated by fatigue. In this incident, the flight crew was working within the window of circadian low and under circadian disruption. While the captain, who was the pilot flying, stated that he was not fatigued during the incident flight, he had been awake for more than 15 hours prior to the incident occurring and was likely experiencing fatigue due to chronic and acute sleep debt due to limited sleep in the days preceding the incident.

The flight crews lack of recognition of their error was likely affected by fatigue, plan continuation bias, and their inability to perceive and efficiently integrate available information.

Operator Fatigue Risk Management

When creating flight schedules FedEx determines the potential risk for fatigue for each pairing by using the Karolinska Sleepiness Scale (KSS) on a 1-9 scaled rating. In evaluating the pairings FedEx also collaborates with the Airline Pilots Association (ALPA) who uses SAFTEFAST which incorporates both the KSS and the Psychomotor Vigilance Test (PVT) on a scale of 1-100% (100% being peak wakefulness). The resulting scores are then compared.

A KSS score of 7 or higher, or a SAFTE-FAST score of 70% or lower, typically indicated the pairing was of high risk and needed further review. The FedEx assessment of the incident flight pairing was a KSS of 6.39 and the score was established using the assumption that the flight crew would nap during their hub-turns. The ALPA assessment of the pairing was a 76.0% SAFTE-FAST score which also incorporates the nap assumption.

FedEx did not publish KSS pairing scores, nor did they provide the scores (including the 30-minute nap assumption) to the flight crew. FedEx crews were expected to nap on a hub turn but were not told that a nap is expected or why that expectation exists. When asked why they adopted this policy, FedEx fatigue risk management program (FRMP) manager expressed concern over overburdening flight crews with additional information.

The manager stated that FedEx feels that notifying flight crews of the pairing fatigue score, and what assumptions are factored into the obtaining of that score, is unnecessary and that FedEx’s current training program effectively addresses flight crew expectations and what fatigue mitigations are available. In this incident, the captain chose to abandon his nap attempt during the hub turn when he was unable to fall asleep. After about 30 minutes he decided to prepare for the next phase of his schedule. In failing to obtain a nap during the hub-turn, the captain unwittingly increased his fatigue score from within limits to high risk (7.4) on the KSS.

Air Traffic Control (ATC)

ATC awareness of the traffic approaching the airport provides an additional barrier to trap and correct errors, such as aircraft misalignment during landing. The tower controller’s failure to monitor the flight throughout the duration of its progress resulted in a missed opportunity to notify the crew and correct the misalignment before landing. Expectation bias occurs when a person hears or sees something or behaves in a way based on what he or she expects rather than what is actually occurring. Past experience or repetition can exacerbate this issue.

In this incident, the controller had a reasonable expectation that the flight — a late night/early morning operation recurrent to TUL — would approach and land on the assigned runway.

Consequently, she directed her attention away from the flight to other tasks. Because she was not monitoring the flight, she was unable to confirm its alignment on the correct runway nor was she able to provide corrective action to prevent the wrong surface event.
Aircraft Registration Data
Registration mark
N949FD
Country of Registration
United States
Date of Registration
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Manufacturer
BOEING
Aircraft Model / Type
757-236
Number of Seats
Mll Subscribe to unlock
ICAO Aircraft Type
B752
Year of Manufacture
Kgpq Subscribe to unlock
Serial Number
piqj Subscribe to unlock
Aircraft Address / Mode S Code (HEX)
Gfnlff Subscribe to unlock
Engine Count
K Subscribe to unlock
Engine Manufacturer
HkgiAhjeml Subscribe to unlock
Engine Model
Fml kfmgqeh Subscribe to unlock
Engine Type
Ahfegbgqj Subscribe to unlock
Pounds of Thrust
Icfl Subscribe to unlock
Main Owner
Q ifqhbmpgnlq kbmeppmgieqlfjmhmegiebngpnfeijgAgdil neclA pfefkefppbhpgl kbi jmkdidkhccpqnAjmAjhAhpimkfipfkkheA Subscribe to unlock
Incident Facts

Date of incident
Jun 8, 2022

Classification
Incident

Airline
Fedex

Flight number
FX-1170

Departure
Fort Worth Alliance, United States

Destination
Tulsa, United States

Aircraft Registration
N949FD

Aircraft Type
Boeing 757-200

ICAO Type Designator
B752

This article is published under license from Avherald.com. © of text by Avherald.com.
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