Air Force blames wrong airport landing in Tampa on fatigue, human error
By Howard Altman | Tampa Tribune, Fla. | Published: January 23, 2013
TAMPA — The crew of a military cargo jet landed at the wrong airport in Tampa in July, in part, because of fatigue, complacency and a lack of flight discipline, an Air Force investigation has found.
It wasn't until the cargo jet was halfway down the runway at Peter O. Knight Airport, a small flight center on Davis Islands, that the crew realized it had missed the intended landing site, 4.6 miles to the southwest at MacDill Air Force Base, according to an 11-page "Hazardous Air Traffic Report."
The report, obtained by the Tribune under the federal Freedom of Information Act, does not address why the C-17A Globemaster III was flying from Italy to MacDill, nor does it identify who was calling the shots.
But in an e-mail to the Tribune on Tuesday, the head of U.S. Central Command at MacDill, Marine Gen. James Mattis, acknowledged he was on the plane.
Mattis, whose responsibilities include running the war in Afghanistan, also said he sought leniency for the crew.
"It was just human error," Mattis wrote. "I've made a lot of mistakes in my time, and some were real doozies (worse than landing at the wrong airstrip). The Marine Corps kept their sense of humor throughout my checkered career and allowed me to move onward and upward."
The report does not say whether disciplinary action was taken against the crew, part of the 305th Air Mobility Wing based at Joint Base McGuire-Dix-Lakehurst in New Jersey.
Officials at MacDill had no comment on the report.
The flight July 20 originally was bound for Kabul, Afghanistan, the report says, but the destination was changed to Andrews Air Force Base outside Washington, then changed to MacDill — an hour before takeoff — by the unidentified aircraft "user."
One potential source of confusion for pilots flying over South Tampa is the figure 22 painted in big white numbers on one of the runways at Peter O. Knight, a reference to the strip's compass direction.
MacDill also has a runway 22, so the two are in direct alignment with each other.
At least one previous military flight bound for MacDill landed at Peter O. Knight in the past decade, the report says, and at least two civilian flights bound for Peter O. Knight landed at MacDill during the past five years.
In addition, several confused pilots have pulled up when they realized they were approaching the wrong runway, the report says.
Despite the "frequency of errors and confusion at this pair of airfields," the report says, the MacDill tower "has no preventative measures in place" to address the confusion. Nor is the potential for confusion cited in materials provided MacDill pilots.
Still, the report says, the runways' alignment was not a factor in the Globemaster landing at the wrong airport.
The days before the flight to Tampa had been "stressful and busy" for the crew, according to the report. They "flew into complex airfields, dealt with multiple mission changes and flew long mission legs with several stops each day."
They arrived in Rome about two days before the flight to Tampa and spent the first day touring the historic city. That night, the pilot lost his cellphone in a taxi; then he lost sleep trying to find it and more sleep worrying about it.
The night before the flight, the crew had an "uneventful dinner" and went to bed to "in order to get rest for the mission the next day."
Still, several crewmembers said that although they had the opportunity to sleep eight hours before taking off, time zone changes prevented them from "getting a good night's rest."
In addition, the co-pilot felt some pressure to make the flight for fear that declining would make their command look bad, the report says. This perceived pressure, the report says, was not a factor in the landing mistake.
Both the pilot and co-pilot told investigators they were "feeling tired" but believed they could function properly as they landed at MacDill.
That's not what an evaluation found afterward.
The two were acting at reduced cognitive capacity, according to the report, with the pilot at 79 percent effectiveness and the co-pilot at 89 percent. The report says 70 percent effectiveness is the same level of impairment induced by a blood-alcohol content of 0.08 percent.
By comparison, that's the level of intoxication at which Florida considers a driver impaired.
The crew originally was supposed to fly from Rome to Kabul, then to Germany. But those plans were changed in what is called a "crew alert." The report does not indicate when that took place.
The plans were changed again about an hour before the flight. Instead of going to Andrews, per the initial crew alert, the crew was told to fly to MacDill. The flight was expected to take about 10½ hours.
The crew was relieved to be flying to the United States, "where they expected the approach and landing to be less dangerous than any of the other approaches" on the mission, the report says.
But the late changes, combined with "non-existent mission planning facilities" in Rome and a hotel printer that was not working forced the crew to use personal iPads to review mission materials.
In addition, because of the changes in destination, the crew was unable to review the physical layout of MacDill during a preflight briefing, something Air Force rules recommend be done as often as possible.
The review was conducted during the flight.
Still, the report says, the flight changes were not a factor in choosing the wrong airport.
The flight taxied and took off from Rome with no problems at 12:20 a.m. Tampa time.
Much of the report focuses on the actions of the pilot, co-pilot and an additional crew member who was certified as a Globemaster pilot.
Because of the length of the flight, a midair refueling was required, a challenging maneuver requiring intense concentration.
The co-pilot said he "did not feel well-enough rested" to perform the task, so he turned it over to the additional crew member. The crew member reported that the refueling "went smoothly" but he "felt shot" after onloading 95,000 pounds of fuel from the tanker.
The co-pilot received a landing briefing, which included a warning: "Use extreme caution PETER O KNIGHT arpt 4 NM NE OF MACDILL AFB."
At 12:06 p.m. Tampa time, the crew was informed it was 11.5 miles from final approach and cleared to descend to 1,600 feet and pick up the signal from MacDill.
A short time later, the pilot reported seeing an airfield, saying it was MacDill. The co-pilot and additional crew member corrected him, saying it was Peter O. Knight.
All three crew members turned out to be wrong.
The airport they had first sighted was Tampa Executive Airport, near Interstate 75 and north of Interstate 4. Believing that Tampa Executive was Peter O. Knight, the crew concluded the next airfield would be MacDill.
At 12:07 p.m., the crew contacted the MacDill tower, saying it was on the tower's signal and had landing gear down. The tower cleared the Globemaster to land.
The crew visually observed runway 22 at Peter O. Knight, mistaking it for runway 22 at MacDill. The co-pilot began to descend as the additional crew member performed a final safety check.
Several mistakes were made at this point, according to the report.
"Multiple visual clues" led the crew to believe it was approaching MacDill, and the plane's low altitude meant the crew could not discern the difference in runway lengths between the two fields.
At the same time, the co-pilot failed to heed several onboard displays that would have shown the plane's true position.
In addition, C-17 pilots routinely turn off a digital navigation page showing their course so they can display a screen showing whether the plane is properly prepared for landing.
The crew failed to visually identify the airfield correctly before the pilot turned off the navigation device. Afterward, the co-pilot failed to monitor the "mission line," a reference to observing the instruments on his side of the plane that would have confirmed whether the plane was landing where it was supposed to.
Four minutes later, the plane touched down at Peter O. Knight.
About halfway down the runway, the crew realized it was at the wrong airport and the co-pilot applied "maximum effort braking" on the smaller runway.
Once the plane came to a halt, the crew radioed MacDill tower that the Globemaster had landed at a different airfield.
Nearly 60 yards long, with a wingspan just as wide, and powered by four giant jet engines, the military gray plane drew a crowd of onlookers once it landed at the small airport near the tip of Davis Islands.
Eight hours later, it took off for the short final leg of its transoceanic flight.