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Report cites fatigue in C-17 airstrip mix-up

Feb. 17, 2013 - 10:32AM   |   Last Updated: Feb. 17, 2013 - 10:32AM  |  
Video screenshot of a C-17 Globemaster as it sits on the runway at Peter O. Knight airport in Tampa, Fla., last July after its crew landed there by mistake instead of the nearby MacDill Air Force Base. An Air Force investigation into the incident, released Jan. 23, 2013, through Freedom of Information Act requests, blamed pilot fatigue as one of the contributing factors.
Video screenshot of a C-17 Globemaster as it sits on the runway at Peter O. Knight airport in Tampa, Fla., last July after its crew landed there by mistake instead of the nearby MacDill Air Force Base. An Air Force investigation into the incident, released Jan. 23, 2013, through Freedom of Information Act requests, blamed pilot fatigue as one of the contributing factors. (WTSP-TV Tampa)
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The video of a hulking C-17 landing at a tiny civilian airport last summer went viral. How could a pilot mistake the Tampa airstrip for nearby MacDill Air Force Base? Turns out, the crew was tired, and they were using personal iPads to review changes to their mission plans because the airport they were departing from did not have a working printer, according to an Air Force report on the incident released Jan. 23.

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The video of a hulking C-17 landing at a tiny civilian airport last summer went viral. How could a pilot mistake the Tampa airstrip for nearby MacDill Air Force Base? Turns out, the crew was tired, and they were using personal iPads to review changes to their mission plans because the airport they were departing from did not have a working printer, according to an Air Force report on the incident released Jan. 23.

The report, obtained through a Freedom of Information Act request, makes no mention of the C-17's VIP passenger: Marine Corps Gen. James Mattis, commander of U.S. Central Command.

According to the Tampa Bay Times, Mattis was unfazed by the mistaken landing at Peter O. Knight Airport.

"The young pilot did a good job landing, albeit on the wrong strip," Mattis told the newspaper, which first obtained a copy of the Hazardous Air Traffic Report through a FOIA request.

The C-17 crew, assigned to 305th Air Mobility Wing at Joint Base McGuire-Dix-Lakehurst, N.J., departed July 20 from Rome Ciampino Airport. The crew was originally ordered to fly from Rome to Kabul International Airport, Afghanistan, and on to Ramstein Air Base, Germany. Shortly before flight, orders changed to Joint Base Andrews, Md., and finally to MacDill. The airport didn't have planning facilities in Rome, or even a working printer, so they had to use personal iPads to review mission materials before the 5:20 a.m. takeoff, according to the report.

Three hours after an uneventful takeoff, the C-17 was refueled over the Atlantic. The C-17's co-pilot told the crew he was too tired to conduct the aircraft refueling so another flight-qualified crew member took over. The refueling went smoothly, but the crew member said he felt "shot" after it, giving the controls back to the co-pilot.

At about 5:07 p.m., the C-17 began to descend for its approach to runway 22 after getting instructions from the tower at MacDill. However, the pilot lined the jet up to land at runway 22 at Peter O. Knight Airport, which does not operate a tower, and began a visual descent, touching down at 5:11 p.m. Halfway down the runway, the crew noticed they were running out of room on the landing strip. The pilot slammed on the brakes, and the C-17 came to a rest at the end of the 3,405-foot runway. Runway 22 at MacDill is 11,421 feet, according to AirNav.com.

The report found several causes for the incident, including a lack of sleep for the entire crew. The crew had two days off in Rome before the mission. They spent one day touring and having an "uneventful" dinner the night before the mission.

"Although they had the opportunity for at least 8 hours of sleep during their crew rest, several of the crewmembers reported sleeping for only a few hours," the report states.

The crew blamed the lack of rest on multiple factors, including the change of time zones. The pilot said he lost his cell phone in a Rome taxi, and his anxiety over the lost phone kept him from getting enough sleep. A Fatigue Avoidance Scheduling Tool program, a computer measurement of the effects of fatigue, found the pilot had 79 percent effectiveness, the co-pilot had 89 percent cognitive effectiveness, and the additional crew member had 72 percent. Seventy percent cognitive effectiveness is equivalent to a blood-alcohol level of 0.08, according to the report.

"Both the [pilot and co-pilot] reported feeling tired, but also feeling like they could still function properly during the approach to landing at MacDill," the report states.

C-17s use various indicators in the cockpit to lead the crew to the correct airfield, but on this approach, the plane's heads-up displays and multifunction displays were configured in a way that did not show navigation information, according to the report.

The pilot on the approach had configured his display to show the aircraft's configuration for landing, which is normal for C-17 pilots, but prevents the pilot from seeing navigation information. The co-pilot also failed to watch the mission line on his side of the aircraft or other instrument displays that would have confirmed the jet was heading toward the right runway.

The report found other contributing factors such as complacency after several difficult missions by the crew, visual illusion of similar runways on approach and similar runway identifiers at Peter O. Knight and MacDill.

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