Large Transport
Flight Crew Air Transport Pilot (ATP)
Flight Crew Last 90 Days 180; Flight Crew Total 10000; Flight Crew Type 6000
Workload; Time Pressure; Distraction; Communication Breakdown; Confusion
ATC Issue All Types; Deviation - Altitude Crossing Restriction Not Met; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Deviation / Discrepancy - Procedural Clearance; Inflight Event / Encounter Unstabilized Approach
Air Traffic Control Issued New Clearance; Flight Crew Executed Go Around / Missed Approach
Weather; Airspace Structure; Procedure
We had briefed extensively before descent the ATIS advertised ILS to runway 28R with special emphasis on closely spaced simultaneous parallel approach on 28L. Upon first contact with NORCAL TRACON; we were assigned the LDA PRM to 28R. We scrambled to brief the 2 page approach which had many steps that were not part of our normal SOP. NORCAL cleared us to follow course only and assigned us 210 knots. NORCAL kept stepping us down to next lower altitude right at FATUS; HEGOT; WASOP; respectively instead of clearing us for the approach. Once inside of WASOP (13 DME) NORCAL finally slowed us to 180kts and then cleared us for the approach. We dropped the gear and slowed but we couldn't get to 3000 ft by MIUKE. With parallel traffic less than 2 miles on TCAS display; NORCAL slowed us to 160 kts. By this point we went IMC and needed 2000 fpm descent from 3000 to 1800 feet but we still had not reached assigned speed of 160 kts. I elected to execute a go around because of our un-stabilized condition and descent into IMC with traffic too close. When executing our go around I called for flap 3 (which they were already there) and then called for gear up. I watched the Captain put his hand on the gear handle and had processed that he heard my call. At the same time NORCAL instructed us to fly runway heading 280 vice the hard right turnout to 030. I had already started my right turn; so the change in course (toward the parallel traffic) I believe distracted the captain from actually raising the gear and then I became fixated on traffic separation; course correction; and not over-speeding the flaps. After reaching 4000 we discussed that it sounded like the gear doors were still open but nothing on the wheels page seemed unusual. We continued to fly around the bay unknowingly with the gear down at 210 kts and scrambling to brief the ILS PRM RWY 28L (another 2 page brief). Once we turned final I realized that the gear was still down. We continued this approach without any other errors. I believe the close proximity of the parallel traffic; unannounced LDA PRM assignment; and the poor IFR speed assignments were factors contributing to our error with the gear on the go around.
The late slowing was aggravating the need to descend as we continued to be high and fast to the point of finally requiring a go around prior to reaching the final approach fix. ATC cleared us to climb to 4000 FT and fly HDG 280. To this point; this had been an extremely busy descent; approach; and now missed approach. Per SOP; my First Officer (FO) selected TOGA thrust; called for the flaps; gear; and missed approach altitude. I clearly remember doing each. After leveling at 4000 FT; I completed the After Takeoff Checklist. Afterward; My FO said that he was hearing an air noise that sounded like the nose gear door was not fully closed. Certain that the gear was up since I had raised it and he saw me raise it; we both checked the WHEEL page and verified that the gear doors were all closed. During this time; we had been vectored for a left downwind for the ILS PRM 28L. After we had turned base leg; my FO realized that the LNDG GEAR panel lights were illuminated green indicating that the gear was in fact still down. We were both dumbfounded to know that although we both saw me reach for the gear handle; I did not raise it and that we both did not see that the gear was still down while we were looking at all the gear indications investigating the air sound. Clearly this was a case of both of us seeing the gear in the position that we expected to see it despite the green down indicator lights. We realized that while I was reaching to raise the gear; ATC was also giving us altitude and heading instructions as well as asking us why we were going around which may have caused me to take my hand off the gear handle before raising it to turn the heading and altitude knobs. I then got further distracted with responding to ATC and didn't realize that I had not raised the gear at all. My FO saw me reach for the gear handle and being task saturated himself concluded that the gear was raised.The actual go around maneuver on the line is one that always requires a debriefing due to the fact that we rarely do them. This is the first time that I have ever done this and it begs the question..how? How do two pilots with our experience make this type of mistake? Although it had been a long day; fatigue was not a significant factor if at all. It was certainly a combination of the contributing factors including stresses and task saturation. I am also certain that there is a psychological response to that question which I am not qualified to make but the fact that two very experienced pilots can see the same gear down indication as gear up for at least 5 minutes is very curious. Also; I initially concluded that I should have waited to communicate with ATC while executing the go around but I did need to advise that we were going around and acknowledge the clearance. In the future I would do that after the immediate actions were completed..TOGA; FLAPS; GEAR; ALTITUDE; then call ATC. In addition; somehow I feel that this event started with us getting an unexpected complex approach from NORCAL APP Control in the descent which wasn't advertised in the most current ATIS which led to us getting behind after being comfortably ahead up to that point. With ATC's poor control of our speed and descent; we never caught up which led to our eventual go around. I should have mitigated that threat by asking for delay vectors or holding to properly brief that approach and then when I became uncomfortable with our speed and altitude; I should have ask for slower and lower. At some point; we may still have needed to go around but we would have more mentally ahead and prepared for it which would have helped me/us manage the task saturation of the go around better. It would have also improved our CRM since I was briefing the approach while my FO was busy flying. I pride my in managing threats well but in the end; I believe that poor management on my part and poor service from ATC led to this event. My very strong recommendation for ATC is that they do not assignthe PRM approach to aircraft in the descent unless it was previously advertised on the ATIS and speed and altitude management need to be more conducive to the approach profile.We landed without further incident after the second approach.
A flight crew was cleared for an approach different from the one they had briefed. They were able to complete the new briefing but were high and fast on final and executed a go-around. On the go-around both pilots thought the gear had been raised but it was not. Task saturation was a factor in their confusion.