37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1192323 |
Time | |
Date | 201407 |
Local Time Of Day | 0001-0600 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Route In Use | Visual Approach |
Flight Plan | IFR |
Component | |
Aircraft Component | Autoflight System |
Person 1 | |
Function | Captain Pilot Not Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Person 2 | |
Function | First Officer Pilot Flying |
Experience | Flight Crew Last 90 Days 100 |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy Inflight Event / Encounter CFTT / CFIT |
Narrative:
We departed late due to a late inbound aircraft. We flew an RNAV STAR arrival and received vectors abeam the airport. Due to the late arrival into the normally busy airport the traffic pattern was clear. The ILS to [runway] xxl was out of service and visual approaches were in use. We loaded the RNAV (GPS) Y runway xxl into the FMS for backup guidance for the visual. While on vectors I extended the centerline off the FAF; however; when I executed the modification; the centerline extended off [runway] xxl and the FAF was deleted from the route; along with its 2;400 ft crossing restriction. We were on a southerly heading at 3;000 MSL; outbound abeam the FAF when the controller turned us to a 080 heading for a base leg. I reentered the FAF into the FMS and extended it; but did not enter the hard altitude of 2;400 ft. The controller asked if we had the field in sight; we said yes and he cleared us the visual approach to [runway] xxl. We were in heading select/VNAV with the autopilot and autothrottles on. I made the mistake of entering the da for the RNAV approach in the altitude window; 900 ft. I should have entered 2;400; the final approach fix altitude. The first officer remained in heading select/VNAV when LNAV should have been selected. I'm not sure what the FMA was at this point because I was looking outside. I believe we were in thr; heading sel; VNAV speed. I noticed we were not intercepting the runway centerline by visual cues to the runway; I told the first officer we were overshooting and needed to turn. He began his turn and corrected to the runway centerline. I saw that we were low on the glidepath; four red lights on the PAPI; and told the first officer we were low. Just after I said that we received an egpws terrain; terrain alert. The first officer immediately executed the CFIT maneuver. I noted we were above 1;600 MSL at the time of the alert. Almost immediately after the maneuver was initiated the alert stopped and we were on glidepath with two white and two red PAPI lights. I believe the alert was triggered by the hill that sits on final for [runway] xxl. We both felt that terrain was no longer a factor and configured the aircraft for landing; we were flaps 10; speed 10 at the time of the alert. After the maneuver we were at least 1;800 MSL; were fully configured and stable before 1;000 AGL. We landed uneventfully. Several factors contributed to this event: first; the ILS xxl out of service. Next; probably extending the centerline off [runway] xxl instead of the FAF. Third; trying to reenter the FAF on a clear night with unlimited visibility. Fourth; not selecting LNAV on base leg. Fifth; entering the decision altitude in the altitude window when we were not on the approach; selecting the FAF altitude would have stopped our descent and the alert probably would not have happened. Last; both pilots relying too much on the [automation] when we should have been looking outside and using visual cues as the runway was in sight and the PAPI clearly visible. Although I didn't feel tired at the time; it was the middle of the night and we had been on duty in excess of 8 hours. I believe fatigue contributed in some way.
Original NASA ASRS Text
Title: An important and illuminating report that addresses the effect of inappropriate and/or improper modifications programmed into the autoflight system by a fatigued flight crew cleared to fly a visual approach on a clear night. They ultimately received an EGPWS 'Terrain' warning for descent below that prescribed by the RNAV approach they had programmed specifically to act as a backup/support mechanism to mitigate the effects of their fatigue.
Narrative: We departed late due to a late inbound aircraft. We flew an RNAV STAR arrival and received vectors abeam the airport. Due to the late arrival into the normally busy airport the traffic pattern was clear. The ILS to [Runway] XXL was out of service and visual approaches were in use. We loaded the RNAV (GPS) Y Runway XXL into the FMS for backup guidance for the visual. While on vectors I extended the centerline off the FAF; however; when I executed the modification; the centerline extended off [Runway] XXL and the FAF was deleted from the route; along with its 2;400 FT crossing restriction. We were on a southerly heading at 3;000 MSL; outbound abeam the FAF when the Controller turned us to a 080 heading for a base leg. I reentered the FAF into the FMS and extended it; but did not enter the hard altitude of 2;400 FT. The Controller asked if we had the field in sight; we said yes and he cleared us the visual approach to [Runway] XXL. We were in heading select/VNAV with the autopilot and autothrottles on. I made the mistake of entering the DA for the RNAV approach in the altitude window; 900 FT. I should have entered 2;400; the final approach fix altitude. The First Officer remained in heading select/VNAV when LNAV should have been selected. I'm not sure what the FMA was at this point because I was looking outside. I believe we were in THR; HDG SEL; VNAV SPD. I noticed we were not intercepting the runway centerline by visual cues to the runway; I told the First Officer we were overshooting and needed to turn. He began his turn and corrected to the runway centerline. I saw that we were low on the glidepath; four red lights on the PAPI; and told the First Officer we were low. Just after I said that we received an EGPWS TERRAIN; TERRAIN alert. The First Officer immediately executed the CFIT maneuver. I noted we were above 1;600 MSL at the time of the alert. Almost immediately after the maneuver was initiated the alert stopped and we were on glidepath with two white and two red PAPI lights. I believe the alert was triggered by the hill that sits on final for [Runway] XXL. We both felt that terrain was no longer a factor and configured the aircraft for landing; we were flaps 10; speed 10 at the time of the alert. After the maneuver we were at least 1;800 MSL; were fully configured and stable before 1;000 AGL. We landed uneventfully. Several factors contributed to this event: First; the ILS XXL out of service. Next; probably extending the centerline off [Runway] XXL instead of the FAF. Third; trying to reenter the FAF on a clear night with unlimited visibility. Fourth; not selecting LNAV on base leg. Fifth; entering the Decision Altitude in the altitude window when we were not on the approach; selecting the FAF altitude would have stopped our descent and the alert probably would not have happened. Last; both pilots relying too much on the [automation] when we should have been looking outside and using visual cues as the runway was in sight and the PAPI clearly visible. Although I didn't feel tired at the time; it was the middle of the night and we had been on duty in excess of 8 hours. I believe fatigue contributed in some way.
Data retrieved from NASA's ASRS site and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.