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|
Attributes | |
ACN | 121354 |
Time | |
Date | 198909 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : fim |
State Reference | CA |
Altitude | msl bound lower : 11400 msl bound upper : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla tower : bfl |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | cruise other descent other |
Route In Use | arrival star : star |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 80 flight time total : 9000 flight time type : 2335 |
ASRS Report | 121354 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 7500 flight time type : 850 |
ASRS Report | 121966 |
Events | |
Anomaly | altitude deviation : crossing restriction not met non adherence : published procedure non adherence : clearance other anomaly |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On descent, cleared for tandy two arrival. The STAR was recently changed to 'expect to cross 'merma' intersection at 14,000.' previously 'tandy' was the 14,000 crossing altitude. Copilot was flying and covering ATC because I had just copied ATIS and was having difficulty with company frequency because of ground radio problems. I heard ATC clear us to cross tandy at 14,000, descend to 6000. As we descended through 15,000 I noted 14,000 set in altitude alerter and told the copilot 'one to go for tandy' and went back to company frequency. When I returned my attention to the navigation, I noted we were just approaching tandy and had descended to about 11,000 with 6000 set in the alerter. Copilot had apparently reset alerter. ATC advised we were at tandy showing 11,400. Copilot apparently mistook merma for tandy and had begun descent at merma (148 degree 29 DME) vice tandy (148 degree 38 DME). Since I was occupied with ATIS and company I was not sufficiently monitoring navigation at the time the deviation occurred. Contributing was fact I was returning from vacation having flown less than 20 hours in past 60 days and copilot's distraction with personal family problems. Supplemental information from acn 121966: I am just finishing the final phase of a divorce that has lasted 2 yrs. My mother was being tested this day for bone cancer. Considering the distrs going on in my life at this point in time, I should of utilized my sick leave. Bfl ILS 30R minimums to 200 and 1/2 are predicated on an approach light system which is entirely behind you when you break out if ceiling/visibility is below 400 and 1. This is because of a displaced threshold (and glide slope transmitter) of nearly 3500'. This creates a 'black hole' even if you do see ALS. How can minimums published at 200 and 1/2 be justified when the ALS is virtually useless when WX makes it most important? There is no in-runway lighting (TDZ or cl) and ALS is medium intensity. What justifies flying over 3500' of pavement (plus 800' stopway)?
Original NASA ASRS Text
Title: ACR MLG ALT DEVIATION OVERSHOT DURING STAR INTO LAX.
Narrative: ON DESCENT, CLRED FOR TANDY TWO ARR. THE STAR WAS RECENTLY CHANGED TO 'EXPECT TO CROSS 'MERMA' INTXN AT 14,000.' PREVIOUSLY 'TANDY' WAS THE 14,000 XING ALT. COPLT WAS FLYING AND COVERING ATC BECAUSE I HAD JUST COPIED ATIS AND WAS HAVING DIFFICULTY WITH COMPANY FREQ BECAUSE OF GND RADIO PROBLEMS. I HEARD ATC CLEAR US TO CROSS TANDY AT 14,000, DSND TO 6000. AS WE DESCENDED THROUGH 15,000 I NOTED 14,000 SET IN ALT ALERTER AND TOLD THE COPLT 'ONE TO GO FOR TANDY' AND WENT BACK TO COMPANY FREQ. WHEN I RETURNED MY ATTN TO THE NAVIGATION, I NOTED WE WERE JUST APCHING TANDY AND HAD DESCENDED TO ABOUT 11,000 WITH 6000 SET IN THE ALERTER. COPLT HAD APPARENTLY RESET ALERTER. ATC ADVISED WE WERE AT TANDY SHOWING 11,400. COPLT APPARENTLY MISTOOK MERMA FOR TANDY AND HAD BEGUN DSCNT AT MERMA (148 DEG 29 DME) VICE TANDY (148 DEG 38 DME). SINCE I WAS OCCUPIED WITH ATIS AND COMPANY I WAS NOT SUFFICIENTLY MONITORING NAVIGATION AT THE TIME THE DEVIATION OCCURRED. CONTRIBUTING WAS FACT I WAS RETURNING FROM VACATION HAVING FLOWN LESS THAN 20 HRS IN PAST 60 DAYS AND COPLT'S DISTR WITH PERSONAL FAMILY PROBLEMS. SUPPLEMENTAL INFORMATION FROM ACN 121966: I AM JUST FINISHING THE FINAL PHASE OF A DIVORCE THAT HAS LASTED 2 YRS. MY MOTHER WAS BEING TESTED THIS DAY FOR BONE CANCER. CONSIDERING THE DISTRS GOING ON IN MY LIFE AT THIS POINT IN TIME, I SHOULD OF UTILIZED MY SICK LEAVE. BFL ILS 30R MINIMUMS TO 200 AND 1/2 ARE PREDICATED ON AN APCH LIGHT SYSTEM WHICH IS ENTIRELY BEHIND YOU WHEN YOU BREAK OUT IF CEILING/VISIBILITY IS BELOW 400 AND 1. THIS IS BECAUSE OF A DISPLACED THRESHOLD (AND GLIDE SLOPE TRANSMITTER) OF NEARLY 3500'. THIS CREATES A 'BLACK HOLE' EVEN IF YOU DO SEE ALS. HOW CAN MINIMUMS PUBLISHED AT 200 AND 1/2 BE JUSTIFIED WHEN THE ALS IS VIRTUALLY USELESS WHEN WX MAKES IT MOST IMPORTANT? THERE IS NO IN-RWY LIGHTING (TDZ OR CL) AND ALS IS MEDIUM INTENSITY. WHAT JUSTIFIES FLYING OVER 3500' OF PAVEMENT (PLUS 800' STOPWAY)?
Data retrieved from NASA's ASRS site as of August 2007 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.