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Attributes | |
ACN | 131353 |
Time | |
Date | 198912 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : den |
State Reference | CO |
Altitude | msl bound lower : 23700 msl bound upper : 24000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdv tower : cle |
Operator | common carrier : air taxi |
Make Model Name | Light Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other other |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 17000 flight time type : 220 |
ASRS Report | 131353 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance |
Independent Detector | other controllera other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | faa : reviewed incident with flight crew faa : investigated |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This flight departed boise, identification for return to den after a cargo trip, with the first officer flying. Inbound to den we were cleared to hold at benam intersection on J56 at FL240 with an efc of approximately 20 mins. Upon reaching the den 313/47 DME fix which defines benam, the first officer initiated a right turn of 30 degree bank angle at 180 KTS to enter holding. I was setting my heading bug to the outbnd course heading when I observed my altimeter showing around 200' low and sinking. I immediately called to the first officer to apply power and bring the nose up. His reaction was rapid, but did not apply enough power or pitch up, so I helped him by pushing the power up and pulling back on the wheel to obtain 10-12 degree pitch up while continuing the right turn. I used the horizon for pitch/bank reference and ivsi to assure positive climb rate, and saw the altimeter indicating 200-300' low and climbing. At FL240 I told the first officer that I would fly the aircraft for the rest of the flight. During this time, ATC called and said maintain FL240, and we acknowledged this call. Later in holding at FL220, ATC suddenly called and said 'maintain 220, you have aircraft below you in the holding pattern.' at this time, my first officer and I were observing FL220 on the altimeter, and we reported this to ATC. Shortly thereafter we were asked to call den ATC on the phone after our arrival in den. This I did, and talked to a controller who said 2 deviations were observed, but that the second one at FL220 might have been the result of equipment problems at center. This did turn out to be the case, as admitted to our D.O.O. Later in day. The contributing factors to the deviation were a combination of: 1) inexperience of the first officer in flying high altitude, lower speed holding pattern turns in high pattern turns in high performance aircraft. 2) first officer reluctance to apply power to a high percent rapidly and initiate rapid pitch-up angle to effect recovery, because of inexperience of the first officer as to the result of these actions. 3) poor planning on my part as captain in not determining that first officer knew what to expect in this maneuver, and thoroughly briefing him in all aspects of the holding pattern before we arrived at the holding fix. 4) slight turbulence and possible mountain wave in this cold frontal system. Again,this should have been briefed by myself, and the first officer warned to expect this condition, since we were holding over mountainous terrain (up to 14000'). 5) finally, failure on my part as PIC to keep closer oversight on the first officer and flight situation, and in not coming in sooner to help affect the recovery. In order to preclude other situations of this type, I have recommended to our D.O.O. That we discuss and train for these possibilities in our first officer training programs. Also,I plan to alter my cockpit procedures to keep better oversight of the total cockpit/flight environment in order to better train and help our first officer's in our operations.
Original NASA ASRS Text
Title: BIZ JET HAS ALT LOSS ON FIRST TURN INTO HIGH ALT HOLDING AT REDUCING SPEED DUE TO INEPTITUDE.
Narrative: THIS FLT DEPARTED BOISE, ID FOR RETURN TO DEN AFTER A CARGO TRIP, WITH THE F/O FLYING. INBND TO DEN WE WERE CLRED TO HOLD AT BENAM INTXN ON J56 AT FL240 WITH AN EFC OF APPROX 20 MINS. UPON REACHING THE DEN 313/47 DME FIX WHICH DEFINES BENAM, THE F/O INITIATED A RIGHT TURN OF 30 DEG BANK ANGLE AT 180 KTS TO ENTER HOLDING. I WAS SETTING MY HDG BUG TO THE OUTBND COURSE HDG WHEN I OBSERVED MY ALTIMETER SHOWING AROUND 200' LOW AND SINKING. I IMMEDIATELY CALLED TO THE F/O TO APPLY PWR AND BRING THE NOSE UP. HIS REACTION WAS RAPID, BUT DID NOT APPLY ENOUGH PWR OR PITCH UP, SO I HELPED HIM BY PUSHING THE PWR UP AND PULLING BACK ON THE WHEEL TO OBTAIN 10-12 DEG PITCH UP WHILE CONTINUING THE RIGHT TURN. I USED THE HORIZON FOR PITCH/BANK REF AND IVSI TO ASSURE POSITIVE CLB RATE, AND SAW THE ALTIMETER INDICATING 200-300' LOW AND CLBING. AT FL240 I TOLD THE F/O THAT I WOULD FLY THE ACFT FOR THE REST OF THE FLT. DURING THIS TIME, ATC CALLED AND SAID MAINTAIN FL240, AND WE ACKNOWLEDGED THIS CALL. LATER IN HOLDING AT FL220, ATC SUDDENLY CALLED AND SAID 'MAINTAIN 220, YOU HAVE ACFT BELOW YOU IN THE HOLDING PATTERN.' AT THIS TIME, MY F/O AND I WERE OBSERVING FL220 ON THE ALTIMETER, AND WE RPTED THIS TO ATC. SHORTLY THEREAFTER WE WERE ASKED TO CALL DEN ATC ON THE PHONE AFTER OUR ARR IN DEN. THIS I DID, AND TALKED TO A CTLR WHO SAID 2 DEVIATIONS WERE OBSERVED, BUT THAT THE SECOND ONE AT FL220 MIGHT HAVE BEEN THE RESULT OF EQUIP PROBS AT CENTER. THIS DID TURN OUT TO BE THE CASE, AS ADMITTED TO OUR D.O.O. LATER IN DAY. THE CONTRIBUTING FACTORS TO THE DEVIATION WERE A COMBINATION OF: 1) INEXPERIENCE OF THE F/O IN FLYING HIGH ALT, LOWER SPD HOLDING PATTERN TURNS IN HIGH PATTERN TURNS IN HIGH PERFORMANCE ACFT. 2) F/O RELUCTANCE TO APPLY PWR TO A HIGH PERCENT RAPIDLY AND INITIATE RAPID PITCH-UP ANGLE TO EFFECT RECOVERY, BECAUSE OF INEXPERIENCE OF THE F/O AS TO THE RESULT OF THESE ACTIONS. 3) POOR PLANNING ON MY PART AS CAPT IN NOT DETERMINING THAT F/O KNEW WHAT TO EXPECT IN THIS MANEUVER, AND THOROUGHLY BRIEFING HIM IN ALL ASPECTS OF THE HOLDING PATTERN BEFORE WE ARRIVED AT THE HOLDING FIX. 4) SLIGHT TURB AND POSSIBLE MOUNTAIN WAVE IN THIS COLD FRONTAL SYS. AGAIN,THIS SHOULD HAVE BEEN BRIEFED BY MYSELF, AND THE F/O WARNED TO EXPECT THIS CONDITION, SINCE WE WERE HOLDING OVER MOUNTAINOUS TERRAIN (UP TO 14000'). 5) FINALLY, FAILURE ON MY PART AS PIC TO KEEP CLOSER OVERSIGHT ON THE F/O AND FLT SITUATION, AND IN NOT COMING IN SOONER TO HELP AFFECT THE RECOVERY. IN ORDER TO PRECLUDE OTHER SITUATIONS OF THIS TYPE, I HAVE RECOMMENDED TO OUR D.O.O. THAT WE DISCUSS AND TRAIN FOR THESE POSSIBILITIES IN OUR F/O TRNING PROGRAMS. ALSO,I PLAN TO ALTER MY COCKPIT PROCS TO KEEP BETTER OVERSIGHT OF THE TOTAL COCKPIT/FLT ENVIRONMENT IN ORDER TO BETTER TRAIN AND HELP OUR F/O'S IN OUR OPS.
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.