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|
Attributes | |
ACN | 132688 |
Time | |
Date | 199001 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : cgt airport : mdw |
State Reference | IL |
Altitude | msl bound lower : 4000 msl bound upper : 5000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : ord |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent : approach |
Route In Use | arrival other enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 19000 flight time type : 10000 |
ASRS Report | 132688 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude altitude deviation : overshoot non adherence : clearance non adherence : published procedure |
Independent Detector | other controllera other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On the 3RD day of a 3-DAY air carrier sequence of flts and after 3 sleepless nights (hard bed, traffic noise, etc), I started a 6-FLT sequence at XA40 at little rock. I informed my first officer that I did not sleep well and was tired and to keep a close watch on me. The first officer flew the first flight to st louis and it was normal. However, while on the second leg, st louis-detroit, my leg, the first officer copied the ATIS for detroit city. After passing 18,000', we did the approach descent checklist and set the altimeter to 29.96. I did the P/a's transferred to det approach, and descended to 7000'. We were IFR, preparing for descent to det city with approximately 300 overcast, 1 mi visibility, icing conditions. The controller commented on my altitude and gave the altimeter setting of 29.66, putting the aircraft about 300' low. I questioned the first officer (a captain, reduced to first officer) what the ATIS said. He replied it was garbled by chicago tower frequency and thought it said 29.96, or assumed it was. The altimeter setting during descent by ATC was missed by me, probably when I was off frequency doing the P/a. I reprimanded the first officer and told him the next time there was a doubt to inform the captain so as to obtain the correct setting, not to keep it to himself that there was a problem getting the ATIS. The landing was made at det city and preparations were being made for our 3RD flight to chicago midway. WX was marginal IFR, windshear reported, light rain, fog, so I elected to fly this flight also. En route we encountered delays, low altitude holding created the use of relays from other aircraft to communicate with company and dispatch. We transferred to chicago approach control. The DME on the ILS was out of service so we had to use cross fixes off chicago heights for hills intersection and a second fix. A 3RD fix, runts had to be called by radar. We were told to maintain 5000' to hills and cleared for the ILS to 30L. The altitude deviation at det city was still bothering me. I read out loud the hill's fix limits, 7.4 mi DME from chicago heights and the radial. I told the first officer to call the needle centered for hills intersection. Being tired I locked into 7.4 DME and at 7.4 DME I called hills, and started descent to 4000'. I thought I heard the first officer say needle centered. Obviously not, I was at the eastern 7.4 DME point of the arch, not the western. A few moments later I realized I descended early. Chicago approach called runts. There was no comment from approach control about the deviation. We transferred to tower and landed. After we parked I asked the first officer why he let me descend early. His reply, 'I told you we weren't there and you chose not to listen'. We had a long discussion about the breakdown of communication between us and the failure of the crew concept on that approach. Fatigue: workload, WX, and the crew were all factors in the incident. The close proximity to the VOR probably made the infraction a small one in the descent point and may or may not trigger action by the FAA. However, the point remains, a failure to communicate did exist, and we did descend early, the crew concept broke down.
Original NASA ASRS Text
Title: CAPT OF ACR MLG COMPLAINS OF FO PERFORMANCE IN NOT CATCHING CAPT ALT DEVIATION, WHICH CAPT ATTRIBUTED TO FATIGUE.
Narrative: ON THE 3RD DAY OF A 3-DAY AIR CARRIER SEQUENCE OF FLTS AND AFTER 3 SLEEPLESS NIGHTS (HARD BED, TFC NOISE, ETC), I STARTED A 6-FLT SEQUENCE AT XA40 AT LITTLE ROCK. I INFORMED MY F/O THAT I DID NOT SLEEP WELL AND WAS TIRED AND TO KEEP A CLOSE WATCH ON ME. THE F/O FLEW THE FIRST FLT TO ST LOUIS AND IT WAS NORMAL. HOWEVER, WHILE ON THE SECOND LEG, ST LOUIS-DETROIT, MY LEG, THE F/O COPIED THE ATIS FOR DETROIT CITY. AFTER PASSING 18,000', WE DID THE APCH DESCENT CHECKLIST AND SET THE ALTIMETER TO 29.96. I DID THE P/A'S TRANSFERRED TO DET APCH, AND DESCENDED TO 7000'. WE WERE IFR, PREPARING FOR DESCENT TO DET CITY WITH APPROX 300 OVCST, 1 MI VISIBILITY, ICING CONDITIONS. THE CTLR COMMENTED ON MY ALT AND GAVE THE ALTIMETER SETTING OF 29.66, PUTTING THE ACFT ABOUT 300' LOW. I QUESTIONED THE F/O (A CAPT, REDUCED TO F/O) WHAT THE ATIS SAID. HE REPLIED IT WAS GARBLED BY CHICAGO TWR FREQ AND THOUGHT IT SAID 29.96, OR ASSUMED IT WAS. THE ALTIMETER SETTING DURING DSCNT BY ATC WAS MISSED BY ME, PROBABLY WHEN I WAS OFF FREQ DOING THE P/A. I REPRIMANDED THE F/O AND TOLD HIM THE NEXT TIME THERE WAS A DOUBT TO INFORM THE CAPT SO AS TO OBTAIN THE CORRECT SETTING, NOT TO KEEP IT TO HIMSELF THAT THERE WAS A PROBLEM GETTING THE ATIS. THE LNDG WAS MADE AT DET CITY AND PREPARATIONS WERE BEING MADE FOR OUR 3RD FLT TO CHICAGO MIDWAY. WX WAS MARGINAL IFR, WINDSHEAR REPORTED, LIGHT RAIN, FOG, SO I ELECTED TO FLY THIS FLT ALSO. ENRTE WE ENCOUNTERED DELAYS, LOW ALT HOLDING CREATED THE USE OF RELAYS FROM OTHER ACFT TO COMMUNICATE WITH COMPANY AND DISPATCH. WE TRANSFERRED TO CHICAGO APCH CTL. THE DME ON THE ILS WAS OUT OF SERVICE SO WE HAD TO USE CROSS FIXES OFF CHICAGO HEIGHTS FOR HILLS INTXN AND A SECOND FIX. A 3RD FIX, RUNTS HAD TO BE CALLED BY RADAR. WE WERE TOLD TO MAINTAIN 5000' TO HILLS AND CLRED FOR THE ILS TO 30L. THE ALT DEVIATION AT DET CITY WAS STILL BOTHERING ME. I READ OUT LOUD THE HILL'S FIX LIMITS, 7.4 MI DME FROM CHICAGO HEIGHTS AND THE RADIAL. I TOLD THE F/O TO CALL THE NEEDLE CENTERED FOR HILLS INTXN. BEING TIRED I LOCKED INTO 7.4 DME AND AT 7.4 DME I CALLED HILLS, AND STARTED DSCNT TO 4000'. I THOUGHT I HEARD THE F/O SAY NEEDLE CENTERED. OBVIOUSLY NOT, I WAS AT THE EASTERN 7.4 DME POINT OF THE ARCH, NOT THE WESTERN. A FEW MOMENTS LATER I REALIZED I DESCENDED EARLY. CHICAGO APCH CALLED RUNTS. THERE WAS NO COMMENT FROM APCH CTL ABOUT THE DEVIATION. WE TRANSFERRED TO TWR AND LANDED. AFTER WE PARKED I ASKED THE F/O WHY HE LET ME DESCEND EARLY. HIS REPLY, 'I TOLD YOU WE WEREN'T THERE AND YOU CHOSE NOT TO LISTEN'. WE HAD A LONG DISCUSSION ABOUT THE BREAKDOWN OF COM BETWEEN US AND THE FAILURE OF THE CREW CONCEPT ON THAT APCH. FATIGUE: WORKLOAD, WX, AND THE CREW WERE ALL FACTORS IN THE INCIDENT. THE CLOSE PROX TO THE VOR PROBABLY MADE THE INFRACTION A SMALL ONE IN THE DESCENT POINT AND MAY OR MAY NOT TRIGGER ACTION BY THE FAA. HOWEVER, THE POINT REMAINS, A FAILURE TO COMMUNICATE DID EXIST, AND WE DID DSND EARLY, THE CREW CONCEPT BROKE DOWN.
Data retrieved from NASA's ASRS site as of July 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.