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|
Attributes | |
ACN | 134987 |
Time | |
Date | 199001 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : bna |
State Reference | TN |
Altitude | msl bound lower : 3000 msl bound upper : 3400 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : bna |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | descent : approach landing : go around |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : instrument pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 130 flight time total : 4100 flight time type : 900 |
ASRS Report | 134987 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : undershoot non adherence : published procedure other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were vectored downwind, slowed to 170 KTS, and stepped down to 3000' when we were turned in to intercept the localizer and cleared for the approach. The ATIS information we had received mins earlier indicated a ceiling of 7000' and visibility of 20 mi. I elected to turn off the autoplt and autothrottles and fly the approach manually. The aircraft was completely configured for landing by 1000' AGL, with both the G/south and localizer needles centered. At 800' AGL I looked outside the cockpit and became distracted. When I returned inside the cockpit I saw I was starting to go high on the G/south. By 650' AGL I had recovered, but unknowingly started to drift right of centerline. I then looked outside the cockpit for the runway or runway environment. We were at 5000' MSL. I started going high on the G/south and was full-scall deflection to the right of course. I realized then that we were in no position to land, I executed a missed approach. Our instructions were to fly runway heading and maintain 3000' MSL. Passing through 1000' AGL I turned on the autoplt. Since ILS had been selected on the flight director, it was still in that mode. The captain suggested I press the go around buttons to place the airplane in that mode. The autothrottles had also been re-engaged. I started to feel I was far behind the airplane and asked the captain if he would take it. With go around selected, the aircraft had pitched up to more than 20 degrees and was climbing at 4000 FPM. In order to more smoothly transition to level flight, the captain turned off the autoplt and selected a speed of 190 KTS for our reference + 5 speed of about 125 KTS. Shortly thereafter, the altitude alert sounded and we were at 3400'. Approach called and said 'you were cleared to 3000.' the captain and I have both made the same mistake. With everything going on so quickly, we were using our altimeters which were set to QFE or AGL for level off instead of the center altimeter, which is set to MSL. I replied to the controller when questioned that we were at 3000' because when I looked at my altimeter, we were just short of 2900' AGL. Immediately after that I realized the mistake I made, however the captain had already realized what was happening and began returning to 3000'. A landing was accomplished from this approach. The ceiling was actually 400'. I learned from this experience not to rely so heavily on the ATIS for accurate WX reports. Thinking that the runway would pop in sight, or even ground contact, where the ATIS said it would started the whole chain of events. Also, old habits are hard to break. When the workload increased dramatically, we both used the altimeters in front of us, which were set 599' lower than the center altimeter. In theory, it's a good system--but when things start happening quickly, you have a tendency to revert back to old procedures, especially when it appears reasonable.the only time we use this procedure is from the surface to 3000' AGL on takeoff and below 10000' landing. This is the busiest time during a flight anyway, but compound this with something out of the ordinary, it can become an unnecessary distraction.
Original NASA ASRS Text
Title: ACR MLG ALT DEVIATION TRACK DEVIATION DURING IAP ILS APCH WITH GO AROUND.
Narrative: WE WERE VECTORED DOWNWIND, SLOWED TO 170 KTS, AND STEPPED DOWN TO 3000' WHEN WE WERE TURNED IN TO INTERCEPT THE LOC AND CLRED FOR THE APCH. THE ATIS INFO WE HAD RECEIVED MINS EARLIER INDICATED A CEILING OF 7000' AND VISIBILITY OF 20 MI. I ELECTED TO TURN OFF THE AUTOPLT AND AUTOTHROTTLES AND FLY THE APCH MANUALLY. THE ACFT WAS COMPLETELY CONFIGURED FOR LNDG BY 1000' AGL, WITH BOTH THE G/S AND LOC NEEDLES CTRED. AT 800' AGL I LOOKED OUTSIDE THE COCKPIT AND BECAME DISTRACTED. WHEN I RETURNED INSIDE THE COCKPIT I SAW I WAS STARTING TO GO HIGH ON THE G/S. BY 650' AGL I HAD RECOVERED, BUT UNKNOWINGLY STARTED TO DRIFT RIGHT OF CTRLINE. I THEN LOOKED OUTSIDE THE COCKPIT FOR THE RWY OR RWY ENVIRONMENT. WE WERE AT 5000' MSL. I STARTED GOING HIGH ON THE G/S AND WAS FULL-SCALL DEFLECTION TO THE RIGHT OF COURSE. I REALIZED THEN THAT WE WERE IN NO POS TO LAND, I EXECUTED A MISSED APCH. OUR INSTRUCTIONS WERE TO FLY RWY HDG AND MAINTAIN 3000' MSL. PASSING THROUGH 1000' AGL I TURNED ON THE AUTOPLT. SINCE ILS HAD BEEN SELECTED ON THE FLT DIRECTOR, IT WAS STILL IN THAT MODE. THE CAPT SUGGESTED I PRESS THE GAR BUTTONS TO PLACE THE AIRPLANE IN THAT MODE. THE AUTOTHROTTLES HAD ALSO BEEN RE-ENGAGED. I STARTED TO FEEL I WAS FAR BEHIND THE AIRPLANE AND ASKED THE CAPT IF HE WOULD TAKE IT. WITH GAR SELECTED, THE ACFT HAD PITCHED UP TO MORE THAN 20 DEGS AND WAS CLBING AT 4000 FPM. IN ORDER TO MORE SMOOTHLY TRANSITION TO LEVEL FLT, THE CAPT TURNED OFF THE AUTOPLT AND SELECTED A SPD OF 190 KTS FOR OUR REF + 5 SPD OF ABOUT 125 KTS. SHORTLY THEREAFTER, THE ALT ALERT SOUNDED AND WE WERE AT 3400'. APCH CALLED AND SAID 'YOU WERE CLRED TO 3000.' THE CAPT AND I HAVE BOTH MADE THE SAME MISTAKE. WITH EVERYTHING GOING ON SO QUICKLY, WE WERE USING OUR ALTIMETERS WHICH WERE SET TO QFE OR AGL FOR LEVEL OFF INSTEAD OF THE CTR ALTIMETER, WHICH IS SET TO MSL. I REPLIED TO THE CTLR WHEN QUESTIONED THAT WE WERE AT 3000' BECAUSE WHEN I LOOKED AT MY ALTIMETER, WE WERE JUST SHORT OF 2900' AGL. IMMEDIATELY AFTER THAT I REALIZED THE MISTAKE I MADE, HOWEVER THE CAPT HAD ALREADY REALIZED WHAT WAS HAPPENING AND BEGAN RETURNING TO 3000'. A LNDG WAS ACCOMPLISHED FROM THIS APCH. THE CEILING WAS ACTUALLY 400'. I LEARNED FROM THIS EXPERIENCE NOT TO RELY SO HEAVILY ON THE ATIS FOR ACCURATE WX RPTS. THINKING THAT THE RWY WOULD POP IN SIGHT, OR EVEN GND CONTACT, WHERE THE ATIS SAID IT WOULD STARTED THE WHOLE CHAIN OF EVENTS. ALSO, OLD HABITS ARE HARD TO BREAK. WHEN THE WORKLOAD INCREASED DRAMATICALLY, WE BOTH USED THE ALTIMETERS IN FRONT OF US, WHICH WERE SET 599' LOWER THAN THE CTR ALTIMETER. IN THEORY, IT'S A GOOD SYS--BUT WHEN THINGS START HAPPENING QUICKLY, YOU HAVE A TENDENCY TO REVERT BACK TO OLD PROCS, ESPECIALLY WHEN IT APPEARS REASONABLE.THE ONLY TIME WE USE THIS PROC IS FROM THE SURFACE TO 3000' AGL ON TKOF AND BELOW 10000' LNDG. THIS IS THE BUSIEST TIME DURING A FLT ANYWAY, BUT COMPOUND THIS WITH SOMETHING OUT OF THE ORDINARY, IT CAN BECOME AN UNNECESSARY DISTR.
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.