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|
Attributes | |
ACN | 138446 |
Time | |
Date | 199002 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : rmg airport : atl |
State Reference | GA |
Altitude | msl bound lower : 12000 msl bound upper : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | artcc : ztl tracon : atl tower : bwi |
Operator | common carrier : air carrier |
Make Model Name | Heavy Transport, Low Wing, 4 Turbojet Eng |
Flight Phase | cruise other descent other |
Route In Use | arrival star : star enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 4770 flight time type : 1300 |
ASRS Report | 138446 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : undershoot non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
As we approached direct to rme VOR for the rme 6 arrival to atl from the north, we were given a clearance to proceed direct to an intersection situated between rme VOR and atl VOR, and to the southeast of rme VOR. We were to the north and west of rme VOR, and so I knew that the 190 degree heading the omega suggested was incorrect, even with the strong westerly winds. The captain was flying and apparently had some difficulty picturing where we were. We argued briefly and I convinced him to turn to the east, but I had underestimated the wind. ATC had to vector us back to the west. The next day the same situation occurred. The captain had on occasion seemed to take offense to my disagreeing with him, and because of events of the previous day I was not disposed to argue with him when he said to follow the omega. But the omega was wrong, and by the time ATC called us we were 20 mi off course to the west. ATC gave us a 20 degree turn to the left and handed us off to atl approach. He gave us another 20 degree turn to the left. A few mins later he asked us if we knew we were off course. We said the omega was unreliable and that the last 2 headings flown were via ATC. We were at 14000'. ATC gave us descent to 12000'. I did not hear this. I remember that we were given a descent and I initiated the descent. The altitude alert signal went off and so I leveled off. The cockpit workload and confusion were very high by this time. The controller assigned us a heading of 090 degrees. As the CDI needle swung, indicating we were crossing the inbound course on the arrival, the captain instructed me to turn right and intercept the course. With no time to think about it, I did. The controller, very irritated by this time, pointed out that he had given us a heading and had said nothing about intercepting the course. Then the controller said that he had given us 12000'. The altimeter read 13000'. The altitude alerter read 14000'. The tone I had interpreted as meaning we were approaching our assigned altitude actually meant we had strayed 700' from our previously assigned altitude. The alerter had never been reset to the new assigned altitude. Several factors were in effect during the incident: tension between captain and first officer. The captain seemed sensitive to any indication that I was questioning his knowledge, skill or authority. Because of my miscalculation the previous day I was also reluctant to challenge his decision based on the omega. Although we had 2 omegas, neither was programmed for the arrival. The captain programmed the assigned intersection into one of them while I flew. Perhaps I should have doublechked. But perhaps programming both omegas would have helped prevent the incident by alerting us to a discrepancy. Our company uses 5 different RNAV system. Neither the captain nor myself was particularly familiar with this system. We were at the end of a long night of flying and were tired. I have implemented 3 policies as a result of this action: 1) I never perform the duties of the other pilot (PF vs PNF). This only sets us up for mistakes. Let him always do his duties. 2) we never file RNAV with omegas. 3) I do not leave altitude until the altitude alerter has been reset.
Original NASA ASRS Text
Title: ACR HVT ALT DEVIATION UNDERSHOT PLUS TRACK HEADING DEVIATION.
Narrative: AS WE APCHED DIRECT TO RME VOR FOR THE RME 6 ARR TO ATL FROM THE N, WE WERE GIVEN A CLRNC TO PROCEED DIRECT TO AN INTXN SITUATED BTWN RME VOR AND ATL VOR, AND TO THE SE OF RME VOR. WE WERE TO THE N AND W OF RME VOR, AND SO I KNEW THAT THE 190 DEG HDG THE OMEGA SUGGESTED WAS INCORRECT, EVEN WITH THE STRONG WESTERLY WINDS. THE CAPT WAS FLYING AND APPARENTLY HAD SOME DIFFICULTY PICTURING WHERE WE WERE. WE ARGUED BRIEFLY AND I CONVINCED HIM TO TURN TO THE E, BUT I HAD UNDERESTIMATED THE WIND. ATC HAD TO VECTOR US BACK TO THE W. THE NEXT DAY THE SAME SITUATION OCCURRED. THE CAPT HAD ON OCCASION SEEMED TO TAKE OFFENSE TO MY DISAGREEING WITH HIM, AND BECAUSE OF EVENTS OF THE PREVIOUS DAY I WAS NOT DISPOSED TO ARGUE WITH HIM WHEN HE SAID TO FOLLOW THE OMEGA. BUT THE OMEGA WAS WRONG, AND BY THE TIME ATC CALLED US WE WERE 20 MI OFF COURSE TO THE W. ATC GAVE US A 20 DEG TURN TO THE LEFT AND HANDED US OFF TO ATL APCH. HE GAVE US ANOTHER 20 DEG TURN TO THE LEFT. A FEW MINS LATER HE ASKED US IF WE KNEW WE WERE OFF COURSE. WE SAID THE OMEGA WAS UNRELIABLE AND THAT THE LAST 2 HDGS FLOWN WERE VIA ATC. WE WERE AT 14000'. ATC GAVE US DSCNT TO 12000'. I DID NOT HEAR THIS. I REMEMBER THAT WE WERE GIVEN A DSCNT AND I INITIATED THE DSCNT. THE ALT ALERT SIGNAL WENT OFF AND SO I LEVELED OFF. THE COCKPIT WORKLOAD AND CONFUSION WERE VERY HIGH BY THIS TIME. THE CTLR ASSIGNED US A HDG OF 090 DEGS. AS THE CDI NEEDLE SWUNG, INDICATING WE WERE XING THE INBND COURSE ON THE ARR, THE CAPT INSTRUCTED ME TO TURN RIGHT AND INTERCEPT THE COURSE. WITH NO TIME TO THINK ABOUT IT, I DID. THE CTLR, VERY IRRITATED BY THIS TIME, POINTED OUT THAT HE HAD GIVEN US A HDG AND HAD SAID NOTHING ABOUT INTERCEPTING THE COURSE. THEN THE CTLR SAID THAT HE HAD GIVEN US 12000'. THE ALTIMETER READ 13000'. THE ALT ALERTER READ 14000'. THE TONE I HAD INTERPRETED AS MEANING WE WERE APCHING OUR ASSIGNED ALT ACTUALLY MEANT WE HAD STRAYED 700' FROM OUR PREVIOUSLY ASSIGNED ALT. THE ALERTER HAD NEVER BEEN RESET TO THE NEW ASSIGNED ALT. SEVERAL FACTORS WERE IN EFFECT DURING THE INCIDENT: TENSION BTWN CAPT AND F/O. THE CAPT SEEMED SENSITIVE TO ANY INDICATION THAT I WAS QUESTIONING HIS KNOWLEDGE, SKILL OR AUTHORITY. BECAUSE OF MY MISCALCULATION THE PREVIOUS DAY I WAS ALSO RELUCTANT TO CHALLENGE HIS DECISION BASED ON THE OMEGA. ALTHOUGH WE HAD 2 OMEGAS, NEITHER WAS PROGRAMMED FOR THE ARR. THE CAPT PROGRAMMED THE ASSIGNED INTXN INTO ONE OF THEM WHILE I FLEW. PERHAPS I SHOULD HAVE DOUBLECHKED. BUT PERHAPS PROGRAMMING BOTH OMEGAS WOULD HAVE HELPED PREVENT THE INCIDENT BY ALERTING US TO A DISCREPANCY. OUR COMPANY USES 5 DIFFERENT RNAV SYS. NEITHER THE CAPT NOR MYSELF WAS PARTICULARLY FAMILIAR WITH THIS SYS. WE WERE AT THE END OF A LONG NIGHT OF FLYING AND WERE TIRED. I HAVE IMPLEMENTED 3 POLICIES AS A RESULT OF THIS ACTION: 1) I NEVER PERFORM THE DUTIES OF THE OTHER PLT (PF VS PNF). THIS ONLY SETS US UP FOR MISTAKES. LET HIM ALWAYS DO HIS DUTIES. 2) WE NEVER FILE RNAV WITH OMEGAS. 3) I DO NOT LEAVE ALT UNTIL THE ALT ALERTER HAS BEEN RESET.
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.