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Attributes | |
ACN | 1420078 |
Time | |
Date | 201701 |
Local Time Of Day | 1201-1800 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Environment | |
Flight Conditions | Mixed |
Light | Night |
Aircraft 1 | |
Make Model Name | Small Transport Low Wing 2 Turboprop Eng |
Operating Under FAR Part | Part 91 |
Flight Phase | Initial Approach |
Flight Plan | IFR |
Person 1 | |
Function | Pilot Not Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) Flight Crew Flight Instructor Flight Crew Instrument Flight Crew Multiengine |
Experience | Flight Crew Last 90 Days 110 Flight Crew Total 6100 Flight Crew Type 1150 |
Events | |
Anomaly | Deviation - Procedural Clearance Deviation - Procedural Published Material / Policy Deviation - Track / Heading All Types Inflight Event / Encounter Unstabilized Approach |
Narrative:
I am a part 135 pilot. I was asked by the owner of our company to serve as a safety pilot for a part 91 owner. Normally; the owner of our part 135 company flies with this part 91 owner and has done so for a few years. Outside of this particular flight; the owner of the part 135 company I fly for; and I operate as a crew on a two-pilot jet aircraft. We've been doing this for years now and have our crew resource management roles down pat. Each of us is comfortable with our expectations of; 'who does what.' that in mind; before this particular part 135 flight; I attempted to set expectations with the owner/pilot - who had years of experience - and thought we were moderately successful in doing so. Knowing this part 91 owner/pilot had been flying routinely with the part 135 owner; who is also the co-captain of the two-crew jet that we fly; I thought the cockpit procedures during this part 91 flight would be very similar to what we do in our jet. After my crew resource management briefing; because I don't normally fly with this owner; I wrapped it up by saying; 'if I'm doing something you normally do; or I'm not doing something you expect; speak up clearly and let me know.' I reiterated that we haven't flown together so I wanted to ensure there were no dropped expectations or sloppy crew resource management processes.on the outbound leg of our flight; everything proceeded smoothly; but; I did notice that with route changes; neither one of us was entering them into the FMS. In our jet; if the autopilot is on; the guy in the left seat (PF) would enter route changes in the FMS. When he was hand flying; the PNF would enter route changes - the PF's role is heading; altitude; and airspeed. I asked the owner/operator; 'who normally does this when he flies with the other pilot?' - the person I fly with on our jet. The part 91 owner/pilot indicated the PNF enters this. This was a different CRM process than what I would have expected given the pilot that normally flies with this part 91 owner was the co-captain of the jet we fly; the person I normally fly with who; as a crew; we have developed very tight role/responsibility expectations. This was different in the part 91 owner's airplane.during the outbound leg; it also became clear that there were other CRM differences. Given an altitude assignment; both the PF and the PNF (me); reached up to set the new altitude when the PF was hand flying. This was different as well. We were either a jumble of hands reaching for the same knobs; or a complete lack of action from either of us on route changes; or loading procedures. While this is not normally a major problem; each time we were faced with the lack of action behavior; I would ask what the PF would like me to do. The answer was always; 'you go ahead and do that.' over time; it became clear - or so it seemed to me - that the co-captain that I flew with as a crew in our part 135 airplane; performed most of the tasks in this part 91 airplane that were the PF's responsibility.this is very important because it sets up a crew dynamic where the PF abrogates some of his PF responsibilities to the PNF; more so if the PNF takes on more of the PF's responsibilities; less so if the PNF does so only at the margin. A contributing factor in this dynamic is that the PNF is a professional pilot and the part 91 owner/pilot is not. There's a natural deference that happens from the part 91 PF to the part 135 PNF. Many of us have been in this situation: the part 91 PF gets into an increasingly marginal safety situation; the part 135 PNF (the safety pilot) coaches the PF as he flies; then; all of a sudden; the PF lets go of the yoke and says; 'you got it.' in these cases; along with the part 91 flight I was acting as a safety pilot on this day; the PF assumes a 'student' posture and the PNF assumes a 'flight instructor' posture. Again; although you can be completely out of process on CRM roles and responsibilities; this should not be an in surmountableissue. On this particular flight; however; it exposed a knowledge gap I had on RNAV (GPS) procedures that the 'student' PF did not challenge; even though he flew this particular procedure two or three times per week.we were cleared for the RNAV (GPS) Z runway xxl approach into ZZZ. Over the past few years; many new process and procedure changes have been integrated into the system. At our part 135 operation; we receive no formal training on the changes. Environmentally; we absorb the knowledge of changes through magazine articles; email alerts; and during performance of our annual part 135 check rides at our contracted providers. I've highlighted this risk area and suggested it would be good if our pilots could take a formal course during our annual requalification training specific to changes in arrival and departure procedures; along with the broad range of approaches that are now available. I am not alone with this concern; which was evident one day when a part 121 carrier completely blew the 'descend via' requirements on a STAR into ZZZ. On this day; the PF executed the approach by selecting the step down altitude; then manually stepping down. I took it upon myself to incorrectly discuss how the PF could just capture the glide slope and follow it down; much like an ILS. When the GS did not become active; I 'told' the PF to step it down manually as if it was a LNAV only approach. Reviewing the approach chart while he did this; I looked up and noticed the CDI was pointing opposite of the intended approach course and that we were turning to a southerly heading rather than the 238 heading noted on the final approach course. We were IMC when this happened and while were we sorting it out; we became VMC; however; I asked for a missed approach. The TRACON controller said to contact the tower instead; which we did. We located the airport visually; contacted the tower; and were cleared to land. Afterward; I asked for a debriefing with the PF and we spent about an hour reviewing the sequence of events. I realized during our debriefing that over the past few years I've never flown an lp approach. We routinely fly ILS; lpv; LNAV/VNAV approaches. During this approach; I read lpv in my mind rather than lp; which it was. I didn't clearly read the approach plate; and we didn't brief the approach together as we should have.what should have been a non-eventful arrival into ZZZ; turned into a breakdown in the cockpit due to several factors and exposed my knowledge gaps; which were not challenged by the PF. Sorry for the long narrative; but; this 'error' includes many nuanced perspectives.
Original NASA ASRS Text
Title: B350 pilot reported CRM issues and his unfamiliarity with LP approaches.
Narrative: I am a Part 135 pilot. I was asked by the owner of our company to serve as a safety pilot for a Part 91 owner. Normally; the owner of our Part 135 company flies with this Part 91 owner and has done so for a few years. Outside of this particular flight; the owner of the Part 135 company I fly for; and I operate as a crew on a two-pilot jet aircraft. We've been doing this for years now and have our crew resource management roles down pat. Each of us is comfortable with our expectations of; 'who does what.' That in mind; before this particular Part 135 flight; I attempted to set expectations with the owner/pilot - who had years of experience - and thought we were moderately successful in doing so. Knowing this Part 91 owner/pilot had been flying routinely with the Part 135 owner; who is also the co-Captain of the two-crew jet that we fly; I thought the cockpit procedures during this Part 91 flight would be very similar to what we do in our jet. After my crew resource management briefing; because I don't normally fly with this owner; I wrapped it up by saying; 'If I'm doing something you normally do; or I'm not doing something you expect; speak up clearly and let me know.' I reiterated that we haven't flown together so I wanted to ensure there were no dropped expectations or sloppy crew resource management processes.On the outbound leg of our flight; everything proceeded smoothly; but; I did notice that with route changes; neither one of us was entering them into the FMS. In our jet; if the autopilot is on; the guy in the left seat (PF) would enter route changes in the FMS. When he was hand flying; the PNF would enter route changes - the PF's role is heading; altitude; and airspeed. I asked the owner/operator; 'who normally does this when he flies with the other pilot?' - the person I fly with on our jet. The Part 91 owner/pilot indicated the PNF enters this. This was a different CRM process than what I would have expected given the pilot that normally flies with this Part 91 owner was the co-Captain of the jet we fly; the person I normally fly with who; as a crew; we have developed very tight role/responsibility expectations. This was different in the Part 91 owner's airplane.During the outbound leg; it also became clear that there were other CRM differences. Given an altitude assignment; both the PF and the PNF (me); reached up to set the new altitude when the PF was hand flying. This was different as well. We were either a jumble of hands reaching for the same knobs; or a complete lack of action from either of us on route changes; or loading procedures. While this is not normally a major problem; each time we were faced with the lack of action behavior; I would ask what the PF would like me to do. The answer was always; 'you go ahead and do that.' Over time; it became clear - or so it seemed to me - that the co-Captain that I flew with as a crew in our Part 135 airplane; performed most of the tasks in this Part 91 airplane that were the PF's responsibility.This is very important because it sets up a crew dynamic where the PF abrogates some of his PF responsibilities to the PNF; more so if the PNF takes on more of the PF's responsibilities; less so if the PNF does so only at the margin. A contributing factor in this dynamic is that the PNF is a professional pilot and the Part 91 owner/pilot is not. There's a natural deference that happens from the Part 91 PF to the Part 135 PNF. Many of us have been in this situation: The Part 91 PF gets into an increasingly marginal safety situation; the Part 135 PNF (the safety pilot) coaches the PF as he flies; then; all of a sudden; the PF lets go of the yoke and says; 'you got it.' In these cases; along with the Part 91 flight I was acting as a safety pilot on this day; the PF assumes a 'student' posture and the PNF assumes a 'Flight Instructor' posture. Again; although you can be completely out of process on CRM Roles and Responsibilities; this should not be an in surmountableissue. On this particular flight; however; it exposed a knowledge gap I had on RNAV (GPS) procedures that the 'student' PF did not challenge; even though he flew this particular procedure two or three times per week.We were cleared for the RNAV (GPS) Z RWY XXL approach into ZZZ. Over the past few years; many new process and procedure changes have been integrated into the system. At our Part 135 operation; we receive no formal training on the changes. Environmentally; we absorb the knowledge of changes through magazine articles; email alerts; and during performance of our annual Part 135 check rides at our contracted providers. I've highlighted this risk area and suggested it would be good if our pilots could take a formal course during our annual requalification training specific to changes in Arrival and Departure procedures; along with the broad range of approaches that are now available. I am not alone with this concern; which was evident one day when a Part 121 carrier completely blew the 'descend via' requirements on a STAR into ZZZ. On this day; the PF executed the approach by selecting the step down altitude; then manually stepping down. I took it upon myself to incorrectly discuss how the PF could just capture the glide slope and follow it down; much like an ILS. When the GS did not become active; I 'told' the PF to step it down manually as if it was a LNAV only approach. Reviewing the approach chart while he did this; I looked up and noticed the CDI was pointing opposite of the intended approach course and that we were turning to a southerly heading rather than the 238 heading noted on the final approach course. We were IMC when this happened and while were we sorting it out; we became VMC; however; I asked for a missed approach. The TRACON controller said to contact the tower instead; which we did. We located the airport visually; contacted the tower; and were cleared to land. Afterward; I asked for a debriefing with the PF and we spent about an hour reviewing the sequence of events. I realized during our debriefing that over the past few years I've never flown an LP approach. We routinely fly ILS; LPV; LNAV/VNAV approaches. During this approach; I read LPV in my mind rather than LP; which it was. I didn't clearly read the approach plate; and we didn't brief the approach together as we should have.What should have been a non-eventful arrival into ZZZ; turned into a breakdown in the cockpit due to several factors and exposed my knowledge gaps; which were not challenged by the PF. Sorry for the long narrative; but; this 'error' includes many nuanced perspectives.
Data retrieved from NASA's ASRS site 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.