Narrative:

On the ILS runway 19L at sfo. Inside the OM, descending through 1000' MSL. Both pilots got red flags for both localizer and G/south (loss of signal). Also lost localizer DME. Initiated missed approach (basically climbed straight ahead while cleaning up the airplane). Called tower, advised loss of signal and missed approach. Tower said roger, fly published missed approach. At this point, I looked down at the approach plate and quickly scanned the missed approach procedure. We had already briefed the procedure during the approach and this was just a quick rescan. Saw that it called for a climbing left turn to go the brijj LOM and hold, climbing to 2000'. I told the first officer, who was flying, to just make a left turn and go to brijj. What I hadn't noticed, and what was to be a factor later, was that the procedure said to intercept the sfo-R101 to go to brijj and hold. At this point I had completely forgotten that if a missed approach is initiated early (before DH) the airplane should be flown to the missed approach point, at or above the DH or MDA, before initiating any turn for a missed approach procedure. So basically, we turned early on the missed. At no time, however, did we tune in the sfo VOR and attempt to intercept the sfo-R101. We just turned left and flew directly toward brijj, which was already tuned in the ADF. The tower pointed out some traffic to us but we were in the clouds and we advised that we were IMC. They handed us off to approach and we were vectored back for a different approach which we completed and landed west/O further incident. While we were taxiing in, the ground controller said he had a phone number for us to call bay approach when we got in. I was very concerned about this as I could not figure out what we had done wrong that would warrant a phone call to ATC. I then looked again at the missed approach procedure and this time I saw that we were supposed to intercept the sfo-R101 on the missed and now I knew what bay wanted to talk to me about. It turns out that our slightly early turn had caused a traffic conflict with a widebody transport which had just departed sfo from a runway which intersects the runway for which we were shooting the approach. The bay supervisor I talked with, however, said that at no time were legal sep minimums violated. Our early turn had just caused a few tense moments until they could turn the widebody transport away from us (he was on a different frequency than we were). I felt terrible. I could hardly believe that I had caused such a potentially serious problem. My first officer felt the same way. But as we analyzed the situation with the benefit of hindsight, we realized how close we must have been to the map when we did start our left turn, and it was probably less than a mi. It further appeared to us that even if we had flown to the map and then turned left there was a good chance we would still have had the conflict with the departing traffic because a left turn at that point is almost directly above the departure runway and a left turn parallels the departures. And we would have been at about 1500' MSL and climbing at that point, which would have been about where any departing jet would also be. The bay supervisor I talked to actually just wanted to know what instructions we had been given by the tower, as they were concerned that the tower had inadvertently turned us into the departing widebody transport. The supervisor very much sympathized with me, saying that unless a plane was actually flown somewhat past the map then the possibility of a conflict with departures was likely.

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Original NASA ASRS Text

Title: FLT CREW ON ILS APCH, INSIDE OUTER MARKER LOOSES LOCALIZER AND GLIDE SLOPE, DOES MAP, TURNS EARLY.

Narrative: ON THE ILS RWY 19L AT SFO. INSIDE THE OM, DSNDING THROUGH 1000' MSL. BOTH PLTS GOT RED FLAGS FOR BOTH LOC AND G/S (LOSS OF SIGNAL). ALSO LOST LOC DME. INITIATED MISSED APCH (BASICALLY CLBED STRAIGHT AHEAD WHILE CLEANING UP THE AIRPLANE). CALLED TWR, ADVISED LOSS OF SIGNAL AND MISSED APCH. TWR SAID ROGER, FLY PUBLISHED MISSED APCH. AT THIS POINT, I LOOKED DOWN AT THE APCH PLATE AND QUICKLY SCANNED THE MISSED APCH PROC. WE HAD ALREADY BRIEFED THE PROC DURING THE APCH AND THIS WAS JUST A QUICK RESCAN. SAW THAT IT CALLED FOR A CLBING L TURN TO GO THE BRIJJ LOM AND HOLD, CLBING TO 2000'. I TOLD THE F/O, WHO WAS FLYING, TO JUST MAKE A L TURN AND GO TO BRIJJ. WHAT I HADN'T NOTICED, AND WHAT WAS TO BE A FACTOR LATER, WAS THAT THE PROC SAID TO INTERCEPT THE SFO-R101 TO GO TO BRIJJ AND HOLD. AT THIS POINT I HAD COMPLETELY FORGOTTEN THAT IF A MISSED APCH IS INITIATED EARLY (BEFORE DH) THE AIRPLANE SHOULD BE FLOWN TO THE MISSED APCH POINT, AT OR ABOVE THE DH OR MDA, BEFORE INITIATING ANY TURN FOR A MISSED APCH PROC. SO BASICALLY, WE TURNED EARLY ON THE MISSED. AT NO TIME, HOWEVER, DID WE TUNE IN THE SFO VOR AND ATTEMPT TO INTERCEPT THE SFO-R101. WE JUST TURNED L AND FLEW DIRECTLY TOWARD BRIJJ, WHICH WAS ALREADY TUNED IN THE ADF. THE TWR POINTED OUT SOME TFC TO US BUT WE WERE IN THE CLOUDS AND WE ADVISED THAT WE WERE IMC. THEY HANDED US OFF TO APCH AND WE WERE VECTORED BACK FOR A DIFFERENT APCH WHICH WE COMPLETED AND LANDED W/O FURTHER INCIDENT. WHILE WE WERE TAXIING IN, THE GND CTLR SAID HE HAD A PHONE NUMBER FOR US TO CALL BAY APCH WHEN WE GOT IN. I WAS VERY CONCERNED ABOUT THIS AS I COULD NOT FIGURE OUT WHAT WE HAD DONE WRONG THAT WOULD WARRANT A PHONE CALL TO ATC. I THEN LOOKED AGAIN AT THE MISSED APCH PROC AND THIS TIME I SAW THAT WE WERE SUPPOSED TO INTERCEPT THE SFO-R101 ON THE MISSED AND NOW I KNEW WHAT BAY WANTED TO TALK TO ME ABOUT. IT TURNS OUT THAT OUR SLIGHTLY EARLY TURN HAD CAUSED A TFC CONFLICT WITH A WDB WHICH HAD JUST DEPARTED SFO FROM A RWY WHICH INTERSECTS THE RWY FOR WHICH WE WERE SHOOTING THE APCH. THE BAY SUPVR I TALKED WITH, HOWEVER, SAID THAT AT NO TIME WERE LEGAL SEP MINIMUMS VIOLATED. OUR EARLY TURN HAD JUST CAUSED A FEW TENSE MOMENTS UNTIL THEY COULD TURN THE WDB AWAY FROM US (HE WAS ON A DIFFERENT FREQ THAN WE WERE). I FELT TERRIBLE. I COULD HARDLY BELIEVE THAT I HAD CAUSED SUCH A POTENTIALLY SERIOUS PROB. MY F/O FELT THE SAME WAY. BUT AS WE ANALYZED THE SITUATION WITH THE BENEFIT OF HINDSIGHT, WE REALIZED HOW CLOSE WE MUST HAVE BEEN TO THE MAP WHEN WE DID START OUR L TURN, AND IT WAS PROBABLY LESS THAN A MI. IT FURTHER APPEARED TO US THAT EVEN IF WE HAD FLOWN TO THE MAP AND THEN TURNED L THERE WAS A GOOD CHANCE WE WOULD STILL HAVE HAD THE CONFLICT WITH THE DEPARTING TFC BECAUSE A L TURN AT THAT POINT IS ALMOST DIRECTLY ABOVE THE DEP RWY AND A L TURN PARALLELS THE DEPS. AND WE WOULD HAVE BEEN AT ABOUT 1500' MSL AND CLBING AT THAT POINT, WHICH WOULD HAVE BEEN ABOUT WHERE ANY DEPARTING JET WOULD ALSO BE. THE BAY SUPVR I TALKED TO ACTUALLY JUST WANTED TO KNOW WHAT INSTRUCTIONS WE HAD BEEN GIVEN BY THE TWR, AS THEY WERE CONCERNED THAT THE TWR HAD INADVERTENTLY TURNED US INTO THE DEPARTING WDB. THE SUPVR VERY MUCH SYMPATHIZED WITH ME, SAYING THAT UNLESS A PLANE WAS ACTUALLY FLOWN SOMEWHAT PAST THE MAP THEN THE POSSIBILITY OF A CONFLICT WITH DEPS WAS LIKELY.

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.