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|
Attributes | |
ACN | 150763 |
Time | |
Date | 199007 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : bna |
State Reference | TN |
Altitude | msl bound lower : 3000 msl bound upper : 3000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
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 | cruise other descent : approach |
Route In Use | approach : visual |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 175 flight time total : 6000 flight time type : 175 |
ASRS Report | 150763 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : declared emergency |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Narrative:
Nearing bowling green, ky, en route from pit to dfw, it became necessary to divert to bna for medical assistance for a passenger with a possible heart attack. An expedited descent from FL310 was started for bna which was approximately 50 NM away. Some descent vectoring was required in order to get down. This resulted in a planned visibility approach to runway 13. The problems began when, in an effort to shorten the approach, the turn in to final was started too early. The runway was sighted late and a safe landing could not be made because we were too high. Approach control was advised and a right 360 degree turn was started about 2 miles on final. Nearing 90 degree of turn, approach control asked if we would rather have runway 20. Rolling wings level, the field was still in sight to the left although the haze looking into the sun was reducing visibility. The controller was advised that runway 20 would be fine and a left base turn was started. About halfway into the turn, we realized the controller had been saying runway 20 not 02 which we were planning to land on. Tense communications ping-ponged back and forth until the confusion was resolved and a landing was made on runway 02. Contributing factors/perceptions. Crew rest. Although on paper we had had proper rest, this was the 3RD day of a 3 day sequence requiring xb:00 (body time) arrivals. I feel that inadequate quality rest contributed to some poor judgement decisions as well as becoming task saturated at times during the approach. Visibility. The 6 miles and haze visibility turned out to be significantly worse when looking into the morning sun. The obscured landmarks used to orient myself for the approach. Lessons learned. Being new to the aircraft, you don't have a great deal of experience on which to base your flight parameter judgements. This, I feel, is what started the chain of events. There were 2 other times when, if I had heeded to my 'gut' feeling, the whole situation could have been avoided. The first was accepting a non-precision approach to visibility condition on runway 13. The visibility was not good and an ILS was available for runway 20/02. Second, when a safe landing could not be made on runway 13, my plan was to make a 360 degree descending turn and land. I allowed myself to be talked out of a safe conservative plan and to be overloaded setting up for a landing on a new runway. Callback conversation with reporter revealed the following: reporter had little to add except that he had a plan of action and the unsolicited offer of other options given him by the controller caught him off guard. He was not trying to transfer blame, just point out that in his haste and due to fatigue he became befuddled.
Original NASA ASRS Text
Title: DURING DIVERSION FOR A PASSENGER MEDICAL EMERGENCY, MLG BEGINS APCH TO WRONG RWY CAUSING CONFLICT.
Narrative: NEARING BOWLING GREEN, KY, ENRTE FROM PIT TO DFW, IT BECAME NECESSARY TO DIVERT TO BNA FOR MEDICAL ASSISTANCE FOR A PAX WITH A POSSIBLE HEART ATTACK. AN EXPEDITED DSNT FROM FL310 WAS STARTED FOR BNA WHICH WAS APPROX 50 NM AWAY. SOME DSNT VECTORING WAS REQUIRED IN ORDER TO GET DOWN. THIS RESULTED IN A PLANNED VIS APCH TO RWY 13. THE PROBS BEGAN WHEN, IN AN EFFORT TO SHORTEN THE APCH, THE TURN IN TO FINAL WAS STARTED TOO EARLY. THE RWY WAS SIGHTED LATE AND A SAFE LNDG COULD NOT BE MADE BECAUSE WE WERE TOO HIGH. APCH CTL WAS ADVISED AND A R 360 DEG TURN WAS STARTED ABOUT 2 MILES ON FINAL. NEARING 90 DEG OF TURN, APCH CTL ASKED IF WE WOULD RATHER HAVE RWY 20. ROLLING WINGS LEVEL, THE FIELD WAS STILL IN SIGHT TO THE L ALTHOUGH THE HAZE LOOKING INTO THE SUN WAS REDUCING VISIBILITY. THE CTLR WAS ADVISED THAT RWY 20 WOULD BE FINE AND A L BASE TURN WAS STARTED. ABOUT HALFWAY INTO THE TURN, WE REALIZED THE CTLR HAD BEEN SAYING RWY 20 NOT 02 WHICH WE WERE PLANNING TO LAND ON. TENSE COMS PING-PONGED BACK AND FORTH UNTIL THE CONFUSION WAS RESOLVED AND A LNDG WAS MADE ON RWY 02. CONTRIBUTING FACTORS/PERCEPTIONS. CREW REST. ALTHOUGH ON PAPER WE HAD HAD PROPER REST, THIS WAS THE 3RD DAY OF A 3 DAY SEQUENCE REQUIRING XB:00 (BODY TIME) ARRIVALS. I FEEL THAT INADEQUATE QUALITY REST CONTRIBUTED TO SOME POOR JUDGEMENT DECISIONS AS WELL AS BECOMING TASK SATURATED AT TIMES DURING THE APCH. VISIBILITY. THE 6 MILES AND HAZE VISIBILITY TURNED OUT TO BE SIGNIFICANTLY WORSE WHEN LOOKING INTO THE MORNING SUN. THE OBSCURED LANDMARKS USED TO ORIENT MYSELF FOR THE APCH. LESSONS LEARNED. BEING NEW TO THE ACFT, YOU DON'T HAVE A GREAT DEAL OF EXPERIENCE ON WHICH TO BASE YOUR FLT PARAMETER JUDGEMENTS. THIS, I FEEL, IS WHAT STARTED THE CHAIN OF EVENTS. THERE WERE 2 OTHER TIMES WHEN, IF I HAD HEEDED TO MY 'GUT' FEELING, THE WHOLE SITUATION COULD HAVE BEEN AVOIDED. THE FIRST WAS ACCEPTING A NON-PRECISION APCH TO VIS CONDITION ON RWY 13. THE VISIBILITY WAS NOT GOOD AND AN ILS WAS AVAILABLE FOR RWY 20/02. SECOND, WHEN A SAFE LNDG COULD NOT BE MADE ON RWY 13, MY PLAN WAS TO MAKE A 360 DEG DSNDING TURN AND LAND. I ALLOWED MYSELF TO BE TALKED OUT OF A SAFE CONSERVATIVE PLAN AND TO BE OVERLOADED SETTING UP FOR A LNDG ON A NEW RWY. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: RPTR HAD LITTLE TO ADD EXCEPT THAT HE HAD A PLAN OF ACTION AND THE UNSOLICITED OFFER OF OTHER OPTIONS GIVEN HIM BY THE CTLR CAUGHT HIM OFF GUARD. HE WAS NOT TRYING TO TRANSFER BLAME, JUST POINT OUT THAT IN HIS HASTE AND DUE TO FATIGUE HE BECAME BEFUDDLED.
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.