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|
Attributes | |
ACN | 151895 |
Time | |
Date | 199007 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ord |
State Reference | IL |
Altitude | msl bound lower : 4000 msl bound upper : 4400 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : ord tower : bwi |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | landing : missed approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 8000 flight time type : 300 |
ASRS Report | 151895 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
About 20 mi from ord approach control gave us 'fly heading 240 degree intercept the localizer 22R cleared for approach tower 126.9 at ridge.' it was my leg and I was flying the heading when I noticed the captain was changing the localizer frequency. When I asked him why he said we had a disagreement between the FMC selected runway and the localizer frequency selected. While we sorted out the source of the problem it became apparent that we were too high to land on 22R and declared a missed approach. During the climb out to 4000' the flight director disappeared from view and I climbed the aircraft to about 4400' before recovering to 4000'. I feel that in this case automation (or our less than optimum use of it) was a major factor. Fatigue was also a factor. The flight was from stockholm and I had been awake since late the previous evening chicago time. Callback conversation with reporter revealed the following: prior to departure from stockholm, the ILS approach for runway 22L had been loaded in the FMC. Upon arrival they were assigned runway 22R. The correct frequencys were loaded and the first officer was flying raw data when the disagreement warning appeared. Rather than ignore the map and concentrating on raw data, the captain was playing catch-up with the computer. It was decided to miss the approach. The first officer advanced the throttles manually and climbed from the approach. Therefore, the computer was still trying to fly the approach and not the missed approach. The altitude alerter was set to 4000' but the 1000 to go call was missed. The '10' (third pilot) was the first to notice the deviation.
Original NASA ASRS Text
Title: THE MISSED APCH ALT WAS OVERSHOT DURING A MISSED APCH AT ORD.
Narrative: ABOUT 20 MI FROM ORD APCH CTL GAVE US 'FLY HDG 240 DEG INTERCEPT THE LOC 22R CLRED FOR APCH TWR 126.9 AT RIDGE.' IT WAS MY LEG AND I WAS FLYING THE HDG WHEN I NOTICED THE CAPT WAS CHANGING THE LOC FREQ. WHEN I ASKED HIM WHY HE SAID WE HAD A DISAGREEMENT BTWN THE FMC SELECTED RWY AND THE LOC FREQ SELECTED. WHILE WE SORTED OUT THE SOURCE OF THE PROB IT BECAME APPARENT THAT WE WERE TOO HIGH TO LAND ON 22R AND DECLARED A MISSED APCH. DURING THE CLIMB OUT TO 4000' THE FLT DIRECTOR DISAPPEARED FROM VIEW AND I CLIMBED THE ACFT TO ABOUT 4400' BEFORE RECOVERING TO 4000'. I FEEL THAT IN THIS CASE AUTOMATION (OR OUR LESS THAN OPTIMUM USE OF IT) WAS A MAJOR FACTOR. FATIGUE WAS ALSO A FACTOR. THE FLT WAS FROM STOCKHOLM AND I HAD BEEN AWAKE SINCE LATE THE PREVIOUS EVENING CHICAGO TIME. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: PRIOR TO DEP FROM STOCKHOLM, THE ILS APCH FOR RWY 22L HAD BEEN LOADED IN THE FMC. UPON ARR THEY WERE ASSIGNED RWY 22R. THE CORRECT FREQS WERE LOADED AND THE F/O WAS FLYING RAW DATA WHEN THE DISAGREEMENT WARNING APPEARED. RATHER THAN IGNORE THE MAP AND CONCENTRATING ON RAW DATA, THE CAPT WAS PLAYING CATCH-UP WITH THE COMPUTER. IT WAS DECIDED TO MISS THE APCH. THE F/O ADVANCED THE THROTTLES MANUALLY AND CLIMBED FROM THE APCH. THEREFORE, THE COMPUTER WAS STILL TRYING TO FLY THE APCH AND NOT THE MISSED APCH. THE ALT ALERTER WAS SET TO 4000' BUT THE 1000 TO GO CALL WAS MISSED. THE '10' (THIRD PLT) WAS THE FIRST TO NOTICE THE DEVIATION.
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.