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|
Attributes | |
ACN | 157162 |
Time | |
Date | 199009 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sju |
State Reference | PR |
Altitude | msl bound lower : 3000 msl bound upper : 3000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : sju tower : stl |
Operator | common carrier : air carrier |
Make Model Name | Heavy Transport, Low Wing, 4 Turbojet Eng |
Flight Phase | descent other landing other |
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 : 123 flight time total : 4500 flight time type : 1500 |
ASRS Report | 157162 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While being vectored to the airport, approach control advised us to expect a lagoon visibility approach to runway 8. I rogered the information and started flipping through my manual to find the approach plate for this to check his manual for the approach plate. He did not have it either. Approach control then cleared us for the lagoon visibility approach to runway 8 and I acknowledged only that we were cleared for a visibility approach to runway 8. I could clearly see the airport in front of us about 6 NM away as we flew a heading of 040 degree to intercept the localizer for an ILS final to runway 8. I was puzzled by the terminology the approach controller was using and was unsure whether he was clearing us for a published approach or simply a visibility approach to runway 8. We continued our track and intercepted the localizer for runway 8 at the OM and were handed off to tower. We landed west/O further incident. After landing I called approach control on the telephone to find out if our clearance was for a published approach. I could not believe that both the first officer and I were both missing the same approach plate. The approach personnel assured me that the approach was indeed a published one. The outbnd company crew walked through the door as I was speaking on the telephone to approach. They showed me their copy of the approach plate and I told approach that we would burn a copy of the plate for the first officer and myself and I hung up. The net result of our deviation from the assigned approach was a flight track to the south of the desired track. I estimate that we may have been as much as 2 mi south of the lagoon visibility approach track as we flew over a built up and populated area. This entire incident would have been avoided if I had confessed immediately that we did not have an approach plate for the assigned approach. I should have simply requested vectors or a visibility approach. In our defense at that moment we had been on duty almost 12 hours since starting the duty period the previous evening. We were all tired and I wasn't thinking very quickly. My fatigue was beginning to show in my reduced level of alertness. Furthermore, as I later looked at the approach plate, I noticed that the missing plate and a recent plate change for sju had very similar numbers. One was numbered 19-1 and the other 19-11. I believe that both the first officer and I inadvertently threw out the lagoon visibility approach plate when the 19-11 approach plate had a revision.
Original NASA ASRS Text
Title: ACR HVT ACCEPTED A ICLRNC FOR A CHARTED VISUAL NTO SJU BUT THE CHARTS DETAILING THE PROC WERE NOT AVAILABLE IN THE COCKPIT. THE FLT CREW HAD THROWN THEM OUT WHEN MAKING A MANUAL REVISION.
Narrative: WHILE BEING VECTORED TO THE ARPT, APCH CTL ADVISED US TO EXPECT A LAGOON VIS APCH TO RWY 8. I ROGERED THE INFO AND STARTED FLIPPING THROUGH MY MANUAL TO FIND THE APCH PLATE FOR THIS TO CHK HIS MANUAL FOR THE APCH PLATE. HE DID NOT HAVE IT EITHER. APCH CTL THEN CLRED US FOR THE LAGOON VIS APCH TO RWY 8 AND I ACKNOWLEDGED ONLY THAT WE WERE CLRED FOR A VIS APCH TO RWY 8. I COULD CLRLY SEE THE ARPT IN FRONT OF US ABOUT 6 NM AWAY AS WE FLEW A HDG OF 040 DEG TO INTERCEPT THE LOC FOR AN ILS FINAL TO RWY 8. I WAS PUZZLED BY THE TERMINOLOGY THE APCH CTLR WAS USING AND WAS UNSURE WHETHER HE WAS CLRING US FOR A PUBLISHED APCH OR SIMPLY A VIS APCH TO RWY 8. WE CONTINUED OUR TRACK AND INTERCEPTED THE LOC FOR RWY 8 AT THE OM AND WERE HANDED OFF TO TWR. WE LANDED W/O FURTHER INCIDENT. AFTER LNDG I CALLED APCH CTL ON THE TELEPHONE TO FIND OUT IF OUR CLRNC WAS FOR A PUBLISHED APCH. I COULD NOT BELIEVE THAT BOTH THE F/O AND I WERE BOTH MISSING THE SAME APCH PLATE. THE APCH PERSONNEL ASSURED ME THAT THE APCH WAS INDEED A PUBLISHED ONE. THE OUTBND COMPANY CREW WALKED THROUGH THE DOOR AS I WAS SPEAKING ON THE TELEPHONE TO APCH. THEY SHOWED ME THEIR COPY OF THE APCH PLATE AND I TOLD APCH THAT WE WOULD BURN A COPY OF THE PLATE FOR THE F/O AND MYSELF AND I HUNG UP. THE NET RESULT OF OUR DEV FROM THE ASSIGNED APCH WAS A FLT TRACK TO THE S OF THE DESIRED TRACK. I ESTIMATE THAT WE MAY HAVE BEEN AS MUCH AS 2 MI S OF THE LAGOON VIS APCH TRACK AS WE FLEW OVER A BUILT UP AND POPULATED AREA. THIS ENTIRE INCIDENT WOULD HAVE BEEN AVOIDED IF I HAD CONFESSED IMMEDIATELY THAT WE DID NOT HAVE AN APCH PLATE FOR THE ASSIGNED APCH. I SHOULD HAVE SIMPLY REQUESTED VECTORS OR A VIS APCH. IN OUR DEFENSE AT THAT MOMENT WE HAD BEEN ON DUTY ALMOST 12 HRS SINCE STARTING THE DUTY PERIOD THE PREVIOUS EVENING. WE WERE ALL TIRED AND I WASN'T THINKING VERY QUICKLY. MY FATIGUE WAS BEGINNING TO SHOW IN MY REDUCED LEVEL OF ALERTNESS. FURTHERMORE, AS I LATER LOOKED AT THE APCH PLATE, I NOTICED THAT THE MISSING PLATE AND A RECENT PLATE CHANGE FOR SJU HAD VERY SIMILAR NUMBERS. ONE WAS NUMBERED 19-1 AND THE OTHER 19-11. I BELIEVE THAT BOTH THE F/O AND I INADVERTENTLY THREW OUT THE LAGOON VIS APCH PLATE WHEN THE 19-11 APCH PLATE HAD A REVISION.
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.