37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1594608 |
Time | |
Date | 201811 |
Local Time Of Day | 0001-0600 |
Place | |
Locale Reference | MEM.Airport |
State Reference | TN |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Make Model Name | Medium Large Transport Low Wing 2 Turbojet Eng |
Operating Under FAR Part | Part 91 |
Flight Phase | Final Approach |
Route In Use | STAR BRBBQ3 |
Flight Plan | IFR |
Person 1 | |
Function | Pilot Flying First Officer |
Qualification | Flight Crew Multiengine Flight Crew Flight Instructor Flight Crew Instrument Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 50 Flight Crew Total 5400 Flight Crew Type 950 |
Events | |
Anomaly | Deviation - Altitude Overshoot Deviation - Procedural Published Material / Policy Deviation - Procedural Clearance Flight Deck / Cabin / Aircraft Event Other / Unknown |
Narrative:
After a long duty day; I was flying the ILS 36C into mem in IMC conditions. My [captain] was the non-flying pilot (will be referred to as nfp here on out) in the right seat. Before we even got established on the final approach; he was making mistakes in the FMS: while on a vectored downwind; hearing everyone else being cleared for the approach via the initial fix; the nfp activated vectors in the FMS; which would only give us guidance for the final fix. Of course when cleared to the initial fix; he had to scramble to put the approach back in the FMS to include that way point. This is relevant to show that his actions and time management were poor consistently before; during; and after the approach(s). Finally established on a stabilized final approach; fully configured and in trail of [another] arrival; mem tower issues a go around for spacing. The command was 'climb 2000 feet; turn heading 270...' the nfp returned the radio call improperly missing the heading instruction. As I initiate the coupled go around and proceed to ask for the first flap reduction and gear retraction around 1500 feet MSL; the tower calls to confirm the wrong read back; to which he responds with the heading; but has completely disregarded the critical timing in this moment. I needed him to do his duties in the go-around transition regarding the configuration change; and set the guidance panel appropriately. He never changed the altitude selector from a previously set 4000 feet; to the tower assigned 2000 feet; and was talking on the radio for several seconds while the aircraft was pitching up and accelerating rapidly in the go-around. When the second tower call came; he should have remained available to me for just 1 or 2 seconds to perform the configuration and guidance panel changes. However with him on the radio my words to call for flaps and gear were never heard. More importantly; the autopilot coupled go-around pitched up and began a climb for 4000 feet rather than 2000 feet. In those moments I did not notice the nfp never reset the altitude for 2000 feet. I saw the pitch combination with the short climb to 2000 feet as a mismatch and an issue; but by the time I disconnected the autopilot and nosed it down; the aircraft had reached 2000 feet; and did not stop climbing until 2300 feet. Tower then assigned 3000 feet and switched us to approach control. The second approach was successful without problems.there is a personality issue underlying here that is difficult to explain. However for research purposes I want to mention those details; not as slander but as relevant information for safety. The nfp has the hazardous attitudes of macho pilot; rogue pilot; and a general inflated sense of self. Between myself and a third [highly experienced captain]; the nfp I am referring to does not play the right seat well; showing a lack of crew concept; lack of trust in the flying pilot; and distracts himself with unnecessary babysitting. For example; somewhere in the volley of tower/plane calls initiating the go around; rather than listen to my commands for flaps; or rather than pause on the radio to help with the go around; he chose to spend several seconds on the radio during the transition of a couple go-around; and only broke the call for a half-second to tell me 'watch your speed...' while my speed was absolutely appropriate for the phase of flight. He must have wanted a higher speed in his mind; but until the configuration is changed; the speed was not to change either. His pilot skills are good; but he has failed to get up to speed on the [aircraft] system; the automation; and adapt a crew concept in this airplane since the company's [other aircraft; of a different manufacturer] was replaced years ago. My best interpretation is that he expected me to disconnect the autopilot and manually fly the go-around; in which case I may have climbed at a lesser rate and stopped at the correct altitude. However; in this airplane; while flying an autopilot coupled approach in IMC; not only is a coupled go-around encouraged; but it is considered standard; at least in the [years of flight and sim training and flight reviews I've done]. Minus the altitude bust; this type of scenario has played out almost the same way every other time we've had to go missed or go-around. He has shown a blatant disregard for this aircraft's limitations; best practices; and safety protocols. He 'wings it' based on his previous knowledge; and it leads to messy operations such as this. I take responsibility for not seeing the issues quick enough to better manage the situation; but I feel this person constantly deals you a bad hand. Authoritative; rogue pilot; macho attitude; inflated ego; above the law - these attitudes have been the cause of multiple situations of similar significance as this. This is a perfect scenario where the 'holes in the swiss cheese line up.' people like this are a danger to the operation; and I hope that there one day be a personality test requirement to help better navigate this issue in our industry. Thank you.
Original NASA ASRS Text
Title: Corporate First Officer reported an altitude deviation during go-around were attributed to serious CRM and SOP issues within the cockpit environment.
Narrative: After a long duty day; I was flying the ILS 36C into MEM in IMC conditions. My [Captain] was the Non-Flying Pilot (will be referred to as NFP here on out) in the right seat. Before we even got established on the final approach; he was making mistakes in the FMS: while on a vectored downwind; hearing everyone else being cleared for the approach via the INITIAL fix; the NFP activated vectors in the FMS; which would only give us guidance for the FINAL fix. Of course when cleared to the initial fix; he had to scramble to put the approach back in the FMS to include that way point. This is relevant to show that his actions and time management were poor consistently before; during; and after the approach(s). Finally established on a stabilized final approach; fully configured and in trail of [another] arrival; MEM tower issues a go around for spacing. The command was 'climb 2000 feet; turn heading 270...' The NFP returned the radio call improperly missing the heading instruction. As I initiate the coupled go around and proceed to ask for the first flap reduction and gear retraction around 1500 feet MSL; the tower calls to confirm the wrong read back; to which he responds with the heading; but has completely disregarded the critical timing in this moment. I needed him to do his duties in the go-around transition regarding the configuration change; and set the guidance panel appropriately. He never changed the Altitude Selector from a previously set 4000 feet; to the tower assigned 2000 feet; and was talking on the radio for several seconds while the aircraft was pitching up and accelerating rapidly in the go-around. When the second tower call came; he should have remained available to me for just 1 or 2 seconds to perform the configuration and guidance panel changes. However with him on the radio my words to call for flaps and gear were never heard. More importantly; the autopilot coupled go-around pitched up and began a climb for 4000 feet rather than 2000 feet. In those moments I did not notice the NFP never reset the altitude for 2000 feet. I saw the pitch combination with the short climb to 2000 feet as a mismatch and an issue; but by the time I disconnected the autopilot and nosed it down; the aircraft had reached 2000 feet; and did not stop climbing until 2300 feet. Tower then assigned 3000 feet and switched us to approach control. The second approach was successful without problems.There is a personality issue underlying here that is difficult to explain. However for research purposes I want to mention those details; not as slander but as relevant information for safety. The NFP has the hazardous attitudes of macho pilot; rogue pilot; and a general inflated sense of self. Between myself and a third [highly experienced Captain]; the NFP I am referring to does not play the right seat well; showing a lack of crew concept; lack of trust in the flying pilot; and distracts himself with unnecessary babysitting. For example; somewhere in the volley of tower/plane calls initiating the go around; rather than listen to my commands for flaps; or rather than pause on the radio to help with the go around; he chose to spend several seconds on the radio during the transition of a couple go-around; and only broke the call for a half-second to tell me 'watch your speed...' while my speed was absolutely appropriate for the phase of flight. He must have wanted a higher speed in his mind; but until the configuration is changed; the speed was not to change either. His pilot skills are good; but he has failed to get up to speed on the [aircraft] system; the automation; and adapt a crew concept in THIS airplane since the company's [other aircraft; of a different manufacturer] was replaced years ago. My best interpretation is that he expected me to disconnect the autopilot and manually fly the go-around; in which case I may have climbed at a lesser rate and stopped at the correct altitude. However; in this airplane; while flying an autopilot coupled approach in IMC; not only is a coupled go-around encouraged; but it is considered standard; at least in the [years of flight and sim training and flight reviews I've done]. Minus the altitude bust; this type of scenario has played out almost the same way every other time we've had to go missed or go-around. He has shown a blatant disregard for this aircraft's limitations; best practices; and safety protocols. He 'wings it' based on his previous knowledge; and it leads to messy operations such as this. I take responsibility for not seeing the issues quick enough to better manage the situation; but I feel this person constantly deals you a bad hand. Authoritative; rogue pilot; macho attitude; inflated ego; above the law - these attitudes have been the cause of multiple situations of similar significance as this. This is a perfect scenario where the 'holes in the Swiss cheese line up.' People like this are a danger to the operation; and I hope that there one day be a personality test requirement to help better navigate this issue in our industry. Thank you.
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.