Flight crew of medium large transport programmed for 26L was changed to 26R visual then, close in, c...

Attributes
ACN	163469
Time
Date	199011
Day	Fri
Local Time Of Day	1201 To 1800
Place
Locale Reference	airport : ont
State Reference	CA
Altitude	msl bound lower : 1600 msl bound upper : 1600
Environment
Flight Conditions	IMC
Light	Daylight
Aircraft 1
Controlling Facilities	tracon : ont
Operator	common carrier : air carrier
Make Model Name	Medium Large Transport, Low Wing, 2 Turbojet Eng
Navigation In Use	Other Other
Flight Phase	descent : approach descent other landing : go around
Route In Use	arrival other enroute : on vectors
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Qualification	pilot : instrument pilot : flight engineer pilot : commercial pilot : atp
Experience	flight time last 90 days : 210 flight time total : 16214 flight time type : 2001
ASRS Report	163469
Person 2
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : instrument pilot : flight engineer pilot : commercial pilot : atp pilot : cfi
Experience	flight time last 90 days : 20 flight time total : 2930 flight time type : 20
ASRS Report	163244
Events
Anomaly	altitude deviation : overshoot other spatial deviation
Independent Detector	other controllera other flight crewa
Resolutory Action	other
Consequence	Other
Supplementary
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

Scheduled air carrier flight, san francisco to ontario, ca. Conducting an IOE for a new first officer. We programmed the FMS, planning the ILS 26L as indicated by ont ATIS. The 26L approach procedure was briefed, VHF/navigation's tuned, idented and set. Special note was made of the high terrain in the area. The first officer was flying the airplane. Before we got to petis, ont approach changed our clearance and vectored us for an ILS 26L because, they said, the field was now IFR. We intercepted the localizer just inside petis with all ILS indications normal. Ont approach cleared us to ont tower as we lowered the gear, set flaps 25 and were accomplishing the final descent checklist. It took two attempts before ont tower acknowledged our call. By this time I realized that the FMS had not captured the G/south and we were passing fonta lower than the published altitude. I took control of the airplane from the first officer and advanced the power for a go around. At that time ont tower asked us about our altitude. I replied 1660', and the tower ordered missed approach instructions. We informed them that we were making a missed approach to their heading and altitude. The problem evolved because of the changes from ILS 26L, to visibility 26R and then to the ILS 26L issued by ont approach so close to the airport and at such low altitude. This more than tripled the workload for two pilots to coordination the changes in the cockpit, set up for the approach as cleared, and make the necessary communications and maintain the integrity of checklists and SOP's. This incident could have been avoided in several ways, including my not accepting the clearance for a visibility to runway 26R. The ziggy arrival to an ILS 26L under normal conditions is complicated and involves numerous navigational radio changes. Changing from an ILS to another runway visibility and then back to the ILS of the first runway, under these conditions, should be avoided by pilots, and by approach control.

Original NASA ASRS Text

Title: FLT CREW OF MLG PROGRAMMED FOR 26L WAS CHANGED TO 26R VISUAL THEN, CLOSE IN, CHANGED BACK TO 26L. FLT CREW DESCENDED BELOW APCH PATH AND MADE A GO AROUND.

Narrative: SCHEDULED AIR CARRIER FLT, SAN FRANCISCO TO ONTARIO, CA. CONDUCTING AN IOE FOR A NEW F/O. WE PROGRAMMED THE FMS, PLANNING THE ILS 26L AS INDICATED BY ONT ATIS. THE 26L APCH PROC WAS BRIEFED, VHF/NAV'S TUNED, IDENTED AND SET. SPECIAL NOTE WAS MADE OF THE HIGH TERRAIN IN THE AREA. THE F/O WAS FLYING THE AIRPLANE. BEFORE WE GOT TO PETIS, ONT APCH CHANGED OUR CLRNC AND VECTORED US FOR AN ILS 26L BECAUSE, THEY SAID, THE FIELD WAS NOW IFR. WE INTERCEPTED THE LOC JUST INSIDE PETIS WITH ALL ILS INDICATIONS NORMAL. ONT APCH CLRED US TO ONT TWR AS WE LOWERED THE GEAR, SET FLAPS 25 AND WERE ACCOMPLISHING THE FINAL DSNT CHKLIST. IT TOOK TWO ATTEMPTS BEFORE ONT TWR ACKNOWLEDGED OUR CALL. BY THIS TIME I REALIZED THAT THE FMS HAD NOT CAPTURED THE G/S AND WE WERE PASSING FONTA LOWER THAN THE PUBLISHED ALT. I TOOK CTL OF THE AIRPLANE FROM THE F/O AND ADVANCED THE PWR FOR A GO AROUND. AT THAT TIME ONT TWR ASKED US ABOUT OUR ALT. I REPLIED 1660', AND THE TWR ORDERED MISSED APCH INSTRUCTIONS. WE INFORMED THEM THAT WE WERE MAKING A MISSED APCH TO THEIR HDG AND ALT. THE PROB EVOLVED BECAUSE OF THE CHANGES FROM ILS 26L, TO VIS 26R AND THEN TO THE ILS 26L ISSUED BY ONT APCH SO CLOSE TO THE ARPT AND AT SUCH LOW ALT. THIS MORE THAN TRIPLED THE WORKLOAD FOR TWO PLTS TO COORD THE CHANGES IN THE COCKPIT, SET UP FOR THE APCH AS CLRED, AND MAKE THE NECESSARY COMS AND MAINTAIN THE INTEGRITY OF CHKLISTS AND SOP'S. THIS INCIDENT COULD HAVE BEEN AVOIDED IN SEVERAL WAYS, INCLUDING MY NOT ACCEPTING THE CLRNC FOR A VIS TO RWY 26R. THE ZIGGY ARR TO AN ILS 26L UNDER NORMAL CONDITIONS IS COMPLICATED AND INVOLVES NUMEROUS NAVIGATIONAL RADIO CHANGES. CHANGING FROM AN ILS TO ANOTHER RWY VIS AND THEN BACK TO THE ILS OF THE FIRST RWY, UNDER THESE CONDITIONS, SHOULD BE AVOIDED BY PLTS, AND BY APCH CTL.

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.

Flight crew of medium large transport programmed for 26L was changed to 26R visual then, close in, changed back to 26L. Flight crew descended below approach path and made a go around.