37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 163552 |
Time | |
Date | 199011 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : pdx |
State Reference | OR |
Altitude | msl bound lower : 7000 msl bound upper : 7000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : pdx artcc : zla |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other descent : approach descent other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : atp pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 180 flight time total : 3000 flight time type : 1000 |
ASRS Report | 163552 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During arrival at pdx we receive ATIS information indicating strong gusty winds requiring us to use a localizer DME approach to the shortest runway (20) at portland. This approach and this runway had never been used by any of the crew members on board, therefore, with potential windshear conditions indicated and other negative WX conditions present, attention unwittingly began to focus on the care needed during the final phases of the approach. The arrival proceeded normally with a clearance direct to the pdx VOR followed by vectors for a set up to the final course. We departed the VOR on a vector with the first officer flying the approach. The captain dialed in the localizer frequency and the inbound course then checked the identifier. This looked good so the first officer changed to the localizer frequency but being engaged in a series of vectors, trying to get lower altitudes and focusing on what was required with the short runway and gusty winds the localizer course was not set on the first officer side. The approach checklist was run but this omission was overlooked by, I think, attention running ahead to the final crucial phase of the approach. An intercept vector was given and the first officer remarked that the intercept angle was rather extreme. A sense of 'something does not seem right' was in the cockpit but the error was not spotted. The turn to intercept the wrong course immediately alerted a sharp and quick acting controller who asked if we had the right frequency for localizer DME 20. This question along with the previously mentioned 'sense', which had already started a scan for problems, alerted us to the incorrect localizer course. We inserted the correct course and answered the controller that we had the proper frequency. The controller immediately turned us to a new intercept heading and west/O missing a beat we were established on the localizer and completed the approach to landing. We did indeed experience a decreasing performance shear of 10-15 KTS during the last mi (crossing over the columbia river). I think this error was founded in looking too intently past one phase of an approach to another. We must always look and plan ahead but not to the point of losing sight of the here and now. Secondly, when a checklist is run we must always be on guard to just responding for the condition on 'my' side of the cockpit. Ultimately, the system worked, an alert controller asked questions in a timely manner that kept the situation from becoming serious. We must not focus on any one phase to the point of blindness.
Original NASA ASRS Text
Title: ACR WDB TRACK HEADING DEVIATION WHILE ON VECTORS TO FINAL FOR IAP LOC APCH.
Narrative: DURING ARR AT PDX WE RECEIVE ATIS INFO INDICATING STRONG GUSTY WINDS REQUIRING US TO USE A LOC DME APCH TO THE SHORTEST RWY (20) AT PORTLAND. THIS APCH AND THIS RWY HAD NEVER BEEN USED BY ANY OF THE CREW MEMBERS ON BOARD, THEREFORE, WITH POTENTIAL WINDSHEAR CONDITIONS INDICATED AND OTHER NEGATIVE WX CONDITIONS PRESENT, ATTN UNWITTINGLY BEGAN TO FOCUS ON THE CARE NEEDED DURING THE FINAL PHASES OF THE APCH. THE ARR PROCEEDED NORMALLY WITH A CLRNC DIRECT TO THE PDX VOR FOLLOWED BY VECTORS FOR A SET UP TO THE FINAL COURSE. WE DEPARTED THE VOR ON A VECTOR WITH THE F/O FLYING THE APCH. THE CAPT DIALED IN THE LOC FREQ AND THE INBND COURSE THEN CHKED THE IDENTIFIER. THIS LOOKED GOOD SO THE F/O CHANGED TO THE LOC FREQ BUT BEING ENGAGED IN A SERIES OF VECTORS, TRYING TO GET LOWER ALTS AND FOCUSING ON WHAT WAS REQUIRED WITH THE SHORT RWY AND GUSTY WINDS THE LOC COURSE WAS NOT SET ON THE F/O SIDE. THE APCH CHKLIST WAS RUN BUT THIS OMISSION WAS OVERLOOKED BY, I THINK, ATTN RUNNING AHEAD TO THE FINAL CRUCIAL PHASE OF THE APCH. AN INTERCEPT VECTOR WAS GIVEN AND THE F/O REMARKED THAT THE INTERCEPT ANGLE WAS RATHER EXTREME. A SENSE OF 'SOMETHING DOES NOT SEEM R' WAS IN THE COCKPIT BUT THE ERROR WAS NOT SPOTTED. THE TURN TO INTERCEPT THE WRONG COURSE IMMEDIATELY ALERTED A SHARP AND QUICK ACTING CTLR WHO ASKED IF WE HAD THE R FREQ FOR LOC DME 20. THIS QUESTION ALONG WITH THE PREVIOUSLY MENTIONED 'SENSE', WHICH HAD ALREADY STARTED A SCAN FOR PROBS, ALERTED US TO THE INCORRECT LOC COURSE. WE INSERTED THE CORRECT COURSE AND ANSWERED THE CTLR THAT WE HAD THE PROPER FREQ. THE CTLR IMMEDIATELY TURNED US TO A NEW INTERCEPT HDG AND W/O MISSING A BEAT WE WERE ESTABLISHED ON THE LOC AND COMPLETED THE APCH TO LNDG. WE DID INDEED EXPERIENCE A DECREASING PERFORMANCE SHEAR OF 10-15 KTS DURING THE LAST MI (XING OVER THE COLUMBIA RIVER). I THINK THIS ERROR WAS FOUNDED IN LOOKING TOO INTENTLY PAST ONE PHASE OF AN APCH TO ANOTHER. WE MUST ALWAYS LOOK AND PLAN AHEAD BUT NOT TO THE POINT OF LOSING SIGHT OF THE HERE AND NOW. SECONDLY, WHEN A CHKLIST IS RUN WE MUST ALWAYS BE ON GUARD TO JUST RESPONDING FOR THE CONDITION ON 'MY' SIDE OF THE COCKPIT. ULTIMATELY, THE SYS WORKED, AN ALERT CTLR ASKED QUESTIONS IN A TIMELY MANNER THAT KEPT THE SITUATION FROM BECOMING SERIOUS. WE MUST NOT FOCUS ON ANY ONE PHASE TO THE POINT OF BLINDNESS.
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.