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|
Attributes | |
ACN | 168334 |
Time | |
Date | 199101 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : alw |
State Reference | WA |
Altitude | msl bound lower : 3200 msl bound upper : 3700 |
Environment | |
Flight Conditions | Marginal |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zse |
Operator | common carrier : air carrier |
Make Model Name | Medium Transport, High Wing, 2 Turboprop Eng |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 120 flight time total : 2885 flight time type : 550 |
ASRS Report | 168334 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : published procedure |
Independent Detector | atc equipment other atc equipment : unspecified other controllera |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On third leg of the second night of a continuous duty overnight, we (flight) were cleared for an approach to alw approximately 18 NM west on V520. We descended to the MEA which is 3200' MSL. At approximately 4 mi from alw VOR we determined that we would execute the full procedure turn rather than requesting the visibility approach. The visibility approach may or may not have been possible. We remained at 3200' during the transition to the LOM and alw radio inquired for sea center as to why we were not at 3700' as published. We immediately climbed to 3700' during our procedure turn and continued a normal ILS runway 20 approach to alw. We were in VMC from the VOR outbnd, throughout the procedure turn, and ibnd from the FAF, except momentarily passing through a scattered layer. Some factors: throughout the whole procedure we had visibility contact with the ground. The captain and I were extremely fatigued due to common scheduling practices by the company. This was second night of the cdo. I had 3 hours of sleep the night before, 3 hours during the day. The captain had a similar amount. The captain (a former sea center controller) had a heated argument with crew scheduling earlier in the evening. Personal opinions: the altitude deviation was our mistake. Mistakes like these are brought on by fatigue and stress. There have been numerous (dozens) reports within the company of missed altitudes, deviations, calling unseen traffic, missed clrncs, blurred vision, etc, all of which point to future incidents, and the potential inability to respond to an emergency. This is not an isolated event. I have been coerced to fly after 16 hours on duty. Specifically, others have flown after 18, 22, 23, 28, and 33 hours on duty. These flts, however, did not carry passengers, but safety is certainly compromised. Callback conversation with reporter revealed the following information. Reporter does not deny that the altitude deviation was the flight crew's fault. He believes this and many other flight crew errors are caused by fatigue, fatigue that results from the air carrier's misinterp of the FARS and coercing the flight crews to remain on duty well beyond any reasonable amount of time.
Original NASA ASRS Text
Title: MDT BEGAN PROC TURN 500' BELOW PRESCRIBED ALT.
Narrative: ON THIRD LEG OF THE SEC NIGHT OF A CONTINUOUS DUTY OVERNIGHT, WE (FLT) WERE CLRED FOR AN APCH TO ALW APPROX 18 NM W ON V520. WE DSNDED TO THE MEA WHICH IS 3200' MSL. AT APPROX 4 MI FROM ALW VOR WE DETERMINED THAT WE WOULD EXECUTE THE FULL PROC TURN RATHER THAN REQUESTING THE VIS APCH. THE VIS APCH MAY OR MAY NOT HAVE BEEN POSSIBLE. WE REMAINED AT 3200' DURING THE TRANSITION TO THE LOM AND ALW RADIO INQUIRED FOR SEA CTR AS TO WHY WE WERE NOT AT 3700' AS PUBLISHED. WE IMMEDIATELY CLBED TO 3700' DURING OUR PROC TURN AND CONTINUED A NORMAL ILS RWY 20 APCH TO ALW. WE WERE IN VMC FROM THE VOR OUTBND, THROUGHOUT THE PROC TURN, AND IBND FROM THE FAF, EXCEPT MOMENTARILY PASSING THROUGH A SCATTERED LAYER. SOME FACTORS: THROUGHOUT THE WHOLE PROC WE HAD VIS CONTACT WITH THE GND. THE CAPT AND I WERE EXTREMELY FATIGUED DUE TO COMMON SCHEDULING PRACTICES BY THE COMPANY. THIS WAS SEC NIGHT OF THE CDO. I HAD 3 HRS OF SLEEP THE NIGHT BEFORE, 3 HRS DURING THE DAY. THE CAPT HAD A SIMILAR AMOUNT. THE CAPT (A FORMER SEA CTR CTLR) HAD A HEATED ARGUMENT WITH CREW SCHEDULING EARLIER IN THE EVENING. PERSONAL OPINIONS: THE ALT DEV WAS OUR MISTAKE. MISTAKES LIKE THESE ARE BROUGHT ON BY FATIGUE AND STRESS. THERE HAVE BEEN NUMEROUS (DOZENS) RPTS WITHIN THE COMPANY OF MISSED ALTS, DEVS, CALLING UNSEEN TFC, MISSED CLRNCS, BLURRED VISION, ETC, ALL OF WHICH POINT TO FUTURE INCIDENTS, AND THE POTENTIAL INABILITY TO RESPOND TO AN EMER. THIS IS NOT AN ISOLATED EVENT. I HAVE BEEN COERCED TO FLY AFTER 16 HRS ON DUTY. SPECIFICALLY, OTHERS HAVE FLOWN AFTER 18, 22, 23, 28, AND 33 HRS ON DUTY. THESE FLTS, HOWEVER, DID NOT CARRY PAXS, BUT SAFETY IS CERTAINLY COMPROMISED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO. RPTR DOES NOT DENY THAT THE ALT DEV WAS THE FLT CREW'S FAULT. HE BELIEVES THIS AND MANY OTHER FLT CREW ERRORS ARE CAUSED BY FATIGUE, FATIGUE THAT RESULTS FROM THE ACR'S MISINTERP OF THE FARS AND COERCING THE FLT CREWS TO REMAIN ON DUTY WELL BEYOND ANY REASONABLE AMOUNT OF TIME.
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.