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|
Attributes | |
ACN | 182877 |
Time | |
Date | 199107 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ktn |
State Reference | AK |
Altitude | msl bound lower : 5000 msl bound upper : 8500 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zan |
Operator | other |
Make Model Name | Small Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | climbout : intermediate altitude landing : go around |
Flight Plan | IFR |
Person 1 | |
Affiliation | government other |
Function | flight crew : captain |
Qualification | pilot : commercial pilot : instrument pilot : cfi |
Experience | flight time last 90 days : 100 flight time total : 1845 flight time type : 600 |
ASRS Report | 182877 |
Person 2 | |
Affiliation | government other |
Function | flight crew : first officer oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance |
Consequence | other Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was flying the aircraft and the captain was in the right seat, PNF. We diverted to ketchikan, instead of our destination of juneau, due to miscalculated fuel reserves and rapidly lowering WX all along the southeast alaska coast. I briefed the copilot to call out 500 ft, 200 ft and 100 ft above, and DH, altitudes for the ILS DME-1 runway 11 approach. Reported WX was a 900 ft ceiling and variable visibility; there was a lot of 'VFR' float traffic below us on the approach. The copilot did not call out any of the requested altitudes, and was missing position reports. I initiated the miss at the map; the copilot was disorganized. During the first seconds of the miss, he became frantic and could barely function due to shaking, trembling and acting totally 'freaked out.' his hands shook, his voice was cracking and he could not respond to commands that I gave. He did not report altitudes, etc. He was physically reaching all over the cockpit and made it very difficult to operate normally. I asked him 4-5 times to verify the last 1/2 of the miss procedure, as I had only memorized the first half. I needed to verify that the DME was from the ILS, not the VOR in the procedure. He was a total wreck by this time and I had configured the aircraft for maximum climb, knowing the steep terrain around ketchikan. I could get no responses so I reached for the plate, which he had and this seemed to jog him into more normal behavior. He heard me and did respond when I told him to tell center (who was calling), that we needed another approach, due to our lowering fuel and the poorer WX to the west (sitka was worse than ketchikan). We were through 8-9000 ft MSL when I finally had a chance to glance down to see the altitude for the miss, which was 5000 ft. Anchorage center was clearing us for 10000 ft at this time, and then for the next approach. I believe we busted the 5000 ft altitude before the shaken copilot ever got the proper frequency dialed in for center and got a proper handoff. His hands were shaking so badly he was continually turning his audio on and off, before I realized what he was doing. He never set the altitude alert once. This person (who is our supervisor and chief pilot) has been suspended from flight status and his chief pilot duties until further determination of his ability. I have never been in such a strange situation and will now expect the worst possible scenario whenever it could even occur. It was difficult to assume his duties, try to monitor what exactly he was doing, and fly the aircraft as well. I concentrated on flying the aircraft and am extremely glad that I did. I am glad that we did not have a load of ice or anything mechanical malfunctioning. I will also never again expect to rely completely on a copilot for feeding me the latter portions of the miss instructions, although every other pilot I fly with would have simply responded with the information. It should make people aware of a possible hazard when persons are preoccupied, disorganized, rambling, 'spacey', etc. This person had shown these signs at work, however, we all accepted it as part of his personality. An aircraft cockpit is no place for someone's mind to wander away. Just for information, we flew a second ILS (I did not rely on him for anything), and a float plane (amphibian) wrecked on the runway when we were several mi out. The copilot wanted me to miss before the map(!!!). We requested clearance to an airport with better WX and diverted to prince rupert, back course. We landed uneventfully in the rain and the copilot's only comments were: 'good job, good job.' I feel this shows how unaware he was of our true situation, a complete lack of 'situational awareness.' he later told me when I inquired as to his assessment of his behavior that: 'we had a pretty good day.' as mentioned earlier, he is currently not on flying status.
Original NASA ASRS Text
Title: GOV MST ALT DEV OVERSHOT DURING GAR FROM IAP ILS APCH TO KTN.
Narrative: I WAS FLYING THE ACFT AND THE CAPT WAS IN THE R SEAT, PNF. WE DIVERTED TO KETCHIKAN, INSTEAD OF OUR DEST OF JUNEAU, DUE TO MISCALCULATED FUEL RESERVES AND RAPIDLY LOWERING WX ALL ALONG THE SE ALASKA COAST. I BRIEFED THE COPLT TO CALL OUT 500 FT, 200 FT AND 100 FT ABOVE, AND DH, ALTS FOR THE ILS DME-1 RWY 11 APCH. RPTED WX WAS A 900 FT CEILING AND VARIABLE VISIBILITY; THERE WAS A LOT OF 'VFR' FLOAT TFC BELOW US ON THE APCH. THE COPLT DID NOT CALL OUT ANY OF THE REQUESTED ALTS, AND WAS MISSING POS RPTS. I INITIATED THE MISS AT THE MAP; THE COPLT WAS DISORGANIZED. DURING THE FIRST SECS OF THE MISS, HE BECAME FRANTIC AND COULD BARELY FUNCTION DUE TO SHAKING, TREMBLING AND ACTING TOTALLY 'FREAKED OUT.' HIS HANDS SHOOK, HIS VOICE WAS CRACKING AND HE COULD NOT RESPOND TO COMMANDS THAT I GAVE. HE DID NOT RPT ALTS, ETC. HE WAS PHYSICALLY REACHING ALL OVER THE COCKPIT AND MADE IT VERY DIFFICULT TO OPERATE NORMALLY. I ASKED HIM 4-5 TIMES TO VERIFY THE LAST 1/2 OF THE MISS PROC, AS I HAD ONLY MEMORIZED THE FIRST HALF. I NEEDED TO VERIFY THAT THE DME WAS FROM THE ILS, NOT THE VOR IN THE PROC. HE WAS A TOTAL WRECK BY THIS TIME AND I HAD CONFIGURED THE ACFT FOR MAX CLB, KNOWING THE STEEP TERRAIN AROUND KETCHIKAN. I COULD GET NO RESPONSES SO I REACHED FOR THE PLATE, WHICH HE HAD AND THIS SEEMED TO JOG HIM INTO MORE NORMAL BEHAVIOR. HE HEARD ME AND DID RESPOND WHEN I TOLD HIM TO TELL CENTER (WHO WAS CALLING), THAT WE NEEDED ANOTHER APCH, DUE TO OUR LOWERING FUEL AND THE POORER WX TO THE W (SITKA WAS WORSE THAN KETCHIKAN). WE WERE THROUGH 8-9000 FT MSL WHEN I FINALLY HAD A CHANCE TO GLANCE DOWN TO SEE THE ALT FOR THE MISS, WHICH WAS 5000 FT. ANCHORAGE CENTER WAS CLRING US FOR 10000 FT AT THIS TIME, AND THEN FOR THE NEXT APCH. I BELIEVE WE BUSTED THE 5000 FT ALT BEFORE THE SHAKEN COPLT EVER GOT THE PROPER FREQ DIALED IN FOR CENTER AND GOT A PROPER HDOF. HIS HANDS WERE SHAKING SO BADLY HE WAS CONTINUALLY TURNING HIS AUDIO ON AND OFF, BEFORE I REALIZED WHAT HE WAS DOING. HE NEVER SET THE ALT ALERT ONCE. THIS PERSON (WHO IS OUR SUPVR AND CHIEF PLT) HAS BEEN SUSPENDED FROM FLT STATUS AND HIS CHIEF PLT DUTIES UNTIL FURTHER DETERMINATION OF HIS ABILITY. I HAVE NEVER BEEN IN SUCH A STRANGE SITUATION AND WILL NOW EXPECT THE WORST POSSIBLE SCENARIO WHENEVER IT COULD EVEN OCCUR. IT WAS DIFFICULT TO ASSUME HIS DUTIES, TRY TO MONITOR WHAT EXACTLY HE WAS DOING, AND FLY THE ACFT AS WELL. I CONCENTRATED ON FLYING THE ACFT AND AM EXTREMELY GLAD THAT I DID. I AM GLAD THAT WE DID NOT HAVE A LOAD OF ICE OR ANYTHING MECHANICAL MALFUNCTIONING. I WILL ALSO NEVER AGAIN EXPECT TO RELY COMPLETELY ON A COPLT FOR FEEDING ME THE LATTER PORTIONS OF THE MISS INSTRUCTIONS, ALTHOUGH EVERY OTHER PLT I FLY WITH WOULD HAVE SIMPLY RESPONDED WITH THE INFO. IT SHOULD MAKE PEOPLE AWARE OF A POSSIBLE HAZARD WHEN PERSONS ARE PREOCCUPIED, DISORGANIZED, RAMBLING, 'SPACEY', ETC. THIS PERSON HAD SHOWN THESE SIGNS AT WORK, HOWEVER, WE ALL ACCEPTED IT AS PART OF HIS PERSONALITY. AN ACFT COCKPIT IS NO PLACE FOR SOMEONE'S MIND TO WANDER AWAY. JUST FOR INFO, WE FLEW A SECOND ILS (I DID NOT RELY ON HIM FOR ANYTHING), AND A FLOAT PLANE (AMPHIBIAN) WRECKED ON THE RWY WHEN WE WERE SEVERAL MI OUT. THE COPLT WANTED ME TO MISS BEFORE THE MAP(!!!). WE REQUESTED CLRNC TO AN ARPT WITH BETTER WX AND DIVERTED TO PRINCE RUPERT, BC. WE LANDED UNEVENTFULLY IN THE RAIN AND THE COPLT'S ONLY COMMENTS WERE: 'GOOD JOB, GOOD JOB.' I FEEL THIS SHOWS HOW UNAWARE HE WAS OF OUR TRUE SITUATION, A COMPLETE LACK OF 'SITUATIONAL AWARENESS.' HE LATER TOLD ME WHEN I INQUIRED AS TO HIS ASSESSMENT OF HIS BEHAVIOR THAT: 'WE HAD A PRETTY GOOD DAY.' AS MENTIONED EARLIER, HE IS CURRENTLY NOT ON FLYING STATUS.
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.