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|
Attributes | |
ACN | 199064 |
Time | |
Date | 199201 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sju |
State Reference | PR |
Altitude | msl bound lower : 4400 msl bound upper : 5100 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : sju |
Operator | other |
Make Model Name | Military Transport |
Flight Phase | descent : approach landing : go around |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : military |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp pilot : military |
Experience | flight time last 90 days : 100 flight time total : 4650 flight time type : 2800 |
ASRS Report | 199064 |
Person 2 | |
Affiliation | government : military |
Function | flight crew : captain oversight : pic |
Qualification | pilot : military |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On jan/xx/92 we departed san juan international (pr) on a local air refueling mission. After an uneventful mission, we obtained clearance back to san juan and started our descent. Due to poor WX (low ceiling, low visibility, night, rain), and traffic congestion, we were given several vectors and step down altitudes. Since we were told by ATC to expect the ILS runway 8, I 'set-up' and briefed my crew on the ILS runway 8 procedures. At approximately 10 mi from the field, we were cleared 'ILS runway 10, circle runway 8.' as a result of this short notice change and inadequate approach planning in poor WX conditions, I went missed approach. I was given radar vectors at 2000 ft to eventually attempt another approach. The initial vectors were north, then west, then southwest on a 220 heading. My crew informed me that we were headed directly for a 4290 ft mountain peak and the MSA for san juan was 5100 ft. We attempted to contact approach control, but were unable due to radio congestion. Obviously approach control forgot about us. At 5 mi from the mountain peak, I was afraid of hitting rising terrain and directed my crew to take action. At that time, approach instructed us to climb immediately to 4400 ft and turn immediately to a 110 heading. I treated this the same as a GPWS (ground proximity warning system) 'pull up' warning. For safety reasons, I applied go around thrust and aggressively applied 20 degrees pitch and 30 degrees bank in order to avoid any ground impact. The upward vector resulted in an altitude deviation. I inadvertently climbed to 5100 ft before correcting back to 4400 ft assigned. We were cleared for the ILS runway 8. The approach/landing was uneventful. Factors in the missed approach: inadequate approach planning (especially night IMC). ATC should anticipate the type approachs. Circling approach at night in marginal WX. ATC should only issue straight-in approachs. Factors in the terrain avoidance/altitude deviation: safety comes first. I did what was necessary to safely recover my airplane. Human consideration -- fear of dying! Traffic congestion/poor WX caused ATC to forget about us and vector us toward a mountain at low altitude. Approach control should plan their arrs to avoid saturation -- use holding patterns or gate holds.
Original NASA ASRS Text
Title: MLT ALTDEV OVERSHOT DURING GAR AT SJC.
Narrative: ON JAN/XX/92 WE DEPARTED SAN JUAN INTL (PR) ON A LCL AIR REFUELING MISSION. AFTER AN UNEVENTFUL MISSION, WE OBTAINED CLRNC BACK TO SAN JUAN AND STARTED OUR DSCNT. DUE TO POOR WX (LOW CEILING, LOW VISIBILITY, NIGHT, RAIN), AND TFC CONGESTION, WE WERE GIVEN SEVERAL VECTORS AND STEP DOWN ALTS. SINCE WE WERE TOLD BY ATC TO EXPECT THE ILS RWY 8, I 'SET-UP' AND BRIEFED MY CREW ON THE ILS RWY 8 PROCS. AT APPROX 10 MI FROM THE FIELD, WE WERE CLRED 'ILS RWY 10, CIRCLE RWY 8.' AS A RESULT OF THIS SHORT NOTICE CHANGE AND INADEQUATE APCH PLANNING IN POOR WX CONDITIONS, I WENT MISSED APCH. I WAS GIVEN RADAR VECTORS AT 2000 FT TO EVENTUALLY ATTEMPT ANOTHER APCH. THE INITIAL VECTORS WERE N, THEN W, THEN SW ON A 220 HDG. MY CREW INFORMED ME THAT WE WERE HEADED DIRECTLY FOR A 4290 FT MOUNTAIN PEAK AND THE MSA FOR SAN JUAN WAS 5100 FT. WE ATTEMPTED TO CONTACT APCH CTL, BUT WERE UNABLE DUE TO RADIO CONGESTION. OBVIOUSLY APCH CTL FORGOT ABOUT US. AT 5 MI FROM THE MOUNTAIN PEAK, I WAS AFRAID OF HITTING RISING TERRAIN AND DIRECTED MY CREW TO TAKE ACTION. AT THAT TIME, APCH INSTRUCTED US TO CLB IMMEDIATELY TO 4400 FT AND TURN IMMEDIATELY TO A 110 HDG. I TREATED THIS THE SAME AS A GPWS (GND PROX WARNING SYS) 'PULL UP' WARNING. FOR SAFETY REASONS, I APPLIED GAR THRUST AND AGGRESSIVELY APPLIED 20 DEGS PITCH AND 30 DEGS BANK IN ORDER TO AVOID ANY GND IMPACT. THE UPWARD VECTOR RESULTED IN AN ALTDEV. I INADVERTENTLY CLBED TO 5100 FT BEFORE CORRECTING BACK TO 4400 FT ASSIGNED. WE WERE CLRED FOR THE ILS RWY 8. THE APCH/LNDG WAS UNEVENTFUL. FACTORS IN THE MISSED APCH: INADEQUATE APCH PLANNING (ESPECIALLY NIGHT IMC). ATC SHOULD ANTICIPATE THE TYPE APCHS. CIRCLING APCH AT NIGHT IN MARGINAL WX. ATC SHOULD ONLY ISSUE STRAIGHT-IN APCHS. FACTORS IN THE TERRAIN AVOIDANCE/ALTDEV: SAFETY COMES FIRST. I DID WHAT WAS NECESSARY TO SAFELY RECOVER MY AIRPLANE. HUMAN CONSIDERATION -- FEAR OF DYING! TFC CONGESTION/POOR WX CAUSED ATC TO FORGET ABOUT US AND VECTOR US TOWARD A MOUNTAIN AT LOW ALT. APCH CTL SHOULD PLAN THEIR ARRS TO AVOID SATURATION -- USE HOLDING PATTERNS OR GATE HOLDS.
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.