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|
Attributes | |
ACN | 206005 |
Time | |
Date | 199203 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : mdw |
State Reference | IL |
Altitude | msl bound lower : 3500 msl bound upper : 4000 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : ord artcc : zny |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | ils localizer & glide slope : hkh |
Flight Phase | cruise other descent : approach |
Route In Use | approach : straight in |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 5500 flight time type : 2500 |
ASRS Report | 206005 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 185 flight time total : 13000 flight time type : 185 |
ASRS Report | 206666 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : excursion from assigned altitude non adherence : published procedure non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : became reoriented flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Situations | |
ATC Facility | other physical facility |
Narrative:
Inbound to mdw, landing runway 4, we were cleared down to 4000 ft approximately 25 mi from field. The initial suggested altitude for the approach is 5000 ft over baner which is defined off the cgt 293 degree radial. The captain set up cgt 293 degree radial and upon crossing, having been cleared for the approach, we both overlooked that we were already at 4000 ft which is the next crossing restriction. Or, probably more correct, we both forgot that we were crossing baner and not cadon. As the captain called out that we were crossing the radial, I began the descent to the final approach fix altitude of 2600 ft. The captain realized our error shortly but not before I had descended to approximately 3500 ft. At this point, I leveled off. I maintained that altitude until such time we were sure that we were past cadon. The approach proceeded without further incident to a safe and normal landing. Simply, I mistook crossing baner for cadon by not properly xchking what radial the captain had dialed in. Partly, I believe, that we were lured into this mistake by being cleared to 4000 ft so far out. I do not believe such a mistake could be made if the mdw ILS runway 4 had DME. Supplemental information from acn 206666: I believe this incident highlights the need for all ILS's to be equipped with DME. The PF the approach, concentrating on line up relies on the PNF to have the correct radial to identify the various let down fixes, for him to verify the proper radial requires a cross cockpit check which at night in the WX is not the optimum situation. If DME was on all ILS the PF would know his position at all times and would allow both pilots to be on the ILS throughout the approach. This would enhance safety by allowing both pilots to monitor the approachs.
Original NASA ASRS Text
Title: ALTDEV ALT EXCURSION ALT XING RESTRICTION NOT MET IN PREMATURE DSCNT IN IAP ILS APCH.
Narrative: INBOUND TO MDW, LNDG RWY 4, WE WERE CLRED DOWN TO 4000 FT APPROX 25 MI FROM FIELD. THE INITIAL SUGGESTED ALT FOR THE APCH IS 5000 FT OVER BANER WHICH IS DEFINED OFF THE CGT 293 DEG RADIAL. THE CAPT SET UP CGT 293 DEG RADIAL AND UPON XING, HAVING BEEN CLRED FOR THE APCH, WE BOTH OVERLOOKED THAT WE WERE ALREADY AT 4000 FT WHICH IS THE NEXT XING RESTRICTION. OR, PROBABLY MORE CORRECT, WE BOTH FORGOT THAT WE WERE XING BANER AND NOT CADON. AS THE CAPT CALLED OUT THAT WE WERE XING THE RADIAL, I BEGAN THE DSCNT TO THE FINAL APCH FIX ALT OF 2600 FT. THE CAPT REALIZED OUR ERROR SHORTLY BUT NOT BEFORE I HAD DSNDED TO APPROX 3500 FT. AT THIS POINT, I LEVELED OFF. I MAINTAINED THAT ALT UNTIL SUCH TIME WE WERE SURE THAT WE WERE PAST CADON. THE APCH PROCEEDED WITHOUT FURTHER INCIDENT TO A SAFE AND NORMAL LNDG. SIMPLY, I MISTOOK XING BANER FOR CADON BY NOT PROPERLY XCHKING WHAT RADIAL THE CAPT HAD DIALED IN. PARTLY, I BELIEVE, THAT WE WERE LURED INTO THIS MISTAKE BY BEING CLRED TO 4000 FT SO FAR OUT. I DO NOT BELIEVE SUCH A MISTAKE COULD BE MADE IF THE MDW ILS RWY 4 HAD DME. SUPPLEMENTAL INFO FROM ACN 206666: I BELIEVE THIS INCIDENT HIGHLIGHTS THE NEED FOR ALL ILS'S TO BE EQUIPPED WITH DME. THE PF THE APCH, CONCENTRATING ON LINE UP RELIES ON THE PNF TO HAVE THE CORRECT RADIAL TO IDENT THE VARIOUS LET DOWN FIXES, FOR HIM TO VERIFY THE PROPER RADIAL REQUIRES A CROSS COCKPIT CHK WHICH AT NIGHT IN THE WX IS NOT THE OPTIMUM SITUATION. IF DME WAS ON ALL ILS THE PF WOULD KNOW HIS POS AT ALL TIMES AND WOULD ALLOW BOTH PLTS TO BE ON THE ILS THROUGHOUT THE APCH. THIS WOULD ENHANCE SAFETY BY ALLOWING BOTH PLTS TO MONITOR THE APCHS.
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.