37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 210904 |
Time | |
Date | 199205 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : lax |
State Reference | CA |
Altitude | msl bound lower : 1200 msl bound upper : 3500 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : lax |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | descent : approach landing : missed approach |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | climbout : intermediate altitude climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 163 flight time total : 4500 flight time type : 661 |
ASRS Report | 210904 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : atp pilot : commercial |
Experience | flight time last 90 days : 157 flight time total : 20935 flight time type : 157 |
ASRS Report | 211078 |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : undershoot conflict : airborne less severe non adherence : required legal separation non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 5000 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
Downwind, east of smo, heading 070, approach changed our expected approach from ILS 24R to ILS 25L. I had my manual opened to the 25L approach plate and had it out in short order. I switched the captain's navigation radio to the new ILS frequency and read out a cursory approach brief with the new frequency, course, and mins. I noticed the captain looking for the new approach plate. I did not offer to fly the plane while he got the plate out. But looking back, it might have helped. We did not brief the missed approach. My reason for skipping the missed approach had to do with the now rushed situation, and it seemed unnecessary since ceilings were in the 900 to 1300 ft range and there was little chance of a missed approach due to WX. I was unfamiliar with the approach to 25L, and I did not have the time to properly familiarize myself with it. I cannot remember ever doing an approach to the south runways, and this was my first look at the approach plate in a long time. This would later add to my confusion just before and after the missed approach by taking me out of the loop to figure out the new tower frequency and the missed approach procedure. It seems approach control had held us high for traffic for the north runways, but they had not made any mention of it or prepared us for the 'slam dunk' we got. We were still at 4000 ft, not descending, so I reminded the captain (a gently nudge that we needed to descend) that we were cleared down to 2200 ft. Again, I noticed he hesitated (I think this may have been because he had his flight director on and hadn't set it for a descent. He may still have had altitude hold on), so I said it was time to descend. Now we were definitely set up to be high on the approach. Shortly, the captain called for flaps 25 and said something about getting down. Missed the localizer active call because I was setting the flap handle for flaps 25 and resetting the airspeed bug. I was glad the so called it for me. I was getting behind. We were getting behind. I didn't believe we were too high to get down to the GS. Still, had my situational awareness of the distance to the runway been better, I would have been a better backup. As it was, I was relying on the captain's experience and his grasp of the situation. I had not preset the tower frequency in the communication radio in preparation for the switch to tower at limma. Distracted and rushed, I didn't get to it. Therefore, at limma, I had my head buried looking for the tower frequency. I was late on the switch - approach called 'remind' us to switch to tower. I was so rushed, I just rogered the call and then realized I missed the frequency and had to continue looking for it on the approach chart. Looking back, I realize that, in haste, it is hard to find the frequency on the lax plate because there are 2 of everything -- 1 for the north complex, and 1 for the south complex. This slowed me down a bit. I noted we were at 2200 ft at just under 6 DME. Then my GS off flag biased out of view and the GS needle came into view. We were coming down and on GS, or so I thought. It turned out to be a false GS and the red flag came back, but it made a confusing situation more confusing. The descent continued at about 12-1300 FPM to about 1200 to 1500 ft and the captain said something to the effect that he was real uncomfortable descending at a high rate without his GS. Very shortly after that, he called missed approach, gear up, flaps 10. I was taken by surprise. The captain demanded the missed approach altitude. I hurriedly looked at my approach plate for the procedure which I now realized I hadn't reviewed. I saw 3000 as the final, but didn't read the whole procedure -- the captain wanted the altitude now! I said 3000, and the captain said he thought it was 2000 (he was correct for the initial missed approach altitude) and began his level off at 2000, pulling the power back. At the same time, I was configuring the captain's radios for the missed approach, dialing in 113.6 for the lax VOR. Tower came back with 'air carrier Y' track outbound on the localizer maintain 2000 ft. While I was reaching across the console tuning the captain's VOR, the so said something to the effect that we couldn't level off! We had a TCASII climb command! Sure enough! There was the RA on the vsi that said min climb 1500 FPM and that calm patient voice that says 'climb, climb, climb.' the so had pushed the throttles up, but there seemed to be a hesitation on the captain's part. Agreeing with the so, I pushed the throttles up too and the so said we have to climb for TCASII. We continued the climb, and the captain ran the throttles up a little more. I believe tower switched us to approach and I checked in at about 3500 ft on the missed approach. Their instructions were to continue the climb to 5000 ft heading 050.
Original NASA ASRS Text
Title: RWY ASSIGNMENT CHANGED FOR AIR CARRIER WDB. KEPT HIGH ON A RUSHED IAP ILS APCH, IN A DESTABILIZED APCH AND HIGH, PIC ELECT MISSED APCH PROC, GETS TCASII RA ON LEVEL OFF AND EXECUTES EVASIVE ACTION, CREATING AN ALTDEV ALT EXCURSION.
Narrative: DOWNWIND, E OF SMO, HDG 070, APCH CHANGED OUR EXPECTED APCH FROM ILS 24R TO ILS 25L. I HAD MY MANUAL OPENED TO THE 25L APCH PLATE AND HAD IT OUT IN SHORT ORDER. I SWITCHED THE CAPT'S NAV RADIO TO THE NEW ILS FREQ AND READ OUT A CURSORY APCH BRIEF WITH THE NEW FREQ, COURSE, AND MINS. I NOTICED THE CAPT LOOKING FOR THE NEW APCH PLATE. I DID NOT OFFER TO FLY THE PLANE WHILE HE GOT THE PLATE OUT. BUT LOOKING BACK, IT MIGHT HAVE HELPED. WE DID NOT BRIEF THE MISSED APCH. MY REASON FOR SKIPPING THE MISSED APCH HAD TO DO WITH THE NOW RUSHED SITUATION, AND IT SEEMED UNNECESSARY SINCE CEILINGS WERE IN THE 900 TO 1300 FT RANGE AND THERE WAS LITTLE CHANCE OF A MISSED APCH DUE TO WX. I WAS UNFAMILIAR WITH THE APCH TO 25L, AND I DID NOT HAVE THE TIME TO PROPERLY FAMILIARIZE MYSELF WITH IT. I CANNOT REMEMBER EVER DOING AN APCH TO THE S RWYS, AND THIS WAS MY FIRST LOOK AT THE APCH PLATE IN A LONG TIME. THIS WOULD LATER ADD TO MY CONFUSION JUST BEFORE AND AFTER THE MISSED APCH BY TAKING ME OUT OF THE LOOP TO FIGURE OUT THE NEW TWR FREQ AND THE MISSED APCH PROC. IT SEEMS APCH CTL HAD HELD US HIGH FOR TFC FOR THE N RWYS, BUT THEY HAD NOT MADE ANY MENTION OF IT OR PREPARED US FOR THE 'SLAM DUNK' WE GOT. WE WERE STILL AT 4000 FT, NOT DSNDING, SO I REMINDED THE CAPT (A GENTLY NUDGE THAT WE NEEDED TO DSND) THAT WE WERE CLRED DOWN TO 2200 FT. AGAIN, I NOTICED HE HESITATED (I THINK THIS MAY HAVE BEEN BECAUSE HE HAD HIS FLT DIRECTOR ON AND HADN'T SET IT FOR A DSCNT. HE MAY STILL HAVE HAD ALT HOLD ON), SO I SAID IT WAS TIME TO DSND. NOW WE WERE DEFINITELY SET UP TO BE HIGH ON THE APCH. SHORTLY, THE CAPT CALLED FOR FLAPS 25 AND SAID SOMETHING ABOUT GETTING DOWN. MISSED THE LOC ACTIVE CALL BECAUSE I WAS SETTING THE FLAP HANDLE FOR FLAPS 25 AND RESETTING THE AIRSPD BUG. I WAS GLAD THE SO CALLED IT FOR ME. I WAS GETTING BEHIND. WE WERE GETTING BEHIND. I DIDN'T BELIEVE WE WERE TOO HIGH TO GET DOWN TO THE GS. STILL, HAD MY SITUATIONAL AWARENESS OF THE DISTANCE TO THE RWY BEEN BETTER, I WOULD HAVE BEEN A BETTER BACKUP. AS IT WAS, I WAS RELYING ON THE CAPT'S EXPERIENCE AND HIS GRASP OF THE SITUATION. I HAD NOT PRESET THE TWR FREQ IN THE COM RADIO IN PREPARATION FOR THE SWITCH TO TWR AT LIMMA. DISTRACTED AND RUSHED, I DIDN'T GET TO IT. THEREFORE, AT LIMMA, I HAD MY HEAD BURIED LOOKING FOR THE TWR FREQ. I WAS LATE ON THE SWITCH - APCH CALLED 'REMIND' US TO SWITCH TO TWR. I WAS SO RUSHED, I JUST ROGERED THE CALL AND THEN REALIZED I MISSED THE FREQ AND HAD TO CONTINUE LOOKING FOR IT ON THE APCH CHART. LOOKING BACK, I REALIZE THAT, IN HASTE, IT IS HARD TO FIND THE FREQ ON THE LAX PLATE BECAUSE THERE ARE 2 OF EVERYTHING -- 1 FOR THE N COMPLEX, AND 1 FOR THE S COMPLEX. THIS SLOWED ME DOWN A BIT. I NOTED WE WERE AT 2200 FT AT JUST UNDER 6 DME. THEN MY GS OFF FLAG BIASED OUT OF VIEW AND THE GS NEEDLE CAME INTO VIEW. WE WERE COMING DOWN AND ON GS, OR SO I THOUGHT. IT TURNED OUT TO BE A FALSE GS AND THE RED FLAG CAME BACK, BUT IT MADE A CONFUSING SITUATION MORE CONFUSING. THE DSCNT CONTINUED AT ABOUT 12-1300 FPM TO ABOUT 1200 TO 1500 FT AND THE CAPT SAID SOMETHING TO THE EFFECT THAT HE WAS REAL UNCOMFORTABLE DSNDING AT A HIGH RATE WITHOUT HIS GS. VERY SHORTLY AFTER THAT, HE CALLED MISSED APCH, GEAR UP, FLAPS 10. I WAS TAKEN BY SURPRISE. THE CAPT DEMANDED THE MISSED APCH ALT. I HURRIEDLY LOOKED AT MY APCH PLATE FOR THE PROC WHICH I NOW REALIZED I HADN'T REVIEWED. I SAW 3000 AS THE FINAL, BUT DIDN'T READ THE WHOLE PROC -- THE CAPT WANTED THE ALT NOW! I SAID 3000, AND THE CAPT SAID HE THOUGHT IT WAS 2000 (HE WAS CORRECT FOR THE INITIAL MISSED APCH ALT) AND BEGAN HIS LEVEL OFF AT 2000, PULLING THE PWR BACK. AT THE SAME TIME, I WAS CONFIGURING THE CAPT'S RADIOS FOR THE MISSED APCH, DIALING IN 113.6 FOR THE LAX VOR. TWR CAME BACK WITH 'AIR CARRIER Y' TRACK OUTBOUND ON THE LOC MAINTAIN 2000 FT. WHILE I WAS REACHING ACROSS THE CONSOLE TUNING THE CAPT'S VOR, THE SO SAID SOMETHING TO THE EFFECT THAT WE COULDN'T LEVEL OFF! WE HAD A TCASII CLB COMMAND! SURE ENOUGH! THERE WAS THE RA ON THE VSI THAT SAID MIN CLB 1500 FPM AND THAT CALM PATIENT VOICE THAT SAYS 'CLB, CLB, CLB.' THE SO HAD PUSHED THE THROTTLES UP, BUT THERE SEEMED TO BE A HESITATION ON THE CAPT'S PART. AGREEING WITH THE SO, I PUSHED THE THROTTLES UP TOO AND THE SO SAID WE HAVE TO CLB FOR TCASII. WE CONTINUED THE CLB, AND THE CAPT RAN THE THROTTLES UP A LITTLE MORE. I BELIEVE TWR SWITCHED US TO APCH AND I CHKED IN AT ABOUT 3500 FT ON THE MISSED APCH. THEIR INSTRUCTIONS WERE TO CONTINUE THE CLB TO 5000 FT HDG 050.
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.