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|
Attributes | |
ACN | 249516 |
Time | |
Date | 199308 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : oak |
State Reference | CA |
Altitude | msl bound lower : 1300 msl bound upper : 1300 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : oak |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | descent : approach |
Flight Plan | IFR |
Aircraft 2 | |
Operator | general aviation : personal |
Make Model Name | Small Aircraft, High Wing, 1 Eng, Fixed Gear |
Flight Phase | climbout : intermediate altitude |
Flight Plan | None |
Person 1 | |
Affiliation | government : faa |
Function | observation : observer |
Qualification | controller : radar |
Experience | controller military : 2 controller radar : 9 |
ASRS Report | 249516 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | conflict : nmac non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 0 vertical : 200 |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Pilot Deviation Operational Error |
Narrative:
I was observing cockpit operations (under the sf-160 program) from the jump seat of an large transport. The captain was lined up on the localizer and the runway was in sight. We were approximately 3-4 mi final and 1300 ft when the TCASII announced 'traffic.' I observed a target on the display at 1 O'clock, 2 mi, converging, indicating 500 ft below us (we were descending on the GS). The captain, first officer, and I all searched for the traffic, but couldn't see it. Very soon after, TCASII announced a 'climb' RA. The first officer looked quickly at the display and then to the captain and said, 'you'd better climb.' the captain said 'there's nobody out there.' I saw on the display that the target was now 12 O'clock, immediately in front of us, showing at our altitude. The first officer said to the captain, 'you've got to follow it!' (the RA.) the captain restated that there was no traffic and continued on the approach. When TCASII announced that the conflict had passed, the visibly shaken first officer cursed loudly, '(XXXX) that scares the (XXXX) out of me!' looking at the display, the target was now behind us and several hundred ft below, leading me to believe that the other pilot may have taken evasive action. When the first officer insisted that there had been traffic, the captain told the first officer to ask the controller if he had any traffic on the final approach course. Up to this point, the tower hadn't issued us anything but a landing clearance. The controller told the crew that he did have traffic (an small aircraft) on final, but that he (the controller) had both of us in sight. The controller went on to apologize, saying that he should have told us of the traffic, but that he got busy doing something else. We flared, touched down, and the captain got on the radio as we rolled out and (very professionally) gave the controller an earful. Captain felt that following a TCASII RA was his option based on whether or not he believed there was traffic. The first officer disagreed. All 3 of us did agree, however, that the local controller should have issued traffic or, more appropriately, kept the traffic away from the final approach course. I believe that I witnessed a 'system' failure. Every built-in safeguard failed. ATC knew of the traffic, was in contact with the traffic, but was distracted and didn't issue traffic to either aircraft. TCASII called the traffic and offered an RA, but because the captain couldn't see it, it wasn't there. And the final xchk, cockpit resource management, broke down at a critical time.
Original NASA ASRS Text
Title: LGT TCASII RA NON RESPONSE HAD NMAC LTSS FROM SMA. SYS ERROR.
Narrative: I WAS OBSERVING COCKPIT OPS (UNDER THE SF-160 PROGRAM) FROM THE JUMP SEAT OF AN LGT. THE CAPT WAS LINED UP ON THE LOC AND THE RWY WAS IN SIGHT. WE WERE APPROX 3-4 MI FINAL AND 1300 FT WHEN THE TCASII ANNOUNCED 'TFC.' I OBSERVED A TARGET ON THE DISPLAY AT 1 O'CLOCK, 2 MI, CONVERGING, INDICATING 500 FT BELOW US (WE WERE DSNDING ON THE GS). THE CAPT, FO, AND I ALL SEARCHED FOR THE TFC, BUT COULDN'T SEE IT. VERY SOON AFTER, TCASII ANNOUNCED A 'CLB' RA. THE FO LOOKED QUICKLY AT THE DISPLAY AND THEN TO THE CAPT AND SAID, 'YOU'D BETTER CLB.' THE CAPT SAID 'THERE'S NOBODY OUT THERE.' I SAW ON THE DISPLAY THAT THE TARGET WAS NOW 12 O'CLOCK, IMMEDIATELY IN FRONT OF US, SHOWING AT OUR ALT. THE FO SAID TO THE CAPT, 'YOU'VE GOT TO FOLLOW IT!' (THE RA.) THE CAPT RESTATED THAT THERE WAS NO TFC AND CONTINUED ON THE APCH. WHEN TCASII ANNOUNCED THAT THE CONFLICT HAD PASSED, THE VISIBLY SHAKEN FO CURSED LOUDLY, '(XXXX) THAT SCARES THE (XXXX) OUT OF ME!' LOOKING AT THE DISPLAY, THE TARGET WAS NOW BEHIND US AND SEVERAL HUNDRED FT BELOW, LEADING ME TO BELIEVE THAT THE OTHER PLT MAY HAVE TAKEN EVASIVE ACTION. WHEN THE FO INSISTED THAT THERE HAD BEEN TFC, THE CAPT TOLD THE FO TO ASK THE CTLR IF HE HAD ANY TFC ON THE FINAL APCH COURSE. UP TO THIS POINT, THE TWR HADN'T ISSUED US ANYTHING BUT A LNDG CLRNC. THE CTLR TOLD THE CREW THAT HE DID HAVE TFC (AN SMA) ON FINAL, BUT THAT HE (THE CTLR) HAD BOTH OF US IN SIGHT. THE CTLR WENT ON TO APOLOGIZE, SAYING THAT HE SHOULD HAVE TOLD US OF THE TFC, BUT THAT HE GOT BUSY DOING SOMETHING ELSE. WE FLARED, TOUCHED DOWN, AND THE CAPT GOT ON THE RADIO AS WE ROLLED OUT AND (VERY PROFESSIONALLY) GAVE THE CTLR AN EARFUL. CAPT FELT THAT FOLLOWING A TCASII RA WAS HIS OPTION BASED ON WHETHER OR NOT HE BELIEVED THERE WAS TFC. THE FO DISAGREED. ALL 3 OF US DID AGREE, HOWEVER, THAT THE LCL CTLR SHOULD HAVE ISSUED TFC OR, MORE APPROPRIATELY, KEPT THE TFC AWAY FROM THE FINAL APCH COURSE. I BELIEVE THAT I WITNESSED A 'SYS' FAILURE. EVERY BUILT-IN SAFEGUARD FAILED. ATC KNEW OF THE TFC, WAS IN CONTACT WITH THE TFC, BUT WAS DISTRACTED AND DIDN'T ISSUE TFC TO EITHER ACFT. TCASII CALLED THE TFC AND OFFERED AN RA, BUT BECAUSE THE CAPT COULDN'T SEE IT, IT WASN'T THERE. AND THE FINAL XCHK, COCKPIT RESOURCE MGMNT, BROKE DOWN AT A CRITICAL 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.