37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 249656 |
Time | |
Date | 199308 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : pae airport : sea |
State Reference | WA |
Altitude | msl bound lower : 12000 msl bound upper : 12000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : sea |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | descent : approach |
Route In Use | arrival other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 15000 flight time type : 1100 |
ASRS Report | 249656 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : overcame equipment problem other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Cleared for clasr 3 arrival. Cleared to 12000 ft MSL. Inbound to jaksn intersection (on pae 075 degree radial at 23 DME). Navigating on INS. #3 INS had been shut down for malfunction. VOR showed I was 1.5 dots off course using INS, 5 mi from jackson. Switched to heading mode and corrected. Began to configure for approach. Inbound flaps did not extend. Called for checklist. Controller called and said I missed the turn at jackson. Turned left to 180 degrees as instructed. Resolved flap problem and landed. I was distracted by operational concerns and reverted back to an old habit of relying on my crew members for assistance. I forgot that the cockpit resource management briefings are too detailed to be of any use and I had not briefed to the exact chain of events that occurred. I had either not stroked my copilot enough (cockpit resource management) and he was pouting or he was enjoying the view of sea with unlimited visibility. He did not see that any big deal had happened and did/would not discuss it. In any event, I was at fault since I was PIC. I accept the blame along with the shield provided by NASA. This situation, and ones likes it at my airline in any case, could be resolved if the FAA and the company would stop using cockpit resource management as a political and economic tool and only provide it as the behavioral modifier it is designed to be.
Original NASA ASRS Text
Title: ACR ON FERRY FLT MISSES TURN ON ARR PROC. HAD FLAP PROB.
Narrative: CLRED FOR CLASR 3 ARR. CLRED TO 12000 FT MSL. INBOUND TO JAKSN INTXN (ON PAE 075 DEG RADIAL AT 23 DME). NAVING ON INS. #3 INS HAD BEEN SHUT DOWN FOR MALFUNCTION. VOR SHOWED I WAS 1.5 DOTS OFF COURSE USING INS, 5 MI FROM JACKSON. SWITCHED TO HDG MODE AND CORRECTED. BEGAN TO CONFIGURE FOR APCH. INBOUND FLAPS DID NOT EXTEND. CALLED FOR CHKLIST. CTLR CALLED AND SAID I MISSED THE TURN AT JACKSON. TURNED L TO 180 DEGS AS INSTRUCTED. RESOLVED FLAP PROB AND LANDED. I WAS DISTRACTED BY OPERATIONAL CONCERNS AND REVERTED BACK TO AN OLD HABIT OF RELYING ON MY CREW MEMBERS FOR ASSISTANCE. I FORGOT THAT THE COCKPIT RESOURCE MGMNT BRIEFINGS ARE TOO DETAILED TO BE OF ANY USE AND I HAD NOT BRIEFED TO THE EXACT CHAIN OF EVENTS THAT OCCURRED. I HAD EITHER NOT STROKED MY COPLT ENOUGH (COCKPIT RESOURCE MGMNT) AND HE WAS POUTING OR HE WAS ENJOYING THE VIEW OF SEA WITH UNLIMITED VISIBILITY. HE DID NOT SEE THAT ANY BIG DEAL HAD HAPPENED AND DID/WOULD NOT DISCUSS IT. IN ANY EVENT, I WAS AT FAULT SINCE I WAS PIC. I ACCEPT THE BLAME ALONG WITH THE SHIELD PROVIDED BY NASA. THIS SIT, AND ONES LIKES IT AT MY AIRLINE IN ANY CASE, COULD BE RESOLVED IF THE FAA AND THE COMPANY WOULD STOP USING COCKPIT RESOURCE MGMNT AS A POLITICAL AND ECONOMIC TOOL AND ONLY PROVIDE IT AS THE BEHAVIORAL MODIFIER IT IS DESIGNED TO BE.
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.