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|
Attributes | |
ACN | 256778 |
Time | |
Date | 199311 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : phl |
State Reference | PA |
Altitude | msl bound lower : 4000 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : phl |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | descent : approach descent other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 100 flight time total : 10000 flight time type : 50 |
ASRS Report | 256778 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Approach descent checklist and brief completed between FL180 and 10000 ft. On phl approach, flight director on, autoplt (center) engaged in heading select. Vectored by approach 240 degree heading to intercept runway 26R ILS localizer. As we crossed the displayed direct intercept course to runway 26R on the map we both observed that the autoplt and flight director did not capture the localizer course (the HSI displayed localizer armed). Visual reference confirmed that we were south of the localizer. I began turn back to re-intercept runway 26R localizer. At that same instance approach informed us that we had gone through the localizer and gave us a turn to 280 degrees to intercept. We called runway 26R in sight and we were switched to tower then cleared to land. The final approach and landing was uneventful!! Even though we did everything by SOP as a crew, 1 item was missed by both pilots. First, the PNF did not set the correct course heading in the one and only ILS tune head. Second, the PF failed to catch it when double-checking the radios tuned even though he idented the frequency. This aircraft has 3 ILS radios, but only 1 tuning head. Not good! If that 1 tuning head is set incorrectly it nullifies all 3 ILS's!! Eliminating the ability of each pilot to tune and identify his separate radio with a separate tuning head creates another potential disaster. Automation is great but removing human backups like this can only increase human error!
Original NASA ASRS Text
Title: FLC OF AN LGT ACR ACFT OVERSHOT THE FINAL APCH LOC COURSE AFTER CLRED FOR AN ILS APCH DUE TO NOT SETTING THE NAV RECEIVER WITH THE CORRECT COURSE HDG.
Narrative: APCH DSCNT CHKLIST AND BRIEF COMPLETED BTWN FL180 AND 10000 FT. ON PHL APCH, FLT DIRECTOR ON, AUTOPLT (CTR) ENGAGED IN HDG SELECT. VECTORED BY APCH 240 DEG HDG TO INTERCEPT RWY 26R ILS LOC. AS WE CROSSED THE DISPLAYED DIRECT INTERCEPT COURSE TO RWY 26R ON THE MAP WE BOTH OBSERVED THAT THE AUTOPLT AND FLT DIRECTOR DID NOT CAPTURE THE LOC COURSE (THE HSI DISPLAYED LOC ARMED). VISUAL REF CONFIRMED THAT WE WERE S OF THE LOC. I BEGAN TURN BACK TO RE-INTERCEPT RWY 26R LOC. AT THAT SAME INSTANCE APCH INFORMED US THAT WE HAD GONE THROUGH THE LOC AND GAVE US A TURN TO 280 DEGS TO INTERCEPT. WE CALLED RWY 26R IN SIGHT AND WE WERE SWITCHED TO TWR THEN CLRED TO LAND. THE FINAL APCH AND LNDG WAS UNEVENTFUL!! EVEN THOUGH WE DID EVERYTHING BY SOP AS A CREW, 1 ITEM WAS MISSED BY BOTH PLTS. FIRST, THE PNF DID NOT SET THE CORRECT COURSE HDG IN THE ONE AND ONLY ILS TUNE HEAD. SECOND, THE PF FAILED TO CATCH IT WHEN DOUBLE-CHKING THE RADIOS TUNED EVEN THOUGH HE IDENTED THE FREQ. THIS ACFT HAS 3 ILS RADIOS, BUT ONLY 1 TUNING HEAD. NOT GOOD! IF THAT 1 TUNING HEAD IS SET INCORRECTLY IT NULLIFIES ALL 3 ILS'S!! ELIMINATING THE ABILITY OF EACH PLT TO TUNE AND IDENT HIS SEPARATE RADIO WITH A SEPARATE TUNING HEAD CREATES ANOTHER POTENTIAL DISASTER. AUTOMATION IS GREAT BUT REMOVING HUMAN BACKUPS LIKE THIS CAN ONLY INCREASE HUMAN ERROR!
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.