37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 281578 |
Time | |
Date | 199408 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : iad |
State Reference | VA |
Altitude | agl bound lower : 300 agl bound upper : 4200 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : iad tower : iad tower : ptk |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent : approach |
Route In Use | approach : straight in |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 9000 flight time type : 500 |
ASRS Report | 281578 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude altitude deviation : overshoot non adherence : clearance non adherence : far other anomaly other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : regained aircraft control flight crew : became reoriented other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
The captain was flying the leg from lax to iad and this was our only assignment for the day in the B-757. We were both well rested when reporting for duty with 18 hours free from all duty while on layover in lax. The flight was uneventful until 5 mins before landing and there was no hint of any incapacitation whatsoever prior to the incident. We both ate dinner on the flight so I don't believe low blood sugar was a problem. However, the captain had been complaining all month whenever any of the small errors, that are an integral part of commercial aviation, occurred as a result of his being human. The reason I mention this is because he said to me, not less than 10 times during the month, 'I don't enjoy doing this anymore -- I'm too old for this shit and I ought to get out of it.' with a high cloud layer and tower visibility of 5 mi in haze there was no discernable horizon whatsoever and we were effectively in IMC. We briefed the approach in detail before starting our descent into iad and were on radar vectors from the southwest to intercept the localizer for runway 12. We even talked about the tailwind that we would have to deal with on the approach as the ATIS reported the wind at 210/4. Our last clearance before calling the tower was, 'maintain 3000 ft until established on the localizer -- cleared the ILS 12 approach.' we were still descending through about 4500 ft MSL when this was received and I remember seeing the GS indicator moving as we began to slow from 250 KTS. The autoplt was still in command as we captured the localizer and I remember being surprised when I looked out the window to see the runway so far below us and about 8 mi ahead. The captain must have seen the same thing as he disconnected the autoplt to arrest our descent and slow the airplane. He called for flaps 1, 5, 15 and then called for the gear down and the final check. I was surprised when he lowered the nose instead of following the normal technique for, 'slam- dunks' which is full flaps and speed brakes until GS capture but, not below 1000 ft AGL. Approach told us to contact the tower which we did and were cleared to land. I ran the final descent checklist and he then began s-turning using 30 degree banked turns to loose altitude. He finally called for flaps 25 and then 30. Our speed was just under 160 KIAS. He continued the s-turns but, we were still too high and so I suggested using the speed brakes. He said we couldn't use speed brakes with flaps but, I reassured him we could down to 1000 ft AGL. He extended the speed brakes for about 2-3 seconds but, then abruptly stowed them without explanation. He lowered the nose again to the runway and the speed exceeded the flap blow-back limit of 162 KIAS which caused the flaps to retract to 25 and further reduce our drag. We continued the s-turns until we were about over the approach lights at 600 ft AGL, at which time I said, 'we're unstable' which is our company's code that a go around is now required. He said, 'let's go around' to which I replied, 'that sounds good.' the captain advanced the throttles to about 1/2 thrust and rotated the nose to about 6 degrees nose up and then froze. His required calls were, 'go around thrust, flaps 20, positive climb, gear up' but, he never said them. I remember putting my hand on the flap lever and beginning to move it before realizing that he was not making his calls. I turned and looked at him and he was looking straight ahead out the window. So I said, 'the flaps are coming to 20' and finished moving them there. He then said, 'gear up.' I remember looking at the airspeed and seeing it decaying through reference speed and I pushed the throttles full-forward and was surprised by the amount of throttle movement required. I called dulles tower and told them we were going around. The controller was very surprised as he took 2-3 seconds to answer and then said in a very distressed voice, '(call sign) do you have the dc-10 just lifting off runway 19R.' I said we did and he told us to turn right immediately to a heading of 190 and climb and maintain 2000 ft. I set the heading in the mode control panel while pushing the heading select knob and set 2000 ft in the altalerter. I pointed to the altitude as is our SOP and awaited a response from the captain confirming he understood the altitude clearance -- he said nothing and starred straight ahead. I said 'do you have the dc-10 just off runway 19R?' and I pointed to it right across the front of his face. He said yes. I then very carefully and distinctly said to him while turning the yoke to the right, 'they want us to turn right to 190 degrees' -- I pointed to the number on the MCP. 'And climb to 2000 ft.' I again pointed to the number on the MCP. I could feel him on the yoke putting the aileron in to make the turn but, the rudders did not move and the airplane yawed. I was very intently looking for the dc-10, although I could not see it while the airplane was in the bank but, remember seeing the bank angle at 45 degrees and thinking it would be excessive were it not for the potential collision. When I saw the dc-10 again the captain had leveled the wings on a heading of 190 degrees and the 10 was no longer a threat to us as he was angling away to the east. The captain then said, 'give me climb thrust.' I pushed the EPR switch without delay but when I looked back at the flight instruments the altitude was approaching 3000 MSL, climbing very fast, and the airspeed was about 135 KIAS. I grabbed for the throttles and pulled them to idle while pushing forward on the yoke. I said, '...I'm 'flching' you to 2000 ft? -- What speed do you want -- 160? He replied, 'I thought we were already doing that.' I set it in the MCP. The tower then called us and told us to make right traffic for 12 and report the company dc-10 on final in sight. I set 300 in the heading window and looked to the right for the traffic. I felt as though the bank angle was getting too steep and looked at the ADI to see what the angle was. We were at 60 degrees right bank and increasing. I grabbed the yoke and moved it to the left and said loudly, 'bank angle.' I continued with my hand lightly on the yoke for the remainder of the flight although I doubt that the captain was aware of it. I called the traffic in sight and the tower cleared us to land again on runway 12. We never did level at 2000 ft MSL. We just continued the descent to landing. He turned base about 4 mi out at 160 KTS and called for flaps, gear and the final check. I think he was trying to fly visually because, our turns to base and final were using bank angles of about 45 degrees despite my repeated calls of bank angle and my control pressure on the yoke. The second approach to landing was uneventful except for a couple of s-turns to line up with the runway.
Original NASA ASRS Text
Title: FLC ATTEMPTED 'SLAM DUNK' ILS WITH KNOWN TAILWIND. FLC OVERSHOT ASSIGNED MISSED APCH ALT 1000 FT MADE 60 DEG BANKS, AND WAS 25 KTS SLOWER THAN DESIRED ON THE GAR.
Narrative: THE CAPT WAS FLYING THE LEG FROM LAX TO IAD AND THIS WAS OUR ONLY ASSIGNMENT FOR THE DAY IN THE B-757. WE WERE BOTH WELL RESTED WHEN RPTING FOR DUTY WITH 18 HRS FREE FROM ALL DUTY WHILE ON LAYOVER IN LAX. THE FLT WAS UNEVENTFUL UNTIL 5 MINS BEFORE LNDG AND THERE WAS NO HINT OF ANY INCAPACITATION WHATSOEVER PRIOR TO THE INCIDENT. WE BOTH ATE DINNER ON THE FLT SO I DON'T BELIEVE LOW BLOOD SUGAR WAS A PROB. HOWEVER, THE CAPT HAD BEEN COMPLAINING ALL MONTH WHENEVER ANY OF THE SMALL ERRORS, THAT ARE AN INTEGRAL PART OF COMMERCIAL AVIATION, OCCURRED AS A RESULT OF HIS BEING HUMAN. THE REASON I MENTION THIS IS BECAUSE HE SAID TO ME, NOT LESS THAN 10 TIMES DURING THE MONTH, 'I DON'T ENJOY DOING THIS ANYMORE -- I'M TOO OLD FOR THIS SHIT AND I OUGHT TO GET OUT OF IT.' WITH A HIGH CLOUD LAYER AND TWR VISIBILITY OF 5 MI IN HAZE THERE WAS NO DISCERNABLE HORIZON WHATSOEVER AND WE WERE EFFECTIVELY IN IMC. WE BRIEFED THE APCH IN DETAIL BEFORE STARTING OUR DSCNT INTO IAD AND WERE ON RADAR VECTORS FROM THE SW TO INTERCEPT THE LOC FOR RWY 12. WE EVEN TALKED ABOUT THE TAILWIND THAT WE WOULD HAVE TO DEAL WITH ON THE APCH AS THE ATIS RPTED THE WIND AT 210/4. OUR LAST CLRNC BEFORE CALLING THE TWR WAS, 'MAINTAIN 3000 FT UNTIL ESTABLISHED ON THE LOC -- CLRED THE ILS 12 APCH.' WE WERE STILL DSNDING THROUGH ABOUT 4500 FT MSL WHEN THIS WAS RECEIVED AND I REMEMBER SEEING THE GS INDICATOR MOVING AS WE BEGAN TO SLOW FROM 250 KTS. THE AUTOPLT WAS STILL IN COMMAND AS WE CAPTURED THE LOC AND I REMEMBER BEING SURPRISED WHEN I LOOKED OUT THE WINDOW TO SEE THE RWY SO FAR BELOW US AND ABOUT 8 MI AHEAD. THE CAPT MUST HAVE SEEN THE SAME THING AS HE DISCONNECTED THE AUTOPLT TO ARREST OUR DSCNT AND SLOW THE AIRPLANE. HE CALLED FOR FLAPS 1, 5, 15 AND THEN CALLED FOR THE GEAR DOWN AND THE FINAL CHK. I WAS SURPRISED WHEN HE LOWERED THE NOSE INSTEAD OF FOLLOWING THE NORMAL TECHNIQUE FOR, 'SLAM- DUNKS' WHICH IS FULL FLAPS AND SPD BRAKES UNTIL GS CAPTURE BUT, NOT BELOW 1000 FT AGL. APCH TOLD US TO CONTACT THE TWR WHICH WE DID AND WERE CLRED TO LAND. I RAN THE FINAL DSCNT CHKLIST AND HE THEN BEGAN S-TURNING USING 30 DEG BANKED TURNS TO LOOSE ALT. HE FINALLY CALLED FOR FLAPS 25 AND THEN 30. OUR SPD WAS JUST UNDER 160 KIAS. HE CONTINUED THE S-TURNS BUT, WE WERE STILL TOO HIGH AND SO I SUGGESTED USING THE SPD BRAKES. HE SAID WE COULDN'T USE SPD BRAKES WITH FLAPS BUT, I REASSURED HIM WE COULD DOWN TO 1000 FT AGL. HE EXTENDED THE SPD BRAKES FOR ABOUT 2-3 SECONDS BUT, THEN ABRUPTLY STOWED THEM WITHOUT EXPLANATION. HE LOWERED THE NOSE AGAIN TO THE RWY AND THE SPD EXCEEDED THE FLAP BLOW-BACK LIMIT OF 162 KIAS WHICH CAUSED THE FLAPS TO RETRACT TO 25 AND FURTHER REDUCE OUR DRAG. WE CONTINUED THE S-TURNS UNTIL WE WERE ABOUT OVER THE APCH LIGHTS AT 600 FT AGL, AT WHICH TIME I SAID, 'WE'RE UNSTABLE' WHICH IS OUR COMPANY'S CODE THAT A GAR IS NOW REQUIRED. HE SAID, 'LET'S GAR' TO WHICH I REPLIED, 'THAT SOUNDS GOOD.' THE CAPT ADVANCED THE THROTTLES TO ABOUT 1/2 THRUST AND ROTATED THE NOSE TO ABOUT 6 DEGS NOSE UP AND THEN FROZE. HIS REQUIRED CALLS WERE, 'GAR THRUST, FLAPS 20, POSITIVE CLB, GEAR UP' BUT, HE NEVER SAID THEM. I REMEMBER PUTTING MY HAND ON THE FLAP LEVER AND BEGINNING TO MOVE IT BEFORE REALIZING THAT HE WAS NOT MAKING HIS CALLS. I TURNED AND LOOKED AT HIM AND HE WAS LOOKING STRAIGHT AHEAD OUT THE WINDOW. SO I SAID, 'THE FLAPS ARE COMING TO 20' AND FINISHED MOVING THEM THERE. HE THEN SAID, 'GEAR UP.' I REMEMBER LOOKING AT THE AIRSPD AND SEEING IT DECAYING THROUGH REF SPD AND I PUSHED THE THROTTLES FULL-FORWARD AND WAS SURPRISED BY THE AMOUNT OF THROTTLE MOVEMENT REQUIRED. I CALLED DULLES TWR AND TOLD THEM WE WERE GOING AROUND. THE CTLR WAS VERY SURPRISED AS HE TOOK 2-3 SECONDS TO ANSWER AND THEN SAID IN A VERY DISTRESSED VOICE, '(CALL SIGN) DO YOU HAVE THE DC-10 JUST LIFTING OFF RWY 19R.' I SAID WE DID AND HE TOLD US TO TURN R IMMEDIATELY TO A HDG OF 190 AND CLB AND MAINTAIN 2000 FT. I SET THE HDG IN THE MODE CTL PANEL WHILE PUSHING THE HDG SELECT KNOB AND SET 2000 FT IN THE ALTALERTER. I POINTED TO THE ALT AS IS OUR SOP AND AWAITED A RESPONSE FROM THE CAPT CONFIRMING HE UNDERSTOOD THE ALT CLRNC -- HE SAID NOTHING AND STARRED STRAIGHT AHEAD. I SAID 'DO YOU HAVE THE DC-10 JUST OFF RWY 19R?' AND I POINTED TO IT RIGHT ACROSS THE FRONT OF HIS FACE. HE SAID YES. I THEN VERY CAREFULLY AND DISTINCTLY SAID TO HIM WHILE TURNING THE YOKE TO THE R, 'THEY WANT US TO TURN R TO 190 DEGS' -- I POINTED TO THE NUMBER ON THE MCP. 'AND CLB TO 2000 FT.' I AGAIN POINTED TO THE NUMBER ON THE MCP. I COULD FEEL HIM ON THE YOKE PUTTING THE AILERON IN TO MAKE THE TURN BUT, THE RUDDERS DID NOT MOVE AND THE AIRPLANE YAWED. I WAS VERY INTENTLY LOOKING FOR THE DC-10, ALTHOUGH I COULD NOT SEE IT WHILE THE AIRPLANE WAS IN THE BANK BUT, REMEMBER SEEING THE BANK ANGLE AT 45 DEGS AND THINKING IT WOULD BE EXCESSIVE WERE IT NOT FOR THE POTENTIAL COLLISION. WHEN I SAW THE DC-10 AGAIN THE CAPT HAD LEVELED THE WINGS ON A HDG OF 190 DEGS AND THE 10 WAS NO LONGER A THREAT TO US AS HE WAS ANGLING AWAY TO THE E. THE CAPT THEN SAID, 'GIVE ME CLB THRUST.' I PUSHED THE EPR SWITCH WITHOUT DELAY BUT WHEN I LOOKED BACK AT THE FLT INSTS THE ALT WAS APCHING 3000 MSL, CLBING VERY FAST, AND THE AIRSPD WAS ABOUT 135 KIAS. I GRABBED FOR THE THROTTLES AND PULLED THEM TO IDLE WHILE PUSHING FORWARD ON THE YOKE. I SAID, '...I'M 'FLCHING' YOU TO 2000 FT? -- WHAT SPD DO YOU WANT -- 160? HE REPLIED, 'I THOUGHT WE WERE ALREADY DOING THAT.' I SET IT IN THE MCP. THE TWR THEN CALLED US AND TOLD US TO MAKE R TFC FOR 12 AND RPT THE COMPANY DC-10 ON FINAL IN SIGHT. I SET 300 IN THE HDG WINDOW AND LOOKED TO THE R FOR THE TFC. I FELT AS THOUGH THE BANK ANGLE WAS GETTING TOO STEEP AND LOOKED AT THE ADI TO SEE WHAT THE ANGLE WAS. WE WERE AT 60 DEGS R BANK AND INCREASING. I GRABBED THE YOKE AND MOVED IT TO THE L AND SAID LOUDLY, 'BANK ANGLE.' I CONTINUED WITH MY HAND LIGHTLY ON THE YOKE FOR THE REMAINDER OF THE FLT ALTHOUGH I DOUBT THAT THE CAPT WAS AWARE OF IT. I CALLED THE TFC IN SIGHT AND THE TWR CLRED US TO LAND AGAIN ON RWY 12. WE NEVER DID LEVEL AT 2000 FT MSL. WE JUST CONTINUED THE DSCNT TO LNDG. HE TURNED BASE ABOUT 4 MI OUT AT 160 KTS AND CALLED FOR FLAPS, GEAR AND THE FINAL CHK. I THINK HE WAS TRYING TO FLY VISUALLY BECAUSE, OUR TURNS TO BASE AND FINAL WERE USING BANK ANGLES OF ABOUT 45 DEGS DESPITE MY REPEATED CALLS OF BANK ANGLE AND MY CTL PRESSURE ON THE YOKE. THE SECOND APCH TO LNDG WAS UNEVENTFUL EXCEPT FOR A COUPLE OF S-TURNS TO LINE UP WITH THE RWY.
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.