37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 288886 |
Time | |
Date | 199411 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : oak |
State Reference | CA |
Altitude | msl bound lower : 2500 msl bound upper : 2500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : oak |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent : approach landing : missed approach other |
Route In Use | approach : visual |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : instrument pilot : atp pilot : cfi |
Experience | flight time last 90 days : 120 flight time total : 9000 flight time type : 3000 |
ASRS Report | 288886 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : private pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 50 flight time total : 15000 flight time type : 50 |
ASRS Report | 288882 |
Events | |
Anomaly | conflict : airborne less severe non adherence : clearance other spatial deviation |
Independent Detector | atc equipment other atc equipment : unspecified other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : took evasive action other |
Consequence | Other |
Miss Distance | horizontal : 9000 vertical : 500 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We had just executed a missed approach due to an aircraft not clearing the runway. The first officer, who was flying, had less than 100 hours in the aircraft (first month on the line). I was talking him through the map procedure and communicating with bay TRACON for another approach. Bay vectored us to the downwind and pointed out an aircraft on final that we were to follow. I acknowledged the traffic (at least what I thought was the traffic!) I pointed the airplane out to the first officer who began a turn in on the base. As we were established on base another aircraft came on radio and said we were turning behind the wrong aircraft. At this time we got a TCASII RA and a TA from approach. I did not see aircraft but saw the conflict on the TCASII. The aircraft was 500 ft below us so we maintained our assigned altitude of 2500 ft and turned away from the final approach course. We executed a 360 degree turn and reentered the final for an uneventful landing. This was definitely a case of pilot overload, mine! The newness of the first officer coupled with the demands of reconfiguring the aircraft for another approach, communicating with ATC and ensuring the first officer had everything 'together' led to plain ole' overload. A simple misident of an aircraft potentially led to a serious accident. This was a classic case of a 'chain-of-events' type scenario. I don't know what I could have done differently to change the outcome. Chalk this one up to dumb luck.
Original NASA ASRS Text
Title: FLC OF AN MLG OBSERVED AND FOLLOWED THE WRONG TFC DURING A VISUAL APCH RESULTING IN ATC INTERVENTION AND ISSUANCE OF NEW INSTRUCTIONS.
Narrative: WE HAD JUST EXECUTED A MISSED APCH DUE TO AN ACFT NOT CLRING THE RWY. THE FO, WHO WAS FLYING, HAD LESS THAN 100 HRS IN THE ACFT (FIRST MONTH ON THE LINE). I WAS TALKING HIM THROUGH THE MAP PROC AND COMMUNICATING WITH BAY TRACON FOR ANOTHER APCH. BAY VECTORED US TO THE DOWNWIND AND POINTED OUT AN ACFT ON FINAL THAT WE WERE TO FOLLOW. I ACKNOWLEDGED THE TFC (AT LEAST WHAT I THOUGHT WAS THE TFC!) I POINTED THE AIRPLANE OUT TO THE FO WHO BEGAN A TURN IN ON THE BASE. AS WE WERE ESTABLISHED ON BASE ANOTHER ACFT CAME ON RADIO AND SAID WE WERE TURNING BEHIND THE WRONG ACFT. AT THIS TIME WE GOT A TCASII RA AND A TA FROM APCH. I DID NOT SEE ACFT BUT SAW THE CONFLICT ON THE TCASII. THE ACFT WAS 500 FT BELOW US SO WE MAINTAINED OUR ASSIGNED ALT OF 2500 FT AND TURNED AWAY FROM THE FINAL APCH COURSE. WE EXECUTED A 360 DEG TURN AND REENTERED THE FINAL FOR AN UNEVENTFUL LNDG. THIS WAS DEFINITELY A CASE OF PLT OVERLOAD, MINE! THE NEWNESS OF THE FO COUPLED WITH THE DEMANDS OF RECONFIGURING THE ACFT FOR ANOTHER APCH, COMMUNICATING WITH ATC AND ENSURING THE FO HAD EVERYTHING 'TOGETHER' LED TO PLAIN OLE' OVERLOAD. A SIMPLE MISIDENT OF AN ACFT POTENTIALLY LED TO A SERIOUS ACCIDENT. THIS WAS A CLASSIC CASE OF A 'CHAIN-OF-EVENTS' TYPE SCENARIO. I DON'T KNOW WHAT I COULD HAVE DONE DIFFERENTLY TO CHANGE THE OUTCOME. CHALK THIS ONE UP TO DUMB LUCK.
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.