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|
Attributes | |
ACN | 289789 |
Time | |
Date | 199411 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : jnu |
State Reference | AK |
Altitude | msl bound lower : 5200 msl bound upper : 10000 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : jnu tower : jnu |
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 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 130 flight time total : 10000 |
ASRS Report | 289789 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 180 flight time total : 5000 flight time type : 180 |
ASRS Report | 289769 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : became reoriented |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After leaving holding pattern over ssr VOR at 10000 ft for the lda approach runway 8 at jnu, ak, I realized the approach was put in FMC incorrectly and we were flying towards barlo intersection instead of lynns. We were a few mi from barlo when I discovered the error. We were descending to 5200 ft as is the MEA on the ssr-lynns transition. We made a steep descent from barlo to the MDA and ended up back on the proper profile. The missed approach procedure for this approach takes you back to barlo and then to ssr with a crossing restr at barlo of 3000 ft, so we were well above minimum altitude along this segment. Contributing to the error was the high workload in the holding pattern at ssr, watching for improved WX at jnu, fuel considerations, alternate airport change, obtaining amended release, icing conditions, in the holding pattern. Also because another airplane was holding at ssr below us, we had to maintain 10000 ft on the approach until we were 5 NM north of ssr. I put this in FMC as an along track waypoint from ssr. My map scale was such that I did not have the next waypoint on the my map, which should have been lynns but because of the error was barlo. Had I seen barlo on the map, I might have discovered the error in the FMC routing and fixed it prior to actually flying the wrong way. Lesson learned here is to double-check all FMC routings especially before an approach. Supplemental information from acn 289769: since we were very high, terrain was never a concern and routing is actually part of the barlo 6 departure. We continued, missed the approach back to ssr and hold. Next approach (fifth) ssr via lynns and landed without incident. Contributing factors: high workload, moderate icing, night, IMC, tracking fuel, changing plans for altitude and number of approachs. We are both experienced at flying in southeast alaska's non radar environment and always xchk radials, distance and NDB bearings. I just got overloaded at that point in the flight. WX was changing and we were trying to fit into a WX window. Should have slowed everything down and crosschecked prior to commencing fourth approach.
Original NASA ASRS Text
Title: MLG MAKES NUMEROUS APCHS AND MISSED APCHS. UPON LEAVING AIRHOLD, DISCOVERS WRONG INFO IN FMC.
Narrative: AFTER LEAVING HOLDING PATTERN OVER SSR VOR AT 10000 FT FOR THE LDA APCH RWY 8 AT JNU, AK, I REALIZED THE APCH WAS PUT IN FMC INCORRECTLY AND WE WERE FLYING TOWARDS BARLO INTXN INSTEAD OF LYNNS. WE WERE A FEW MI FROM BARLO WHEN I DISCOVERED THE ERROR. WE WERE DSNDING TO 5200 FT AS IS THE MEA ON THE SSR-LYNNS TRANSITION. WE MADE A STEEP DSCNT FROM BARLO TO THE MDA AND ENDED UP BACK ON THE PROPER PROFILE. THE MISSED APCH PROC FOR THIS APCH TAKES YOU BACK TO BARLO AND THEN TO SSR WITH A XING RESTR AT BARLO OF 3000 FT, SO WE WERE WELL ABOVE MINIMUM ALT ALONG THIS SEGMENT. CONTRIBUTING TO THE ERROR WAS THE HIGH WORKLOAD IN THE HOLDING PATTERN AT SSR, WATCHING FOR IMPROVED WX AT JNU, FUEL CONSIDERATIONS, ALTERNATE ARPT CHANGE, OBTAINING AMENDED RELEASE, ICING CONDITIONS, IN THE HOLDING PATTERN. ALSO BECAUSE ANOTHER AIRPLANE WAS HOLDING AT SSR BELOW US, WE HAD TO MAINTAIN 10000 FT ON THE APCH UNTIL WE WERE 5 NM N OF SSR. I PUT THIS IN FMC AS AN ALONG TRACK WAYPOINT FROM SSR. MY MAP SCALE WAS SUCH THAT I DID NOT HAVE THE NEXT WAYPOINT ON THE MY MAP, WHICH SHOULD HAVE BEEN LYNNS BUT BECAUSE OF THE ERROR WAS BARLO. HAD I SEEN BARLO ON THE MAP, I MIGHT HAVE DISCOVERED THE ERROR IN THE FMC ROUTING AND FIXED IT PRIOR TO ACTUALLY FLYING THE WRONG WAY. LESSON LEARNED HERE IS TO DOUBLE-CHK ALL FMC ROUTINGS ESPECIALLY BEFORE AN APCH. SUPPLEMENTAL INFORMATION FROM ACN 289769: SINCE WE WERE VERY HIGH, TERRAIN WAS NEVER A CONCERN AND ROUTING IS ACTUALLY PART OF THE BARLO 6 DEP. WE CONTINUED, MISSED THE APCH BACK TO SSR AND HOLD. NEXT APCH (FIFTH) SSR VIA LYNNS AND LANDED WITHOUT INCIDENT. CONTRIBUTING FACTORS: HIGH WORKLOAD, MODERATE ICING, NIGHT, IMC, TRACKING FUEL, CHANGING PLANS FOR ALT AND NUMBER OF APCHS. WE ARE BOTH EXPERIENCED AT FLYING IN SE ALASKA'S NON RADAR ENVIRONMENT AND ALWAYS XCHK RADIALS, DISTANCE AND NDB BEARINGS. I JUST GOT OVERLOADED AT THAT POINT IN THE FLT. WX WAS CHANGING AND WE WERE TRYING TO FIT INTO A WX WINDOW. SHOULD HAVE SLOWED EVERYTHING DOWN AND XCHKED PRIOR TO COMMENCING FOURTH APCH.
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.