37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 295387 |
Time | |
Date | 199502 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : crg |
State Reference | FL |
Altitude | msl bound lower : 2000 msl bound upper : 2000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : jax tower : dfw |
Operator | general aviation : corporate |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 91 |
Navigation In Use | Other Other |
Flight Phase | descent : approach landing : missed approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 100 flight time total : 11000 flight time type : 100 |
ASRS Report | 295387 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
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 |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
My co-captain and I were en route to craig field. The WX at our time of departure was clear and 7 mi. Fog was forecast, however, not developing at our destination. We were just transitioning into an EFIS equipped aircraft with about 6 weeks of regular use, and were still getting used to the equipment. As we approached our destination, ATIS was checked and we found our destination was down to minimums. We reviewed the approach plate, talked about the missed approach procedure and I requested altitude callouts and deviations by the PNF. I hand flew the approach down to minimums, missed and went to the missed approach procedure as published. The miss called for a climb to 700 ft followed by a course reversal outbound on the localizer, to the fix and hold, also continuing the climb to 1800 ft. Up to this point the procedure was totally correct however, as I crossed the localizer site and continued to intercept, I corrected the wrong way and failed to join the localizer. My co-captain noticed this was occurring, but failed to call it to my attention. I was several mi east before I figured it out and rejoined the hold. The controller had cleared us to hold direction and turns our discretion, also legs our discretion. At time we entered the hold with 15 mi legs, upon turning back in, we were advised that the WX had improved so we shot the approach and landed. Several factors led to this situation. 1) our cockpit resource management training didn't work as well as it should have because the PNF did not challenge the situation. 2) the fact that I was not totally in tune to the new EFIS presentation and its back-up ability, FMS. 3) both navigation units were tuned to the localizer, so there was no RMI information to back up my position. This was really poor because the VOR was right on the field and would have reinforced my position. Additional factors were that I failed to eat a good breakfast. The week started with a late night arrival on monday followed by a trip tuesday, office on wednesday, and trips on thursday and friday. And last was the fact that the WX deteriorated so quickly and I rushed myself into the miss.
Original NASA ASRS Text
Title: PLT CORRECTS THE WRONG WAY FLYING OUTBOUND ON THE FRONT COURSE.
Narrative: MY CO-CAPT AND I WERE ENRTE TO CRAIG FIELD. THE WX AT OUR TIME OF DEP WAS CLR AND 7 MI. FOG WAS FORECAST, HOWEVER, NOT DEVELOPING AT OUR DEST. WE WERE JUST TRANSITIONING INTO AN EFIS EQUIPPED ACFT WITH ABOUT 6 WKS OF REGULAR USE, AND WERE STILL GETTING USED TO THE EQUIP. AS WE APCHED OUR DEST, ATIS WAS CHKED AND WE FOUND OUR DEST WAS DOWN TO MINIMUMS. WE REVIEWED THE APCH PLATE, TALKED ABOUT THE MISSED APCH PROC AND I REQUESTED ALT CALLOUTS AND DEVS BY THE PNF. I HAND FLEW THE APCH DOWN TO MINIMUMS, MISSED AND WENT TO THE MISSED APCH PROC AS PUBLISHED. THE MISS CALLED FOR A CLB TO 700 FT FOLLOWED BY A COURSE REVERSAL OUTBOUND ON THE LOC, TO THE FIX AND HOLD, ALSO CONTINUING THE CLB TO 1800 FT. UP TO THIS POINT THE PROC WAS TOTALLY CORRECT HOWEVER, AS I CROSSED THE LOC SITE AND CONTINUED TO INTERCEPT, I CORRECTED THE WRONG WAY AND FAILED TO JOIN THE LOC. MY CO-CAPT NOTICED THIS WAS OCCURRING, BUT FAILED TO CALL IT TO MY ATTN. I WAS SEVERAL MI E BEFORE I FIGURED IT OUT AND REJOINED THE HOLD. THE CTLR HAD CLRED US TO HOLD DIRECTION AND TURNS OUR DISCRETION, ALSO LEGS OUR DISCRETION. AT TIME WE ENTERED THE HOLD WITH 15 MI LEGS, UPON TURNING BACK IN, WE WERE ADVISED THAT THE WX HAD IMPROVED SO WE SHOT THE APCH AND LANDED. SEVERAL FACTORS LED TO THIS SIT. 1) OUR COCKPIT RESOURCE MGMNT TRAINING DIDN'T WORK AS WELL AS IT SHOULD HAVE BECAUSE THE PNF DID NOT CHALLENGE THE SIT. 2) THE FACT THAT I WAS NOT TOTALLY IN TUNE TO THE NEW EFIS PRESENTATION AND ITS BACK-UP ABILITY, FMS. 3) BOTH NAV UNITS WERE TUNED TO THE LOC, SO THERE WAS NO RMI INFO TO BACK UP MY POS. THIS WAS REALLY POOR BECAUSE THE VOR WAS RIGHT ON THE FIELD AND WOULD HAVE REINFORCED MY POS. ADDITIONAL FACTORS WERE THAT I FAILED TO EAT A GOOD BREAKFAST. THE WK STARTED WITH A LATE NIGHT ARR ON MONDAY FOLLOWED BY A TRIP TUESDAY, OFFICE ON WEDNESDAY, AND TRIPS ON THURSDAY AND FRIDAY. AND LAST WAS THE FACT THAT THE WX DETERIORATED SO QUICKLY AND I RUSHED MYSELF INTO THE MISS.
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.