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|
Attributes | |
ACN | 295602 |
Time | |
Date | 199501 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : sbeg |
State Reference | FO |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : sbeg tower : ord |
Operator | common carrier : air carrier |
Make Model Name | DC-8 62 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach landing other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 13800 flight time type : 6000 |
ASRS Report | 295602 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : flight engineer |
Experience | flight time last 90 days : 235 flight time total : 1422 flight time type : 1379 |
ASRS Report | 295599 |
Events | |
Anomaly | inflight encounter : weather other anomaly other other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : exited adverse environment other |
Consequence | other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was working as captain on a cargo charter from miami to manaus, brazil (sbeg). About 180 mi out of sbeg I requested airport conditions in order to plan the approach and brief the crew. We were given as I remember, scattered 800 ft, 1000 meters, temperature 28 degrees C, winds 120 at 6 KTS and 1010 MB. I asked my first officer to ask the reason for reduced visibility. After asking several times they finally answered 'rain.' having landed there many times in rain in the past, I thought I had a pretty good idea of what to expect. There were several layers of clouds and I remember I thought I saw a buildup out to the right of my course line but nothing showed up on my WX radar. The WX radar had been written up several times in the past as painting very weak. I planned to hand fly the aircraft since on autoplt in turns it would go to 35 degrees of bank and disconnect. In my briefing I instructed my first officer that approaching the VOR I would have him tune me to the ILS and keep himself on the VOR to identify station passage. The VOR is co-located with the OM and is 3.5 mi so I didn't want to rely on it and I did want to verify passing the VOR and xchk GS altitude. We were initially cleared to descend to FL190 then turned over to manaus approach who then cleared us to FL040. Approaching the VOR we were cleared to 2000 ft and cleared straightin ILS runway 10. Knowing the approach is short and things happen very fast, I started configuring early and was established on the ILS outside the VOR. WX information was given a couple more times varying 'scattered' 600 ft to 800 ft and visibility was given as 800 meters, minimums for the approach. Right at the VOR I heard visibility reported as 500 meters but since we were established I decided to continue. I could see no reason not to and we had plenty of fuel to miss and hold for a while. Crossing the VOR approach control said contact tower. The first officer, very new in the aircraft and company, changed to tower and called, got no answer, called again and after what seemed like a huge pause, finally was given winds 120 degrees at 6 KTS, cleared to land. While all this was going on, I saw my GS needle bounce but it came right back in again and never showed an off flag. By this time we were getting pretty low on the approach and entered heavy rain, light and occasional moderate turbulence. The first officer was just finally able to retune his navigation to the ILS. As the first officer was doing all this I was hand flying the approach and I remember seeing the speed increasing and adjusting. At the time I didn't think much of it probably because I had my hands full but in hindsight had I not made adjustments for it I think the speed increase would have been significant. I then heard the GPWS sound 'minimums' and knowing my barometric altitude was still well above minimums, I knew something was wrong but couldn't tell what. I also remember at this point, all at the same time, the speed began bleeding off I started adding power. I didn't want to get too fast because the runway was short and wet and we were at maximum landing weight but within wet landing limits. The GS became erratic then went full up deflection. I caught a glimpse outside and saw tree tops, went to firewall power and pitched up. On the miss we clipped the tops of some trees and flamed out #4 engine. I remember during the miss seeing some lightning and that was the first clue I had that the rain they were reporting was very heavy and part of a thunderstorm over the field. Nothing about thunderstorms was ever reported to me. I elected to hold and await better WX, declared an emergency, requested emergency equipment since I didn't know full extent of damage, then after the WX improved we landed without further incident. No emergency equipment was in sight when we landed. In hindsight, I think the reason for the incident was wind shear/microburst. The symptoms were there, however, at the time I had no knowledge of any convective activity, let alone a thunderstorm over the field. Contributors were understated WX, WX radar that was very weak, a large discrepancy between radar and barometric altimeters, a GS that became erratic and complicating all this, is the short distance from the VOR/OM to missedapch and changing to tower at the VOR. I've learned through this incident that the military sense of mission accomplishment is still there. I thought I had gotten rid of it through the yrs but it's still there and from now on any time things don't feel just right, it's time to go around and regroup. Callback conversation with reporter revealed the following information: his crew members were all low time pilots, thus very inexperienced. The flight engineer was not pilot qualified. Was very diligent and hard working, but had no instrument experience. First officer just had enough time to have a commercial and instrument rating. Reporter captain was not informed that a thunderstorm was over the airport. The meteorologist was not on duty and WX information had not changed during the course of the storm. The altimeter setting was 4-6 hours old. The GS had a few bumps in it, but it seemed acceptable to the reporter. He followed the GS down, then when it went full scale up suddenly, he applied power, saw a tree ahead of them and rotated to maximum angle up. He never saw the runway or runway environment, just the tree that he hit and his immediate reaction as he rotated the nose up was that, 'we were not going to make it.' #4 engine was struck by the tree, and was destroyed by the ingestion of the branches. Damage was severe so it is thought that tree was a mahogany tree. The tree was hit at an altitude of 600 ft but field elevation is approximately 250 ft. Since the tree would not be 350 ft tall but in all probability 100 ft in ht, the difference is explained by the non current altimeter setting. Reporter feels the ILS he followed presented a false GS. There have been many rumors to the effect that the GS was frequently false in heavy rain. GS was tested okay in good flight conditions, no testing was done in heavy rain. The air carrier company has now changed the minimums to 300 ft higher than prior to this event. The NTSB has investigated this occurrence and has declared it an incident. None of the flight crew were disciplined as a result of this incident. Callback conversation with reporter acn #295321 revealed the following information: the reporter was flying the dc-8-62 for an air carrier that has been shut down by the FAA for maintenance shortcomings. The captain was on the GS when he hit the trees. The #4 engine was damaged beyond repair and was left in mao. The aircraft flew home on a 3 engine ferry. An aci flew into mao with another crew recently that would have flown into the ground had they stayed on the GS. The reporter has heard nothing from the FAA since a fact finding session. He believes that they were exonerated. The captain is already flying for another air carrier.
Original NASA ASRS Text
Title: ACFT STRIKES TREE DURING INST APCH.
Narrative: I WAS WORKING AS CAPT ON A CARGO CHARTER FROM MIAMI TO MANAUS, BRAZIL (SBEG). ABOUT 180 MI OUT OF SBEG I REQUESTED ARPT CONDITIONS IN ORDER TO PLAN THE APCH AND BRIEF THE CREW. WE WERE GIVEN AS I REMEMBER, SCATTERED 800 FT, 1000 METERS, TEMP 28 DEGS C, WINDS 120 AT 6 KTS AND 1010 MB. I ASKED MY FO TO ASK THE REASON FOR REDUCED VISIBILITY. AFTER ASKING SEVERAL TIMES THEY FINALLY ANSWERED 'RAIN.' HAVING LANDED THERE MANY TIMES IN RAIN IN THE PAST, I THOUGHT I HAD A PRETTY GOOD IDEA OF WHAT TO EXPECT. THERE WERE SEVERAL LAYERS OF CLOUDS AND I REMEMBER I THOUGHT I SAW A BUILDUP OUT TO THE R OF MY COURSE LINE BUT NOTHING SHOWED UP ON MY WX RADAR. THE WX RADAR HAD BEEN WRITTEN UP SEVERAL TIMES IN THE PAST AS PAINTING VERY WEAK. I PLANNED TO HAND FLY THE ACFT SINCE ON AUTOPLT IN TURNS IT WOULD GO TO 35 DEGS OF BANK AND DISCONNECT. IN MY BRIEFING I INSTRUCTED MY FO THAT APCHING THE VOR I WOULD HAVE HIM TUNE ME TO THE ILS AND KEEP HIMSELF ON THE VOR TO IDENT STATION PASSAGE. THE VOR IS CO-LOCATED WITH THE OM AND IS 3.5 MI SO I DIDN'T WANT TO RELY ON IT AND I DID WANT TO VERIFY PASSING THE VOR AND XCHK GS ALT. WE WERE INITIALLY CLRED TO DSND TO FL190 THEN TURNED OVER TO MANAUS APCH WHO THEN CLRED US TO FL040. APCHING THE VOR WE WERE CLRED TO 2000 FT AND CLRED STRAIGHTIN ILS RWY 10. KNOWING THE APCH IS SHORT AND THINGS HAPPEN VERY FAST, I STARTED CONFIGURING EARLY AND WAS ESTABLISHED ON THE ILS OUTSIDE THE VOR. WX INFO WAS GIVEN A COUPLE MORE TIMES VARYING 'SCATTERED' 600 FT TO 800 FT AND VISIBILITY WAS GIVEN AS 800 METERS, MINIMUMS FOR THE APCH. RIGHT AT THE VOR I HEARD VISIBILITY RPTED AS 500 METERS BUT SINCE WE WERE ESTABLISHED I DECIDED TO CONTINUE. I COULD SEE NO REASON NOT TO AND WE HAD PLENTY OF FUEL TO MISS AND HOLD FOR A WHILE. XING THE VOR APCH CTL SAID CONTACT TWR. THE FO, VERY NEW IN THE ACFT AND COMPANY, CHANGED TO TWR AND CALLED, GOT NO ANSWER, CALLED AGAIN AND AFTER WHAT SEEMED LIKE A HUGE PAUSE, FINALLY WAS GIVEN WINDS 120 DEGS AT 6 KTS, CLRED TO LAND. WHILE ALL THIS WAS GOING ON, I SAW MY GS NEEDLE BOUNCE BUT IT CAME RIGHT BACK IN AGAIN AND NEVER SHOWED AN OFF FLAG. BY THIS TIME WE WERE GETTING PRETTY LOW ON THE APCH AND ENTERED HVY RAIN, LIGHT AND OCCASIONAL MODERATE TURB. THE FO WAS JUST FINALLY ABLE TO RETUNE HIS NAV TO THE ILS. AS THE FO WAS DOING ALL THIS I WAS HAND FLYING THE APCH AND I REMEMBER SEEING THE SPD INCREASING AND ADJUSTING. AT THE TIME I DIDN'T THINK MUCH OF IT PROBABLY BECAUSE I HAD MY HANDS FULL BUT IN HINDSIGHT HAD I NOT MADE ADJUSTMENTS FOR IT I THINK THE SPD INCREASE WOULD HAVE BEEN SIGNIFICANT. I THEN HEARD THE GPWS SOUND 'MINIMUMS' AND KNOWING MY BAROMETRIC ALT WAS STILL WELL ABOVE MINIMUMS, I KNEW SOMETHING WAS WRONG BUT COULDN'T TELL WHAT. I ALSO REMEMBER AT THIS POINT, ALL AT THE SAME TIME, THE SPD BEGAN BLEEDING OFF I STARTED ADDING PWR. I DIDN'T WANT TO GET TOO FAST BECAUSE THE RWY WAS SHORT AND WET AND WE WERE AT MAX LNDG WT BUT WITHIN WET LNDG LIMITS. THE GS BECAME ERRATIC THEN WENT FULL UP DEFLECTION. I CAUGHT A GLIMPSE OUTSIDE AND SAW TREE TOPS, WENT TO FIREWALL PWR AND PITCHED UP. ON THE MISS WE CLIPPED THE TOPS OF SOME TREES AND FLAMED OUT #4 ENG. I REMEMBER DURING THE MISS SEEING SOME LIGHTNING AND THAT WAS THE FIRST CLUE I HAD THAT THE RAIN THEY WERE RPTING WAS VERY HVY AND PART OF A TSTM OVER THE FIELD. NOTHING ABOUT TSTMS WAS EVER RPTED TO ME. I ELECTED TO HOLD AND AWAIT BETTER WX, DECLARED AN EMER, REQUESTED EMER EQUIP SINCE I DIDN'T KNOW FULL EXTENT OF DAMAGE, THEN AFTER THE WX IMPROVED WE LANDED WITHOUT FURTHER INCIDENT. NO EMER EQUIP WAS IN SIGHT WHEN WE LANDED. IN HINDSIGHT, I THINK THE REASON FOR THE INCIDENT WAS WIND SHEAR/MICROBURST. THE SYMPTOMS WERE THERE, HOWEVER, AT THE TIME I HAD NO KNOWLEDGE OF ANY CONVECTIVE ACTIVITY, LET ALONE A TSTM OVER THE FIELD. CONTRIBUTORS WERE UNDERSTATED WX, WX RADAR THAT WAS VERY WEAK, A LARGE DISCREPANCY BTWN RADAR AND BAROMETRIC ALTIMETERS, A GS THAT BECAME ERRATIC AND COMPLICATING ALL THIS, IS THE SHORT DISTANCE FROM THE VOR/OM TO MISSEDAPCH AND CHANGING TO TWR AT THE VOR. I'VE LEARNED THROUGH THIS INCIDENT THAT THE MIL SENSE OF MISSION ACCOMPLISHMENT IS STILL THERE. I THOUGHT I HAD GOTTEN RID OF IT THROUGH THE YRS BUT IT'S STILL THERE AND FROM NOW ON ANY TIME THINGS DON'T FEEL JUST RIGHT, IT'S TIME TO GAR AND REGROUP. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: HIS CREW MEMBERS WERE ALL LOW TIME PLTS, THUS VERY INEXPERIENCED. THE FE WAS NOT PLT QUALIFIED. WAS VERY DILIGENT AND HARD WORKING, BUT HAD NO INST EXPERIENCE. FO JUST HAD ENOUGH TIME TO HAVE A COMMERCIAL AND INST RATING. RPTR CAPT WAS NOT INFORMED THAT A TSTM WAS OVER THE ARPT. THE METEOROLOGIST WAS NOT ON DUTY AND WX INFO HAD NOT CHANGED DURING THE COURSE OF THE STORM. THE ALTIMETER SETTING WAS 4-6 HRS OLD. THE GS HAD A FEW BUMPS IN IT, BUT IT SEEMED ACCEPTABLE TO THE RPTR. HE FOLLOWED THE GS DOWN, THEN WHEN IT WENT FULL SCALE UP SUDDENLY, HE APPLIED PWR, SAW A TREE AHEAD OF THEM AND ROTATED TO MAX ANGLE UP. HE NEVER SAW THE RWY OR RWY ENVIRONMENT, JUST THE TREE THAT HE HIT AND HIS IMMEDIATE REACTION AS HE ROTATED THE NOSE UP WAS THAT, 'WE WERE NOT GOING TO MAKE IT.' #4 ENG WAS STRUCK BY THE TREE, AND WAS DESTROYED BY THE INGESTION OF THE BRANCHES. DAMAGE WAS SEVERE SO IT IS THOUGHT THAT TREE WAS A MAHOGANY TREE. THE TREE WAS HIT AT AN ALT OF 600 FT BUT FIELD ELEVATION IS APPROX 250 FT. SINCE THE TREE WOULD NOT BE 350 FT TALL BUT IN ALL PROBABILITY 100 FT IN HT, THE DIFFERENCE IS EXPLAINED BY THE NON CURRENT ALTIMETER SETTING. RPTR FEELS THE ILS HE FOLLOWED PRESENTED A FALSE GS. THERE HAVE BEEN MANY RUMORS TO THE EFFECT THAT THE GS WAS FREQUENTLY FALSE IN HVY RAIN. GS WAS TESTED OKAY IN GOOD FLT CONDITIONS, NO TESTING WAS DONE IN HVY RAIN. THE ACR COMPANY HAS NOW CHANGED THE MINIMUMS TO 300 FT HIGHER THAN PRIOR TO THIS EVENT. THE NTSB HAS INVESTIGATED THIS OCCURRENCE AND HAS DECLARED IT AN INCIDENT. NONE OF THE FLC WERE DISCIPLINED AS A RESULT OF THIS INCIDENT. CALLBACK CONVERSATION WITH RPTR ACN #295321 REVEALED THE FOLLOWING INFO: THE RPTR WAS FLYING THE DC-8-62 FOR AN ACR THAT HAS BEEN SHUT DOWN BY THE FAA FOR MAINT SHORTCOMINGS. THE CAPT WAS ON THE GS WHEN HE HIT THE TREES. THE #4 ENG WAS DAMAGED BEYOND REPAIR AND WAS LEFT IN MAO. THE ACFT FLEW HOME ON A 3 ENG FERRY. AN ACI FLEW INTO MAO WITH ANOTHER CREW RECENTLY THAT WOULD HAVE FLOWN INTO THE GND HAD THEY STAYED ON THE GS. THE RPTR HAS HEARD NOTHING FROM THE FAA SINCE A FACT FINDING SESSION. HE BELIEVES THAT THEY WERE EXONERATED. THE CAPT IS ALREADY FLYING FOR ANOTHER ACR.
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.