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|
Attributes | |
ACN | 296315 |
Time | |
Date | 199502 |
Day | Thu |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : mci |
State Reference | MO |
Altitude | msl bound lower : 7000 msl bound upper : 7900 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Controlling Facilities | tracon : mci |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other |
Route In Use | enroute : direct |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air taxi |
Make Model Name | MU-2 Undifferentiated or Other Model |
Operating Under FAR Part | Part 135 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | VFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : instrument pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 130 flight time total : 10000 flight time type : 4500 |
ASRS Report | 296315 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : far non adherence : published procedure non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified |
Resolutory Action | flight crew : took evasive action |
Consequence | Other |
Miss Distance | horizontal : 3000 vertical : 500 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Flight X (us) at 7000 ft proceeding from east direct to mci. With radio/radar contact with mci approach control. Mitsubashi called in at 4000 ft, reported visual contact with us and cleared to climb to 15000 ft reference visual with us by approach control. Approach called traffic to us, no contact, then called again (suspect that approach was trying to let us down from 7000 ft and couldn't until we had visual on the MU2). We indicated we thought we had the traffic. No TA, then RA commanding descent in excess of 4000 FPM down. TCASII indicated traffic approximately 3/4 mi and climbing through 5800 ft MSL at 11:30 O'clock position and closing. Split decision time: I elected to ignore TCASII vsi RA command and executed a pull-up and break right as traffic continued to climb through 6200 ft and closing. We leveled at 7900 ft, advised approach and then continued to normal visual approach and landing at mci. Problem arose because: mu-2 made careless and reckless visual climb. Most likely impatient thus not maintaining course reasonably clear of traffic. Controller overload probably prevented us from receiving vector clear of climbing traffic (last clearance was direct mci at 7000 ft). Visual separation at night looking at landing lights is deceptive until too close! TCASII system limitations (had we followed RA there is no doubt in my mind that it would have caused a catastrophe!). Human performance considerations: TCASII at our airlines, we have no provision for simulator training of RA maneuvers. Anyone associated with training and the history of accidents knows that instrument flying is based on trust of instruments and practice to the level of 'conditioned response.' TCASII procedures can be talked about until you are 'blue in the face,' but response action and time will always be faulty and slow at best! Until the system is flawless and we can 'practice what is preached,' then those famous last words 'why is that damned thing going off!?!' will be on tape again. The ATC system broke down (as it will due to human factors from time to time) and the TCASII backup system didn't work as advertised. We were lucky, this time.
Original NASA ASRS Text
Title: POTENTIAL CONFLICT IN A NIGHT OP BTWN CLBING OPPOSITE DIRECTION TFC.
Narrative: FLT X (US) AT 7000 FT PROCEEDING FROM E DIRECT TO MCI. WITH RADIO/RADAR CONTACT WITH MCI APCH CTL. MITSUBASHI CALLED IN AT 4000 FT, RPTED VISUAL CONTACT WITH US AND CLRED TO CLB TO 15000 FT REF VISUAL WITH US BY APCH CTL. APCH CALLED TFC TO US, NO CONTACT, THEN CALLED AGAIN (SUSPECT THAT APCH WAS TRYING TO LET US DOWN FROM 7000 FT AND COULDN'T UNTIL WE HAD VISUAL ON THE MU2). WE INDICATED WE THOUGHT WE HAD THE TFC. NO TA, THEN RA COMMANDING DSCNT IN EXCESS OF 4000 FPM DOWN. TCASII INDICATED TFC APPROX 3/4 MI AND CLBING THROUGH 5800 FT MSL AT 11:30 O'CLOCK POS AND CLOSING. SPLIT DECISION TIME: I ELECTED TO IGNORE TCASII VSI RA COMMAND AND EXECUTED A PULL-UP AND BREAK R AS TFC CONTINUED TO CLB THROUGH 6200 FT AND CLOSING. WE LEVELED AT 7900 FT, ADVISED APCH AND THEN CONTINUED TO NORMAL VISUAL APCH AND LNDG AT MCI. PROB AROSE BECAUSE: MU-2 MADE CARELESS AND RECKLESS VISUAL CLB. MOST LIKELY IMPATIENT THUS NOT MAINTAINING COURSE REASONABLY CLR OF TFC. CTLR OVERLOAD PROBABLY PREVENTED US FROM RECEIVING VECTOR CLR OF CLBING TFC (LAST CLRNC WAS DIRECT MCI AT 7000 FT). VISUAL SEPARATION AT NIGHT LOOKING AT LNDG LIGHTS IS DECEPTIVE UNTIL TOO CLOSE! TCASII SYS LIMITATIONS (HAD WE FOLLOWED RA THERE IS NO DOUBT IN MY MIND THAT IT WOULD HAVE CAUSED A CATASTROPHE!). HUMAN PERFORMANCE CONSIDERATIONS: TCASII AT OUR AIRLINES, WE HAVE NO PROVISION FOR SIMULATOR TRAINING OF RA MANEUVERS. ANYONE ASSOCIATED WITH TRAINING AND THE HISTORY OF ACCIDENTS KNOWS THAT INST FLYING IS BASED ON TRUST OF INSTS AND PRACTICE TO THE LEVEL OF 'CONDITIONED RESPONSE.' TCASII PROCS CAN BE TALKED ABOUT UNTIL YOU ARE 'BLUE IN THE FACE,' BUT RESPONSE ACTION AND TIME WILL ALWAYS BE FAULTY AND SLOW AT BEST! UNTIL THE SYS IS FLAWLESS AND WE CAN 'PRACTICE WHAT IS PREACHED,' THEN THOSE FAMOUS LAST WORDS 'WHY IS THAT DAMNED THING GOING OFF!?!' WILL BE ON TAPE AGAIN. THE ATC SYS BROKE DOWN (AS IT WILL DUE TO HUMAN FACTORS FROM TIME TO TIME) AND THE TCASII BACKUP SYS DIDN'T WORK AS ADVERTISED. WE WERE LUCKY, THIS TIME.
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.