37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 304068 |
Time | |
Date | 199505 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : iiyq airport : iyq |
State Reference | WV |
Altitude | msl bound lower : 2600 msl bound upper : 2800 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc |
Operator | common carrier : air taxi |
Make Model Name | Cessna Citation Undifferentiated or Other Model |
Operating Under FAR Part | Part 135 |
Flight Phase | descent : approach landing : missed approach other |
Route In Use | approach : circling |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 45 flight time total : 5000 flight time type : 140 |
ASRS Report | 304068 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : overshoot inflight encounter : weather non adherence : clearance non adherence : published procedure other anomaly other |
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:
After electing to make a missed approach on ILS due to a GS fluctuation, I began the initial climb to the missed approach altitude and calling for the appropriate checks. The first officer had only approximately 6 hours in the right seat and I was trying to direct him in what I needed as to the missed approach procedure. Workload was high and as we approached the holding fix we entered an area of moderate turbulence which spilled our approach plates and we had to announce missed approach with the approach controller after switching from tower. The turbulence contributed to our going over the altitude by a couple hundred ft (estimated) as we entered the hold. Contributing factors were: low time copilot and this was the first time the crew had flown together in addition to high workload area and the first time in a non radar, tower controled environment in a while. Callback conversation with reporter revealed the following information: the reporter stated he was flying a citation. He said that in the report he meant to say his localizer was fluctuating as obviously there is no GS associated with this lda. He has about 25 yrs experience and when the approach came together as poorly as this one did he abandoned the approach to get better briefed and organized. He subsequently completed gathering everything together, did the briefing and made the approach in an appropriately orderly fashion. The reporter mentioned he had difficulty with the presentation of the government charts, the grade of paper used, the loose leaf format. In the turbulence the government charts came apart and contributed to his problems. The pilot and copilot in their procedures only have 1 set of approach charts and the PNF holds the charts for the PF during the approach. Other than that, their procedures regarding briefings and callouts are similar to airline standards. There is a pre approach briefing and there are callouts at 1000 ft above the airport, and 100 ft above minimums and each 100 ft below 500 ft to minimums if minimums are below 500 ft. To prevent this deviation from occurring next time, he plans to have the first officer better briefed for the approach and hopes government chart maker is coming out with the book like they used to have. The reporter said a problem with the mission is the constraint that requires the air evacuate/evacuation flight be airborne within 30 mins of notification and this does not provide sufficient time to thoroughly research those places that are being pioneered into.
Original NASA ASRS Text
Title: FLC DEVIATES FROM HOLDING FIX ALT.
Narrative: AFTER ELECTING TO MAKE A MISSED APCH ON ILS DUE TO A GS FLUCTUATION, I BEGAN THE INITIAL CLB TO THE MISSED APCH ALT AND CALLING FOR THE APPROPRIATE CHKS. THE FO HAD ONLY APPROX 6 HRS IN THE R SEAT AND I WAS TRYING TO DIRECT HIM IN WHAT I NEEDED AS TO THE MISSED APCH PROC. WORKLOAD WAS HIGH AND AS WE APCHED THE HOLDING FIX WE ENTERED AN AREA OF MODERATE TURB WHICH SPILLED OUR APCH PLATES AND WE HAD TO ANNOUNCE MISSED APCH WITH THE APCH CTLR AFTER SWITCHING FROM TWR. THE TURB CONTRIBUTED TO OUR GOING OVER THE ALT BY A COUPLE HUNDRED FT (ESTIMATED) AS WE ENTERED THE HOLD. CONTRIBUTING FACTORS WERE: LOW TIME COPLT AND THIS WAS THE FIRST TIME THE CREW HAD FLOWN TOGETHER IN ADDITION TO HIGH WORKLOAD AREA AND THE FIRST TIME IN A NON RADAR, TWR CTLED ENVIRONMENT IN A WHILE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED HE WAS FLYING A CITATION. HE SAID THAT IN THE RPT HE MEANT TO SAY HIS LOC WAS FLUCTUATING AS OBVIOUSLY THERE IS NO GS ASSOCIATED WITH THIS LDA. HE HAS ABOUT 25 YRS EXPERIENCE AND WHEN THE APCH CAME TOGETHER AS POORLY AS THIS ONE DID HE ABANDONED THE APCH TO GET BETTER BRIEFED AND ORGANIZED. HE SUBSEQUENTLY COMPLETED GATHERING EVERYTHING TOGETHER, DID THE BRIEFING AND MADE THE APCH IN AN APPROPRIATELY ORDERLY FASHION. THE RPTR MENTIONED HE HAD DIFFICULTY WITH THE PRESENTATION OF THE GOV CHARTS, THE GRADE OF PAPER USED, THE LOOSE LEAF FORMAT. IN THE TURB THE GOV CHARTS CAME APART AND CONTRIBUTED TO HIS PROBS. THE PLT AND COPLT IN THEIR PROCS ONLY HAVE 1 SET OF APCH CHARTS AND THE PNF HOLDS THE CHARTS FOR THE PF DURING THE APCH. OTHER THAN THAT, THEIR PROCS REGARDING BRIEFINGS AND CALLOUTS ARE SIMILAR TO AIRLINE STANDARDS. THERE IS A PRE APCH BRIEFING AND THERE ARE CALLOUTS AT 1000 FT ABOVE THE ARPT, AND 100 FT ABOVE MINIMUMS AND EACH 100 FT BELOW 500 FT TO MINIMUMS IF MINIMUMS ARE BELOW 500 FT. TO PREVENT THIS DEV FROM OCCURRING NEXT TIME, HE PLANS TO HAVE THE FO BETTER BRIEFED FOR THE APCH AND HOPES GOV CHART MAKER IS COMING OUT WITH THE BOOK LIKE THEY USED TO HAVE. THE RPTR SAID A PROB WITH THE MISSION IS THE CONSTRAINT THAT REQUIRES THE AIR EVAC FLT BE AIRBORNE WITHIN 30 MINS OF NOTIFICATION AND THIS DOES NOT PROVIDE SUFFICIENT TIME TO THOROUGHLY RESEARCH THOSE PLACES THAT ARE BEING PIONEERED INTO.
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.