 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
The flight crew of a beech twin turboprop deviated from altitude and heading clearance. Captain was falling asleep.
| Attributes | |
| ACN | 314263 |
| Time | |
| Date | 199508 |
| Day | Wed |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : det |
| State Reference | MI |
| Environment | |
| Flight Conditions | IMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tracon : dtw |
| Operator | common carrier : air taxi |
| Make Model Name | Beechcraft Twin Turboprop Jet Undifferentiated or Other Model |
| Operating Under FAR Part | Part 135 |
| Flight Phase | cruise other descent : approach descent other |
| Route In Use | enroute : on vectors |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air taxi |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 100 flight time total : 2200 |
| ASRS Report | 314263 |
| Person 2 | |
| Affiliation | company : air taxi |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance other anomaly other other spatial deviation |
| Independent Detector | other flight crewa |
| Resolutory Action | flight crew : returned to intended course or assigned course other |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
On the evening stated above, the captain flying was becoming very fatigued and tired. He began to 'nod off' which resulted in an altitude deviation. The heading was also affected. The first altitude and heading deviation was 300 ft and left 20 degrees from assigned. I then brought this to the captain's attention when passing through 150 ft and 15 degrees of heading. He immediately corrected. Within the next 10-15 mi the same occurrences happened. Each time I brought this to the attention of the captain. Deviations were becoming plus or minus 300 ft and heading plus or minus 30 degrees from assigned. My corrective action was trying to let the captain know that I was very much awake and could continue the flight. The captain said he was better. I also cooled down the cabin temperature and directed airflow onto the captain. This 'woke' him up. However I believe that the captain still suffered from sleep deprivation because the ILS runway 15 (det) approach was not executed well. The captain had difficulty tracking the localizer. One time, the localizer was 8-9 degrees left. I kept bringing it to his attention throughout the approach. Each time the captain acknowledged and made corrective actions. Prior to the OM, the localizer and GS were finally centered and the approach was safely completed. Corrective action: I will now only warn of altitude and heading deviations twice. After these warnings I will be forced to ask the captain if he or she would like me to fly and be very persistent about the flying if the captain is ill or extremely tired.
Original NASA ASRS Text
Title: THE FLC OF A BEECH TWIN TURBOPROP DEVIATED FROM ALT AND HDG CLRNC. CAPT WAS FALLING ASLEEP.
Narrative: ON THE EVENING STATED ABOVE, THE CAPT FLYING WAS BECOMING VERY FATIGUED AND TIRED. HE BEGAN TO 'NOD OFF' WHICH RESULTED IN AN ALTDEV. THE HDG WAS ALSO AFFECTED. THE FIRST ALT AND HDG DEV WAS 300 FT AND L 20 DEGS FROM ASSIGNED. I THEN BROUGHT THIS TO THE CAPT'S ATTN WHEN PASSING THROUGH 150 FT AND 15 DEGS OF HDG. HE IMMEDIATELY CORRECTED. WITHIN THE NEXT 10-15 MI THE SAME OCCURRENCES HAPPENED. EACH TIME I BROUGHT THIS TO THE ATTN OF THE CAPT. DEVS WERE BECOMING PLUS OR MINUS 300 FT AND HDG PLUS OR MINUS 30 DEGS FROM ASSIGNED. MY CORRECTIVE ACTION WAS TRYING TO LET THE CAPT KNOW THAT I WAS VERY MUCH AWAKE AND COULD CONTINUE THE FLT. THE CAPT SAID HE WAS BETTER. I ALSO COOLED DOWN THE CABIN TEMP AND DIRECTED AIRFLOW ONTO THE CAPT. THIS 'WOKE' HIM UP. HOWEVER I BELIEVE THAT THE CAPT STILL SUFFERED FROM SLEEP DEPRIVATION BECAUSE THE ILS RWY 15 (DET) APCH WAS NOT EXECUTED WELL. THE CAPT HAD DIFFICULTY TRACKING THE LOC. ONE TIME, THE LOC WAS 8-9 DEGS L. I KEPT BRINGING IT TO HIS ATTN THROUGHOUT THE APCH. EACH TIME THE CAPT ACKNOWLEDGED AND MADE CORRECTIVE ACTIONS. PRIOR TO THE OM, THE LOC AND GS WERE FINALLY CTRED AND THE APCH WAS SAFELY COMPLETED. CORRECTIVE ACTION: I WILL NOW ONLY WARN OF ALT AND HDG DEVS TWICE. AFTER THESE WARNINGS I WILL BE FORCED TO ASK THE CAPT IF HE OR SHE WOULD LIKE ME TO FLY AND BE VERY PERSISTENT ABOUT THE FLYING IF THE CAPT IS ILL OR EXTREMELY TIRED.
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.