Narrative:

On sep/mon/95 while descending into sea, we were cleared for the jaksn FMS transition for a runway 16R ILS. The arrival and ILS was programmed into the CDU and altitudes verified at this time. The ILS had been briefed earlier upon receipt of the ATIS information. At about the turn-in point of F343Q of the jaksn arrival, we were cleared for the runway 16R ILS. The approach mode was selected and the aircraft turned at this time, however, it failed to show localizer capture. I had never been on this arrival and advised the first officer I had no localizer capture. He said he had done it before and expect a capture right at the marker. I showed the aircraft tracking the magenta line and quickly looked at the approach plate which showed the fixes by name as indicated on my HSI moving map, including the missed approach procedure and hold fix. We had been asked to maintain 170 KTS until the OM. As we approached the OM showing GS captured and coming down on profile, gear extension was called, speed was dialed back and flaps were configured for landing as speed allowed. The first officer again stated as he looked closely at his moving map, 'I show you about to capture.' we crossed the OM right on altitude with a good aural identify. The track showed right on the magenta line on the moving map showing the runway dead ahead. At about 300-400 ft AGL, go around was called for with the approach lights just to our left. We requested another approach. After localizer capture on the second approach the aircraft tracked left of the magenta line and waypoints, including the OM, until nearly the approach light visual pickup. A landing was made without further problems. After reviewing what went wrong at the gate we discovered the jaksn arrival plates showed 158 degrees inbound over the same waypoints as the ILS plate on the 161 degree inbound. The aircraft tracked the jaksn arrival. I notified the proper company officials of the differences for clarification. Human factors: as a big supporter of CRM concepts and having worked within the program, this is a most haunting experience. I fell into a trap I thought I could avoid yet, 'it happened.' I keep asking myself 'why.' I believe we failed to brief the transition and the ILS as one. We looked at them separate and never caught the difference in the inbound headings. Although I had raw data resources available, I used only the ADI runway extension which did show the runway alive but to the left. I always brief the entire crew, if you see anything of question, 'sing out' or if you are uncomfortable, let me know, yet I allowed an approach to continue with a not certain feeling of my own. Was it because I had visual cues, a first officer who had said he had done the approach before and stated the xover would occur at the marker? Was I allowing his experience to overshadow my uneasiness? That is the haunting question. Later in our debrief at the gate he said he believed the ILS used to be 158 degrees inbound. What can I do in the future to insure this does not occur? I have personally talked to the training manager and suggested although they certainly do emphasize utilizing all your resources which includes raw data information they can't over emphasize the importance of raw data backup. Reliability and time tends to create a confidence to believe the computer without question. My operational philosophy in the future will be to utilize the computer but verify everything with raw data. Finally, I have contacted the CRM manager to relay the event of just how insidious a situation can be. It points out the need of emphasis toward ongoing personal discipline and evaluation. To err is human. To establish a teamwork that captures error is an absolute necessity.

Related reports:

Google
 

Original NASA ASRS Text

Title: FLC TECHNIQUE NAV. ACR CREW USED IMPROPER TECHNIQUE WHEN TRANSITIONING FROM FMS NAV TO THE FMS ILS.

Narrative: ON SEP/MON/95 WHILE DSNDING INTO SEA, WE WERE CLRED FOR THE JAKSN FMS TRANSITION FOR A RWY 16R ILS. THE ARR AND ILS WAS PROGRAMMED INTO THE CDU AND ALTS VERIFIED AT THIS TIME. THE ILS HAD BEEN BRIEFED EARLIER UPON RECEIPT OF THE ATIS INFO. AT ABOUT THE TURN-IN POINT OF F343Q OF THE JAKSN ARR, WE WERE CLRED FOR THE RWY 16R ILS. THE APCH MODE WAS SELECTED AND THE ACFT TURNED AT THIS TIME, HOWEVER, IT FAILED TO SHOW LOC CAPTURE. I HAD NEVER BEEN ON THIS ARR AND ADVISED THE FO I HAD NO LOC CAPTURE. HE SAID HE HAD DONE IT BEFORE AND EXPECT A CAPTURE RIGHT AT THE MARKER. I SHOWED THE ACFT TRACKING THE MAGENTA LINE AND QUICKLY LOOKED AT THE APCH PLATE WHICH SHOWED THE FIXES BY NAME AS INDICATED ON MY HSI MOVING MAP, INCLUDING THE MISSED APCH PROC AND HOLD FIX. WE HAD BEEN ASKED TO MAINTAIN 170 KTS UNTIL THE OM. AS WE APCHED THE OM SHOWING GS CAPTURED AND COMING DOWN ON PROFILE, GEAR EXTENSION WAS CALLED, SPD WAS DIALED BACK AND FLAPS WERE CONFIGURED FOR LNDG AS SPD ALLOWED. THE FO AGAIN STATED AS HE LOOKED CLOSELY AT HIS MOVING MAP, 'I SHOW YOU ABOUT TO CAPTURE.' WE CROSSED THE OM RIGHT ON ALT WITH A GOOD AURAL IDENT. THE TRACK SHOWED RIGHT ON THE MAGENTA LINE ON THE MOVING MAP SHOWING THE RWY DEAD AHEAD. AT ABOUT 300-400 FT AGL, GAR WAS CALLED FOR WITH THE APCH LIGHTS JUST TO OUR L. WE REQUESTED ANOTHER APCH. AFTER LOC CAPTURE ON THE SECOND APCH THE ACFT TRACKED L OF THE MAGENTA LINE AND WAYPOINTS, INCLUDING THE OM, UNTIL NEARLY THE APCH LIGHT VISUAL PICKUP. A LNDG WAS MADE WITHOUT FURTHER PROBS. AFTER REVIEWING WHAT WENT WRONG AT THE GATE WE DISCOVERED THE JAKSN ARR PLATES SHOWED 158 DEGS INBOUND OVER THE SAME WAYPOINTS AS THE ILS PLATE ON THE 161 DEG INBOUND. THE ACFT TRACKED THE JAKSN ARR. I NOTIFIED THE PROPER COMPANY OFFICIALS OF THE DIFFERENCES FOR CLARIFICATION. HUMAN FACTORS: AS A BIG SUPPORTER OF CRM CONCEPTS AND HAVING WORKED WITHIN THE PROGRAM, THIS IS A MOST HAUNTING EXPERIENCE. I FELL INTO A TRAP I THOUGHT I COULD AVOID YET, 'IT HAPPENED.' I KEEP ASKING MYSELF 'WHY.' I BELIEVE WE FAILED TO BRIEF THE TRANSITION AND THE ILS AS ONE. WE LOOKED AT THEM SEPARATE AND NEVER CAUGHT THE DIFFERENCE IN THE INBOUND HDGS. ALTHOUGH I HAD RAW DATA RESOURCES AVAILABLE, I USED ONLY THE ADI RWY EXTENSION WHICH DID SHOW THE RWY ALIVE BUT TO THE L. I ALWAYS BRIEF THE ENTIRE CREW, IF YOU SEE ANYTHING OF QUESTION, 'SING OUT' OR IF YOU ARE UNCOMFORTABLE, LET ME KNOW, YET I ALLOWED AN APCH TO CONTINUE WITH A NOT CERTAIN FEELING OF MY OWN. WAS IT BECAUSE I HAD VISUAL CUES, A FO WHO HAD SAID HE HAD DONE THE APCH BEFORE AND STATED THE XOVER WOULD OCCUR AT THE MARKER? WAS I ALLOWING HIS EXPERIENCE TO OVERSHADOW MY UNEASINESS? THAT IS THE HAUNTING QUESTION. LATER IN OUR DEBRIEF AT THE GATE HE SAID HE BELIEVED THE ILS USED TO BE 158 DEGS INBOUND. WHAT CAN I DO IN THE FUTURE TO INSURE THIS DOES NOT OCCUR? I HAVE PERSONALLY TALKED TO THE TRAINING MANAGER AND SUGGESTED ALTHOUGH THEY CERTAINLY DO EMPHASIZE UTILIZING ALL YOUR RESOURCES WHICH INCLUDES RAW DATA INFO THEY CAN'T OVER EMPHASIZE THE IMPORTANCE OF RAW DATA BACKUP. RELIABILITY AND TIME TENDS TO CREATE A CONFIDENCE TO BELIEVE THE COMPUTER WITHOUT QUESTION. MY OPERATIONAL PHILOSOPHY IN THE FUTURE WILL BE TO UTILIZE THE COMPUTER BUT VERIFY EVERYTHING WITH RAW DATA. FINALLY, I HAVE CONTACTED THE CRM MGR TO RELAY THE EVENT OF JUST HOW INSIDIOUS A SIT CAN BE. IT POINTS OUT THE NEED OF EMPHASIS TOWARD ONGOING PERSONAL DISCIPLINE AND EVALUATION. TO ERR IS HUMAN. TO ESTABLISH A TEAMWORK THAT CAPTURES ERROR IS AN ABSOLUTE NECESSITY.

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.