37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 343101 |
Time | |
Date | 199607 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : pdx |
State Reference | OR |
Altitude | msl bound lower : 3500 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : pdx |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-100 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 110 flight time total : 13500 flight time type : 6000 |
ASRS Report | 343101 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial |
Events | |
Anomaly | conflict : nmac other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | other |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 750 vertical : 300 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Narrative:
After takeoff and upon reaching 3000 ft, we were instructed by ATC to turn to 110 degrees and climb to 13000 ft, which we complied with. While steady on that heading, we listened and watched a company dornier flight which had taken off behind us on runway 28R for eug. The departure controller queried whether the dornier crew had us in sight. The pilot acknowledged that they had. The controller then gave an instruction to the dornier crew to maintain a visual separation with us, and then cleared them for their sbound turn to join V23. Since we were departing on a left downwind, I was able to see the dornier clearly, while my first officer (who was flying) did not. I watched the dornier pilot start his left turn, but instead of a gradual bank to pass behind us, the aircraft made more than a 90 degree turn to put us on a direct intercept course. I relayed to my first officer who was watching the TCASII graphics that the dornier had made pretty much a direct turn toward us. We then discussed whether we thought the dornier was planning to go underneath us or over the top. The intruder symbol went quickly to 'round yellow,' and we got a 'traffic, traffic' aural warning from the TCASII equipment. The surface temperature when we took off just before XX00 pm was still in the 80's. It appeared that the dornier had planned to climb over us, but the climb performance was just not there. I was surprised that the dornier pilot had not appraised his situation, realizing that the vertical separation was not going to be there, and then give way to us horizontally. It was evident we were going to experience an RA, and I told my first officer to prepare for an escape maneuver. The dornier just kept coming right at us. As the dornier rapidly closed to less than a mi laterally, it was difficult at night to determine vertically where we should go to prevent a collision. I sensed that we should flatten our climb, and with our altitude around 4000 ft, I instructed my first officer to do that. Just as he started to pitch over, the TCASII began an RA, orally instructing us to 'descend, descend,' with the vertical speed green lighting directing us to descend at a maximum vertical speed. I instructed the first officer to follow the RA quickly, as the dornier flashed by over our heads. Once the RA commenced, I informed the controller that we had broken off our climb, and were descending due to an RA. We descended to around 3500 ft until the TCASII advised that the conflict was over. We then resumed our climb and flight to rdm without further incident. Reflecting on this event, I found it hard to believe that we could have come as close to a midair as we did, being in an IFR environment and with TCASII equipment installed on both airplanes. But we did. If one ever wanted a scenario for a midair collision with the 'system' working, this was it. Obviously, this event should have never happened, and was totally avoidable. It was a pure failure on the human end. If the dornier pilot had lost sight of us, he should have communicated that immediately to the controller, who could have then reentered the picture to provide separation. If the dornier pilots had us in sight the whole way (which by the way they flew said to me they did), what is 20 seconds to delay their turn and pass safely behind us? Both these flts were being flown late at night, the legs being the last ones for both crews. It was the second night of a 3-NIGHT series of what we call continuous duty overnights, or 'standups,' with a limited amount of sleep (usually on the ground less than 6.5 hours). But the reality of this flight schedule still doesn't excuse a 'rush-rush' mentality, where pilots are flying not in the present moment but hours, days, a whole bid schedule down the road. If pilots don't concentrate on what they're doing right now, they might not make it to their bed, vacation, or B747 job.
Original NASA ASRS Text
Title: DHC8-100 ACFT FLC WATCHES AS ACFT WHICH SUPPOSEDLY HAS THEM IN SIGHT FLIES DIRECTLY TOWARD THEM. TCASII GIVES RA TO DSND WHICH THEY DO PROMPTLY. SECOND ACFT RPTED VISUAL CONTACT WITH THIS ACFT AND CLRED TO MAINTAIN VISUAL SEPARATION.
Narrative: AFTER TKOF AND UPON REACHING 3000 FT, WE WERE INSTRUCTED BY ATC TO TURN TO 110 DEGS AND CLB TO 13000 FT, WHICH WE COMPLIED WITH. WHILE STEADY ON THAT HEADING, WE LISTENED AND WATCHED A COMPANY DORNIER FLT WHICH HAD TAKEN OFF BEHIND US ON RWY 28R FOR EUG. THE DEP CTLR QUERIED WHETHER THE DORNIER CREW HAD US IN SIGHT. THE PLT ACKNOWLEDGED THAT THEY HAD. THE CTLR THEN GAVE AN INSTRUCTION TO THE DORNIER CREW TO MAINTAIN A VISUAL SEPARATION WITH US, AND THEN CLRED THEM FOR THEIR SBOUND TURN TO JOIN V23. SINCE WE WERE DEPARTING ON A L DOWNWIND, I WAS ABLE TO SEE THE DORNIER CLRLY, WHILE MY FO (WHO WAS FLYING) DID NOT. I WATCHED THE DORNIER PLT START HIS L TURN, BUT INSTEAD OF A GRADUAL BANK TO PASS BEHIND US, THE ACFT MADE MORE THAN A 90 DEG TURN TO PUT US ON A DIRECT INTERCEPT COURSE. I RELAYED TO MY FO WHO WAS WATCHING THE TCASII GRAPHICS THAT THE DORNIER HAD MADE PRETTY MUCH A DIRECT TURN TOWARD US. WE THEN DISCUSSED WHETHER WE THOUGHT THE DORNIER WAS PLANNING TO GO UNDERNEATH US OR OVER THE TOP. THE INTRUDER SYMBOL WENT QUICKLY TO 'ROUND YELLOW,' AND WE GOT A 'TFC, TFC' AURAL WARNING FROM THE TCASII EQUIP. THE SURFACE TEMP WHEN WE TOOK OFF JUST BEFORE XX00 PM WAS STILL IN THE 80'S. IT APPEARED THAT THE DORNIER HAD PLANNED TO CLB OVER US, BUT THE CLB PERFORMANCE WAS JUST NOT THERE. I WAS SURPRISED THAT THE DORNIER PLT HAD NOT APPRAISED HIS SIT, REALIZING THAT THE VERT SEPARATION WAS NOT GOING TO BE THERE, AND THEN GIVE WAY TO US HORIZLY. IT WAS EVIDENT WE WERE GOING TO EXPERIENCE AN RA, AND I TOLD MY FO TO PREPARE FOR AN ESCAPE MANEUVER. THE DORNIER JUST KEPT COMING RIGHT AT US. AS THE DORNIER RAPIDLY CLOSED TO LESS THAN A MI LATERALLY, IT WAS DIFFICULT AT NIGHT TO DETERMINE VERTLY WHERE WE SHOULD GO TO PREVENT A COLLISION. I SENSED THAT WE SHOULD FLATTEN OUR CLB, AND WITH OUR ALT AROUND 4000 FT, I INSTRUCTED MY FO TO DO THAT. JUST AS HE STARTED TO PITCH OVER, THE TCASII BEGAN AN RA, ORALLY INSTRUCTING US TO 'DSND, DSND,' WITH THE VERT SPD GREEN LIGHTING DIRECTING US TO DSND AT A MAX VERT SPD. I INSTRUCTED THE FO TO FOLLOW THE RA QUICKLY, AS THE DORNIER FLASHED BY OVER OUR HEADS. ONCE THE RA COMMENCED, I INFORMED THE CTLR THAT WE HAD BROKEN OFF OUR CLB, AND WERE DSNDING DUE TO AN RA. WE DSNDED TO AROUND 3500 FT UNTIL THE TCASII ADVISED THAT THE CONFLICT WAS OVER. WE THEN RESUMED OUR CLB AND FLT TO RDM WITHOUT FURTHER INCIDENT. REFLECTING ON THIS EVENT, I FOUND IT HARD TO BELIEVE THAT WE COULD HAVE COME AS CLOSE TO A MIDAIR AS WE DID, BEING IN AN IFR ENVIRONMENT AND WITH TCASII EQUIP INSTALLED ON BOTH AIRPLANES. BUT WE DID. IF ONE EVER WANTED A SCENARIO FOR A MIDAIR COLLISION WITH THE 'SYS' WORKING, THIS WAS IT. OBVIOUSLY, THIS EVENT SHOULD HAVE NEVER HAPPENED, AND WAS TOTALLY AVOIDABLE. IT WAS A PURE FAILURE ON THE HUMAN END. IF THE DORNIER PLT HAD LOST SIGHT OF US, HE SHOULD HAVE COMMUNICATED THAT IMMEDIATELY TO THE CTLR, WHO COULD HAVE THEN REENTERED THE PICTURE TO PROVIDE SEPARATION. IF THE DORNIER PLTS HAD US IN SIGHT THE WHOLE WAY (WHICH BY THE WAY THEY FLEW SAID TO ME THEY DID), WHAT IS 20 SECONDS TO DELAY THEIR TURN AND PASS SAFELY BEHIND US? BOTH THESE FLTS WERE BEING FLOWN LATE AT NIGHT, THE LEGS BEING THE LAST ONES FOR BOTH CREWS. IT WAS THE SECOND NIGHT OF A 3-NIGHT SERIES OF WHAT WE CALL CONTINUOUS DUTY OVERNIGHTS, OR 'STANDUPS,' WITH A LIMITED AMOUNT OF SLEEP (USUALLY ON THE GND LESS THAN 6.5 HRS). BUT THE REALITY OF THIS FLT SCHEDULE STILL DOESN'T EXCUSE A 'RUSH-RUSH' MENTALITY, WHERE PLTS ARE FLYING NOT IN THE PRESENT MOMENT BUT HRS, DAYS, A WHOLE BID SCHEDULE DOWN THE ROAD. IF PLTS DON'T CONCENTRATE ON WHAT THEY'RE DOING RIGHT NOW, THEY MIGHT NOT MAKE IT TO THEIR BED, VACATION, OR B747 JOB.
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.