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|
Attributes | |
ACN | 355660 |
Time | |
Date | 199612 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lga |
State Reference | NY |
Altitude | msl bound lower : 8000 msl bound upper : 8000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90 artcc : zkc |
Operator | common carrier : air carrier |
Make Model Name | DC-9 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | other |
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 : 200 flight time total : 11200 |
ASRS Report | 355660 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : clearance other anomaly other other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was flying as captain, PIC, of a scheduled part 121 revenue flight from ric to lga on dec xx 1996. This was the last day of a 4 day trip and was our 19TH flight in 4 days. We departed ric at AA13 and were en route to lga when we were given a hold at yardley VOR and stayed in holding there for approximately 20 mins. At that position the holding pattern was r-hand turns. We were then allowed to proceed with the arrival and descended to 8000 ft and handed to new york approach control. We were being vectored for the ILS runway 4 at lga when we were told that the runway had closed due to an RVR of 'nil.' we were told to hold on the localizer at 11.1 DME southwest of lga. We were also told left turns which I didn't hear or, because of fatigue, did not consciously acknowledge (although the first officer wrote it down). We intercepted the localizer holding course and at 11.1 DME I started a r-hand turn. The approach plate does not depict a holding pattern and I had just finished 20 mins of holding in a r-hand pattern. The controller caught our error half way through my turn and gave me an immediate turn to the left to re-enter the holding airspace. He eventually gave me a turn to a heading of 170 degrees. Again because of fatigue I turned to a heading of 190 degrees (10 degrees to the wrong side of south). I feel that this problem occurred for 2 reasons. First, the first officer was busy coordinating a possible diversion (our fuel was between 8000-9000 pounds) and so he was not monitoring me when I made my initial turn. Second, the cumulative effect of fatigue had caught up with me and I just didn't hear the initial holding clearance correctly, plus I just finished a holding pattern with r-hand turns. Unfortunately my employer schedules us on many hard trips with long 12-14 hour duty days and up to 8 legs a day! This is too tiring for the average person. No one can remain sharp when following these heavy schedules. Many of my fellow pilots are complaining about these trips but nothing is being done to correct the situation. I would hope that some one from NASA would contact me directly so that this matter can be addressed. It is only a matter of time before fatigue factors cause this carrier another major accident. Fortunately, this mistake was caught by the controller quickly and we were never in serious difficulty. Who knows what may happen next time.
Original NASA ASRS Text
Title: DC9 CLRED TO HOLD SW OF LGA AT GREENE INTXN IN A L-HAND PATTERN TURNS R INSTEAD.
Narrative: I WAS FLYING AS CAPT, PIC, OF A SCHEDULED PART 121 REVENUE FLT FROM RIC TO LGA ON DEC XX 1996. THIS WAS THE LAST DAY OF A 4 DAY TRIP AND WAS OUR 19TH FLT IN 4 DAYS. WE DEPARTED RIC AT AA13 AND WERE ENRTE TO LGA WHEN WE WERE GIVEN A HOLD AT YARDLEY VOR AND STAYED IN HOLDING THERE FOR APPROX 20 MINS. AT THAT POS THE HOLDING PATTERN WAS R-HAND TURNS. WE WERE THEN ALLOWED TO PROCEED WITH THE ARR AND DSNDED TO 8000 FT AND HANDED TO NEW YORK APCH CTL. WE WERE BEING VECTORED FOR THE ILS RWY 4 AT LGA WHEN WE WERE TOLD THAT THE RWY HAD CLOSED DUE TO AN RVR OF 'NIL.' WE WERE TOLD TO HOLD ON THE LOC AT 11.1 DME SW OF LGA. WE WERE ALSO TOLD L TURNS WHICH I DIDN'T HEAR OR, BECAUSE OF FATIGUE, DID NOT CONSCIOUSLY ACKNOWLEDGE (ALTHOUGH THE FO WROTE IT DOWN). WE INTERCEPTED THE LOC HOLDING COURSE AND AT 11.1 DME I STARTED A R-HAND TURN. THE APCH PLATE DOES NOT DEPICT A HOLDING PATTERN AND I HAD JUST FINISHED 20 MINS OF HOLDING IN A R-HAND PATTERN. THE CTLR CAUGHT OUR ERROR HALF WAY THROUGH MY TURN AND GAVE ME AN IMMEDIATE TURN TO THE LEFT TO RE-ENTER THE HOLDING AIRSPACE. HE EVENTUALLY GAVE ME A TURN TO A HDG OF 170 DEGS. AGAIN BECAUSE OF FATIGUE I TURNED TO A HDG OF 190 DEGS (10 DEGS TO THE WRONG SIDE OF S). I FEEL THAT THIS PROB OCCURRED FOR 2 REASONS. FIRST, THE FO WAS BUSY COORDINATING A POSSIBLE DIVERSION (OUR FUEL WAS BTWN 8000-9000 LBS) AND SO HE WAS NOT MONITORING ME WHEN I MADE MY INITIAL TURN. SECOND, THE CUMULATIVE EFFECT OF FATIGUE HAD CAUGHT UP WITH ME AND I JUST DIDN'T HEAR THE INITIAL HOLDING CLRNC CORRECTLY, PLUS I JUST FINISHED A HOLDING PATTERN WITH R-HAND TURNS. UNFORTUNATELY MY EMPLOYER SCHEDULES US ON MANY HARD TRIPS WITH LONG 12-14 HR DUTY DAYS AND UP TO 8 LEGS A DAY! THIS IS TOO TIRING FOR THE AVERAGE PERSON. NO ONE CAN REMAIN SHARP WHEN FOLLOWING THESE HVY SCHEDULES. MANY OF MY FELLOW PLTS ARE COMPLAINING ABOUT THESE TRIPS BUT NOTHING IS BEING DONE TO CORRECT THE SIT. I WOULD HOPE THAT SOME ONE FROM NASA WOULD CONTACT ME DIRECTLY SO THAT THIS MATTER CAN BE ADDRESSED. IT IS ONLY A MATTER OF TIME BEFORE FATIGUE FACTORS CAUSE THIS CARRIER ANOTHER MAJOR ACCIDENT. FORTUNATELY, THIS MISTAKE WAS CAUGHT BY THE CTLR QUICKLY AND WE WERE NEVER IN SERIOUS DIFFICULTY. WHO KNOWS WHAT MAY HAPPEN NEXT 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.