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|
Attributes | |
ACN | 356040 |
Time | |
Date | 199612 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : jac |
State Reference | WY |
Altitude | msl bound lower : 13700 msl bound upper : 15000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zlc |
Operator | common carrier : air carrier |
Make Model Name | Brasilia EMB-120 All Series |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent : approach descent other |
Route In Use | arrival other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
ASRS Report | 356040 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 3200 flight time type : 400 |
ASRS Report | 355665 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude altitude deviation : crossing restriction not met non adherence : published procedure non adherence : clearance non adherence other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : became reoriented flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
We were at 15000 ft MSL, northbound to the jac VOR. The controller cleared us to cross jac VOR at 15000 ft. They said cleared for the ILS runway 18 approach. My first officer stated that after we cross the VOR we are good to descend to 12000 ft. Without checking to see if he was correct, I contacted our ground people to give our fuel outbound and ETA. Shortly, I saw the first officer climbing quickly back to 15000 ft. I asked what he was doing and he stated that we need to be at 15000 ft at this stage of the flight. I looked it up at this time and found he was correct. The observance that we had deviated below published altitude was first noted by ZLC. She questioned the first officer about the altitude during that segment of the approach and then he noted that she was correct and started an immediate climb out of 13700 ft back to 15000 ft. Lesson learned: always doublechk, our altitudes. Callback conversation with reporter revealed the following information: reporter was flying an EMB120. He had not reported the incident to the company chief pilot and safety department but felt, that after our conversation, he should and will. He will incorporate this incident along with other difficult approach stations that are in proximity of mountainous terrain. He feels that the company, who just went part 121, is intimidated by the FAA. The FAA stated that this company would not have their pilots protected from violation by any 'no fault' safety reporting system. Reporter felt that this did not produce a good climate for safety growth. Supplemental information from acn 355665: on our descent into jackson hole, we initially began a VOR runway 36 approach, however, our VOR needles (captain and first officer) were swinging +/-10 degrees. We both agreed that the signal was unreliable and called center and requested the ILS runway 18. They cleared us for the ILS runway 18 and to cross the VOR at 15000 ft. I then briefed the approach with the captain. I somehow stated that after crossing the VOR we could descend to 12000 ft outbound on the 004 degree radial and the captain agreed. As we neared the VOR the captain switched radios to call company. I crossed the VOR, intercepted the 004 degree radial and began a descent to 12000 ft with the autoplt engaged. During the descent the center controller called. The captain who was still on a different radio, became alarmed when I disengaged the autoplt and began climbing. I believe this deviation would never have occurred if: 1) I had read and briefed the approach properly. 2) the captain had read the approach properly. 3) the captain had monitored the approach more closely instead of calling company. 4) this was an unfamiliar airport and approach to me, the first time I had ever flown this approach. 5) fatigue may also have been a factor, both of us had very little sleep on the 2 nights of the 3 day trip. This was the third day. I'm glad they were monitoring our approach and tactfully pointed out our mistake. This could have been a major disaster had I not been on the 004 degree radial since there are high mountains in the area. I will use this experience to monitor all phases of flight more closely and to doublechk any approach altitudes.
Original NASA ASRS Text
Title: CFIT, CFTT. CTLED FLT TOWARDS DESIGNATED MOUNTAINOUS TERRAIN WHEN COMMUTER FO MISREADS THE APCH CHART, MISLEADS OR MISINFORMS THE CAPT WHO GOES OVER TO COMPANY FREQ. FO THEN PERFORMS AN ALTDEV ALT EXCURSION FROM ASSIGNED, NOT CONFORMING TO CHART ALTS. NON ADHERENCE TO ATC PROC CLRNC STERILE COCKPIT PROC.
Narrative: WE WERE AT 15000 FT MSL, NBOUND TO THE JAC VOR. THE CTLR CLRED US TO CROSS JAC VOR AT 15000 FT. THEY SAID CLRED FOR THE ILS RWY 18 APCH. MY FO STATED THAT AFTER WE CROSS THE VOR WE ARE GOOD TO DSND TO 12000 FT. WITHOUT CHKING TO SEE IF HE WAS CORRECT, I CONTACTED OUR GND PEOPLE TO GIVE OUR FUEL OUTBOUND AND ETA. SHORTLY, I SAW THE FO CLBING QUICKLY BACK TO 15000 FT. I ASKED WHAT HE WAS DOING AND HE STATED THAT WE NEED TO BE AT 15000 FT AT THIS STAGE OF THE FLT. I LOOKED IT UP AT THIS TIME AND FOUND HE WAS CORRECT. THE OBSERVANCE THAT WE HAD DEVIATED BELOW PUBLISHED ALT WAS FIRST NOTED BY ZLC. SHE QUESTIONED THE FO ABOUT THE ALT DURING THAT SEGMENT OF THE APCH AND THEN HE NOTED THAT SHE WAS CORRECT AND STARTED AN IMMEDIATE CLB OUT OF 13700 FT BACK TO 15000 FT. LESSON LEARNED: ALWAYS DOUBLECHK, OUR ALTS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR WAS FLYING AN EMB120. HE HAD NOT RPTED THE INCIDENT TO THE COMPANY CHIEF PLT AND SAFETY DEPT BUT FELT, THAT AFTER OUR CONVERSATION, HE SHOULD AND WILL. HE WILL INCORPORATE THIS INCIDENT ALONG WITH OTHER DIFFICULT APCH STATIONS THAT ARE IN PROX OF MOUNTAINOUS TERRAIN. HE FEELS THAT THE COMPANY, WHO JUST WENT PART 121, IS INTIMIDATED BY THE FAA. THE FAA STATED THAT THIS COMPANY WOULD NOT HAVE THEIR PLTS PROTECTED FROM VIOLATION BY ANY 'NO FAULT' SAFETY RPTING SYS. RPTR FELT THAT THIS DID NOT PRODUCE A GOOD CLIMATE FOR SAFETY GROWTH. SUPPLEMENTAL INFO FROM ACN 355665: ON OUR DSCNT INTO JACKSON HOLE, WE INITIALLY BEGAN A VOR RWY 36 APCH, HOWEVER, OUR VOR NEEDLES (CAPT AND FO) WERE SWINGING +/-10 DEGS. WE BOTH AGREED THAT THE SIGNAL WAS UNRELIABLE AND CALLED CTR AND REQUESTED THE ILS RWY 18. THEY CLRED US FOR THE ILS RWY 18 AND TO CROSS THE VOR AT 15000 FT. I THEN BRIEFED THE APCH WITH THE CAPT. I SOMEHOW STATED THAT AFTER XING THE VOR WE COULD DSND TO 12000 FT OUTBOUND ON THE 004 DEG RADIAL AND THE CAPT AGREED. AS WE NEARED THE VOR THE CAPT SWITCHED RADIOS TO CALL COMPANY. I CROSSED THE VOR, INTERCEPTED THE 004 DEG RADIAL AND BEGAN A DSCNT TO 12000 FT WITH THE AUTOPLT ENGAGED. DURING THE DSCNT THE CTR CTLR CALLED. THE CAPT WHO WAS STILL ON A DIFFERENT RADIO, BECAME ALARMED WHEN I DISENGAGED THE AUTOPLT AND BEGAN CLBING. I BELIEVE THIS DEV WOULD NEVER HAVE OCCURRED IF: 1) I HAD READ AND BRIEFED THE APCH PROPERLY. 2) THE CAPT HAD READ THE APCH PROPERLY. 3) THE CAPT HAD MONITORED THE APCH MORE CLOSELY INSTEAD OF CALLING COMPANY. 4) THIS WAS AN UNFAMILIAR ARPT AND APCH TO ME, THE FIRST TIME I HAD EVER FLOWN THIS APCH. 5) FATIGUE MAY ALSO HAVE BEEN A FACTOR, BOTH OF US HAD VERY LITTLE SLEEP ON THE 2 NIGHTS OF THE 3 DAY TRIP. THIS WAS THE THIRD DAY. I'M GLAD THEY WERE MONITORING OUR APCH AND TACTFULLY POINTED OUT OUR MISTAKE. THIS COULD HAVE BEEN A MAJOR DISASTER HAD I NOT BEEN ON THE 004 DEG RADIAL SINCE THERE ARE HIGH MOUNTAINS IN THE AREA. I WILL USE THIS EXPERIENCE TO MONITOR ALL PHASES OF FLT MORE CLOSELY AND TO DOUBLECHK ANY APCH ALTS.
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.