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|
Attributes | |
ACN | 369632 |
Time | |
Date | 199705 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lax |
State Reference | CA |
Altitude | msl bound lower : 3500 msl bound upper : 3500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : lax |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent : approach |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 200 flight time total : 3250 flight time type : 680 |
ASRS Report | 369632 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : commercial pilot : atp pilot : instrument pilot : flight engineer |
Experience | flight time last 90 days : 200 flight time total : 7000 flight time type : 1500 |
ASRS Report | 369633 |
Events | |
Anomaly | other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Day began at about XA00 in seattle hotel room on a layover as I awoke with stomach pains, nausea, and a terrible headache. I took tylenol and pepto-bismal and called the crew desk to tell them I wanted to get off the trip and have a reserve take over for me. The crew desk told me there was not a B737-300 base in sea and that a first officer would have to be flown in from sfo but that they (crew desk) were very short on reserves and that our departure at XA30 the next morning would be delayed in order to get a reserve flown in. I talked with the crew desk a while and told him that if my condition did not worsen I could fly to lax and get off there. I informed the crew desk that if the condition did worsen, ie, vomiting, I would call them back and they would just deal with the problem. I slept very little (approximately 2-3 hours) after calling the crew desk and awoke for the XB15 hotel pickup. At the hotel I told the captain that I was not feeling too well, but I felt ok to go to lax where arrangements were made to take me off the trip. The captain and I decided that he would fly and I work the radios. All predep checks and briefings were normal. Cruise was normal with the exception that conversation was curtailed due to my continual nausea. As we neared lax I copied ATIS down. ATIS was calling for scattered clouds 7 mi visibility in haze. Approachs to runway 24 and runway 25 in effect, winds out of west at 7 KTS. NOTAMS runway 24R ILS and DME OTS and runway 24L ILS OTS as well. I listened to the ATIS twice in order to doublechk the NOTAMS. The captain briefed for the visual approach to runway 24R which included the runway lights, turnoff, autobrake setting, target speed, that we would be vigilant for other aircraft in the high density area, and that since the ILS and DME was notamed OTS we would load the runway in the FMC as a backup. After the approach descent checklist we were handed off to approach control who said he was going to begin vectoring us for the ILS runway 24R. The captain, as we were being vectored, said he had the ILS frequency in his navigation box and thathe had a positive identify. I then looked over at his side and dialed in his frequency, and put my HSI in the 'VOR localizer mode' so that I would see when we were intercepting the localizer. I did not look in my approach plate book to check to see if the frequency was the correct one. I erroneously thought the captain had the correct frequency. When we started getting vectors for runway 24R, I extended the runway centerline for visual reference in the FMC. We were finally given the final intercept vector for runway 24R. Still in the 'map' mode I could see we were getting closer to the extended final approach course. So I switched, as mentioned earlier, to the 'VOR/localizer mode.' a few seconds passed and I realized that we should have gotten needle movement on the localizer needle, so I then switched back to the map mode. At that moment it was clear we had flown south of the runway 24R localizer course, according to the map mode of the HSI presentation. Right as I was about to question the captain, we got a TA on our TCASII and at the same time instructions from approach to fly heading 290 degrees to reintercept the localizer because we had flown through it and to call tower at the OM. I then looked down at my approach plate and realized that the frequency the captain had dialed in was for the ILS runway 25R, not runway 24R. The reintercept was normal and landing and taxi in was normal. I was put on sick leave and deadheaded home that morning. The captain was contacted shortly after landing by the TRACON and was informed that a flight for runway 25R had to go missed approach because of our encroachment. Neither I, nor the captain, saw the aircraft for runway 25R. I believe my nauseous state contributed to my lackadaisical manner in not being more inquisitive to the captain and controllers about the NOTAMS on the ATIS. I also should have doublechked the ILS frequency the captain had on his side and checked the morse code for the correct identify. Our guard seemed to have been 'let down' because we were being vectored for the visual versus an IMC approach. I definitely feel if I had been feeling better I would not have let these chain of eventsstack up against us. Next time I'm feeling bad there will certainly not be any more 'pushing the envelope.' I also believe one other factor for my neglect in doublechking the captain was because I was too involved in working the radios and keeping a vigilant watch outside for other traffic in the high density area we were flying in. Had it been a less crowded area, I probably would have looked up the frequency and doublechked the capts.
Original NASA ASRS Text
Title: B737-300 FLC OVERSHOT APCH TO FINAL AND FORCES GAR OF ACFT ON PARALLEL APCH.
Narrative: DAY BEGAN AT ABOUT XA00 IN SEATTLE HOTEL ROOM ON A LAYOVER AS I AWOKE WITH STOMACH PAINS, NAUSEA, AND A TERRIBLE HEADACHE. I TOOK TYLENOL AND PEPTO-BISMAL AND CALLED THE CREW DESK TO TELL THEM I WANTED TO GET OFF THE TRIP AND HAVE A RESERVE TAKE OVER FOR ME. THE CREW DESK TOLD ME THERE WAS NOT A B737-300 BASE IN SEA AND THAT A FO WOULD HAVE TO BE FLOWN IN FROM SFO BUT THAT THEY (CREW DESK) WERE VERY SHORT ON RESERVES AND THAT OUR DEP AT XA30 THE NEXT MORNING WOULD BE DELAYED IN ORDER TO GET A RESERVE FLOWN IN. I TALKED WITH THE CREW DESK A WHILE AND TOLD HIM THAT IF MY CONDITION DID NOT WORSEN I COULD FLY TO LAX AND GET OFF THERE. I INFORMED THE CREW DESK THAT IF THE CONDITION DID WORSEN, IE, VOMITING, I WOULD CALL THEM BACK AND THEY WOULD JUST DEAL WITH THE PROB. I SLEPT VERY LITTLE (APPROX 2-3 HRS) AFTER CALLING THE CREW DESK AND AWOKE FOR THE XB15 HOTEL PICKUP. AT THE HOTEL I TOLD THE CAPT THAT I WAS NOT FEELING TOO WELL, BUT I FELT OK TO GO TO LAX WHERE ARRANGEMENTS WERE MADE TO TAKE ME OFF THE TRIP. THE CAPT AND I DECIDED THAT HE WOULD FLY AND I WORK THE RADIOS. ALL PREDEP CHKS AND BRIEFINGS WERE NORMAL. CRUISE WAS NORMAL WITH THE EXCEPTION THAT CONVERSATION WAS CURTAILED DUE TO MY CONTINUAL NAUSEA. AS WE NEARED LAX I COPIED ATIS DOWN. ATIS WAS CALLING FOR SCATTERED CLOUDS 7 MI VISIBILITY IN HAZE. APCHS TO RWY 24 AND RWY 25 IN EFFECT, WINDS OUT OF W AT 7 KTS. NOTAMS RWY 24R ILS AND DME OTS AND RWY 24L ILS OTS AS WELL. I LISTENED TO THE ATIS TWICE IN ORDER TO DOUBLECHK THE NOTAMS. THE CAPT BRIEFED FOR THE VISUAL APCH TO RWY 24R WHICH INCLUDED THE RWY LIGHTS, TURNOFF, AUTOBRAKE SETTING, TARGET SPD, THAT WE WOULD BE VIGILANT FOR OTHER ACFT IN THE HIGH DENSITY AREA, AND THAT SINCE THE ILS AND DME WAS NOTAMED OTS WE WOULD LOAD THE RWY IN THE FMC AS A BACKUP. AFTER THE APCH DSCNT CHKLIST WE WERE HANDED OFF TO APCH CTL WHO SAID HE WAS GOING TO BEGIN VECTORING US FOR THE ILS RWY 24R. THE CAPT, AS WE WERE BEING VECTORED, SAID HE HAD THE ILS FREQ IN HIS NAV BOX AND THATHE HAD A POSITIVE IDENT. I THEN LOOKED OVER AT HIS SIDE AND DIALED IN HIS FREQ, AND PUT MY HSI IN THE 'VOR LOC MODE' SO THAT I WOULD SEE WHEN WE WERE INTERCEPTING THE LOC. I DID NOT LOOK IN MY APCH PLATE BOOK TO CHK TO SEE IF THE FREQ WAS THE CORRECT ONE. I ERRONEOUSLY THOUGHT THE CAPT HAD THE CORRECT FREQ. WHEN WE STARTED GETTING VECTORS FOR RWY 24R, I EXTENDED THE RWY CTRLINE FOR VISUAL REF IN THE FMC. WE WERE FINALLY GIVEN THE FINAL INTERCEPT VECTOR FOR RWY 24R. STILL IN THE 'MAP' MODE I COULD SEE WE WERE GETTING CLOSER TO THE EXTENDED FINAL APCH COURSE. SO I SWITCHED, AS MENTIONED EARLIER, TO THE 'VOR/LOC MODE.' A FEW SECONDS PASSED AND I REALIZED THAT WE SHOULD HAVE GOTTEN NEEDLE MOVEMENT ON THE LOC NEEDLE, SO I THEN SWITCHED BACK TO THE MAP MODE. AT THAT MOMENT IT WAS CLR WE HAD FLOWN S OF THE RWY 24R LOC COURSE, ACCORDING TO THE MAP MODE OF THE HSI PRESENTATION. RIGHT AS I WAS ABOUT TO QUESTION THE CAPT, WE GOT A TA ON OUR TCASII AND AT THE SAME TIME INSTRUCTIONS FROM APCH TO FLY HDG 290 DEGS TO REINTERCEPT THE LOC BECAUSE WE HAD FLOWN THROUGH IT AND TO CALL TWR AT THE OM. I THEN LOOKED DOWN AT MY APCH PLATE AND REALIZED THAT THE FREQ THE CAPT HAD DIALED IN WAS FOR THE ILS RWY 25R, NOT RWY 24R. THE REINTERCEPT WAS NORMAL AND LNDG AND TAXI IN WAS NORMAL. I WAS PUT ON SICK LEAVE AND DEADHEADED HOME THAT MORNING. THE CAPT WAS CONTACTED SHORTLY AFTER LNDG BY THE TRACON AND WAS INFORMED THAT A FLT FOR RWY 25R HAD TO GO MISSED APCH BECAUSE OF OUR ENCROACHMENT. NEITHER I, NOR THE CAPT, SAW THE ACFT FOR RWY 25R. I BELIEVE MY NAUSEOUS STATE CONTRIBUTED TO MY LACKADAISICAL MANNER IN NOT BEING MORE INQUISITIVE TO THE CAPT AND CTLRS ABOUT THE NOTAMS ON THE ATIS. I ALSO SHOULD HAVE DOUBLECHKED THE ILS FREQ THE CAPT HAD ON HIS SIDE AND CHKED THE MORSE CODE FOR THE CORRECT IDENT. OUR GUARD SEEMED TO HAVE BEEN 'LET DOWN' BECAUSE WE WERE BEING VECTORED FOR THE VISUAL VERSUS AN IMC APCH. I DEFINITELY FEEL IF I HAD BEEN FEELING BETTER I WOULD NOT HAVE LET THESE CHAIN OF EVENTSSTACK UP AGAINST US. NEXT TIME I'M FEELING BAD THERE WILL CERTAINLY NOT BE ANY MORE 'PUSHING THE ENVELOPE.' I ALSO BELIEVE ONE OTHER FACTOR FOR MY NEGLECT IN DOUBLECHKING THE CAPT WAS BECAUSE I WAS TOO INVOLVED IN WORKING THE RADIOS AND KEEPING A VIGILANT WATCH OUTSIDE FOR OTHER TFC IN THE HIGH DENSITY AREA WE WERE FLYING IN. HAD IT BEEN A LESS CROWDED AREA, I PROBABLY WOULD HAVE LOOKED UP THE FREQ AND DOUBLECHKED THE CAPTS.
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.