37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 386711 |
Time | |
Date | 199711 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : iah |
State Reference | TX |
Altitude | msl bound lower : 6000 msl bound upper : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : iah |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent : approach descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 10000 flight time type : 8000 |
ASRS Report | 386711 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence : clearance non adherence : far other spatial deviation |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
My most vivid lesson about fatigue. The aircraft had deferred maintenance items that affected the rate of descent, engines operating at 'high idle' RPM. During approach phase, when clearance for visual approach received, we also had instructions to slow. The aircraft performance was such that to slow down and descend at the same time was almost impossible. I became fixated on the speed and descent problem, and momentarily lost track of our horizontal navigation situation. After realizing I had crossed the localizer approach course I had difficulty reacquiring the airport. All this resulted in a very poor approach being flown with major deviations from the intended ground track. I am sure that my slow reactions and 'tunnel vision' were from fatigue. This was the second all night flight in as many days for me. Although I felt I had had adequate rest prior to the flight. More vigilance and an added sense of urgency is needed by crews as the days become longer, and the accumulated sleep pattern change makes itself known. I had always thought the fatigue issue was somewhat self serving, but I now realize the seriousness of the issues.
Original NASA ASRS Text
Title: AN ACR MLG FLC OVERSHOT THE LOC COURSE DURING AN APCH. THE ENGS ON THIS ACFT COULD NOT BE RETARDED BELOW THE 'HIGH IDLE' POS DUE TO A MALFUNCTION AND THE EFFECT OF THIS ON THE DSCNT RATE AND THE CAPT'S ADMITTED FATIGUE CAUSED THE FLC TO BE DISTR.
Narrative: MY MOST VIVID LESSON ABOUT FATIGUE. THE ACFT HAD DEFERRED MAINT ITEMS THAT AFFECTED THE RATE OF DSCNT, ENGS OPERATING AT 'HIGH IDLE' RPM. DURING APCH PHASE, WHEN CLRNC FOR VISUAL APCH RECEIVED, WE ALSO HAD INSTRUCTIONS TO SLOW. THE ACFT PERFORMANCE WAS SUCH THAT TO SLOW DOWN AND DSND AT THE SAME TIME WAS ALMOST IMPOSSIBLE. I BECAME FIXATED ON THE SPD AND DSCNT PROB, AND MOMENTARILY LOST TRACK OF OUR HORIZ NAV SIT. AFTER REALIZING I HAD CROSSED THE LOC APCH COURSE I HAD DIFFICULTY REACQUIRING THE ARPT. ALL THIS RESULTED IN A VERY POOR APCH BEING FLOWN WITH MAJOR DEVS FROM THE INTENDED GND TRACK. I AM SURE THAT MY SLOW REACTIONS AND 'TUNNEL VISION' WERE FROM FATIGUE. THIS WAS THE SECOND ALL NIGHT FLT IN AS MANY DAYS FOR ME. ALTHOUGH I FELT I HAD HAD ADEQUATE REST PRIOR TO THE FLT. MORE VIGILANCE AND AN ADDED SENSE OF URGENCY IS NEEDED BY CREWS AS THE DAYS BECOME LONGER, AND THE ACCUMULATED SLEEP PATTERN CHANGE MAKES ITSELF KNOWN. I HAD ALWAYS THOUGHT THE FATIGUE ISSUE WAS SOMEWHAT SELF SERVING, BUT I NOW REALIZE THE SERIOUSNESS OF THE ISSUES.
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.