37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 386754 |
Time | |
Date | 199711 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : leb |
State Reference | NH |
Altitude | msl bound lower : 2800 msl bound upper : 8000 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : leb |
Operator | common carrier : air carrier |
Make Model Name | Beech 1900 |
Operating Under FAR Part | Part 135 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude descent : approach landing : missed approach |
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 : 275 flight time total : 6000 flight time type : 3500 |
ASRS Report | 386754 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 260 flight time total : 2350 flight time type : 600 |
ASRS Report | 387280 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Given a hold at burgr left turns 7000 ft. We entered the hold and while in the hold we were cleared for the ILS runway 18 at leb. We started our descent to 3500 ft. As we turned inbound on the approach we became established on the localizer and continued our descent. The GS started coming in and became centered momentarily, but then started giving us full scale deflection up and down near burgr. My decision at that time was to go around and go missed approach. I asked my first officer to review the missed approach procedure. I thought he said climb to 8000 ft and right turn to ivv NDB. During this time we called leb tower and told them we were going missed. Tower did not acknowledge us on the first call. On the second call to tower we made contact, but at this time we were flying through 7000 ft. We should have been at 4800 ft. Tower then cleared us to burgr to shoot the ILS again. We shot the ILS the second time with all good indications. How the problem arose: poor CRM. If my first officer read 8000 ft I should have questioned that altitude. If my first officer didn't read 8000 ft he should have questioned me. It was discovered by me and the controller about the same time, I then read the missed approach and saw it was indeed 4800 ft. Corrective action: I don't believe we got all the way up to 8000 ft but I descended back down once the error was discovered and at that time the controller gave us approach clearance. Other contributing factors: started my day at XA35 (8 hour day thus far) finished XL50 local. Flew 4 hours that day at the time of the event. 6.3 total for the day. Fatigue: this was my 5TH leg. 3 more after the event.
Original NASA ASRS Text
Title: THE CAPT OF A BEECH 1900, BE02, OVERSHOT CLB ALT DURING A MISSED APCH DUE TO A MISUNDERSTANDING OF THE ALT TO WHICH TO CLB.
Narrative: GIVEN A HOLD AT BURGR L TURNS 7000 FT. WE ENTERED THE HOLD AND WHILE IN THE HOLD WE WERE CLRED FOR THE ILS RWY 18 AT LEB. WE STARTED OUR DSCNT TO 3500 FT. AS WE TURNED INBOUND ON THE APCH WE BECAME ESTABLISHED ON THE LOC AND CONTINUED OUR DSCNT. THE GS STARTED COMING IN AND BECAME CTRED MOMENTARILY, BUT THEN STARTED GIVING US FULL SCALE DEFLECTION UP AND DOWN NEAR BURGR. MY DECISION AT THAT TIME WAS TO GAR AND GO MISSED APCH. I ASKED MY FO TO REVIEW THE MISSED APCH PROC. I THOUGHT HE SAID CLB TO 8000 FT AND R TURN TO IVV NDB. DURING THIS TIME WE CALLED LEB TWR AND TOLD THEM WE WERE GOING MISSED. TWR DID NOT ACKNOWLEDGE US ON THE FIRST CALL. ON THE SECOND CALL TO TWR WE MADE CONTACT, BUT AT THIS TIME WE WERE FLYING THROUGH 7000 FT. WE SHOULD HAVE BEEN AT 4800 FT. TWR THEN CLRED US TO BURGR TO SHOOT THE ILS AGAIN. WE SHOT THE ILS THE SECOND TIME WITH ALL GOOD INDICATIONS. HOW THE PROB AROSE: POOR CRM. IF MY FO READ 8000 FT I SHOULD HAVE QUESTIONED THAT ALT. IF MY FO DIDN'T READ 8000 FT HE SHOULD HAVE QUESTIONED ME. IT WAS DISCOVERED BY ME AND THE CTLR ABOUT THE SAME TIME, I THEN READ THE MISSED APCH AND SAW IT WAS INDEED 4800 FT. CORRECTIVE ACTION: I DON'T BELIEVE WE GOT ALL THE WAY UP TO 8000 FT BUT I DSNDED BACK DOWN ONCE THE ERROR WAS DISCOVERED AND AT THAT TIME THE CTLR GAVE US APCH CLRNC. OTHER CONTRIBUTING FACTORS: STARTED MY DAY AT XA35 (8 HR DAY THUS FAR) FINISHED XL50 LCL. FLEW 4 HRS THAT DAY AT THE TIME OF THE EVENT. 6.3 TOTAL FOR THE DAY. FATIGUE: THIS WAS MY 5TH LEG. 3 MORE AFTER THE EVENT.
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.