37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 403210 |
Time | |
Date | 199805 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : stl |
State Reference | MO |
Altitude | msl bound lower : 5600 msl bound upper : 6000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : stl |
Operator | general aviation : corporate |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach descent other |
Route In Use | arrival other enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 110 flight time total : 10750 flight time type : 6000 |
ASRS Report | 403210 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course flight crew : became reoriented |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
We were being radar vectored by stl approach control for the runway 12L lda approach at stl. Approach briefing had been completed and we were in a series of turns and stepdowns. WX conditions were changing and I believed approach was setting us up for a slam-dunk base to final. It had been a nice calm flight but things were starting to happen fast. Approximately 7 mi northwest of the airport at 7000 ft on a 270 degree heading, we were told to turn to a 290 degree heading and descend to 6000 ft. Somewhere about here we were told to reduce to 210 KTS and descending through 6400 ft we were told to change to the runway 12L ILS approach! I felt time was getting real short before they would turn us on a base (to intercept the localizer) and I waited with anxiety while the copilot tried to find the runway 12L ILS approach plate. My attention was diverted to helping him find the proper approach and getting it clipped to the yoke, which I did clumsily. Then the altitude alert chime rang and I looked up to find us going through 5700 ft! We descended to almost 5600 ft before the airplane started back up and I quickly leveled off at 6000 ft when approach gave us another speed reduction and turn. Approach made no comment about our altitude. From there on in we were hurried getting set up for the changed approach and only had time to each do a self brief. Looking back at this event is quite painful because of the contributing factors. From my perspective: 1) stl approach control started the ball rolling by changing to a new different approach for us way too late and close in for our position! We felt very pressured! If they would have told us that we could have extra time if we needed it to set up for the approach, it could have made a world of difference. On the other hand, we could have asked for or demanded the extra time. 2) fatigue. This was the 10TH hour of a 13 1/2 hour day and I was tired with no rest throughout the day. 3) CRM. Where was it? Fly the airplane first! I knew better and should have let the copilot do his job and I mine. Here is where I believe fatigue played a big part in slowing and clouding my judgement. 4) avionics. A 300 ft deviation is a violation. So why can't an altitude alert chime (which got my attention) be set to ring at 100 or 150 ft deviation? This should be looked into as a helpful fix. 5) make better use of the autoplt. We like to hand fly a lot of the time below 15000 ft to keep us sharp. But there are times that using the autoplt is smarter and safer!
Original NASA ASRS Text
Title: A CPR JET PIC OVERSHOT HIS ALT IN DSCNT WHEN SEARCHING FOR ANOTHER APCH PLATE. STL APCH CTLR HAD CHANGED THE IAP TO A REGULAR ILS FROM AN LDA RWY 12 APCH.
Narrative: WE WERE BEING RADAR VECTORED BY STL APCH CTL FOR THE RWY 12L LDA APCH AT STL. APCH BRIEFING HAD BEEN COMPLETED AND WE WERE IN A SERIES OF TURNS AND STEPDOWNS. WX CONDITIONS WERE CHANGING AND I BELIEVED APCH WAS SETTING US UP FOR A SLAM-DUNK BASE TO FINAL. IT HAD BEEN A NICE CALM FLT BUT THINGS WERE STARTING TO HAPPEN FAST. APPROX 7 MI NW OF THE ARPT AT 7000 FT ON A 270 DEG HDG, WE WERE TOLD TO TURN TO A 290 DEG HDG AND DSND TO 6000 FT. SOMEWHERE ABOUT HERE WE WERE TOLD TO REDUCE TO 210 KTS AND DSNDING THROUGH 6400 FT WE WERE TOLD TO CHANGE TO THE RWY 12L ILS APCH! I FELT TIME WAS GETTING REAL SHORT BEFORE THEY WOULD TURN US ON A BASE (TO INTERCEPT THE LOC) AND I WAITED WITH ANXIETY WHILE THE COPLT TRIED TO FIND THE RWY 12L ILS APCH PLATE. MY ATTN WAS DIVERTED TO HELPING HIM FIND THE PROPER APCH AND GETTING IT CLIPPED TO THE YOKE, WHICH I DID CLUMSILY. THEN THE ALT ALERT CHIME RANG AND I LOOKED UP TO FIND US GOING THROUGH 5700 FT! WE DSNDED TO ALMOST 5600 FT BEFORE THE AIRPLANE STARTED BACK UP AND I QUICKLY LEVELED OFF AT 6000 FT WHEN APCH GAVE US ANOTHER SPD REDUCTION AND TURN. APCH MADE NO COMMENT ABOUT OUR ALT. FROM THERE ON IN WE WERE HURRIED GETTING SET UP FOR THE CHANGED APCH AND ONLY HAD TIME TO EACH DO A SELF BRIEF. LOOKING BACK AT THIS EVENT IS QUITE PAINFUL BECAUSE OF THE CONTRIBUTING FACTORS. FROM MY PERSPECTIVE: 1) STL APCH CTL STARTED THE BALL ROLLING BY CHANGING TO A NEW DIFFERENT APCH FOR US WAY TOO LATE AND CLOSE IN FOR OUR POS! WE FELT VERY PRESSURED! IF THEY WOULD HAVE TOLD US THAT WE COULD HAVE EXTRA TIME IF WE NEEDED IT TO SET UP FOR THE APCH, IT COULD HAVE MADE A WORLD OF DIFFERENCE. ON THE OTHER HAND, WE COULD HAVE ASKED FOR OR DEMANDED THE EXTRA TIME. 2) FATIGUE. THIS WAS THE 10TH HR OF A 13 1/2 HR DAY AND I WAS TIRED WITH NO REST THROUGHOUT THE DAY. 3) CRM. WHERE WAS IT? FLY THE AIRPLANE FIRST! I KNEW BETTER AND SHOULD HAVE LET THE COPLT DO HIS JOB AND I MINE. HERE IS WHERE I BELIEVE FATIGUE PLAYED A BIG PART IN SLOWING AND CLOUDING MY JUDGEMENT. 4) AVIONICS. A 300 FT DEV IS A VIOLATION. SO WHY CAN'T AN ALT ALERT CHIME (WHICH GOT MY ATTN) BE SET TO RING AT 100 OR 150 FT DEV? THIS SHOULD BE LOOKED INTO AS A HELPFUL FIX. 5) MAKE BETTER USE OF THE AUTOPLT. WE LIKE TO HAND FLY A LOT OF THE TIME BELOW 15000 FT TO KEEP US SHARP. BUT THERE ARE TIMES THAT USING THE AUTOPLT IS SMARTER AND SAFER!
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.