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|
Attributes | |
ACN | 422969 |
Time | |
Date | 199812 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : crq |
State Reference | CA |
Altitude | agl bound lower : 344 agl bound upper : 672 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Operator | general aviation : corporate |
Make Model Name | Learjet 35 |
Navigation In Use | Other |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 40 flight time total : 6300 flight time type : 3200 |
ASRS Report | 422969 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : commercial |
Events | |
Anomaly | altitude deviation : overshoot non adherence : far other anomaly other other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Air Traffic Incident | Pilot Deviation |
Narrative:
The ILS system at palomar airport had been down for the preceding 2 months, and the only available approach was a VOR approach. The minimums on the chart were 1000 ft MSL for category B and C, the minimums being 672 ft above the ground. The crew in error set the approach minimums to 672 ft instead of 1000 ft, thereby breaking minimum approach altitudes by 328 ft. During the first approach we were forced to declare a missed approach, even at the lower approach altitude. During the second approach, the crew repeated the same error, failing to set the correct altitude a second time. Contact with the airport was made during the second approach, and the crew landed the aircraft safely. The error was not realized until I was putting the chart away. I do not know why I would make such a fundamental error. I have made hundreds of approachs, and I am not weak in chart interps. We return to flight safety every 6 months for pilot recurrencies, and I receive excellent reviews. Neither crew member recognized the error, even though it was repeated twice. Palomar did call 'altimeter alert' once to us, and they gave us a new altimeter setting. Once we adjusted the altimeters, we thought we gained some more space, and we descended yet again another hundred ft to the minimums that we believed the new altimeter setting afforded us.
Original NASA ASRS Text
Title: CAPT OF A CPR LEAR JET 35 DISCOVERED THAT HE HAD ALLOWED THE FO TO DSND BELOW PUBLISHED MINIMUMS DURING A VOR CIRCLING APCH DUE TO MISREADING THE APCH CHART'S PUBLISHED MDA AS AN AGL INSTEAD OF MSL ALT.
Narrative: THE ILS SYS AT PALOMAR ARPT HAD BEEN DOWN FOR THE PRECEDING 2 MONTHS, AND THE ONLY AVAILABLE APCH WAS A VOR APCH. THE MINIMUMS ON THE CHART WERE 1000 FT MSL FOR CATEGORY B AND C, THE MINIMUMS BEING 672 FT ABOVE THE GND. THE CREW IN ERROR SET THE APCH MINIMUMS TO 672 FT INSTEAD OF 1000 FT, THEREBY BREAKING MINIMUM APCH ALTS BY 328 FT. DURING THE FIRST APCH WE WERE FORCED TO DECLARE A MISSED APCH, EVEN AT THE LOWER APCH ALT. DURING THE SECOND APCH, THE CREW REPEATED THE SAME ERROR, FAILING TO SET THE CORRECT ALT A SECOND TIME. CONTACT WITH THE ARPT WAS MADE DURING THE SECOND APCH, AND THE CREW LANDED THE ACFT SAFELY. THE ERROR WAS NOT REALIZED UNTIL I WAS PUTTING THE CHART AWAY. I DO NOT KNOW WHY I WOULD MAKE SUCH A FUNDAMENTAL ERROR. I HAVE MADE HUNDREDS OF APCHS, AND I AM NOT WEAK IN CHART INTERPS. WE RETURN TO FLT SAFETY EVERY 6 MONTHS FOR PLT RECURRENCIES, AND I RECEIVE EXCELLENT REVIEWS. NEITHER CREW MEMBER RECOGNIZED THE ERROR, EVEN THOUGH IT WAS REPEATED TWICE. PALOMAR DID CALL 'ALTIMETER ALERT' ONCE TO US, AND THEY GAVE US A NEW ALTIMETER SETTING. ONCE WE ADJUSTED THE ALTIMETERS, WE THOUGHT WE GAINED SOME MORE SPACE, AND WE DSNDED YET AGAIN ANOTHER HUNDRED FT TO THE MINIMUMS THAT WE BELIEVED THE NEW ALTIMETER SETTING AFFORDED US.
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.