37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 428391 |
Time | |
Date | 199902 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : jnu.airport |
State Reference | AK |
Altitude | msl bound lower : 500 msl bound upper : 20000 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Ice |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : jnu.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils other localizer |
Flight Phase | cruise : enroute altitude change descent : approach |
Route In Use | approach : visual arrival other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 4000 flight time type : 1200 |
ASRS Report | 728391 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 220 flight time total : 11000 flight time type : 4000 |
ASRS Report | 428655 |
Events | |
Anomaly | altitude deviation : overshoot inflight encounter : weather non adherence : far non adherence : company policies non adherence : published procedure other spatial deviation |
Resolutory Action | flight crew : returned to original clearance other |
Consequence | Other |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Approaching FL200 we received clearance to cross fakes at or above FL190, descend and maintain 11000 ft. Slightly nonstandard for this arrival. This is about the time we would normally be performing the 'approach check' where 29.92 would be reset to qnh (today's qnh was 29.28). Rather than reprogramming the FMS, the PF utilized vertical speed mode of autoplt to make the crossing restr, then reset the altitude to 11000 ft. Soon after the crossing restr, we encountered some heavy rime ice but for only a short period of time. While descending, I was a little self absorbed about reporting this. The icing followed by a breakout into beautiful cavu WX conditions further distraction me into some untimely sightseeing in southeast alaska. Although the WX was good enough for a visual approach the PF elected to fly the procedure for practice. The first hint something may have been wrong was crossing dibol intersection where the peaks seemed to look a little close. The 'light' never came on until the missed approach (3.3 NM from the airport, 1000 ft MSL) where things definitely looked wrong and the 3 degree VASI showed us red/red. I saw the altimeters set at 29.92. At this point almost simultaneously, the PF climbed back to the VASI and the flight was completed uneventfully. We were both well rested for the flight, it was the first leg of the third day of a 3 day trip. Cavu conditions definitely led to complacency in this case, coupled with minor distrs about the point we would normally perform the 'approach check.' I have annotated on other approach/arrival plates where this check should be performed, especially when it coincides with a busy intersection. I will add this note to fakes intersection now also. All in all, a very cheap lesson that it can happen to any of us.
Original NASA ASRS Text
Title: B737 CREW FLEW A VISUAL LDA APCH 640 FT LOWER THAN THEY SHOULD HAVE.
Narrative: APCHING FL200 WE RECEIVED CLRNC TO CROSS FAKES AT OR ABOVE FL190, DSND AND MAINTAIN 11000 FT. SLIGHTLY NONSTANDARD FOR THIS ARR. THIS IS ABOUT THE TIME WE WOULD NORMALLY BE PERFORMING THE 'APCH CHK' WHERE 29.92 WOULD BE RESET TO QNH (TODAY'S QNH WAS 29.28). RATHER THAN REPROGRAMMING THE FMS, THE PF UTILIZED VERT SPD MODE OF AUTOPLT TO MAKE THE XING RESTR, THEN RESET THE ALT TO 11000 FT. SOON AFTER THE XING RESTR, WE ENCOUNTERED SOME HVY RIME ICE BUT FOR ONLY A SHORT PERIOD OF TIME. WHILE DSNDING, I WAS A LITTLE SELF ABSORBED ABOUT RPTING THIS. THE ICING FOLLOWED BY A BREAKOUT INTO BEAUTIFUL CAVU WX CONDITIONS FURTHER DISTR ME INTO SOME UNTIMELY SIGHTSEEING IN SE ALASKA. ALTHOUGH THE WX WAS GOOD ENOUGH FOR A VISUAL APCH THE PF ELECTED TO FLY THE PROC FOR PRACTICE. THE FIRST HINT SOMETHING MAY HAVE BEEN WRONG WAS XING DIBOL INTXN WHERE THE PEAKS SEEMED TO LOOK A LITTLE CLOSE. THE 'LIGHT' NEVER CAME ON UNTIL THE MISSED APCH (3.3 NM FROM THE ARPT, 1000 FT MSL) WHERE THINGS DEFINITELY LOOKED WRONG AND THE 3 DEG VASI SHOWED US RED/RED. I SAW THE ALTIMETERS SET AT 29.92. AT THIS POINT ALMOST SIMULTANEOUSLY, THE PF CLBED BACK TO THE VASI AND THE FLT WAS COMPLETED UNEVENTFULLY. WE WERE BOTH WELL RESTED FOR THE FLT, IT WAS THE FIRST LEG OF THE THIRD DAY OF A 3 DAY TRIP. CAVU CONDITIONS DEFINITELY LED TO COMPLACENCY IN THIS CASE, COUPLED WITH MINOR DISTRS ABOUT THE POINT WE WOULD NORMALLY PERFORM THE 'APCH CHK.' I HAVE ANNOTATED ON OTHER APCH/ARR PLATES WHERE THIS CHK SHOULD BE PERFORMED, ESPECIALLY WHEN IT COINCIDES WITH A BUSY INTXN. I WILL ADD THIS NOTE TO FAKES INTXN NOW ALSO. ALL IN ALL, A VERY CHEAP LESSON THAT IT CAN HAPPEN TO ANY OF 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.