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Flight crew of medium large transport makes several approach attempts prior to discovering flight management switches in wrong position arriving atl.
| Attributes | |
| ACN | 445948 |
| Time | |
| Date | 199908 |
| Day | Sat |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : atl.airport |
| State Reference | GA |
| Altitude | msl bound lower : 4000 msl bound upper : 5000 |
| Environment | |
| Flight Conditions | IMC |
| Weather Elements | other |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : atl.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | ils localizer only : 26r other other vortac |
| Flight Phase | descent : approach landing other |
| Route In Use | approach : instrument precision approach : visual |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : atp |
| Experience | flight time last 90 days : 200 flight time total : 3000 flight time type : 400 |
| ASRS Report | 445948 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | aircraft equipment problem : critical non adherence : published procedure other spatial deviation |
| Independent Detector | aircraft equipment other aircraft equipment : 927 other controllera other flight crewa other flight crewb |
| Resolutory Action | controller : issued new clearance flight crew : became reoriented |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
Narrative:
First and foremost, it should be known that an extremely bad (hostile) CRM environment had developed the day prior and carried over for the remainder of the trip! On the macey 2 arrival into atlanta, we were given holding instructions at macey at about FL200. Following our entry into holding, I noticed the captain changed the front course set in the MCP to reflect our holding course (we both changed course). We both had the localizer runway 26R front course dialed in, and setting the holding course in was superfluous since the holding course was set in the FMC and we were in an automated holding mode with the MCP in the navigation position. After 1 turn in holding, atl gave us a vector for the localizer and we were told to descend and intercept the final approach course. I switched the navigation system from the navigation mode to the VOR/ILS mode and called for the approach checklist. One item of the approach checklist is to ensure the final approach course is dialed in. The pilot monitoring verbally 'accomplished' the checklist and called it complete. However, the final approach course was never changed from 221 degrees (holding course) to 264 degrees (approach course). Upon reaching the localizer intercept point, the front course was captured, but the holding course in the MCP was tracked. We reported 'off flags' and atl gave us a northwest vector to reintercept and the cycle was repeated. Again, atl gave us a steeper vector back to the localizer and inquired if we had the proper frequency dialed -- we did. At that time, the captain said, 'you have the wrong front course dialed in!' I pointed to his side and said,' so do you!' the captain took the aircraft from me and flew northwest until a visual on runway 26R was acquired. He then gave me the aircraft for landing. I don't know if separation was lost. Initially it was very confusing! I think the hostile CRM environment was the main catalyst to this incident. I'm obviously certain of it!
Original NASA ASRS Text
Title: FLC OF MLG MAKES SEVERAL APCH ATTEMPTS PRIOR TO DISCOVERING FLT MGMNT SWITCHES IN WRONG POS ARRIVING ATL.
Narrative: FIRST AND FOREMOST, IT SHOULD BE KNOWN THAT AN EXTREMELY BAD (HOSTILE) CRM ENVIRONMENT HAD DEVELOPED THE DAY PRIOR AND CARRIED OVER FOR THE REMAINDER OF THE TRIP! ON THE MACEY 2 ARR INTO ATLANTA, WE WERE GIVEN HOLDING INSTRUCTIONS AT MACEY AT ABOUT FL200. FOLLOWING OUR ENTRY INTO HOLDING, I NOTICED THE CAPT CHANGED THE FRONT COURSE SET IN THE MCP TO REFLECT OUR HOLDING COURSE (WE BOTH CHANGED COURSE). WE BOTH HAD THE LOC RWY 26R FRONT COURSE DIALED IN, AND SETTING THE HOLDING COURSE IN WAS SUPERFLUOUS SINCE THE HOLDING COURSE WAS SET IN THE FMC AND WE WERE IN AN AUTOMATED HOLDING MODE WITH THE MCP IN THE NAV POS. AFTER 1 TURN IN HOLDING, ATL GAVE US A VECTOR FOR THE LOC AND WE WERE TOLD TO DSND AND INTERCEPT THE FINAL APCH COURSE. I SWITCHED THE NAV SYS FROM THE NAV MODE TO THE VOR/ILS MODE AND CALLED FOR THE APCH CHKLIST. ONE ITEM OF THE APCH CHKLIST IS TO ENSURE THE FINAL APCH COURSE IS DIALED IN. THE PLT MONITORING VERBALLY 'ACCOMPLISHED' THE CHKLIST AND CALLED IT COMPLETE. HOWEVER, THE FINAL APCH COURSE WAS NEVER CHANGED FROM 221 DEGS (HOLDING COURSE) TO 264 DEGS (APCH COURSE). UPON REACHING THE LOC INTERCEPT POINT, THE FRONT COURSE WAS CAPTURED, BUT THE HOLDING COURSE IN THE MCP WAS TRACKED. WE RPTED 'OFF FLAGS' AND ATL GAVE US A NW VECTOR TO REINTERCEPT AND THE CYCLE WAS REPEATED. AGAIN, ATL GAVE US A STEEPER VECTOR BACK TO THE LOC AND INQUIRED IF WE HAD THE PROPER FREQ DIALED -- WE DID. AT THAT TIME, THE CAPT SAID, 'YOU HAVE THE WRONG FRONT COURSE DIALED IN!' I POINTED TO HIS SIDE AND SAID,' SO DO YOU!' THE CAPT TOOK THE ACFT FROM ME AND FLEW NW UNTIL A VISUAL ON RWY 26R WAS ACQUIRED. HE THEN GAVE ME THE ACFT FOR LNDG. I DON'T KNOW IF SEPARATION WAS LOST. INITIALLY IT WAS VERY CONFUSING! I THINK THE HOSTILE CRM ENVIRONMENT WAS THE MAIN CATALYST TO THIS INCIDENT. I'M OBVIOUSLY CERTAIN OF IT!
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.