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|
Attributes | |
ACN | 456197 |
Time | |
Date | 199912 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : pxr.vortac |
State Reference | AZ |
Altitude | msl single value : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : p50.tracon |
Operator | general aviation : corporate |
Make Model Name | Learjet 31 |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | descent : approach |
Route In Use | approach : instrument non precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : multi engine |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Experience | flight time last 90 days : 180 flight time total : 2480 flight time type : 380 |
ASRS Report | 456197 |
Events | |
Anomaly | non adherence : company policies non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued advisory flight crew : became reoriented |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
This report describes a failure of the flight crew to track a VOR inbound. We failed in this simple task due to improperly configured navigation equipment, and more importantly due to a breakdown in cockpit communication. The event occurred on the third day of a 3-DAY trip. Earlier in the trip the captain had declared he was in a 'bad mood' and his subsequent behavior both inside and outside the cockpit clearly showed that this was the case. Cockpit communication was very poor and the captain, in my opinion, was allowing his mood to interfere with good judgement. The crew was conducting a practice VOR approach. The captain did not conduct an approach briefing. The crew received a clearance to: 'fly heading 300 degrees intercept the pxr 170 degree radial and track inbound to the station. Fly the 002 degree radial outbound, maintain 4000 ft.' the captain configured his own instrumentation, setting the HSI for the 002 degree radial and when questioned indicated he was going to use his standby HSI (located on the lower left of his panel) to intercept the 170 degree radial. I set my HSI to intercept the 170 degree radial. We then proceeded to fly through the 170 degree radial and after my second prompt to begin a turn, the captain turned to intercept. Once the captain was established inbound to pxr, I made the first of 2 important errors. First, I reset my HSI to the 002 degree radial in anticipation of crossing the VOR. Given the excellent visibility, I was focused primarily outside the cockpit and was not relying on my instrumentation. I assumed that the captain would track the VOR properly once established. As we neared pxr, I gained visual contact with the transmitter on the ground and realized that we were east of course. At this point I made my second, and larger, mistake. I debated whether to once again challenge the captain and elected not to do so. I did not want to risk angering the captain by questioning his heading. Phx approach then notified us that we were 1 mi east of the VOR. The fact that a professional flight crew failed at a task as basic as tracking a VOR inbound is a clear indication of a problem. I consider the primary issue to be an almost complete breakdown in cockpit communication. The captain had established a very strained and uncomfortable environment. While the captain was lost in his own world, I was thoroughly distraction by his mood, wondering both what was causing it and how I could help fix it. I let concern over these distrs take me out of my normal game plan with respect to how I perform my job. Specifically: by failing to perform an approach briefing we failed to comply with our own company SOP and lost an opportunity to clarify how to best use our navigation equipment. By allowing myself to be overly concerned with improving the cockpit environment, I exercised poor judgement. I should not have worried about upsetting the captain since the more important consideration was complying with our clearance. In the future, if I am aware of a failure to meet goals, I will not be shy about bringing it to the captain's attention. Pacification is a poor strategy in the cockpit.
Original NASA ASRS Text
Title: LEARJET CREW FAILS TO TRACK VOR DURING APCH AFTER INTERCOCKPIT COM BREAKS DOWN.
Narrative: THIS RPT DESCRIBES A FAILURE OF THE FLC TO TRACK A VOR INBOUND. WE FAILED IN THIS SIMPLE TASK DUE TO IMPROPERLY CONFIGURED NAV EQUIP, AND MORE IMPORTANTLY DUE TO A BREAKDOWN IN COCKPIT COM. THE EVENT OCCURRED ON THE THIRD DAY OF A 3-DAY TRIP. EARLIER IN THE TRIP THE CAPT HAD DECLARED HE WAS IN A 'BAD MOOD' AND HIS SUBSEQUENT BEHAVIOR BOTH INSIDE AND OUTSIDE THE COCKPIT CLRLY SHOWED THAT THIS WAS THE CASE. COCKPIT COM WAS VERY POOR AND THE CAPT, IN MY OPINION, WAS ALLOWING HIS MOOD TO INTERFERE WITH GOOD JUDGEMENT. THE CREW WAS CONDUCTING A PRACTICE VOR APCH. THE CAPT DID NOT CONDUCT AN APCH BRIEFING. THE CREW RECEIVED A CLRNC TO: 'FLY HDG 300 DEGS INTERCEPT THE PXR 170 DEG RADIAL AND TRACK INBOUND TO THE STATION. FLY THE 002 DEG RADIAL OUTBOUND, MAINTAIN 4000 FT.' THE CAPT CONFIGURED HIS OWN INSTRUMENTATION, SETTING THE HSI FOR THE 002 DEG RADIAL AND WHEN QUESTIONED INDICATED HE WAS GOING TO USE HIS STANDBY HSI (LOCATED ON THE LOWER L OF HIS PANEL) TO INTERCEPT THE 170 DEG RADIAL. I SET MY HSI TO INTERCEPT THE 170 DEG RADIAL. WE THEN PROCEEDED TO FLY THROUGH THE 170 DEG RADIAL AND AFTER MY SECOND PROMPT TO BEGIN A TURN, THE CAPT TURNED TO INTERCEPT. ONCE THE CAPT WAS ESTABLISHED INBOUND TO PXR, I MADE THE FIRST OF 2 IMPORTANT ERRORS. FIRST, I RESET MY HSI TO THE 002 DEG RADIAL IN ANTICIPATION OF XING THE VOR. GIVEN THE EXCELLENT VISIBILITY, I WAS FOCUSED PRIMARILY OUTSIDE THE COCKPIT AND WAS NOT RELYING ON MY INSTRUMENTATION. I ASSUMED THAT THE CAPT WOULD TRACK THE VOR PROPERLY ONCE ESTABLISHED. AS WE NEARED PXR, I GAINED VISUAL CONTACT WITH THE XMITTER ON THE GND AND REALIZED THAT WE WERE E OF COURSE. AT THIS POINT I MADE MY SECOND, AND LARGER, MISTAKE. I DEBATED WHETHER TO ONCE AGAIN CHALLENGE THE CAPT AND ELECTED NOT TO DO SO. I DID NOT WANT TO RISK ANGERING THE CAPT BY QUESTIONING HIS HDG. PHX APCH THEN NOTIFIED US THAT WE WERE 1 MI E OF THE VOR. THE FACT THAT A PROFESSIONAL FLC FAILED AT A TASK AS BASIC AS TRACKING A VOR INBOUND IS A CLR INDICATION OF A PROB. I CONSIDER THE PRIMARY ISSUE TO BE AN ALMOST COMPLETE BREAKDOWN IN COCKPIT COM. THE CAPT HAD ESTABLISHED A VERY STRAINED AND UNCOMFORTABLE ENVIRONMENT. WHILE THE CAPT WAS LOST IN HIS OWN WORLD, I WAS THOROUGHLY DISTR BY HIS MOOD, WONDERING BOTH WHAT WAS CAUSING IT AND HOW I COULD HELP FIX IT. I LET CONCERN OVER THESE DISTRS TAKE ME OUT OF MY NORMAL GAME PLAN WITH RESPECT TO HOW I PERFORM MY JOB. SPECIFICALLY: BY FAILING TO PERFORM AN APCH BRIEFING WE FAILED TO COMPLY WITH OUR OWN COMPANY SOP AND LOST AN OPPORTUNITY TO CLARIFY HOW TO BEST USE OUR NAV EQUIP. BY ALLOWING MYSELF TO BE OVERLY CONCERNED WITH IMPROVING THE COCKPIT ENVIRONMENT, I EXERCISED POOR JUDGEMENT. I SHOULD NOT HAVE WORRIED ABOUT UPSETTING THE CAPT SINCE THE MORE IMPORTANT CONSIDERATION WAS COMPLYING WITH OUR CLRNC. IN THE FUTURE, IF I AM AWARE OF A FAILURE TO MEET GOALS, I WILL NOT BE SHY ABOUT BRINGING IT TO THE CAPT'S ATTN. PACIFICATION IS A POOR STRATEGY IN THE COCKPIT.
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.