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|
Attributes | |
ACN | 467525 |
Time | |
Date | 200003 |
Day | Sun |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | navaid : acv.ils |
State Reference | NJ |
Altitude | msl single value : 480 |
Environment | |
Flight Conditions | IMC |
Weather Elements | other |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : acy.tower tower : lga.tower |
Operator | common carrier : air carrier |
Make Model Name | Beech 1900 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | descent : approach |
Route In Use | approach : instrument non precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 3180 flight time type : 1700 |
ASRS Report | 467525 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : commercial pilot : instrument |
Events | |
Anomaly | non adherence : far non adherence : published procedure other anomaly |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Narrative:
It was the 4TH leg of an 8 leg, 14 hour shift and the 3RD consecutive day of 5 leg, 14 hour shifts. This event occurred on the 12TH instrument approach in 2 days in low IFR WX with moderate turbulence on all approachs. We were both tired with the usual after lunch cobwebs, but had 4 more legs to go before we would get home. After briefing the VOR 4 approach we ran all checklists and had the aircraft configured prior to the FAF. I had mentioned I was tired to the first officer a while back, but this is pretty much routine on this shift. We crossed the FAF and I started my descent to the MDA of 480 ft. I think the first officer was a little behind at this point because I do not remember him keeping up with the standard calls, but this could also have been my not hearing them. The radar altimeter called 'minimums' at 410 ft AGL and I remember being surprised that we were there already. Almost simultaneously the tower gave us 'low altitude' warning and instructed us to climb back to MDA. I had already leveled off and was indicating 480 ft on my altimeter. We were not yet at the missed approach point, visibility was poor in light rain and I remember feeling very confused by everything that had just happened in the last 3 seconds. At that point I decided to go missed approach so we could get away from the ground and regroup. After this, I elected to do the ILS to runway 13. There were no further problems. Contributing factors: 1) fatigue. 2) relatively inexperienced crew.
Original NASA ASRS Text
Title: A BE1900D CAPT RPTED THAT DURING AN APCH TO ACY IN IMC THE CTLR WARNED HIM OF A LOW ALT. THE CAPT WENT AROUND FOR THE ILS.
Narrative: IT WAS THE 4TH LEG OF AN 8 LEG, 14 HR SHIFT AND THE 3RD CONSECUTIVE DAY OF 5 LEG, 14 HR SHIFTS. THIS EVENT OCCURRED ON THE 12TH INST APCH IN 2 DAYS IN LOW IFR WX WITH MODERATE TURB ON ALL APCHS. WE WERE BOTH TIRED WITH THE USUAL AFTER LUNCH COBWEBS, BUT HAD 4 MORE LEGS TO GO BEFORE WE WOULD GET HOME. AFTER BRIEFING THE VOR 4 APCH WE RAN ALL CHKLISTS AND HAD THE ACFT CONFIGURED PRIOR TO THE FAF. I HAD MENTIONED I WAS TIRED TO THE FO A WHILE BACK, BUT THIS IS PRETTY MUCH ROUTINE ON THIS SHIFT. WE CROSSED THE FAF AND I STARTED MY DSCNT TO THE MDA OF 480 FT. I THINK THE FO WAS A LITTLE BEHIND AT THIS POINT BECAUSE I DO NOT REMEMBER HIM KEEPING UP WITH THE STANDARD CALLS, BUT THIS COULD ALSO HAVE BEEN MY NOT HEARING THEM. THE RADAR ALTIMETER CALLED 'MINIMUMS' AT 410 FT AGL AND I REMEMBER BEING SURPRISED THAT WE WERE THERE ALREADY. ALMOST SIMULTANEOUSLY THE TWR GAVE US 'LOW ALT' WARNING AND INSTRUCTED US TO CLB BACK TO MDA. I HAD ALREADY LEVELED OFF AND WAS INDICATING 480 FT ON MY ALTIMETER. WE WERE NOT YET AT THE MISSED APCH POINT, VISIBILITY WAS POOR IN LIGHT RAIN AND I REMEMBER FEELING VERY CONFUSED BY EVERYTHING THAT HAD JUST HAPPENED IN THE LAST 3 SECONDS. AT THAT POINT I DECIDED TO GO MISSED APCH SO WE COULD GET AWAY FROM THE GND AND REGROUP. AFTER THIS, I ELECTED TO DO THE ILS TO RWY 13. THERE WERE NO FURTHER PROBS. CONTRIBUTING FACTORS: 1) FATIGUE. 2) RELATIVELY INEXPERIENCED CREW.
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.