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|
Attributes | |
ACN | 468925 |
Time | |
Date | 200004 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo.airport |
State Reference | CA |
Altitude | msl bound lower : 1900 msl bound upper : 3400 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : o90.tracon |
Operator | common carrier : air carrier |
Make Model Name | A300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 28r other |
Flight Phase | descent : intermediate altitude landing : go around |
Route In Use | approach : visual arrival star : ns |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain observation : company check pilot oversight : pic |
Qualification | pilot : instrument pilot : atp pilot : commercial pilot : flight engineer pilot : multi engine |
Experience | flight time last 90 days : 100 flight time total : 11000 flight time type : 250 |
ASRS Report | 468925 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : multi engine pilot : instrument |
Experience | flight time type : 25 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure other anomaly other anomaly other anomaly other |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : became reoriented flight crew : executed go around flight crew : regained aircraft control flight crew : returned to assigned altitude |
Consequence | Other |
Supplementary | |
Problem Areas | ATC Human Performance Aircraft Flight Crew Human Performance Environmental Factor |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
A missed approach was initiated from the quiet bridge visual approach to sfo runway 28R. The aircraft was being flown by the first officer on the last leg of IOE. The aircraft was high and fast approaching the runway 28R GS just inside bridge OM. Shortly after intercepting the runway 28R localizer, sfo tower cleared us to land on runway 28L. The first officer executed a go around from an altitude of approximately 1900 ft at about 3 mi from the threshold of runway 28L. Tapping the 'go lever' increased thrust to go around and the first officer manually pitched the aircraft up to vap speed displayed by the srs-speed reference system -- pitch bar and engaged the autoplt. After some initial confusion as to the direction of turn to be flown, we established the aircraft on the 265 degree heading called for in the notes of the arrival. The first officer was engrossed in trying to program the automated flight control system as I tried to establish communication with tower and departure control. I noticed that we were rapidly reaching our assigned altitude of 3000 ft with no action being taken to level off. I alerted the first officer to this and he immediately disconnected the autoplt and manually flew the aircraft back down from 3400 ft to 3000 ft as cleared. The first officer correctly decided to go around from what was clearly an unsalvageable approach. He was not mentally prepared for the go around procedure. His lack of experience in the aircraft and last min landing instructions by ATC compounded the subsequent confusion experienced during the go around. Our missed approach/go around procedure utilizes the automated flight control system in both instances. No deviation or allowance is made procedurally if one misses at 100 ft or within 500 ft of the initial missed approach leveloff altitude. Increased awareness and more detailed briefings are required if one sees a potential for a missed approach or go around from an approach being flown manually and/or on autoplt. As a captain, I am too aware of the many accidents resulting from botched go around executions caused by being too engrossed in automation. It must be remembered that the first and foremost task it to 'fly the airplane.'
Original NASA ASRS Text
Title: AN A300 FLC GETS HIGH AND FAST ON THE APCH AND AFTER A RWY CHANGE THE FO EXECUTES A GAR WITH AN OVERSHOOT FROM HIS ASSIGNED MISSED APCH ALT AT SFO, CA.
Narrative: A MISSED APCH WAS INITIATED FROM THE QUIET BRIDGE VISUAL APCH TO SFO RWY 28R. THE ACFT WAS BEING FLOWN BY THE FO ON THE LAST LEG OF IOE. THE ACFT WAS HIGH AND FAST APCHING THE RWY 28R GS JUST INSIDE BRIDGE OM. SHORTLY AFTER INTERCEPTING THE RWY 28R LOC, SFO TWR CLRED US TO LAND ON RWY 28L. THE FO EXECUTED A GAR FROM AN ALT OF APPROX 1900 FT AT ABOUT 3 MI FROM THE THRESHOLD OF RWY 28L. TAPPING THE 'GO LEVER' INCREASED THRUST TO GAR AND THE FO MANUALLY PITCHED THE ACFT UP TO VAP SPD DISPLAYED BY THE SRS-SPD REF SYS -- PITCH BAR AND ENGAGED THE AUTOPLT. AFTER SOME INITIAL CONFUSION AS TO THE DIRECTION OF TURN TO BE FLOWN, WE ESTABLISHED THE ACFT ON THE 265 DEG HDG CALLED FOR IN THE NOTES OF THE ARR. THE FO WAS ENGROSSED IN TRYING TO PROGRAM THE AUTOMATED FLT CTL SYS AS I TRIED TO ESTABLISH COM WITH TWR AND DEP CTL. I NOTICED THAT WE WERE RAPIDLY REACHING OUR ASSIGNED ALT OF 3000 FT WITH NO ACTION BEING TAKEN TO LEVEL OFF. I ALERTED THE FO TO THIS AND HE IMMEDIATELY DISCONNECTED THE AUTOPLT AND MANUALLY FLEW THE ACFT BACK DOWN FROM 3400 FT TO 3000 FT AS CLRED. THE FO CORRECTLY DECIDED TO GO AROUND FROM WHAT WAS CLRLY AN UNSALVAGEABLE APCH. HE WAS NOT MENTALLY PREPARED FOR THE GAR PROC. HIS LACK OF EXPERIENCE IN THE ACFT AND LAST MIN LNDG INSTRUCTIONS BY ATC COMPOUNDED THE SUBSEQUENT CONFUSION EXPERIENCED DURING THE GAR. OUR MISSED APCH/GAR PROC UTILIZES THE AUTOMATED FLT CTL SYS IN BOTH INSTANCES. NO DEV OR ALLOWANCE IS MADE PROCEDURALLY IF ONE MISSES AT 100 FT OR WITHIN 500 FT OF THE INITIAL MISSED APCH LEVELOFF ALT. INCREASED AWARENESS AND MORE DETAILED BRIEFINGS ARE REQUIRED IF ONE SEES A POTENTIAL FOR A MISSED APCH OR GAR FROM AN APCH BEING FLOWN MANUALLY AND/OR ON AUTOPLT. AS A CAPT, I AM TOO AWARE OF THE MANY ACCIDENTS RESULTING FROM BOTCHED GAR EXECUTIONS CAUSED BY BEING TOO ENGROSSED IN AUTOMATION. IT MUST BE REMEMBERED THAT THE FIRST AND FOREMOST TASK IT TO 'FLY THE AIRPLANE.'
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.