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|
Attributes | |
ACN | 470040 |
Time | |
Date | 200004 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : sbv.vortac |
State Reference | VA |
Altitude | msl bound lower : 10000 msl bound upper : 12000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Thunderstorm |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc.artcc |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65, Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other other vortac |
Flight Phase | descent : intermediate altitude |
Route In Use | arrival : holding pattern |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 85 flight time total : 5000 flight time type : 85 |
ASRS Report | 470040 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer pilot : multi engine |
Experience | flight time last 90 days : 100 flight time total : 5750 flight time type : 1000 |
ASRS Report | 469500 |
Events | |
Anomaly | aircraft equipment problem : less severe inflight encounter : weather non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance flight crew : became reoriented |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Environmental Factor Weather ATC Human Performance Airspace Structure |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On the sbv 3 arrival into rdu, WX (cumulo nimbus) moved across field causing tower to close. Issued last min holding instructions. Turned around to hold at sbv VOR 'northeast on the 032 degree radial.' I was PF, captain received and wrote down instructions, then attempted to program FMS for the holding pattern. FMS would not take programming after repeated attempts during few mins available before reaching sbv VOR. I hadn't clearly heard the holding instructions due to rain noise and attention diverted by flying/navigation airplane back to sbv manually since FMS was in the process of rejecting programming attempts by captain. Upon reaching sbv VOR, confirmed (erroneously) that I needed to tune and hold inbound on the 032 degree radial, which we did. (We were supposed to hold outbound on the 032 degree radial.) proceeded to hold for about 15-20 mins in this way, with nothing said by ATC. We were able to program into the FMS a 'hold at present position' pattern after 2 turns. After 15 mins, ATC asked us (again) to 'hold northeast on the 032 degree radial,' whereupon the captain re-read his previously copied instructions and we realized our mistake. He had copied them correctly, but we flew it incorrectly. We reprogrammed, but prior to flying the new pattern, the airport re-opened and we continued to landing via vectors. Factors involved and contributing to our mistake: 1) airport suddenly closing, close proximity to holding fix, problems programming FMS due to inoperative GPS reception needed for holding pattern. 2) high workload just prior to hitting fix. IMC, cumulo nimbus in area and monitoring radar and navigation on my part while flying as captain dealt with communications and FMS. Discussion of icing conditions (we were in icing temperatures, but no buildup was observed). We observed no conflict (on TCASII) with any other aircraft. Our primary concern was the cumulo nimbus moving through the area and fuel status (when we would need to divert, and given the WX en route to our alternates, which would be the best choice). The time constraints and high workload demanded good decision making quickly, and we made an error in setting up our raw data navigation needles, resulting in holding opposite of where we were supposed to, and then proceeded onto the next tasks. Probably, with more time to discuss clearance, a concern about terrain, a working FMS, fewer concerns about WX and alternates, we wouldn't have made the mistake. We should have spent a few mins discussing the instructions, better crew coordination through communication. Supplemental information from acn 469500: although I've been flying the crj for almost 18 months, I was in my first week as a captain. (IOE was completed 1 week before.) while I sure like FMS, I've always said if you can't make it do what you want, you still have to do what needs to be done, ie, go out of navigation mode and get into heading mode. Sbv was behind and to our right. At first, even after getting the holding clearance, the first officer pressed on straight ahead towards argal. Expected him to at least turn towards sbv while I got things set up. (I don't recall exactly how far we were from sbv, but probably 3-4 mins.) when I noticed we hadn't turned (this was only 10-15 seconds), I said something about it and we then turned. I have no problems with FMS setup, but I could not get the thing to take this hold. In the frustration of not being able to get the FMS to accept the hold, and all the ATC and company calls required and watching the first officer, I set us up to hold inbound on the 212 degree radial sbv. After 4-5 turns in the hold, ATC asked us to hold on the 032 degree radial. I about died. What I learned: as a first officer, I was sharp and usually saw the big picture rather well. I didn't like being micro managed, and am trying not to be a micro manager from the left seat. In this case, I don't believe the first officer was seeing the big picture. He didn't write down the holding clearance and as mentioned, didn't turn towards sbv. Things happened quickly and he was along for the ride. This was my only turn with the first officer (I had flown to dca). It's not much time to evaluate a person, but maybe that initial hesitation to turn should have put me on 'high' alert.
Original NASA ASRS Text
Title: A CL65 FLC RPT ON THE ADVENTURES ENCOUNTERED WHILE ATTEMPTING AN ENRTE HOLD AT SBV FOR TFC DELAYS INTO RDU, NC.
Narrative: ON THE SBV 3 ARR INTO RDU, WX (CUMULO NIMBUS) MOVED ACROSS FIELD CAUSING TWR TO CLOSE. ISSUED LAST MIN HOLDING INSTRUCTIONS. TURNED AROUND TO HOLD AT SBV VOR 'NE ON THE 032 DEG RADIAL.' I WAS PF, CAPT RECEIVED AND WROTE DOWN INSTRUCTIONS, THEN ATTEMPTED TO PROGRAM FMS FOR THE HOLDING PATTERN. FMS WOULD NOT TAKE PROGRAMMING AFTER REPEATED ATTEMPTS DURING FEW MINS AVAILABLE BEFORE REACHING SBV VOR. I HADN'T CLRLY HEARD THE HOLDING INSTRUCTIONS DUE TO RAIN NOISE AND ATTN DIVERTED BY FLYING/NAV AIRPLANE BACK TO SBV MANUALLY SINCE FMS WAS IN THE PROCESS OF REJECTING PROGRAMMING ATTEMPTS BY CAPT. UPON REACHING SBV VOR, CONFIRMED (ERRONEOUSLY) THAT I NEEDED TO TUNE AND HOLD INBOUND ON THE 032 DEG RADIAL, WHICH WE DID. (WE WERE SUPPOSED TO HOLD OUTBOUND ON THE 032 DEG RADIAL.) PROCEEDED TO HOLD FOR ABOUT 15-20 MINS IN THIS WAY, WITH NOTHING SAID BY ATC. WE WERE ABLE TO PROGRAM INTO THE FMS A 'HOLD AT PRESENT POS' PATTERN AFTER 2 TURNS. AFTER 15 MINS, ATC ASKED US (AGAIN) TO 'HOLD NE ON THE 032 DEG RADIAL,' WHEREUPON THE CAPT RE-READ HIS PREVIOUSLY COPIED INSTRUCTIONS AND WE REALIZED OUR MISTAKE. HE HAD COPIED THEM CORRECTLY, BUT WE FLEW IT INCORRECTLY. WE REPROGRAMMED, BUT PRIOR TO FLYING THE NEW PATTERN, THE ARPT RE-OPENED AND WE CONTINUED TO LNDG VIA VECTORS. FACTORS INVOLVED AND CONTRIBUTING TO OUR MISTAKE: 1) ARPT SUDDENLY CLOSING, CLOSE PROX TO HOLDING FIX, PROBS PROGRAMMING FMS DUE TO INOP GPS RECEPTION NEEDED FOR HOLDING PATTERN. 2) HIGH WORKLOAD JUST PRIOR TO HITTING FIX. IMC, CUMULO NIMBUS IN AREA AND MONITORING RADAR AND NAV ON MY PART WHILE FLYING AS CAPT DEALT WITH COMS AND FMS. DISCUSSION OF ICING CONDITIONS (WE WERE IN ICING TEMPS, BUT NO BUILDUP WAS OBSERVED). WE OBSERVED NO CONFLICT (ON TCASII) WITH ANY OTHER ACFT. OUR PRIMARY CONCERN WAS THE CUMULO NIMBUS MOVING THROUGH THE AREA AND FUEL STATUS (WHEN WE WOULD NEED TO DIVERT, AND GIVEN THE WX ENRTE TO OUR ALTERNATES, WHICH WOULD BE THE BEST CHOICE). THE TIME CONSTRAINTS AND HIGH WORKLOAD DEMANDED GOOD DECISION MAKING QUICKLY, AND WE MADE AN ERROR IN SETTING UP OUR RAW DATA NAV NEEDLES, RESULTING IN HOLDING OPPOSITE OF WHERE WE WERE SUPPOSED TO, AND THEN PROCEEDED ONTO THE NEXT TASKS. PROBABLY, WITH MORE TIME TO DISCUSS CLRNC, A CONCERN ABOUT TERRAIN, A WORKING FMS, FEWER CONCERNS ABOUT WX AND ALTERNATES, WE WOULDN'T HAVE MADE THE MISTAKE. WE SHOULD HAVE SPENT A FEW MINS DISCUSSING THE INSTRUCTIONS, BETTER CREW COORD THROUGH COM. SUPPLEMENTAL INFO FROM ACN 469500: ALTHOUGH I'VE BEEN FLYING THE CRJ FOR ALMOST 18 MONTHS, I WAS IN MY FIRST WK AS A CAPT. (IOE WAS COMPLETED 1 WK BEFORE.) WHILE I SURE LIKE FMS, I'VE ALWAYS SAID IF YOU CAN'T MAKE IT DO WHAT YOU WANT, YOU STILL HAVE TO DO WHAT NEEDS TO BE DONE, IE, GO OUT OF NAV MODE AND GET INTO HDG MODE. SBV WAS BEHIND AND TO OUR R. AT FIRST, EVEN AFTER GETTING THE HOLDING CLRNC, THE FO PRESSED ON STRAIGHT AHEAD TOWARDS ARGAL. EXPECTED HIM TO AT LEAST TURN TOWARDS SBV WHILE I GOT THINGS SET UP. (I DON'T RECALL EXACTLY HOW FAR WE WERE FROM SBV, BUT PROBABLY 3-4 MINS.) WHEN I NOTICED WE HADN'T TURNED (THIS WAS ONLY 10-15 SECONDS), I SAID SOMETHING ABOUT IT AND WE THEN TURNED. I HAVE NO PROBS WITH FMS SETUP, BUT I COULD NOT GET THE THING TO TAKE THIS HOLD. IN THE FRUSTRATION OF NOT BEING ABLE TO GET THE FMS TO ACCEPT THE HOLD, AND ALL THE ATC AND COMPANY CALLS REQUIRED AND WATCHING THE FO, I SET US UP TO HOLD INBOUND ON THE 212 DEG RADIAL SBV. AFTER 4-5 TURNS IN THE HOLD, ATC ASKED US TO HOLD ON THE 032 DEG RADIAL. I ABOUT DIED. WHAT I LEARNED: AS A FO, I WAS SHARP AND USUALLY SAW THE BIG PICTURE RATHER WELL. I DIDN'T LIKE BEING MICRO MANAGED, AND AM TRYING NOT TO BE A MICRO MGR FROM THE L SEAT. IN THIS CASE, I DON'T BELIEVE THE FO WAS SEEING THE BIG PICTURE. HE DIDN'T WRITE DOWN THE HOLDING CLRNC AND AS MENTIONED, DIDN'T TURN TOWARDS SBV. THINGS HAPPENED QUICKLY AND HE WAS ALONG FOR THE RIDE. THIS WAS MY ONLY TURN WITH THE FO (I HAD FLOWN TO DCA). IT'S NOT MUCH TIME TO EVALUATE A PERSON, BUT MAYBE THAT INITIAL HESITATION TO TURN SHOULD HAVE PUT ME ON 'HIGH' ALERT.
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.