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|
Attributes | |
ACN | 483716 |
Time | |
Date | 200008 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : lga.vor |
State Reference | NY |
Altitude | msl single value : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | common carrier : air carrier |
Make Model Name | B757 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : intermediate altitude |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : n90.tracon |
Operator | general aviation : personal |
Make Model Name | Small Aircraft |
Flight Phase | cruise : level |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : private pilot : multi engine pilot : instrument pilot : atp pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 240 flight time total : 20000 flight time type : 2500 |
ASRS Report | 483716 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 145 flight time total : 3300 flight time type : 375 |
ASRS Report | 483595 |
Events | |
Anomaly | conflict : airborne critical non adherence : published procedure non adherence : far non adherence : company policies non adherence other |
Independent Detector | aircraft equipment : tcas other controllera other flight crewa other flight crewb |
Resolutory Action | controller : provided flight assist flight crew : took evasive action |
Consequence | faa : reviewed incident with flight crew other |
Miss Distance | horizontal : 0 vertical : 600 |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
During this incident the cockpit indications happened very rapidly, but to the best of my knowledge this report represents an accurate reconstruction of the events. Departed ord on time and proceeded normally from ord toward lga in VFR WX conditions. This incident began at a point approximately 50 mi west of lga in communication with new york TRACON and level at 10000 ft. The cockpit had been prepared for the approach, briefing completed and the approach descent checklist accomplished. I chose to fly the first leg of the trip and was in control of the aircraft. The incident began with ATC issuing a warning of VFR traffic to our left converging at 10500 ft. As this is a minimum amount of separation (almost within the 'near miss' category) we immediately began trying to find the traffic visually. The TCASII idented the traffic and indicated the intruding aircraft was in a descent (the first officer noted the descent, I was searching for the traffic visually). While we continued the effort to find the traffic visually, TCASII issued a yellow traffic alert. The alert showed the traffic very close at about 11 O'clock position on the 10 mi scale. Almost immediately TCASII issued a preventive RA of 'monitor vertical speed.' the pitch guidance bar indicated that we should be in level flight and I verbalized to the first officer that 'we would maintain level flight.' at this point, we still have not idented the traffic visually. (The sky was hazy and looking above us it was nearly white). I continued trying to find the traffic visually. At this point, first officer verbalized emphatically that we needed to climb. Since I had said only a few seconds earlier that we were going to remain in level flight, I felt that she had seen the traffic and perhaps a collision was imminent. As I looked back in the cockpit, I disconnected the autoplt and started a slow ascent while I checked the TCASII intruder bearing and altitude. (At this point the first officer advised ATC that we were following a TCASII alert and were climbing.) I did note that the TCASII pitch bar showed that we should climb. In the absence of a climb RA, I chose to ignore the visual command. I immediately realized that the traffic was still above us, stopped the climb and aggressively descended back to 10000 ft. (We reached about 10200 ft.) the first officer verbalized that the pitch bar was showing a climb and we needed to follow its guidance. (Remember, we did not have the intruding traffic visually at this time.) needless to say, ATC advised us not to climb, that the traffic was about to pass above us. A few seconds later, a white private aircraft passed directly above us at 10600 ft. The rest of the flight proceeded normally except during taxi in, ground provided us with a phone number to call TRACON. The incident was discussed with them to their satisfaction and a TCASII report was the only report filed by TRACON. We immediately discussed the incident with the fleet, the duty flight manager, and maintenance. The TCASII unit was disabled and deferred. Both pilots will file NASA reports. The first officer and I discussed the incident thoroughly on the next leg. All of the above happened in a matter of a few seconds, especially pertaining to the climb commands. I believe that the first officer based her climb verbalizations on the fact that the TCASII pitch bar showed a climb even though we were to remain in level flight. I do not recall hearing a climb RA and neither does the first officer. The fom does have a reference to remaining level during a preventive RA and this is what I based my actions on. However, in rereading the section, I find that it is rather vaguely written with no direct reference to ignoring the pitch bars. I have no explanation why the pitch bars would indicate level flight at the beginning of the incident and then in very close proximity to the traffic indicate a climb. I felt it best to write up the TCASII in that the climb indication in this situation did not seem normal to me. If the system is designed like this, it's a very poor design and in the heat of the battle could be confused with a climb command. It was also noted that prior to the intruder passing above us, all climb indications disappeared from the screen, and only the TA indication remained with the intruder'salt. I think it's certainly fair to say that in the confusion had we followed the pitch guidance, a near miss or worse could have occurred.
Original NASA ASRS Text
Title: AN ACR FLC FLYING A B757 NEAR LGA RPTS A TFC CONFLICT AND TCASII RA STATING THAT TCASII WAS NOT FUNCTIONING PROPERLY.
Narrative: DURING THIS INCIDENT THE COCKPIT INDICATIONS HAPPENED VERY RAPIDLY, BUT TO THE BEST OF MY KNOWLEDGE THIS RPT REPRESENTS AN ACCURATE RECONSTRUCTION OF THE EVENTS. DEPARTED ORD ON TIME AND PROCEEDED NORMALLY FROM ORD TOWARD LGA IN VFR WX CONDITIONS. THIS INCIDENT BEGAN AT A POINT APPROX 50 MI W OF LGA IN COM WITH NEW YORK TRACON AND LEVEL AT 10000 FT. THE COCKPIT HAD BEEN PREPARED FOR THE APCH, BRIEFING COMPLETED AND THE APCH DSCNT CHKLIST ACCOMPLISHED. I CHOSE TO FLY THE FIRST LEG OF THE TRIP AND WAS IN CTL OF THE ACFT. THE INCIDENT BEGAN WITH ATC ISSUING A WARNING OF VFR TFC TO OUR L CONVERGING AT 10500 FT. AS THIS IS A MINIMUM AMOUNT OF SEPARATION (ALMOST WITHIN THE 'NEAR MISS' CATEGORY) WE IMMEDIATELY BEGAN TRYING TO FIND THE TFC VISUALLY. THE TCASII IDENTED THE TFC AND INDICATED THE INTRUDING ACFT WAS IN A DSCNT (THE FO NOTED THE DSCNT, I WAS SEARCHING FOR THE TFC VISUALLY). WHILE WE CONTINUED THE EFFORT TO FIND THE TFC VISUALLY, TCASII ISSUED A YELLOW TFC ALERT. THE ALERT SHOWED THE TFC VERY CLOSE AT ABOUT 11 O'CLOCK POS ON THE 10 MI SCALE. ALMOST IMMEDIATELY TCASII ISSUED A PREVENTIVE RA OF 'MONITOR VERT SPD.' THE PITCH GUIDANCE BAR INDICATED THAT WE SHOULD BE IN LEVEL FLT AND I VERBALIZED TO THE FO THAT 'WE WOULD MAINTAIN LEVEL FLT.' AT THIS POINT, WE STILL HAVE NOT IDENTED THE TFC VISUALLY. (THE SKY WAS HAZY AND LOOKING ABOVE US IT WAS NEARLY WHITE). I CONTINUED TRYING TO FIND THE TFC VISUALLY. AT THIS POINT, FO VERBALIZED EMPHATICALLY THAT WE NEEDED TO CLB. SINCE I HAD SAID ONLY A FEW SECONDS EARLIER THAT WE WERE GOING TO REMAIN IN LEVEL FLT, I FELT THAT SHE HAD SEEN THE TFC AND PERHAPS A COLLISION WAS IMMINENT. AS I LOOKED BACK IN THE COCKPIT, I DISCONNECTED THE AUTOPLT AND STARTED A SLOW ASCENT WHILE I CHKED THE TCASII INTRUDER BEARING AND ALT. (AT THIS POINT THE FO ADVISED ATC THAT WE WERE FOLLOWING A TCASII ALERT AND WERE CLBING.) I DID NOTE THAT THE TCASII PITCH BAR SHOWED THAT WE SHOULD CLB. IN THE ABSENCE OF A CLB RA, I CHOSE TO IGNORE THE VISUAL COMMAND. I IMMEDIATELY REALIZED THAT THE TFC WAS STILL ABOVE US, STOPPED THE CLB AND AGGRESSIVELY DSNDED BACK TO 10000 FT. (WE REACHED ABOUT 10200 FT.) THE FO VERBALIZED THAT THE PITCH BAR WAS SHOWING A CLB AND WE NEEDED TO FOLLOW ITS GUIDANCE. (REMEMBER, WE DID NOT HAVE THE INTRUDING TFC VISUALLY AT THIS TIME.) NEEDLESS TO SAY, ATC ADVISED US NOT TO CLB, THAT THE TFC WAS ABOUT TO PASS ABOVE US. A FEW SECONDS LATER, A WHITE PVT ACFT PASSED DIRECTLY ABOVE US AT 10600 FT. THE REST OF THE FLT PROCEEDED NORMALLY EXCEPT DURING TAXI IN, GND PROVIDED US WITH A PHONE NUMBER TO CALL TRACON. THE INCIDENT WAS DISCUSSED WITH THEM TO THEIR SATISFACTION AND A TCASII RPT WAS THE ONLY RPT FILED BY TRACON. WE IMMEDIATELY DISCUSSED THE INCIDENT WITH THE FLEET, THE DUTY FLT MGR, AND MAINT. THE TCASII UNIT WAS DISABLED AND DEFERRED. BOTH PLTS WILL FILE NASA RPTS. THE FO AND I DISCUSSED THE INCIDENT THOROUGHLY ON THE NEXT LEG. ALL OF THE ABOVE HAPPENED IN A MATTER OF A FEW SECONDS, ESPECIALLY PERTAINING TO THE CLB COMMANDS. I BELIEVE THAT THE FO BASED HER CLB VERBALIZATIONS ON THE FACT THAT THE TCASII PITCH BAR SHOWED A CLB EVEN THOUGH WE WERE TO REMAIN IN LEVEL FLT. I DO NOT RECALL HEARING A CLB RA AND NEITHER DOES THE FO. THE FOM DOES HAVE A REF TO REMAINING LEVEL DURING A PREVENTIVE RA AND THIS IS WHAT I BASED MY ACTIONS ON. HOWEVER, IN REREADING THE SECTION, I FIND THAT IT IS RATHER VAGUELY WRITTEN WITH NO DIRECT REF TO IGNORING THE PITCH BARS. I HAVE NO EXPLANATION WHY THE PITCH BARS WOULD INDICATE LEVEL FLT AT THE BEGINNING OF THE INCIDENT AND THEN IN VERY CLOSE PROX TO THE TFC INDICATE A CLB. I FELT IT BEST TO WRITE UP THE TCASII IN THAT THE CLB INDICATION IN THIS SIT DID NOT SEEM NORMAL TO ME. IF THE SYS IS DESIGNED LIKE THIS, IT'S A VERY POOR DESIGN AND IN THE HEAT OF THE BATTLE COULD BE CONFUSED WITH A CLB COMMAND. IT WAS ALSO NOTED THAT PRIOR TO THE INTRUDER PASSING ABOVE US, ALL CLB INDICATIONS DISAPPEARED FROM THE SCREEN, AND ONLY THE TA INDICATION REMAINED WITH THE INTRUDER'SALT. I THINK IT'S CERTAINLY FAIR TO SAY THAT IN THE CONFUSION HAD WE FOLLOWED THE PITCH GUIDANCE, A NEAR MISS OR WORSE COULD HAVE OCCURRED.
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.