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|
Attributes | |
ACN | 504504 |
Time | |
Date | 200103 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : bji.airport |
State Reference | MN |
Altitude | msl single value : 3100 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Fog |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zmp.artcc |
Operator | common carrier : air carrier |
Make Model Name | SF 340A |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | descent : holding descent : intermediate altitude |
Route In Use | arrival : holding pattern |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : cfi pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 4015 flight time type : 200 |
ASRS Report | 504504 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : cfi pilot : multi engine |
Experience | flight time last 90 days : 230 flight time total : 4220 flight time type : 230 |
ASRS Report | 504790 |
Events | |
Anomaly | inflight encounter : weather non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Weather Flight Crew Human Performance Environmental Factor Company |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During the descent check into bji, the approach for the ILS runway 31 was briefed, including intercepting the 17 DME arc from the south with an initial right turn to join the arc then arcing to the left to join the ILS runway 31 to bji. However, due to WX, we held over the bji VOR at our specified altitude. The first turn in holding the WX improved and we were cleared to another altitude and cleared for the ILS runway 31 approach. The workload was extremely high, talking to center, informing dispatch we were cleared out of the hold and ensuring the cabin was still secure. The minimums for the approach were rebriefed, navaids idented, however, we were now going to intercept the arc from the north, not from the south. I failed to brief this intercept and my initial turn was to the right when it should have been left. ZMP realized my mistake and we received radar vectors for the approach from which a landing was made. Factors that contributed to the situation include high workload, not rebriefing the approach including the entry onto the arc from the north. Pilot fatigue, early morning report and I did not sleep very well the night prior, I also had not eaten since the previous evening. Looking back, another turn in the hold would have given us time to reduce the workload for the approach -- a full approach briefing including the initial turn to intercept the arc from the north or discuss other options such as radar vectors for the approach. Supplemental information from acn 504790: in retrospect, this could have been avoided if either flight crew member would have suggested another turn in holding to give ourselves time to prepare effectively and reduce our workload. I should have waited until the captain had us established on the arc to perform my other duties. We could have discussed other options such as radar vectors for the approach instead of the arc. I have learned several things from this experience. First about how important it is to brief and rebrief completely so that there is not a breakdown in CRM and, second, that it is better to take your time (another turn in holding) rather than rush and have your workload so high that mistakes are made.
Original NASA ASRS Text
Title: AN SF340 PIC TURNS THE WRONG WAY FOR AN ARC INTERCEPTION FOR THE ILS TO RWY 31 AT BJI, MN.
Narrative: DURING THE DSCNT CHK INTO BJI, THE APCH FOR THE ILS RWY 31 WAS BRIEFED, INCLUDING INTERCEPTING THE 17 DME ARC FROM THE S WITH AN INITIAL R TURN TO JOIN THE ARC THEN ARCING TO THE L TO JOIN THE ILS RWY 31 TO BJI. HOWEVER, DUE TO WX, WE HELD OVER THE BJI VOR AT OUR SPECIFIED ALT. THE FIRST TURN IN HOLDING THE WX IMPROVED AND WE WERE CLRED TO ANOTHER ALT AND CLRED FOR THE ILS RWY 31 APCH. THE WORKLOAD WAS EXTREMELY HIGH, TALKING TO CTR, INFORMING DISPATCH WE WERE CLRED OUT OF THE HOLD AND ENSURING THE CABIN WAS STILL SECURE. THE MINIMUMS FOR THE APCH WERE REBRIEFED, NAVAIDS IDENTED, HOWEVER, WE WERE NOW GOING TO INTERCEPT THE ARC FROM THE N, NOT FROM THE S. I FAILED TO BRIEF THIS INTERCEPT AND MY INITIAL TURN WAS TO THE R WHEN IT SHOULD HAVE BEEN L. ZMP REALIZED MY MISTAKE AND WE RECEIVED RADAR VECTORS FOR THE APCH FROM WHICH A LNDG WAS MADE. FACTORS THAT CONTRIBUTED TO THE SIT INCLUDE HIGH WORKLOAD, NOT REBRIEFING THE APCH INCLUDING THE ENTRY ONTO THE ARC FROM THE N. PLT FATIGUE, EARLY MORNING RPT AND I DID NOT SLEEP VERY WELL THE NIGHT PRIOR, I ALSO HAD NOT EATEN SINCE THE PREVIOUS EVENING. LOOKING BACK, ANOTHER TURN IN THE HOLD WOULD HAVE GIVEN US TIME TO REDUCE THE WORKLOAD FOR THE APCH -- A FULL APCH BRIEFING INCLUDING THE INITIAL TURN TO INTERCEPT THE ARC FROM THE N OR DISCUSS OTHER OPTIONS SUCH AS RADAR VECTORS FOR THE APCH. SUPPLEMENTAL INFO FROM ACN 504790: IN RETROSPECT, THIS COULD HAVE BEEN AVOIDED IF EITHER FLC MEMBER WOULD HAVE SUGGESTED ANOTHER TURN IN HOLDING TO GIVE OURSELVES TIME TO PREPARE EFFECTIVELY AND REDUCE OUR WORKLOAD. I SHOULD HAVE WAITED UNTIL THE CAPT HAD US ESTABLISHED ON THE ARC TO PERFORM MY OTHER DUTIES. WE COULD HAVE DISCUSSED OTHER OPTIONS SUCH AS RADAR VECTORS FOR THE APCH INSTEAD OF THE ARC. I HAVE LEARNED SEVERAL THINGS FROM THIS EXPERIENCE. FIRST ABOUT HOW IMPORTANT IT IS TO BRIEF AND REBRIEF COMPLETELY SO THAT THERE IS NOT A BREAKDOWN IN CRM AND, SECOND, THAT IT IS BETTER TO TAKE YOUR TIME (ANOTHER TURN IN HOLDING) RATHER THAN RUSH AND HAVE YOUR WORKLOAD SO HIGH THAT MISTAKES ARE MADE.
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.