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|
Attributes | |
ACN | 511332 |
Time | |
Date | 200105 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : swf.airport |
State Reference | NY |
Altitude | msl single value : 1900 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Fog other |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon tracon : m98.tracon |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer only : 9 |
Route In Use | approach : visual |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : private pilot : atp pilot : commercial pilot : instrument pilot : multi engine |
Experience | flight time last 90 days : 110 flight time total : 4000 flight time type : 1500 |
ASRS Report | 511332 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 90 flight time total : 4000 flight time type : 220 |
ASRS Report | 511083 |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : crossing restriction not met inflight encounter : weather inflight encounter other non adherence : published procedure non adherence : clearance other anomaly |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance flight crew : returned to assigned altitude flight crew : took evasive action flight crew : became reoriented |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Weather Environmental Factor |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Early morning approach to swf (approximately XA15 EDT). Cleared to cross lhy at 7000 ft, then cleared to 3000 ft MSL. Bright sun near horizon and early fog/haze and ground mist made visibility to the east nearly impossible. WX was clear otherwise. Briefed ILS (GS out) approach to runway 9 as a backup to a visual. Level at 3000 ft, I (PF) started to look for the city/airfield (about 40% outside, 60% inside). I mistook 8 DME to hgo for 8 DME pat hgo and started to worry about being too high to make a safe descent. I asked for lower and new york approach cleared us to 1900 ft MSL (approach altitude is 2100 ft MSL). New york then cleared us for the ILS runway 9 expect a visual. We knew the ILS GS was OTS and queried approach. He said we could expect a visual. I thought we were very close to the FAF then, and did not yet see a runway. I asked the PNF if we'd past the FAF and could we descend to 982 ft MSL. He thought I said 'we're past the FAF.' since a descent to 980 ft MSL but about 1300 ft MSL, new york approach asked us why we'd left 1900 ft. We told him where we thought we were and he corrected us and directed we return to 1900 ft MSL. We were still about 10 mi short of the FAF. We landed a few mins later at swf. I failed to brief thoroughly the anticipated effect of the sun and haze. I forgot to fly the instruments and let the others look, or to brief a monitored approach. Communications broke down at a critical time. I failed to maintain situational awareness. Supplemental information from acn 511083: as I was concentrating on visual references outside, the captain apparently asked if we had passed the LOM (neely). I thought he was instead declaring passage of the LOM and was starting his descent. I confirmed he was cleared to the MDA of 980 ft MSL. However, I did not verify that he had in fact passed the marker as I was intensifying my effort to pick up the airport/runway. New york approach then stated we were still short of the LOM and should be at 1900 ft MSL. We immediately climbed to 1900 ft MSL, and simultaneous with LOM passage picked up the airport/runway. I called 'runway in sight' and new york approach then cleared us for the visual and to contact the tower. Landing uneventful. The altitude incursion was primarily caused by a glaring sun making instrument panel interpretation difficult and acquisition of ground references in otherwise VMC (with some low ground fog present), a significant challenge. A breakdown in crew coordination on IAF and LOM passage contributed to the situation. Supplemental information from acn 510907: I was on my first night on duty and felt very fatigued. This was caused by the requirement of getting adjusted to the night cycle after having had several days off. I was performing my final checks for preparation for landing when the captain asked me to help look for the field. When I looked to the left of the aircraft, I saw orange county airport. I looked at the captain's altimeter and realized we were below what I thought was the assigned altitude. I told the captain to climb. As the captain initiated the climb, ATC also told us to climb. The bright glare created by the sunrise in combination with the thick patchy ground fog was also another factor. Fatigue is a continuing problem. To make sure this does not occur again, I will use oxygen before entering the terminal area to increase my situational awareness. When asked to look outside, I will make sure one of the pilots is monitoring the flight instruments.
Original NASA ASRS Text
Title: B727 CARGO FLC BECOME DISORIENTED DUE TO WX, EARLY MORNING SUN, AND APCH POS AND BEGIN EARLY DSCNT INTO SWF, BEING QUESTIONED BY N90.
Narrative: EARLY MORNING APCH TO SWF (APPROX XA15 EDT). CLRED TO CROSS LHY AT 7000 FT, THEN CLRED TO 3000 FT MSL. BRIGHT SUN NEAR HORIZON AND EARLY FOG/HAZE AND GND MIST MADE VISIBILITY TO THE E NEARLY IMPOSSIBLE. WX WAS CLR OTHERWISE. BRIEFED ILS (GS OUT) APCH TO RWY 9 AS A BACKUP TO A VISUAL. LEVEL AT 3000 FT, I (PF) STARTED TO LOOK FOR THE CITY/AIRFIELD (ABOUT 40% OUTSIDE, 60% INSIDE). I MISTOOK 8 DME TO HGO FOR 8 DME PAT HGO AND STARTED TO WORRY ABOUT BEING TOO HIGH TO MAKE A SAFE DSCNT. I ASKED FOR LOWER AND NEW YORK APCH CLRED US TO 1900 FT MSL (APCH ALT IS 2100 FT MSL). NEW YORK THEN CLRED US FOR THE ILS RWY 9 EXPECT A VISUAL. WE KNEW THE ILS GS WAS OTS AND QUERIED APCH. HE SAID WE COULD EXPECT A VISUAL. I THOUGHT WE WERE VERY CLOSE TO THE FAF THEN, AND DID NOT YET SEE A RWY. I ASKED THE PNF IF WE'D PAST THE FAF AND COULD WE DSND TO 982 FT MSL. HE THOUGHT I SAID 'WE'RE PAST THE FAF.' SINCE A DSCNT TO 980 FT MSL BUT ABOUT 1300 FT MSL, NEW YORK APCH ASKED US WHY WE'D LEFT 1900 FT. WE TOLD HIM WHERE WE THOUGHT WE WERE AND HE CORRECTED US AND DIRECTED WE RETURN TO 1900 FT MSL. WE WERE STILL ABOUT 10 MI SHORT OF THE FAF. WE LANDED A FEW MINS LATER AT SWF. I FAILED TO BRIEF THOROUGHLY THE ANTICIPATED EFFECT OF THE SUN AND HAZE. I FORGOT TO FLY THE INSTS AND LET THE OTHERS LOOK, OR TO BRIEF A MONITORED APCH. COMS BROKE DOWN AT A CRITICAL TIME. I FAILED TO MAINTAIN SITUATIONAL AWARENESS. SUPPLEMENTAL INFO FROM ACN 511083: AS I WAS CONCENTRATING ON VISUAL REFS OUTSIDE, THE CAPT APPARENTLY ASKED IF WE HAD PASSED THE LOM (NEELY). I THOUGHT HE WAS INSTEAD DECLARING PASSAGE OF THE LOM AND WAS STARTING HIS DSCNT. I CONFIRMED HE WAS CLRED TO THE MDA OF 980 FT MSL. HOWEVER, I DID NOT VERIFY THAT HE HAD IN FACT PASSED THE MARKER AS I WAS INTENSIFYING MY EFFORT TO PICK UP THE ARPT/RWY. NEW YORK APCH THEN STATED WE WERE STILL SHORT OF THE LOM AND SHOULD BE AT 1900 FT MSL. WE IMMEDIATELY CLBED TO 1900 FT MSL, AND SIMULTANEOUS WITH LOM PASSAGE PICKED UP THE ARPT/RWY. I CALLED 'RWY IN SIGHT' AND NEW YORK APCH THEN CLRED US FOR THE VISUAL AND TO CONTACT THE TWR. LNDG UNEVENTFUL. THE ALT INCURSION WAS PRIMARILY CAUSED BY A GLARING SUN MAKING INST PANEL INTERP DIFFICULT AND ACQUISITION OF GND REFS IN OTHERWISE VMC (WITH SOME LOW GND FOG PRESENT), A SIGNIFICANT CHALLENGE. A BREAKDOWN IN CREW COORD ON IAF AND LOM PASSAGE CONTRIBUTED TO THE SIT. SUPPLEMENTAL INFO FROM ACN 510907: I WAS ON MY FIRST NIGHT ON DUTY AND FELT VERY FATIGUED. THIS WAS CAUSED BY THE REQUIREMENT OF GETTING ADJUSTED TO THE NIGHT CYCLE AFTER HAVING HAD SEVERAL DAYS OFF. I WAS PERFORMING MY FINAL CHKS FOR PREPARATION FOR LNDG WHEN THE CAPT ASKED ME TO HELP LOOK FOR THE FIELD. WHEN I LOOKED TO THE L OF THE ACFT, I SAW ORANGE COUNTY ARPT. I LOOKED AT THE CAPT'S ALTIMETER AND REALIZED WE WERE BELOW WHAT I THOUGHT WAS THE ASSIGNED ALT. I TOLD THE CAPT TO CLB. AS THE CAPT INITIATED THE CLB, ATC ALSO TOLD US TO CLB. THE BRIGHT GLARE CREATED BY THE SUNRISE IN COMBINATION WITH THE THICK PATCHY GND FOG WAS ALSO ANOTHER FACTOR. FATIGUE IS A CONTINUING PROB. TO MAKE SURE THIS DOES NOT OCCUR AGAIN, I WILL USE OXYGEN BEFORE ENTERING THE TERMINAL AREA TO INCREASE MY SITUATIONAL AWARENESS. WHEN ASKED TO LOOK OUTSIDE, I WILL MAKE SURE ONE OF THE PLTS IS MONITORING THE FLT INSTS.
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.