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Attributes | |
ACN | 519513 |
Time | |
Date | 200107 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : dca.airport |
State Reference | DC |
Altitude | msl bound lower : 2500 msl bound upper : 3300 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Windshear Rain |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : dca.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach landing : go around climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : instrument pilot : multi engine pilot : flight engineer pilot : commercial pilot : private |
Experience | flight time last 90 days : 170 flight time total : 10000 flight time type : 1800 |
ASRS Report | 519513 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : overshoot inflight encounter : weather non adherence : clearance |
Independent Detector | other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance flight crew : executed go around |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On the ILS runway 1, dca, heavy rain shower across and west of the final approach course, we had discussed going east of the final in the event of a missed approach with the final approach controller, but by this time we were with the tower. The aircraft 3-4 mi in front of us had just reported 2 speed increases, the first 10 KTS and the second 20 KTS, followed a couple of seconds later by tower reporting a windshear alert. We decided to go around from 1600 ft MSL. The tower acknowledged our desire, told us to maintain 2500 ft MSL and turn to a heading of 340 degrees. Once in the approach mode tracking localizer and GS on an ILS, the B737-800 can only be taken out of the approach mode by either hitting the takeoff/go around switches, tuning away from the ILS frequency, or disconnecting the autoplt, turning off the flight directors, and re-engaging another pitch and roll mode. Since we were not close to the ground, the PF wanted to be smooth as we went around (the gear was down and flaps 15 degrees selected), but hesitated as he considered his options, then asked me if I thought he should hit the takeoff/go around switches. Rather than discuss the other options (we were still headed down into the windshear reports), I agreed takeoff/go around would be a good plan. I put 2500 ft in the altitude arming window as he went to takeoff/go around, since we were in single channel approach mode. The autoplt immediately disconnected and the aircraft began to pitch up as the power increased to go around thrust. I called positive rate, he replied 'takeoff/go around power, flaps 15 degrees....' I said the flaps were 15 degrees, positive rate, gear up, he agreed gear up and I raised the gear. I then hit heading select to get the aircraft heading 340 degrees and started looking at my radar presentation. The tower's order for a left turn after discussing a right turn with approach, had me mildly concerned that we might be turning in a direction we really didn't want to go. I checked my navigation display for the WX depiction, I changed range scales to see a bigger picture, I looked at the PF's primary flight display and saw the altitude tape going through 2200 ft MSL. I said, 'here's your 2500 ft,' the aircraft continued to climb. We went through 2500 ft MSL and I looked at the aircraft pitch, we were at 32 degrees nose up. I pushed forward on the yoke and said we were assigned 2500 ft, look at the nose attitude. The PF finally realized the autoplt was not engaged and stopped the rate of climb at 3300 ft MSL. I asked the tower for a higher altitude (than 2500 ft). He finally said to maintain 3000 ft and that he had assigned 2500 ft. We switched to approach and made an uneventful approach to landing. The obvious mistake here was the PF failing to control the aircraft manually when the autoplt disconnected (as it was supposed to). The more subtle problem, though, is our tendency to react in our most familiar habit pattern in an abnormal situation. In this case the PF reverted back to his MD88 habits -- press the takeoff/GA switch and watch the airplane go around automatically (which he then didn't really do, because he was looking at the WX radar).
Original NASA ASRS Text
Title: A B737-800 CREW ON A GAR AT DCA OVERSHOT ALT ASSIGNED BY TWR.
Narrative: ON THE ILS RWY 1, DCA, HVY RAIN SHOWER ACROSS AND W OF THE FINAL APCH COURSE, WE HAD DISCUSSED GOING E OF THE FINAL IN THE EVENT OF A MISSED APCH WITH THE FINAL APCH CTLR, BUT BY THIS TIME WE WERE WITH THE TWR. THE ACFT 3-4 MI IN FRONT OF US HAD JUST RPTED 2 SPD INCREASES, THE FIRST 10 KTS AND THE SECOND 20 KTS, FOLLOWED A COUPLE OF SECONDS LATER BY TWR RPTING A WINDSHEAR ALERT. WE DECIDED TO GO AROUND FROM 1600 FT MSL. THE TWR ACKNOWLEDGED OUR DESIRE, TOLD US TO MAINTAIN 2500 FT MSL AND TURN TO A HDG OF 340 DEGS. ONCE IN THE APCH MODE TRACKING LOC AND GS ON AN ILS, THE B737-800 CAN ONLY BE TAKEN OUT OF THE APCH MODE BY EITHER HITTING THE TKOF/GAR SWITCHES, TUNING AWAY FROM THE ILS FREQ, OR DISCONNECTING THE AUTOPLT, TURNING OFF THE FLT DIRECTORS, AND RE-ENGAGING ANOTHER PITCH AND ROLL MODE. SINCE WE WERE NOT CLOSE TO THE GND, THE PF WANTED TO BE SMOOTH AS WE WENT AROUND (THE GEAR WAS DOWN AND FLAPS 15 DEGS SELECTED), BUT HESITATED AS HE CONSIDERED HIS OPTIONS, THEN ASKED ME IF I THOUGHT HE SHOULD HIT THE TKOF/GAR SWITCHES. RATHER THAN DISCUSS THE OTHER OPTIONS (WE WERE STILL HEADED DOWN INTO THE WINDSHEAR RPTS), I AGREED TKOF/GAR WOULD BE A GOOD PLAN. I PUT 2500 FT IN THE ALT ARMING WINDOW AS HE WENT TO TKOF/GAR, SINCE WE WERE IN SINGLE CHANNEL APCH MODE. THE AUTOPLT IMMEDIATELY DISCONNECTED AND THE ACFT BEGAN TO PITCH UP AS THE PWR INCREASED TO GAR THRUST. I CALLED POSITIVE RATE, HE REPLIED 'TKOF/GAR PWR, FLAPS 15 DEGS....' I SAID THE FLAPS WERE 15 DEGS, POSITIVE RATE, GEAR UP, HE AGREED GEAR UP AND I RAISED THE GEAR. I THEN HIT HDG SELECT TO GET THE ACFT HDG 340 DEGS AND STARTED LOOKING AT MY RADAR PRESENTATION. THE TWR'S ORDER FOR A L TURN AFTER DISCUSSING A R TURN WITH APCH, HAD ME MILDLY CONCERNED THAT WE MIGHT BE TURNING IN A DIRECTION WE REALLY DIDN'T WANT TO GO. I CHKED MY NAV DISPLAY FOR THE WX DEPICTION, I CHANGED RANGE SCALES TO SEE A BIGGER PICTURE, I LOOKED AT THE PF'S PRIMARY FLT DISPLAY AND SAW THE ALT TAPE GOING THROUGH 2200 FT MSL. I SAID, 'HERE'S YOUR 2500 FT,' THE ACFT CONTINUED TO CLB. WE WENT THROUGH 2500 FT MSL AND I LOOKED AT THE ACFT PITCH, WE WERE AT 32 DEGS NOSE UP. I PUSHED FORWARD ON THE YOKE AND SAID WE WERE ASSIGNED 2500 FT, LOOK AT THE NOSE ATTITUDE. THE PF FINALLY REALIZED THE AUTOPLT WAS NOT ENGAGED AND STOPPED THE RATE OF CLB AT 3300 FT MSL. I ASKED THE TWR FOR A HIGHER ALT (THAN 2500 FT). HE FINALLY SAID TO MAINTAIN 3000 FT AND THAT HE HAD ASSIGNED 2500 FT. WE SWITCHED TO APCH AND MADE AN UNEVENTFUL APCH TO LNDG. THE OBVIOUS MISTAKE HERE WAS THE PF FAILING TO CTL THE ACFT MANUALLY WHEN THE AUTOPLT DISCONNECTED (AS IT WAS SUPPOSED TO). THE MORE SUBTLE PROB, THOUGH, IS OUR TENDENCY TO REACT IN OUR MOST FAMILIAR HABIT PATTERN IN AN ABNORMAL SIT. IN THIS CASE THE PF REVERTED BACK TO HIS MD88 HABITS -- PRESS THE TKOF/GA SWITCH AND WATCH THE AIRPLANE GO AROUND AUTOMATICALLY (WHICH HE THEN DIDN'T REALLY DO, BECAUSE HE WAS LOOKING AT THE WX RADAR).
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.