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|
Attributes | |
ACN | 540537 |
Time | |
Date | 200203 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : phl.airport |
State Reference | PA |
Altitude | msl single value : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : phl.tracon tower : phl.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 9r other |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision arrival : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : phl.tracon |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | other : ns |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision |
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 : 18000 flight time type : 3000 |
ASRS Report | 540537 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera other controllerb other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance controller : separated traffic |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance |
Primary Problem | Ambiguous |
Narrative:
On vector for ILS runway 9R phl. On a heading of 060 degrees we were expecting either a turn to a base or a dogleg to final. While trying to insert a change into FMC, approach controller gave us a frequency change to the final controller with a heading change. First officer was flying, did not hear heading change. I heard it but by the time I changed frequency I realized we had not begun to turn and was now unsure of what the new heading was supposed to be. I advised controller on check-in that we had not turned yet, still on a heading of 060 degrees. He gave us an immediate left turn to 270 degrees. We initiated turn, I observed TCASII target 400 ft off our altitude pass approximately 2.5 to 3.0 mi off our starboard. No TCASII alert or resolution. I assumed first officer heard heading change and while preoccupied with FMC and radio frequency change, I did not notice our failure to turn until checking in with final controller. Conclusions: 1) leave FMC alone during high workload! 2) was not expecting turn to downwind so turn subconsciously didn't make sense. When ATC plans course reversal for a downwind a heads up should be given. 3) number overload, 4 digit flight number, 3 digit heading change, 5 digit frequency change, all in same transmission.
Original NASA ASRS Text
Title: B737 PF ON VECTOR TO FINAL FAILS TO HEAR TURN TO INSTRUCTIONS AND OVERSHOOTS THE FINAL APCH COURSE.
Narrative: ON VECTOR FOR ILS RWY 9R PHL. ON A HEADING OF 060 DEGS WE WERE EXPECTING EITHER A TURN TO A BASE OR A DOGLEG TO FINAL. WHILE TRYING TO INSERT A CHANGE INTO FMC, APCH CTLR GAVE US A FREQ CHANGE TO THE FINAL CTLR WITH A HEADING CHANGE. FO WAS FLYING, DID NOT HEAR HEADING CHANGE. I HEARD IT BUT BY THE TIME I CHANGED FREQ I REALIZED WE HAD NOT BEGUN TO TURN AND WAS NOW UNSURE OF WHAT THE NEW HEADING WAS SUPPOSED TO BE. I ADVISED CTLR ON CHK-IN THAT WE HAD NOT TURNED YET, STILL ON A HEADING OF 060 DEGS. HE GAVE US AN IMMEDIATE L TURN TO 270 DEGS. WE INITIATED TURN, I OBSERVED TCASII TARGET 400 FT OFF OUR ALT PASS APPROX 2.5 TO 3.0 MI OFF OUR STARBOARD. NO TCASII ALERT OR RESOLUTION. I ASSUMED FO HEARD HEADING CHANGE AND WHILE PREOCCUPIED WITH FMC AND RADIO FREQ CHANGE, I DID NOT NOTICE OUR FAILURE TO TURN UNTIL CHKING IN WITH FINAL CTLR. CONCLUSIONS: 1) LEAVE FMC ALONE DURING HIGH WORKLOAD! 2) WAS NOT EXPECTING TURN TO DOWNWIND SO TURN SUBCONSCIOUSLY DIDN'T MAKE SENSE. WHEN ATC PLANS COURSE REVERSAL FOR A DOWNWIND A HEADS UP SHOULD BE GIVEN. 3) NUMBER OVERLOAD, 4 DIGIT FLT NUMBER, 3 DIGIT HEADING CHANGE, 5 DIGIT FREQ CHANGE, ALL IN SAME XMISSION.
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.