37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 565175 |
Time | |
Date | 200211 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : cak.airport |
State Reference | OH |
Altitude | msl bound lower : 2300 msl bound upper : 3200 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : cak.tracon |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65, Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 23 other |
Flight Phase | descent : approach |
Route In Use | approach : visual approach : instrument precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 3700 flight time type : 150 |
ASRS Report | 565175 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot non adherence : far non adherence : published procedure |
Independent Detector | aircraft equipment other aircraft equipment : glideslope indicator other flight crewa other flight crewb |
Resolutory Action | none taken : anomaly accepted |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This was a continuous duty overnight assignment, the third in a row. The previous night, I had no sleep due to noise in the hotel. I was unable to get any sleep the following day either. I estimate I had been without sleep for about 42 hours. Due to the short flight (dtw-cak) my first officer suggested, and I agreed, to brief the ILS runway 23 approach to cak before departing dtw. The approach calls for intercepting the GS at or above 3200 ft MSL. Once acquiring the airport visually, we were cleared for a visual approach to runway 23. I maneuvered the aircraft to intercept the localizer outside the FAF and set the GS intercept altitude to 2300 ft instead of 3200 ft as I should have. I then descended to 2300 ft since the GS indication seemed to agree we were slightly 'high.' once established on the localizer at 2300 ft, the GS indication was correctly indicating 'low.' at this point. I noticed the VASI lights also indicating below GS and the first officer noticed our altitude and said we should be at 3200 ft, not 2300 ft. We continued until GS intercept and completed the approach. I believe I transposed the altitude digits due to fatigue. Also, I will no longer brief an approach before takeoff. I will brief it shortly before the approach so that it is more easily recalled during the approach, even if cleared for a visual approach.
Original NASA ASRS Text
Title: CL65 FLC INTERCEPTS ILS GS 900 FT BELOW PUBLISHED HT.
Narrative: THIS WAS A CONTINUOUS DUTY OVERNIGHT ASSIGNMENT, THE THIRD IN A ROW. THE PREVIOUS NIGHT, I HAD NO SLEEP DUE TO NOISE IN THE HOTEL. I WAS UNABLE TO GET ANY SLEEP THE FOLLOWING DAY EITHER. I ESTIMATE I HAD BEEN WITHOUT SLEEP FOR ABOUT 42 HRS. DUE TO THE SHORT FLT (DTW-CAK) MY FO SUGGESTED, AND I AGREED, TO BRIEF THE ILS RWY 23 APCH TO CAK BEFORE DEPARTING DTW. THE APCH CALLS FOR INTERCEPTING THE GS AT OR ABOVE 3200 FT MSL. ONCE ACQUIRING THE ARPT VISUALLY, WE WERE CLRED FOR A VISUAL APCH TO RWY 23. I MANEUVERED THE ACFT TO INTERCEPT THE LOC OUTSIDE THE FAF AND SET THE GS INTERCEPT ALT TO 2300 FT INSTEAD OF 3200 FT AS I SHOULD HAVE. I THEN DSNDED TO 2300 FT SINCE THE GS INDICATION SEEMED TO AGREE WE WERE SLIGHTLY 'HIGH.' ONCE ESTABLISHED ON THE LOC AT 2300 FT, THE GS INDICATION WAS CORRECTLY INDICATING 'LOW.' AT THIS POINT. I NOTICED THE VASI LIGHTS ALSO INDICATING BELOW GS AND THE FO NOTICED OUR ALT AND SAID WE SHOULD BE AT 3200 FT, NOT 2300 FT. WE CONTINUED UNTIL GS INTERCEPT AND COMPLETED THE APCH. I BELIEVE I TRANSPOSED THE ALT DIGITS DUE TO FATIGUE. ALSO, I WILL NO LONGER BRIEF AN APCH BEFORE TKOF. I WILL BRIEF IT SHORTLY BEFORE THE APCH SO THAT IT IS MORE EASILY RECALLED DURING THE APCH, EVEN IF CLRED FOR A VISUAL APCH.
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.