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B747-400 crew descended below the published altitude while flying a VNAV automatic coupled approach at dtw runway 22R.
| Attributes | |
| ACN | 567606 |
| Time | |
| Date | 200212 |
| Day | Fri |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | intersection : joydd |
| State Reference | MI |
| Altitude | msl bound lower : 4000 msl bound upper : 4200 |
| Environment | |
| Flight Conditions | Mixed |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : d21.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | B747-400 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | ils localizer & glide slope : 22r other |
| Flight Phase | descent : approach |
| Route In Use | approach : instrument precision approach other |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp pilot : flight engineer pilot : multi engine |
| Experience | flight time last 90 days : 150 flight time total : 12000 flight time type : 1200 |
| ASRS Report | 567606 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Events | |
| Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude altitude deviation : overshoot non adherence : clearance non adherence : published procedure non adherence : far non adherence : company policies |
| Independent Detector | other flight crewa other flight crewb |
| Resolutory Action | none taken : anomaly accepted |
| Supplementary | |
| Problem Areas | Aircraft Company Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
We were approaching dtw for an approach to runway 22R and decided to practice a VNAV approach. We selected the VNAV approach to runway 22R. Nujnt was the key waypoint. ATC vectored us to intercept the localizer between fepbu and joydd at 4000 ft. We were cleared for the approach just outside joydd. Per sopa, we have a checklist to accomplish when 'cleared for the approach.' this checklist was devised because crew members were lacking in the basic understanding of how to accomplish a VNAV approach and the checklist was a series of actions that would ensure that the aircraft would descend on the glide path and not cruise by the airport in VNAV altitude. We accomplished the checklist and the aircraft descended below 4000 ft at joydd. This is ok with ATC approval, but we did not have that. I believe we were within 200 ft of 4000 ft at crossing, but I am not sure. We were so busy trying to make sure the checklist was accomplished that our attention was diverted. This is not the first incident where this has occurred. The same thing happened at jfk on the VOR approach to runway 13L/right. I had to disconnect the autoplt and hand fly to stop descent below 1500 ft. Causes: the main reason for these sits is inadequate training. I practiced 'dive and drive approachs' for yrs prior to my employment as a professional through hundreds of approachs. I have refined my skills. The VNAV approach is a 'new breed of CAT.' most of the training has been by bulletin with very little simulator time. There has never been a ground school with an instructor who explained the nuances of the VNAV approach. In 90% of the simulator VNAV approachs, the approach has failed. I had a recency of experience 1 yr ago in which we never had a successful VNAV approach. Solutions. I know it costs money, but we need more thorough training so that we are not caught up in accomplishing checklists designed to make up for our lack of knowledge.
Original NASA ASRS Text
Title: B747-400 CREW DSNDED BELOW THE PUBLISHED ALT WHILE FLYING A VNAV AUTO COUPLED APCH AT DTW RWY 22R.
Narrative: WE WERE APCHING DTW FOR AN APCH TO RWY 22R AND DECIDED TO PRACTICE A VNAV APCH. WE SELECTED THE VNAV APCH TO RWY 22R. NUJNT WAS THE KEY WAYPOINT. ATC VECTORED US TO INTERCEPT THE LOC BTWN FEPBU AND JOYDD AT 4000 FT. WE WERE CLRED FOR THE APCH JUST OUTSIDE JOYDD. PER SOPA, WE HAVE A CHKLIST TO ACCOMPLISH WHEN 'CLRED FOR THE APCH.' THIS CHKLIST WAS DEVISED BECAUSE CREW MEMBERS WERE LACKING IN THE BASIC UNDERSTANDING OF HOW TO ACCOMPLISH A VNAV APCH AND THE CHKLIST WAS A SERIES OF ACTIONS THAT WOULD ENSURE THAT THE ACFT WOULD DSND ON THE GLIDE PATH AND NOT CRUISE BY THE ARPT IN VNAV ALT. WE ACCOMPLISHED THE CHKLIST AND THE ACFT DSNDED BELOW 4000 FT AT JOYDD. THIS IS OK WITH ATC APPROVAL, BUT WE DID NOT HAVE THAT. I BELIEVE WE WERE WITHIN 200 FT OF 4000 FT AT XING, BUT I AM NOT SURE. WE WERE SO BUSY TRYING TO MAKE SURE THE CHKLIST WAS ACCOMPLISHED THAT OUR ATTN WAS DIVERTED. THIS IS NOT THE FIRST INCIDENT WHERE THIS HAS OCCURRED. THE SAME THING HAPPENED AT JFK ON THE VOR APCH TO RWY 13L/R. I HAD TO DISCONNECT THE AUTOPLT AND HAND FLY TO STOP DSCNT BELOW 1500 FT. CAUSES: THE MAIN REASON FOR THESE SITS IS INADEQUATE TRAINING. I PRACTICED 'DIVE AND DRIVE APCHS' FOR YRS PRIOR TO MY EMPLOYMENT AS A PROFESSIONAL THROUGH HUNDREDS OF APCHS. I HAVE REFINED MY SKILLS. THE VNAV APCH IS A 'NEW BREED OF CAT.' MOST OF THE TRAINING HAS BEEN BY BULLETIN WITH VERY LITTLE SIMULATOR TIME. THERE HAS NEVER BEEN A GND SCHOOL WITH AN INSTRUCTOR WHO EXPLAINED THE NUANCES OF THE VNAV APCH. IN 90% OF THE SIMULATOR VNAV APCHS, THE APCH HAS FAILED. I HAD A RECENCY OF EXPERIENCE 1 YR AGO IN WHICH WE NEVER HAD A SUCCESSFUL VNAV APCH. SOLUTIONS. I KNOW IT COSTS MONEY, BUT WE NEED MORE THOROUGH TRAINING SO THAT WE ARE NOT CAUGHT UP IN ACCOMPLISHING CHKLISTS DESIGNED TO MAKE UP FOR OUR LACK OF KNOWLEDGE.
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.