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|
Attributes | |
ACN | 571473 |
Time | |
Date | 200301 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | agl single value : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc tower : zzz.tower tower : lfpg.tower |
Operator | general aviation : corporate |
Make Model Name | Challenger Jet Undifferentiated or Other Model |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | descent : approach landing : roll |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 55 flight time total : 7000 flight time type : 170 |
ASRS Report | 571473 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : atp |
Experience | flight time last 90 days : 17 flight time total : 10545 flight time type : 345 |
ASRS Report | 571622 |
Events | |
Anomaly | excursion : runway non adherence : published procedure non adherence : far other anomaly other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | aircraft : automation overrode flight crew aircraft : evacuated flight crew : overrode automation |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance Airport |
Primary Problem | Flight Crew Human Performance |
Narrative:
Being vectored to localizer approach to ZZZ, ATC vectored us direct to abcde while at FL250. Unable to get through to ATC to request lower, we were then allowed to get within approximately 12 mi of abcde still at FL250. Finally getting through to ATC to request lower they stated, 'sorry, I forgot you' and cleared us for the approach. Due to rapid descent, we were fast on final approach, touched down long on the runway and went off of end before stopping. There is no known damage to aircraft or other property. Human factors included ATC 'forgetting' us and pilot action to continue landing when not on stabilized approach on short final. Supplemental information from acn 571622: our company is developing procedures for going into ZZZ at night. The captain decided to test the procedure while completing a business trip. Our procedures basically follow the VOR-DME approach, but we require higher visibility requirements so that we can create a GS using the vpath feature in our FMS. We fly a vpath to a 1.5 mi fix east of the threshold. Upon reaching the 1.5 fix, we are at an altitude to intercept to the PAPI and continue the approach to landing using the PAPI. This is not an instrument approach, it is to be used only in VFR conditions with the vpath being used as a reference to arrive at the 1.5 mi fix from the runway and then complete a normal descent rate to landing. Our procedures call for crossing the abcde intersection fully configured (gear down and full flaps). Due to traffic below us we were held at FL250 until 10 mi from abcde and then center cleared us to cross abcde at 14000 ft MSL and cleared for the approach. The captain had been slowing the aircraft on manual speed to configure the aircraft, but with the steep descent rate to lose 11000 ft in 10 mi we couldn't get slats or flaps out until we leveled at 14000 ft. During this period, the autoplt was engaged and we were flying FMS waypoints which overlaid the approach and vpath was also coupled. At the abcde intersection, the gear was extended and the before landing checklist completed except for final flaps. Just after abcde, I believe the autoplt was disconnected and the captain was flying the aircraft manually. He extended full spoilers and continued to follow the vpath indications, but he could not get the aircraft slowed down to extend full flaps. He briefed that upon reaching the 1.5 mi fix, he would level off to slow the aircraft to final flap speed. At the 1.5 mi fix he leveled off but the aircraft seemed to accelerate. We got a GPWS because we were not at full flaps. He called for full flaps, then said 'don't, because we are above the final flap speed.' I said we were not configured and we should go around, but he called for full flaps. I extended full flaps. This canceled the GPWS, but now we got a flap overspd warning. The aircraft still was not slowing down. We crossed over the threshold of the runway at vref plus at least 20 KTS and I looked down at the power levers and saw that they were forward at almost full thrust. I pointed this out to him and he pulled back on the power levers and reduced them to idle. By this time we were 1/2 way down the runway and I called for him to go around, but he said 'I can get it down.' he continued to try to put the aircraft down but we were so fast that we were using up a lot of runway. When about 1/3 of the runway remained, I called again for him to go around again and was reaching for the power levers to take over the aircraft and go around when he forced the aircraft to the runway and applied hard braking and full thrust reverse. At this point we had around 2000 ft of runway remaining. He continued straight ahead, braking hard, but we went past the end of the runway and the runway overrun and continued in the dirt about 365 ft past the overrun. After inspection, the aircraft was towed off the clrway to the FBO. Our flight department doesn't fly a lot of hours and during that time I have accumulated around 300 hours and the captain has around 200 hours. We hadn't flown the aircraft in close to 30 days. It is my theory that he might have left the speed control in manual setting instead of FMS speed which would have slowed us down to vref, although as fast as we were going at the 1.5 fix, I don't think we could have slowed to vref anyway. I am also confused by the captain's total lack of judgement by trying to land an aircraft of this size with only 2000 ft of runway remaining and ignoring at least 3 'go around' commands by me. In retrospect, I should have taken command of the aircraft at an earlier point. With all the technology in these newer aircraft (EFIS, FMS, autothrottles, VNAV, etc) it is very easy in a high workload environment to forget to switch speed control from manual back to FMS. If you are below 10000 ft MSL and 250 KTS, you have to put the speed control in manual to slow the aircraft to the first slat and flap setting at 220 KTS. Once slat and flaps are extended, then you have to go back to FMS speed and then the aircraft can fly easily on FMS programmed speed. During high workloads, I have seen many times people forgetting to switch from manual back to FMS speed control.
Original NASA ASRS Text
Title: CL60 FLC, TESTING A VFR COMPANY DESIGNED APCH PROC TO AN ARPT IN MOUNTAINOUS TERRAIN, HAS A RWY EXCURSION WHEN PIC APPARENTLY BECOMES FIXATED WITH THE 'I CAN MAKE IT' MENTALITY.
Narrative: BEING VECTORED TO LOC APCH TO ZZZ, ATC VECTORED US DIRECT TO ABCDE WHILE AT FL250. UNABLE TO GET THROUGH TO ATC TO REQUEST LOWER, WE WERE THEN ALLOWED TO GET WITHIN APPROX 12 MI OF ABCDE STILL AT FL250. FINALLY GETTING THROUGH TO ATC TO REQUEST LOWER THEY STATED, 'SORRY, I FORGOT YOU' AND CLRED US FOR THE APCH. DUE TO RAPID DSCNT, WE WERE FAST ON FINAL APCH, TOUCHED DOWN LONG ON THE RWY AND WENT OFF OF END BEFORE STOPPING. THERE IS NO KNOWN DAMAGE TO ACFT OR OTHER PROPERTY. HUMAN FACTORS INCLUDED ATC 'FORGETTING' US AND PLT ACTION TO CONTINUE LNDG WHEN NOT ON STABILIZED APCH ON SHORT FINAL. SUPPLEMENTAL INFO FROM ACN 571622: OUR COMPANY IS DEVELOPING PROCS FOR GOING INTO ZZZ AT NIGHT. THE CAPT DECIDED TO TEST THE PROC WHILE COMPLETING A BUSINESS TRIP. OUR PROCS BASICALLY FOLLOW THE VOR-DME APCH, BUT WE REQUIRE HIGHER VISIBILITY REQUIREMENTS SO THAT WE CAN CREATE A GS USING THE VPATH FEATURE IN OUR FMS. WE FLY A VPATH TO A 1.5 MI FIX E OF THE THRESHOLD. UPON REACHING THE 1.5 FIX, WE ARE AT AN ALT TO INTERCEPT TO THE PAPI AND CONTINUE THE APCH TO LNDG USING THE PAPI. THIS IS NOT AN INST APCH, IT IS TO BE USED ONLY IN VFR CONDITIONS WITH THE VPATH BEING USED AS A REF TO ARRIVE AT THE 1.5 MI FIX FROM THE RWY AND THEN COMPLETE A NORMAL DSCNT RATE TO LNDG. OUR PROCS CALL FOR XING THE ABCDE INTXN FULLY CONFIGURED (GEAR DOWN AND FULL FLAPS). DUE TO TFC BELOW US WE WERE HELD AT FL250 UNTIL 10 MI FROM ABCDE AND THEN CTR CLRED US TO CROSS ABCDE AT 14000 FT MSL AND CLRED FOR THE APCH. THE CAPT HAD BEEN SLOWING THE ACFT ON MANUAL SPD TO CONFIGURE THE ACFT, BUT WITH THE STEEP DSCNT RATE TO LOSE 11000 FT IN 10 MI WE COULDN'T GET SLATS OR FLAPS OUT UNTIL WE LEVELED AT 14000 FT. DURING THIS PERIOD, THE AUTOPLT WAS ENGAGED AND WE WERE FLYING FMS WAYPOINTS WHICH OVERLAID THE APCH AND VPATH WAS ALSO COUPLED. AT THE ABCDE INTXN, THE GEAR WAS EXTENDED AND THE BEFORE LNDG CHKLIST COMPLETED EXCEPT FOR FINAL FLAPS. JUST AFTER ABCDE, I BELIEVE THE AUTOPLT WAS DISCONNECTED AND THE CAPT WAS FLYING THE ACFT MANUALLY. HE EXTENDED FULL SPOILERS AND CONTINUED TO FOLLOW THE VPATH INDICATIONS, BUT HE COULD NOT GET THE ACFT SLOWED DOWN TO EXTEND FULL FLAPS. HE BRIEFED THAT UPON REACHING THE 1.5 MI FIX, HE WOULD LEVEL OFF TO SLOW THE ACFT TO FINAL FLAP SPD. AT THE 1.5 MI FIX HE LEVELED OFF BUT THE ACFT SEEMED TO ACCELERATE. WE GOT A GPWS BECAUSE WE WERE NOT AT FULL FLAPS. HE CALLED FOR FULL FLAPS, THEN SAID 'DON'T, BECAUSE WE ARE ABOVE THE FINAL FLAP SPD.' I SAID WE WERE NOT CONFIGURED AND WE SHOULD GO AROUND, BUT HE CALLED FOR FULL FLAPS. I EXTENDED FULL FLAPS. THIS CANCELED THE GPWS, BUT NOW WE GOT A FLAP OVERSPD WARNING. THE ACFT STILL WAS NOT SLOWING DOWN. WE CROSSED OVER THE THRESHOLD OF THE RWY AT VREF PLUS AT LEAST 20 KTS AND I LOOKED DOWN AT THE PWR LEVERS AND SAW THAT THEY WERE FORWARD AT ALMOST FULL THRUST. I POINTED THIS OUT TO HIM AND HE PULLED BACK ON THE PWR LEVERS AND REDUCED THEM TO IDLE. BY THIS TIME WE WERE 1/2 WAY DOWN THE RWY AND I CALLED FOR HIM TO GO AROUND, BUT HE SAID 'I CAN GET IT DOWN.' HE CONTINUED TO TRY TO PUT THE ACFT DOWN BUT WE WERE SO FAST THAT WE WERE USING UP A LOT OF RWY. WHEN ABOUT 1/3 OF THE RWY REMAINED, I CALLED AGAIN FOR HIM TO GO AROUND AGAIN AND WAS REACHING FOR THE PWR LEVERS TO TAKE OVER THE ACFT AND GO AROUND WHEN HE FORCED THE ACFT TO THE RWY AND APPLIED HARD BRAKING AND FULL THRUST REVERSE. AT THIS POINT WE HAD AROUND 2000 FT OF RWY REMAINING. HE CONTINUED STRAIGHT AHEAD, BRAKING HARD, BUT WE WENT PAST THE END OF THE RWY AND THE RWY OVERRUN AND CONTINUED IN THE DIRT ABOUT 365 FT PAST THE OVERRUN. AFTER INSPECTION, THE ACFT WAS TOWED OFF THE CLRWAY TO THE FBO. OUR FLT DEPT DOESN'T FLY A LOT OF HRS AND DURING THAT TIME I HAVE ACCUMULATED AROUND 300 HRS AND THE CAPT HAS AROUND 200 HRS. WE HADN'T FLOWN THE ACFT IN CLOSE TO 30 DAYS. IT IS MY THEORY THAT HE MIGHT HAVE LEFT THE SPD CTL IN MANUAL SETTING INSTEAD OF FMS SPD WHICH WOULD HAVE SLOWED US DOWN TO VREF, ALTHOUGH AS FAST AS WE WERE GOING AT THE 1.5 FIX, I DON'T THINK WE COULD HAVE SLOWED TO VREF ANYWAY. I AM ALSO CONFUSED BY THE CAPT'S TOTAL LACK OF JUDGEMENT BY TRYING TO LAND AN ACFT OF THIS SIZE WITH ONLY 2000 FT OF RWY REMAINING AND IGNORING AT LEAST 3 'GAR' COMMANDS BY ME. IN RETROSPECT, I SHOULD HAVE TAKEN COMMAND OF THE ACFT AT AN EARLIER POINT. WITH ALL THE TECHNOLOGY IN THESE NEWER ACFT (EFIS, FMS, AUTOTHROTTLES, VNAV, ETC) IT IS VERY EASY IN A HIGH WORKLOAD ENVIRONMENT TO FORGET TO SWITCH SPD CTL FROM MANUAL BACK TO FMS. IF YOU ARE BELOW 10000 FT MSL AND 250 KTS, YOU HAVE TO PUT THE SPD CTL IN MANUAL TO SLOW THE ACFT TO THE FIRST SLAT AND FLAP SETTING AT 220 KTS. ONCE SLAT AND FLAPS ARE EXTENDED, THEN YOU HAVE TO GO BACK TO FMS SPD AND THEN THE ACFT CAN FLY EASILY ON FMS PROGRAMMED SPD. DURING HIGH WORKLOADS, I HAVE SEEN MANY TIMES PEOPLE FORGETTING TO SWITCH FROM MANUAL BACK TO FMS SPD CTL.
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.