Narrative:

We were vectored to the final approach course of the tjsj VOR DME 26 approach. The vector had us intercepting the course about 7.5 NM from the VOR (between the IAF and FAF) even though we were still at 6000 ft (3000 ft above the IAF altitude). The FAF was at 5 DME. At the FAF, we were still above 4000 ft and clean. (FAF altitude is 2000 ft.) we configured for landing inside the FAF while trying to lose our excess altitude. Although I often quip that 'you're never high in an ATR,' I refused to descend at a rate greater than 1500 FPM, because we were unpressurized (due to an MEL on a door seal). We broke out over the field about 1300 ft above the 400 ft MDA. I initiated the missed approach, and the first officer said she was calling ATC. I told her to wait until we had the missed approach under control. This procedure called for a turn from runway heading toward the missed approach course at 2000 ft, while climbing to 3000 ft. At some point during the missed approach, the first officer noted that our heading was wrong. (We initiated the missed approach while correcting toward final approach course. The heading hold feature of the flight director's go around mode locked us into that heading.) somewhere around 2500 ft, the tower controller called us while we were still busy with confign changes and flight director input. The first officer answered as soon as she could, which kept her from hearing my calls for the turn we were supposed to have started at 2000 ft. My calls for the turn kept me from hearing the controller's instructions. She relayed to me that the controller told us to head 350 degrees and maintain 2000 ft. I hadn't heard the instructions, but it was consistent with previous experience with go around instructions from this tower. At this point, I realized that we had already blown through the missed approach altitude of 3000 ft. Normally, we would have set the missed approach target altitude into the flight director upon reaching MDA. Since we never got to MDA, (or anywhere near it), the missed approach altitude was not set. Our lack of coordination, interference by ATC, and unusually high altitude combined to have us above the missed approach altitude before we expected and before we had a chance to set the flight director to capture it. We topped out at about 3600 ft. As we got down to 2000 ft, we contacted the approach controller, who told us to climb to 3000 ft. I'm sure the passenger enjoyed the roller-coaster ride. There are a lot of people I would like to blame for how poorly this missed approach went: the approach controller for the too-high, too-close intercept, the first officer for putting 'communicate' ahead of 'aviate,' the tower controller, who didn't wait for us to make contact after we were cleaned up and established on the missed approach track, the airline's doctrine, which makes a missed approach a terribly complex dance with lots of opportunities to trip up, the maintenance department for releasing the plane without pressurization, and perhaps even the schedule planners for me being tired and hungry. Waah. The only one I have to blame is myself for being complacent and letting my situational awareness break down. When I read articles about cases like this, I wonder 'what was that pilot thinking?' in this case, I was thinking that, if I kept it coming, it might work out. Hey, it always did, right? As a result, I allowed myself to fall behind an aircraft that was already behind the approach. Having accepted the approach clearance (first mistake), I should have anticipated the missed approach from the beginning -- even stopped the descent at 3000 ft, and flown the procedure track. Instead, I was mentally unprepared to fly the missed approach. I had built up such a strong visualization of making the approach work out that I was actually caught off guard when I saw the runway 2000 ft below me.

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Original NASA ASRS Text

Title: ATR42 CREW HAD ALT AND TRACK DEV ON A GAR AT TJSJ.

Narrative: WE WERE VECTORED TO THE FINAL APCH COURSE OF THE TJSJ VOR DME 26 APCH. THE VECTOR HAD US INTERCEPTING THE COURSE ABOUT 7.5 NM FROM THE VOR (BTWN THE IAF AND FAF) EVEN THOUGH WE WERE STILL AT 6000 FT (3000 FT ABOVE THE IAF ALT). THE FAF WAS AT 5 DME. AT THE FAF, WE WERE STILL ABOVE 4000 FT AND CLEAN. (FAF ALT IS 2000 FT.) WE CONFIGURED FOR LNDG INSIDE THE FAF WHILE TRYING TO LOSE OUR EXCESS ALT. ALTHOUGH I OFTEN QUIP THAT 'YOU'RE NEVER HIGH IN AN ATR,' I REFUSED TO DSND AT A RATE GREATER THAN 1500 FPM, BECAUSE WE WERE UNPRESSURIZED (DUE TO AN MEL ON A DOOR SEAL). WE BROKE OUT OVER THE FIELD ABOUT 1300 FT ABOVE THE 400 FT MDA. I INITIATED THE MISSED APCH, AND THE FO SAID SHE WAS CALLING ATC. I TOLD HER TO WAIT UNTIL WE HAD THE MISSED APCH UNDER CTL. THIS PROC CALLED FOR A TURN FROM RWY HDG TOWARD THE MISSED APCH COURSE AT 2000 FT, WHILE CLBING TO 3000 FT. AT SOME POINT DURING THE MISSED APCH, THE FO NOTED THAT OUR HDG WAS WRONG. (WE INITIATED THE MISSED APCH WHILE CORRECTING TOWARD FINAL APCH COURSE. THE HDG HOLD FEATURE OF THE FLT DIRECTOR'S GAR MODE LOCKED US INTO THAT HDG.) SOMEWHERE AROUND 2500 FT, THE TWR CTLR CALLED US WHILE WE WERE STILL BUSY WITH CONFIGN CHANGES AND FLT DIRECTOR INPUT. THE FO ANSWERED AS SOON AS SHE COULD, WHICH KEPT HER FROM HEARING MY CALLS FOR THE TURN WE WERE SUPPOSED TO HAVE STARTED AT 2000 FT. MY CALLS FOR THE TURN KEPT ME FROM HEARING THE CTLR'S INSTRUCTIONS. SHE RELAYED TO ME THAT THE CTLR TOLD US TO HEAD 350 DEGS AND MAINTAIN 2000 FT. I HADN'T HEARD THE INSTRUCTIONS, BUT IT WAS CONSISTENT WITH PREVIOUS EXPERIENCE WITH GAR INSTRUCTIONS FROM THIS TWR. AT THIS POINT, I REALIZED THAT WE HAD ALREADY BLOWN THROUGH THE MISSED APCH ALT OF 3000 FT. NORMALLY, WE WOULD HAVE SET THE MISSED APCH TARGET ALT INTO THE FLT DIRECTOR UPON REACHING MDA. SINCE WE NEVER GOT TO MDA, (OR ANYWHERE NEAR IT), THE MISSED APCH ALT WAS NOT SET. OUR LACK OF COORD, INTERFERENCE BY ATC, AND UNUSUALLY HIGH ALT COMBINED TO HAVE US ABOVE THE MISSED APCH ALT BEFORE WE EXPECTED AND BEFORE WE HAD A CHANCE TO SET THE FLT DIRECTOR TO CAPTURE IT. WE TOPPED OUT AT ABOUT 3600 FT. AS WE GOT DOWN TO 2000 FT, WE CONTACTED THE APCH CTLR, WHO TOLD US TO CLB TO 3000 FT. I'M SURE THE PAX ENJOYED THE ROLLER-COASTER RIDE. THERE ARE A LOT OF PEOPLE I WOULD LIKE TO BLAME FOR HOW POORLY THIS MISSED APCH WENT: THE APCH CTLR FOR THE TOO-HIGH, TOO-CLOSE INTERCEPT, THE FO FOR PUTTING 'COMMUNICATE' AHEAD OF 'AVIATE,' THE TWR CTLR, WHO DIDN'T WAIT FOR US TO MAKE CONTACT AFTER WE WERE CLEANED UP AND ESTABLISHED ON THE MISSED APCH TRACK, THE AIRLINE'S DOCTRINE, WHICH MAKES A MISSED APCH A TERRIBLY COMPLEX DANCE WITH LOTS OF OPPORTUNITIES TO TRIP UP, THE MAINT DEPT FOR RELEASING THE PLANE WITHOUT PRESSURIZATION, AND PERHAPS EVEN THE SCHEDULE PLANNERS FOR ME BEING TIRED AND HUNGRY. WAAH. THE ONLY ONE I HAVE TO BLAME IS MYSELF FOR BEING COMPLACENT AND LETTING MY SITUATIONAL AWARENESS BREAK DOWN. WHEN I READ ARTICLES ABOUT CASES LIKE THIS, I WONDER 'WHAT WAS THAT PLT THINKING?' IN THIS CASE, I WAS THINKING THAT, IF I KEPT IT COMING, IT MIGHT WORK OUT. HEY, IT ALWAYS DID, RIGHT? AS A RESULT, I ALLOWED MYSELF TO FALL BEHIND AN ACFT THAT WAS ALREADY BEHIND THE APCH. HAVING ACCEPTED THE APCH CLRNC (FIRST MISTAKE), I SHOULD HAVE ANTICIPATED THE MISSED APCH FROM THE BEGINNING -- EVEN STOPPED THE DSCNT AT 3000 FT, AND FLOWN THE PROC TRACK. INSTEAD, I WAS MENTALLY UNPREPARED TO FLY THE MISSED APCH. I HAD BUILT UP SUCH A STRONG VISUALIZATION OF MAKING THE APCH WORK OUT THAT I WAS ACTUALLY CAUGHT OFF GUARD WHEN I SAW THE RWY 2000 FT BELOW ME.

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.