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|
Attributes | |
ACN | 578106 |
Time | |
Date | 200303 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | msl bound lower : 5000 msl bound upper : 5300 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : approach landing : missed approach |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : l30.tracon |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | descent : approach |
Route In Use | approach : visual |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 220 flight time total : 7000 flight time type : 450 |
ASRS Report | 578106 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude conflict : airborne less severe non adherence : clearance non adherence : published procedure non adherence : required legal separation other anomaly other anomaly other |
Independent Detector | aircraft equipment : gpws other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : executed go around flight crew : took precautionary avoidance action other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Airspace Structure Environmental Factor ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Operational Error Pilot Deviation |
Narrative:
The event began when ATC vectored us onto final for a visual to runway 1R at las. The controller turned us onto final, and had another aircraft turning onto final simultaneously in front of us. (We were configured with landing gear down flaps 15, and the FMC had the RNAV runway 1R approach loaded, and the autoplt was already in the approach mode (still in heading, but it had intercepted the approach course). The traffic was very close, and we said so to the controller. He asked if we wanted south turns or a vector. At first it appeared that an south turn or 2 may work, but the traffic slowed too quickly. We asked for a vector, and were issued one. I advanced the power, began a turn for the vector, and asked the captain (PNF) for the after takeoff check, followed by the descent checklist, and asked for gear up flaps up to clean up the aircraft and speed mode for the autoplt. (Later, I realized that I had not pressed the toga switch. The autoplt was locked in approach mode, and would not engage or take a speed mode.) at the finish of the turn for the vector, I noticed the predictive GPWS was showing green, followed by yellow, indicating terrain was anywhere from 2000 ft below us to 2000 ft above us. I also noticed an aircraft at my 2 O'clock position being vectored on a base to final turn. He was above our altitude. I asked the captain to get a clearance to 6000 ft, he said MSA for the area was 'ok' at our altitude. I asked him to get 6000 ft anyway, as my GPWS map was showing terrain at 12 O'clock position, and to get me 6000 ft. He called the controller for the climb. The controller was talking to other traffic, and I noted that the yellow area was closing quickly. My TCASII showed no critical traffic, so I began a climb, and again, asked for the altitude. Just as I reached 5300 ft, the controller cleared us to 6000 ft and asked if we had a GPWS alert. The captain answered 'no.' we were vectored for another visual and landed without further incident. Factors included lack of crew coordination, vigorous multi-tasking, night and mountainous terrain, traffic congestion, and controller workload. The captain felt that we were at a safe altitude, and instead of complying with my request for higher, he set about trying to convince me of his position. The PNF was reconfiguring the aircraft and running checklists, communicating with ATC. It was a moonless night, we were on a vector from a controller who was very busy, and had just given us a bad vector. This made me question in my own mind the veracity of his vector, and whether he, in fact, was going to turn us in time for the oncoming terrain. The vector given didn't give a clear sense of whether this was a go around or a simple vector. We could have just left the gear down and flaps at 15 degrees for a short turn back to final, but if it was going to be a long vector, it would be better to clean up. There were, to say the least, lots of judgements being made, and we were outside the realm of 'written or trained for' procedures. In short, the overall situation of night, traffic congestion, a busy controller, an extremely busy cockpit, and a PNF with a different agenda, and closing on rising terrain, contributed to the altitude deviation. Clrer command from the PIC could have avoided it (if he didn't like what I was doing, he could have asked for the aircraft) or if the PNF had just gotten the altitude clearance when first asked for, the deviation could have been avoided.
Original NASA ASRS Text
Title: CONFUSION REIGNS IN THE COCKPIT OF A B737-800 DURING A NIGHT OP MISSED APCH AND AN ALT EXCURSION WHEN APCH CTLR ATTEMPTS TO SQUEEZE ANOTHER FLT AHEAD OF IT ON AN RNAV APCH TO RWY 1 AT LAS, NV.
Narrative: THE EVENT BEGAN WHEN ATC VECTORED US ONTO FINAL FOR A VISUAL TO RWY 1R AT LAS. THE CTLR TURNED US ONTO FINAL, AND HAD ANOTHER ACFT TURNING ONTO FINAL SIMULTANEOUSLY IN FRONT OF US. (WE WERE CONFIGURED WITH LNDG GEAR DOWN FLAPS 15, AND THE FMC HAD THE RNAV RWY 1R APCH LOADED, AND THE AUTOPLT WAS ALREADY IN THE APCH MODE (STILL IN HDG, BUT IT HAD INTERCEPTED THE APCH COURSE). THE TFC WAS VERY CLOSE, AND WE SAID SO TO THE CTLR. HE ASKED IF WE WANTED S TURNS OR A VECTOR. AT FIRST IT APPEARED THAT AN S TURN OR 2 MAY WORK, BUT THE TFC SLOWED TOO QUICKLY. WE ASKED FOR A VECTOR, AND WERE ISSUED ONE. I ADVANCED THE PWR, BEGAN A TURN FOR THE VECTOR, AND ASKED THE CAPT (PNF) FOR THE AFTER TKOF CHK, FOLLOWED BY THE DSCNT CHKLIST, AND ASKED FOR GEAR UP FLAPS UP TO CLEAN UP THE ACFT AND SPD MODE FOR THE AUTOPLT. (LATER, I REALIZED THAT I HAD NOT PRESSED THE TOGA SWITCH. THE AUTOPLT WAS LOCKED IN APCH MODE, AND WOULD NOT ENGAGE OR TAKE A SPD MODE.) AT THE FINISH OF THE TURN FOR THE VECTOR, I NOTICED THE PREDICTIVE GPWS WAS SHOWING GREEN, FOLLOWED BY YELLOW, INDICATING TERRAIN WAS ANYWHERE FROM 2000 FT BELOW US TO 2000 FT ABOVE US. I ALSO NOTICED AN ACFT AT MY 2 O'CLOCK POS BEING VECTORED ON A BASE TO FINAL TURN. HE WAS ABOVE OUR ALT. I ASKED THE CAPT TO GET A CLRNC TO 6000 FT, HE SAID MSA FOR THE AREA WAS 'OK' AT OUR ALT. I ASKED HIM TO GET 6000 FT ANYWAY, AS MY GPWS MAP WAS SHOWING TERRAIN AT 12 O'CLOCK POS, AND TO GET ME 6000 FT. HE CALLED THE CTLR FOR THE CLB. THE CTLR WAS TALKING TO OTHER TFC, AND I NOTED THAT THE YELLOW AREA WAS CLOSING QUICKLY. MY TCASII SHOWED NO CRITICAL TFC, SO I BEGAN A CLB, AND AGAIN, ASKED FOR THE ALT. JUST AS I REACHED 5300 FT, THE CTLR CLRED US TO 6000 FT AND ASKED IF WE HAD A GPWS ALERT. THE CAPT ANSWERED 'NO.' WE WERE VECTORED FOR ANOTHER VISUAL AND LANDED WITHOUT FURTHER INCIDENT. FACTORS INCLUDED LACK OF CREW COORD, VIGOROUS MULTI-TASKING, NIGHT AND MOUNTAINOUS TERRAIN, TFC CONGESTION, AND CTLR WORKLOAD. THE CAPT FELT THAT WE WERE AT A SAFE ALT, AND INSTEAD OF COMPLYING WITH MY REQUEST FOR HIGHER, HE SET ABOUT TRYING TO CONVINCE ME OF HIS POS. THE PNF WAS RECONFIGURING THE ACFT AND RUNNING CHKLISTS, COMMUNICATING WITH ATC. IT WAS A MOONLESS NIGHT, WE WERE ON A VECTOR FROM A CTLR WHO WAS VERY BUSY, AND HAD JUST GIVEN US A BAD VECTOR. THIS MADE ME QUESTION IN MY OWN MIND THE VERACITY OF HIS VECTOR, AND WHETHER HE, IN FACT, WAS GOING TO TURN US IN TIME FOR THE ONCOMING TERRAIN. THE VECTOR GIVEN DIDN'T GIVE A CLR SENSE OF WHETHER THIS WAS A GAR OR A SIMPLE VECTOR. WE COULD HAVE JUST LEFT THE GEAR DOWN AND FLAPS AT 15 DEGS FOR A SHORT TURN BACK TO FINAL, BUT IF IT WAS GOING TO BE A LONG VECTOR, IT WOULD BE BETTER TO CLEAN UP. THERE WERE, TO SAY THE LEAST, LOTS OF JUDGEMENTS BEING MADE, AND WE WERE OUTSIDE THE REALM OF 'WRITTEN OR TRAINED FOR' PROCS. IN SHORT, THE OVERALL SIT OF NIGHT, TFC CONGESTION, A BUSY CTLR, AN EXTREMELY BUSY COCKPIT, AND A PNF WITH A DIFFERENT AGENDA, AND CLOSING ON RISING TERRAIN, CONTRIBUTED TO THE ALTDEV. CLRER COMMAND FROM THE PIC COULD HAVE AVOIDED IT (IF HE DIDN'T LIKE WHAT I WAS DOING, HE COULD HAVE ASKED FOR THE ACFT) OR IF THE PNF HAD JUST GOTTEN THE ALT CLRNC WHEN FIRST ASKED FOR, THE DEV COULD HAVE BEEN AVOIDED.
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.