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|
Attributes | |
ACN | 582944 |
Time | |
Date | 200305 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : jfk.airport |
State Reference | NY |
Altitude | msl single value : 1200 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon tower : jfk.tower tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 4l |
Flight Phase | descent : approach landing : missed approach |
Route In Use | approach : instrument precision arrival : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : jfk.tower |
Operator | common carrier : air carrier |
Make Model Name | B747 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | ground : takeoff roll ground other : aborted tkof |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 260 flight time total : 5500 flight time type : 2200 |
ASRS Report | 582944 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | conflict : airborne less severe non adherence : required legal separation non adherence : published procedure non adherence : clearance |
Independent Detector | atc equipment other atc equipment : radar aircraft equipment : tcas other controllera other controllerb other flight crewa |
Resolutory Action | controller : issued new clearance controller : separated traffic controller : issued advisory flight crew : took evasive action flight crew : executed go around flight crew : took precautionary avoidance action |
Consequence | faa : investigated faa : reviewed incident with flight crew |
Miss Distance | horizontal : 4500 vertical : 400 |
Supplementary | |
Problem Areas | ATC Human Performance Environmental Factor Flight Crew Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Inter Facility Coordination Failure Intra Facility Coordination Failure Operational Error |
Narrative:
On arrival into approach control airspace at jfk, we had set up the FMGS for ILS runway 4R. We were then told to expect ILS runway 4L. I set up the FMGS and briefed runway 4L to the first officer who was flying. We were cleared for the approach for ILS runway 4L. The first officer captured the localizer but missed the GS, we were on a 5 mi final. I took control of the aircraft to fly the approach and recaptured the GS. The aircraft was fully stabilized and on speed by 1000 ft AGL, as per company policy. On breaking out at 900 ft AGL, I heard air carrier Y cleared for takeoff runway 4L. I saw a B747 pull out onto runway 4L. It was obvious that we were not going to have enough separation. I told the first officer to ask the tower for missed approach instruction, as parallel runway operations were in effect and the published missed would not have worked. The first officer relayed the information and the tower immediately told air carrier Y to abort, which they did. We were given a heading and climb and told to go missed. We initiated soft go around to 2000 ft. I spoke to the passenger explaining that there was not enough space between the traffic departing and us landing. ATC told us they would give us a short vector back in for another approach. I xferred control to the first officer while I ran the checklists and recycled the approach for ILS runway 4L. We had been very busy in the cockpit. We were given a frequency change to the next controller. That controller gave us vector for a second approach and we were told to join the localizer. We were cleared for the approach (no runway was mentioned). We presumed that the vectors were back to runway 4L, as no mention of runway 4R was made. We were at 2000 ft and I saw we were going to be high on the GS. ATC was very busy with a lot of tight spacing between aircraft. I asked for lower and was quickly given 1500 ft. This time the first officer forgot to push the approach button, so I reached up and pushed it as we crossed the localizer to runway 4L. The autoplt turned us back towards the localizer just as the controller told us to fly 060 degrees to join the localizer again. We intercepted runway 4L, got configured and started down. On passing the final approach fix, we were still on approach frequency. I asked for 'air carrier XXX to tower for runway 4L?' the approach controller, with surprise, asked us if we were still with him, which I replied affirmative. He told us there was traffic right behind us and we should make an immediate right turn to 090 degrees. Seeing the other aircraft behind us on TCASII, I took control, disengaged the autoplt, turned to 090 degrees at 30 degree bank angle. We were then told to pick up the speed. We applied toga maximum power. We climbed to 10000 ft. Approach was so busy telling other aircraft to break off their approachs to runway 4R (which we were now about to cross), we were not able to get an altitude assignment or confirmation. I climbed to 1500 ft and eventually, we were told to climb to 2000 ft. We notified the passenger that this time an aircraft behind us was too close. We were vectored for another approach. I opted to fly the approach this time. As we approached the localizer course for ILS runway 4L, about 3/4 NM from localizer, we were cleared for ILS runway 4L. I told first officer we could not accept runway 4R, as we had set up for the ILS runway 4L. ATC vectored us around again for a 3RD missed approach. The 4TH approach was to runway 4L and we landed without further incident. I called the tower supervisor to find out if we had done anything wrong. It became clear that ATC had expected the 1ST approach to runway 4L and that they had made a mistake by clearing air carrier Y for takeoff. They then logged us as shooting the next 2 approachs to ILS runway 4R. The problem being no one informed us of the runway change. The 2ND approach clearance did not include a runway assignment. Normally I would have read back the clearance and added the runway number if the controller did not mention it, but due to the first officer forgetting to activate the approach, I wanted to get off the radio to tell him that he had missed the approach button and was still on heading. So I read back the abbreviated join the localizer cleared for the approach. A contributing factor was the frequency congestion caused by our first missed approach, coupled with the pressure of executing a missed with no response to our altitude request and the need to run checklists, talk to the passenger, and set up for the next approach, and receiving a badvector and an altitude which would have brought us high on the GS for runway 4L. The first officer was new, with 3 months in the airplane. We were at the end of an 8 hour flight day and had been awake since XA00 am, which was a 12 1/2 hour day. We did not feel tired and followed all the SOP's in an efficient manner. Runway 4L is 3000 ft from 4R, so it is difficult to see if another aircraft is shooting an approach to you or the parallel runway on TCASII. The aircraft behind us was faster than us and did not realize that we were only 1 SM or less in front of them on their TCASII. He was talking to tower and the approach controller was not able to talk to him to tell him. While the aircraft behind us was viewing us on their TCASII display on front mode, they had higher resolution in statute mi than we had viewing them on our front mode display. We did not receive a TCASII traffic or RA alert. Our speed was 140 KTS. I estimate the aircraft behind us was 30 KTS faster.
Original NASA ASRS Text
Title: A320 FLT CREW REQUIRED TO EXECUTE 3 GAR'S DUE TO N90 AND JFK LCL CTLR ASSUMPTIONS AND FAILURE TO ENSURE RWY ASSIGNMENT AT JFK ARPT, INCLUDING A FLT CREW LOC OVERSHOOT.
Narrative: ON ARR INTO APCH CTL AIRSPACE AT JFK, WE HAD SET UP THE FMGS FOR ILS RWY 4R. WE WERE THEN TOLD TO EXPECT ILS RWY 4L. I SET UP THE FMGS AND BRIEFED RWY 4L TO THE FO WHO WAS FLYING. WE WERE CLRED FOR THE APCH FOR ILS RWY 4L. THE FO CAPTURED THE LOC BUT MISSED THE GS, WE WERE ON A 5 MI FINAL. I TOOK CTL OF THE ACFT TO FLY THE APCH AND RECAPTURED THE GS. THE ACFT WAS FULLY STABILIZED AND ON SPD BY 1000 FT AGL, AS PER COMPANY POLICY. ON BREAKING OUT AT 900 FT AGL, I HEARD ACR Y CLRED FOR TKOF RWY 4L. I SAW A B747 PULL OUT ONTO RWY 4L. IT WAS OBVIOUS THAT WE WERE NOT GOING TO HAVE ENOUGH SEPARATION. I TOLD THE FO TO ASK THE TWR FOR MISSED APCH INSTRUCTION, AS PARALLEL RWY OPS WERE IN EFFECT AND THE PUBLISHED MISSED WOULD NOT HAVE WORKED. THE FO RELAYED THE INFO AND THE TWR IMMEDIATELY TOLD ACR Y TO ABORT, WHICH THEY DID. WE WERE GIVEN A HEADING AND CLB AND TOLD TO GO MISSED. WE INITIATED SOFT GAR TO 2000 FT. I SPOKE TO THE PAX EXPLAINING THAT THERE WAS NOT ENOUGH SPACE BTWN THE TFC DEPARTING AND US LNDG. ATC TOLD US THEY WOULD GIVE US A SHORT VECTOR BACK IN FOR ANOTHER APCH. I XFERRED CTL TO THE FO WHILE I RAN THE CHKLISTS AND RECYCLED THE APCH FOR ILS RWY 4L. WE HAD BEEN VERY BUSY IN THE COCKPIT. WE WERE GIVEN A FREQ CHANGE TO THE NEXT CTLR. THAT CTLR GAVE US VECTOR FOR A SECOND APCH AND WE WERE TOLD TO JOIN THE LOC. WE WERE CLRED FOR THE APCH (NO RWY WAS MENTIONED). WE PRESUMED THAT THE VECTORS WERE BACK TO RWY 4L, AS NO MENTION OF RWY 4R WAS MADE. WE WERE AT 2000 FT AND I SAW WE WERE GOING TO BE HIGH ON THE GS. ATC WAS VERY BUSY WITH A LOT OF TIGHT SPACING BTWN ACFT. I ASKED FOR LOWER AND WAS QUICKLY GIVEN 1500 FT. THIS TIME THE FO FORGOT TO PUSH THE APCH BUTTON, SO I REACHED UP AND PUSHED IT AS WE CROSSED THE LOC TO RWY 4L. THE AUTOPLT TURNED US BACK TOWARDS THE LOC JUST AS THE CTLR TOLD US TO FLY 060 DEGS TO JOIN THE LOC AGAIN. WE INTERCEPTED RWY 4L, GOT CONFIGURED AND STARTED DOWN. ON PASSING THE FINAL APCH FIX, WE WERE STILL ON APCH FREQ. I ASKED FOR 'ACR XXX TO TWR FOR RWY 4L?' THE APCH CTLR, WITH SURPRISE, ASKED US IF WE WERE STILL WITH HIM, WHICH I REPLIED AFFIRMATIVE. HE TOLD US THERE WAS TFC RIGHT BEHIND US AND WE SHOULD MAKE AN IMMEDIATE R TURN TO 090 DEGS. SEEING THE OTHER ACFT BEHIND US ON TCASII, I TOOK CTL, DISENGAGED THE AUTOPLT, TURNED TO 090 DEGS AT 30 DEG BANK ANGLE. WE WERE THEN TOLD TO PICK UP THE SPD. WE APPLIED TOGA MAX PWR. WE CLBED TO 10000 FT. APCH WAS SO BUSY TELLING OTHER ACFT TO BREAK OFF THEIR APCHS TO RWY 4R (WHICH WE WERE NOW ABOUT TO CROSS), WE WERE NOT ABLE TO GET AN ALT ASSIGNMENT OR CONFIRMATION. I CLBED TO 1500 FT AND EVENTUALLY, WE WERE TOLD TO CLB TO 2000 FT. WE NOTIFIED THE PAX THAT THIS TIME AN ACFT BEHIND US WAS TOO CLOSE. WE WERE VECTORED FOR ANOTHER APCH. I OPTED TO FLY THE APCH THIS TIME. AS WE APCHED THE LOC COURSE FOR ILS RWY 4L, ABOUT 3/4 NM FROM LOC, WE WERE CLRED FOR ILS RWY 4L. I TOLD FO WE COULD NOT ACCEPT RWY 4R, AS WE HAD SET UP FOR THE ILS RWY 4L. ATC VECTORED US AROUND AGAIN FOR A 3RD MISSED APCH. THE 4TH APCH WAS TO RWY 4L AND WE LANDED WITHOUT FURTHER INCIDENT. I CALLED THE TWR SUPVR TO FIND OUT IF WE HAD DONE ANYTHING WRONG. IT BECAME CLR THAT ATC HAD EXPECTED THE 1ST APCH TO RWY 4L AND THAT THEY HAD MADE A MISTAKE BY CLRING ACR Y FOR TKOF. THEY THEN LOGGED US AS SHOOTING THE NEXT 2 APCHS TO ILS RWY 4R. THE PROB BEING NO ONE INFORMED US OF THE RWY CHANGE. THE 2ND APCH CLRNC DID NOT INCLUDE A RWY ASSIGNMENT. NORMALLY I WOULD HAVE READ BACK THE CLRNC AND ADDED THE RWY NUMBER IF THE CTLR DID NOT MENTION IT, BUT DUE TO THE FO FORGETTING TO ACTIVATE THE APCH, I WANTED TO GET OFF THE RADIO TO TELL HIM THAT HE HAD MISSED THE APCH BUTTON AND WAS STILL ON HEADING. SO I READ BACK THE ABBREVIATED JOIN THE LOC CLRED FOR THE APCH. A CONTRIBUTING FACTOR WAS THE FREQ CONGESTION CAUSED BY OUR FIRST MISSED APCH, COUPLED WITH THE PRESSURE OF EXECUTING A MISSED WITH NO RESPONSE TO OUR ALT REQUEST AND THE NEED TO RUN CHKLISTS, TALK TO THE PAX, AND SET UP FOR THE NEXT APCH, AND RECEIVING A BADVECTOR AND AN ALT WHICH WOULD HAVE BROUGHT US HIGH ON THE GS FOR RWY 4L. THE FO WAS NEW, WITH 3 MONTHS IN THE AIRPLANE. WE WERE AT THE END OF AN 8 HR FLT DAY AND HAD BEEN AWAKE SINCE XA00 AM, WHICH WAS A 12 1/2 HR DAY. WE DID NOT FEEL TIRED AND FOLLOWED ALL THE SOP'S IN AN EFFICIENT MANNER. RWY 4L IS 3000 FT FROM 4R, SO IT IS DIFFICULT TO SEE IF ANOTHER ACFT IS SHOOTING AN APCH TO YOU OR THE PARALLEL RWY ON TCASII. THE ACFT BEHIND US WAS FASTER THAN US AND DID NOT REALIZE THAT WE WERE ONLY 1 SM OR LESS IN FRONT OF THEM ON THEIR TCASII. HE WAS TALKING TO TWR AND THE APCH CTLR WAS NOT ABLE TO TALK TO HIM TO TELL HIM. WHILE THE ACFT BEHIND US WAS VIEWING US ON THEIR TCASII DISPLAY ON FRONT MODE, THEY HAD HIGHER RESOLUTION IN STATUTE MI THAN WE HAD VIEWING THEM ON OUR FRONT MODE DISPLAY. WE DID NOT RECEIVE A TCASII TFC OR RA ALERT. OUR SPD WAS 140 KTS. I ESTIMATE THE ACFT BEHIND US WAS 30 KTS FASTER.
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.