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Attributes | |
ACN | 590203 |
Time | |
Date | 200308 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : iah.airport |
State Reference | TX |
Environment | |
Flight Conditions | Mixed |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : i90.tracon |
Operator | common carrier : air carrier |
Make Model Name | Widebody Transport |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 27 |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 20000 flight time type : 5000 |
ASRS Report | 590203 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : crossing restriction not met non adherence : clearance non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance |
Supplementary | |
Problem Areas | Chart Or Publication Environmental Factor Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
Operating into iah, an airport that is not a normal destination for this type aircraft, the crew assumed (based on ATIS and the fact that we were arriving from the north) that the landing would be using iah ILS runway 26. The arrival, that approach, and landing were briefed before top of descent. On first contact with approach control, we were instead assigned iah ILS runway 27. We were at 6000 ft cleared to descend to 4000 ft and assigned a heading to intercept the runway 27 localizer. We were very busy trying to reprogram the FMS for runway 27 plus fighting a blinding setting sun. Bottom line is in setting up and briefing the new approach, both pilots missed what I consider highly unusual altitude restrs shown only in small vertical depiction block. Those restrs came into play after we were given instructions to maintain 4000 ft until established and then cleared for the ILS runway 27 to iah. As in most approachs, I elected to wait for GS intercept to begin final descent. That, due to our failure to completely study the arrival approach plate, caused us to maintain altitude until the approach controller told us to make the crossing restrs. We asked what restrs and he replied we needed to be at 3000 ft in 2 mi. We complied, but still failed to find the restrs on the approach plate. Not until after shutdown, with the sun out of my eyes and time to look, did I find the restrs on the vertical depiction section. In my experience (over 3 decades) I honestly don't recall seeing an ILS approach plate with 4 altitude restrs labeled mandatory, taking me down to 1400 ft AGL, before I could intercept the GS. In addition, when on radar vectors, and hearing cleared for the approach, it is an accepted technique in my type aircraft to arm the approach/land segment of the FMS. This would require maintaining altitude until GS intercept, rather than doing a manual descent to meet the required altitudes. While I recognize my responsibility and failure to find the altitude restrs on the approach plate, I believe, from a human factors perspective, pilots would be better served if those restrs were also depicted on the larger horizontal depiction section and mentioned in the note block below the missed approach instructions. Operationally, there are numerous circumstances that do not allow time for a complete diagnosis of an approach plate. Otherwise, we would be doing go around's each time a runway change occurred in close.
Original NASA ASRS Text
Title: FLT CREW OF WDB ARRIVING AT IAH FAILED TO NOTE MANDATORY XING RESTRS ON ILS RWY 27 APCH.
Narrative: OPERATING INTO IAH, AN ARPT THAT IS NOT A NORMAL DEST FOR THIS TYPE ACFT, THE CREW ASSUMED (BASED ON ATIS AND THE FACT THAT WE WERE ARRIVING FROM THE N) THAT THE LNDG WOULD BE USING IAH ILS RWY 26. THE ARR, THAT APCH, AND LNDG WERE BRIEFED BEFORE TOP OF DSCNT. ON FIRST CONTACT WITH APCH CTL, WE WERE INSTEAD ASSIGNED IAH ILS RWY 27. WE WERE AT 6000 FT CLRED TO DSND TO 4000 FT AND ASSIGNED A HDG TO INTERCEPT THE RWY 27 LOC. WE WERE VERY BUSY TRYING TO REPROGRAM THE FMS FOR RWY 27 PLUS FIGHTING A BLINDING SETTING SUN. BOTTOM LINE IS IN SETTING UP AND BRIEFING THE NEW APCH, BOTH PLTS MISSED WHAT I CONSIDER HIGHLY UNUSUAL ALT RESTRS SHOWN ONLY IN SMALL VERT DEPICTION BLOCK. THOSE RESTRS CAME INTO PLAY AFTER WE WERE GIVEN INSTRUCTIONS TO MAINTAIN 4000 FT UNTIL ESTABLISHED AND THEN CLRED FOR THE ILS RWY 27 TO IAH. AS IN MOST APCHS, I ELECTED TO WAIT FOR GS INTERCEPT TO BEGIN FINAL DSCNT. THAT, DUE TO OUR FAILURE TO COMPLETELY STUDY THE ARR APCH PLATE, CAUSED US TO MAINTAIN ALT UNTIL THE APCH CTLR TOLD US TO MAKE THE XING RESTRS. WE ASKED WHAT RESTRS AND HE REPLIED WE NEEDED TO BE AT 3000 FT IN 2 MI. WE COMPLIED, BUT STILL FAILED TO FIND THE RESTRS ON THE APCH PLATE. NOT UNTIL AFTER SHUTDOWN, WITH THE SUN OUT OF MY EYES AND TIME TO LOOK, DID I FIND THE RESTRS ON THE VERT DEPICTION SECTION. IN MY EXPERIENCE (OVER 3 DECADES) I HONESTLY DON'T RECALL SEEING AN ILS APCH PLATE WITH 4 ALT RESTRS LABELED MANDATORY, TAKING ME DOWN TO 1400 FT AGL, BEFORE I COULD INTERCEPT THE GS. IN ADDITION, WHEN ON RADAR VECTORS, AND HEARING CLRED FOR THE APCH, IT IS AN ACCEPTED TECHNIQUE IN MY TYPE ACFT TO ARM THE APCH/LAND SEGMENT OF THE FMS. THIS WOULD REQUIRE MAINTAINING ALT UNTIL GS INTERCEPT, RATHER THAN DOING A MANUAL DSCNT TO MEET THE REQUIRED ALTS. WHILE I RECOGNIZE MY RESPONSIBILITY AND FAILURE TO FIND THE ALT RESTRS ON THE APCH PLATE, I BELIEVE, FROM A HUMAN FACTORS PERSPECTIVE, PLTS WOULD BE BETTER SERVED IF THOSE RESTRS WERE ALSO DEPICTED ON THE LARGER HORIZ DEPICTION SECTION AND MENTIONED IN THE NOTE BLOCK BELOW THE MISSED APCH INSTRUCTIONS. OPERATIONALLY, THERE ARE NUMEROUS CIRCUMSTANCES THAT DO NOT ALLOW TIME FOR A COMPLETE DIAGNOSIS OF AN APCH PLATE. OTHERWISE, WE WOULD BE DOING GAR'S EACH TIME A RWY CHANGE OCCURRED IN CLOSE.
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.