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A B737 captain becomes disoriented on approach, resulting in an unstabilized approach that came close to a stall and a crossing restr not being met.
| Attributes | |
| ACN | 600796 |
| Time | |
| Date | 200312 |
| Day | Mon |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : oak.airport |
| State Reference | CA |
| Altitude | msl single value : 2400 |
| Environment | |
| Flight Conditions | IMC |
| Light | Dusk |
| Aircraft 1 | |
| Controlling Facilities | tracon : nct.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | B737-700 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | ils localizer & glide slope : 11 |
| Flight Phase | descent : approach descent : intermediate altitude |
| Route In Use | approach : instrument precision |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Experience | flight time last 90 days : 200 flight time total : 6000 flight time type : 1500 |
| ASRS Report | 600796 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Events | |
| Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : published procedure non adherence : far non adherence : company policies other anomaly other anomaly |
| Independent Detector | other flight crewa |
| Resolutory Action | flight crew : regained aircraft control flight crew : became reoriented |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
I was PNF. Approach gave us a vector of 150 degrees to join the final approach course for runway 11 at oakland. The PF (captain) selected 160 degrees in the course selector window. I remarked 'course should be 160 degrees, unless you wanted 150 degrees.' we were then given 'plaza at 1800 ft' which is a mandatory altitude for the FAF on the approach chart. At this point he began configuring, gear down, flaps 15 degrees. He began his turn at 2500 ft and slowed the aircraft to a near stall (reference minus 15 KTS) in a 30 degree bank. I made the altitude deviation call 'airspeed! Airspeed.' he gave the airplane nearly maximum power and disconnected the autoplt. The power solved the airspeed, but we then began climbing. I told him 'we can't climb here,' then, 'we have to cross plaza at 1800 ft.' he leveled off, but did not descend. I called the deviation again, but by this time he had intercepted the localizer and thankfully, we broke out of the clouds and rejoined the GS for an uneventful landing. It was a classic attempt at a stall/spin on the base to final turn. I have no idea what caused his actions, other than getting disoriented in the clouds. We climbed from an assigned altitude of 2000 ft to 2400 ft and crossed plaza (required at 1800 ft) still at about 2400 ft, so we missed the restr by not quite 500 ft. This is airspace under sfo and I was worried about ATC, but we did not hear anything about our (very short) altitude excursion. I discussed what happened afterward with the captain, remarking, 'you scared me on final.' he explained what happened by explaining that a headwind changed to a tailwind (or vice versa) and the localizer button didn't arm. He didn't offer an explanation for the near stall and altitude bust from recovery. I think (hope) norcal didn't notice, we didn't hear anything from them. The passenger sure noticed, I was buttonholed by both flight attendants and passenger while deplaning, who wanted to know 'what happened back there?'
Original NASA ASRS Text
Title: A B737 CAPT BECOMES DISORIENTED ON APCH, RESULTING IN AN UNSTABILIZED APCH THAT CAME CLOSE TO A STALL AND A XING RESTR NOT BEING MET.
Narrative: I WAS PNF. APCH GAVE US A VECTOR OF 150 DEGS TO JOIN THE FINAL APCH COURSE FOR RWY 11 AT OAKLAND. THE PF (CAPT) SELECTED 160 DEGS IN THE COURSE SELECTOR WINDOW. I REMARKED 'COURSE SHOULD BE 160 DEGS, UNLESS YOU WANTED 150 DEGS.' WE WERE THEN GIVEN 'PLAZA AT 1800 FT' WHICH IS A MANDATORY ALT FOR THE FAF ON THE APCH CHART. AT THIS POINT HE BEGAN CONFIGURING, GEAR DOWN, FLAPS 15 DEGS. HE BEGAN HIS TURN AT 2500 FT AND SLOWED THE ACFT TO A NEAR STALL (REF MINUS 15 KTS) IN A 30 DEG BANK. I MADE THE ALTDEV CALL 'AIRSPD! AIRSPD.' HE GAVE THE AIRPLANE NEARLY MAX PWR AND DISCONNECTED THE AUTOPLT. THE PWR SOLVED THE AIRSPD, BUT WE THEN BEGAN CLBING. I TOLD HIM 'WE CAN'T CLB HERE,' THEN, 'WE HAVE TO CROSS PLAZA AT 1800 FT.' HE LEVELED OFF, BUT DID NOT DSND. I CALLED THE DEV AGAIN, BUT BY THIS TIME HE HAD INTERCEPTED THE LOC AND THANKFULLY, WE BROKE OUT OF THE CLOUDS AND REJOINED THE GS FOR AN UNEVENTFUL LNDG. IT WAS A CLASSIC ATTEMPT AT A STALL/SPIN ON THE BASE TO FINAL TURN. I HAVE NO IDEA WHAT CAUSED HIS ACTIONS, OTHER THAN GETTING DISORIENTED IN THE CLOUDS. WE CLBED FROM AN ASSIGNED ALT OF 2000 FT TO 2400 FT AND CROSSED PLAZA (REQUIRED AT 1800 FT) STILL AT ABOUT 2400 FT, SO WE MISSED THE RESTR BY NOT QUITE 500 FT. THIS IS AIRSPACE UNDER SFO AND I WAS WORRIED ABOUT ATC, BUT WE DID NOT HEAR ANYTHING ABOUT OUR (VERY SHORT) ALT EXCURSION. I DISCUSSED WHAT HAPPENED AFTERWARD WITH THE CAPT, REMARKING, 'YOU SCARED ME ON FINAL.' HE EXPLAINED WHAT HAPPENED BY EXPLAINING THAT A HEADWIND CHANGED TO A TAILWIND (OR VICE VERSA) AND THE LOC BUTTON DIDN'T ARM. HE DIDN'T OFFER AN EXPLANATION FOR THE NEAR STALL AND ALT BUST FROM RECOVERY. I THINK (HOPE) NORCAL DIDN'T NOTICE, WE DIDN'T HEAR ANYTHING FROM THEM. THE PAX SURE NOTICED, I WAS BUTTONHOLED BY BOTH FLT ATTENDANTS AND PAX WHILE DEPLANING, WHO WANTED TO KNOW 'WHAT HAPPENED BACK THERE?'
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.