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|
Attributes | |
ACN | 608581 |
Time | |
Date | 200402 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : slc.airport |
State Reference | UT |
Altitude | msl single value : 5000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Fog |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : s56.tracon tower : slc.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 35 |
Flight Phase | descent : approach landing : missed approach |
Route In Use | approach : instrument precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 608581 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 190 flight time total : 13300 flight time type : 8000 |
ASRS Report | 608582 |
Events | |
Anomaly | conflict : airborne less severe inflight encounter : weather non adherence : clearance other spatial deviation |
Resolutory Action | controller : issued advisory controller : issued new clearance flight crew : executed missed approach |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Weather ATC Human Performance |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Inter Facility Coordination Failure |
Narrative:
We received the following ATIS during our descent into slc: winds 320 degrees at 4 KTS, 1/2 mi visibility and mist, scattered at 9500 ft, 29.86 altimeter, surface visibility 1 1/4 mi. We contacted slc operations to get an update on condition and to make the in-range call. We decided to request the CAT IIIA to runway 34R due to the rapidly changing conditions. Our request was denied due to departure traffic on runway 34R. We were cleared for the ILS CAT I to runway 35. The captain flew a HUD approach using company procedures. Once we reached minimums of 200 hat, the runway was not in sight. The captain executed a go around. I called missed approach on tower frequency. I then turned my attention to backing up the captain by reading the missed approach instructions to him. The missed approach called for a climb to 5000 ft, then climbing left turn to 9000 ft via 300 degree heading. During the turn, tower asked us what we were doing, and I again told them we were flying the published missed approach. They told us to fly runway heading, so we started a turn back to the right to a 340 degree heading. During the turn to the right, he changed the clearance to a left turn to 260 degrees and told us to contact departure. I read back the clearance and included that we were climbing to 9000 ft. Once we checked in with departure, they resequenced us for another ILS. We again requested the CAT IIIA ILS runway 34R. This time, we got clearance as requested. We flew an uneventful HUD approach to CAT IIIA minimums and landed. Once clear of the runway, ground control asked us to call the tower supervisor. They told the captain that on missed approach they had instructed us to fly runway heading. Neither the captain nor I heard these instructions due to high cockpit workload. The captain was calling for flaps 15 degrees landing gear up and I was echoing and executing the command. The tower supervisor told us they were pulling and reviewing the tapes. We continued boarding for our next flight and waited for a call from tower. The tower supervisor called the captain and told him 'there was no problem.' the tower had instructed us to fly runway heading, but we didn't respond. This call was most likely made during the critical phase of flight while executing missed approach. I believe this incident could have been avoided if we had been cleared the CAT IIIA to runway 34R. Additionally, if they don't want us to fly the published missed approach, then it would help if the controller would give climb out prior to the approach when the cockpit workload is not as high.
Original NASA ASRS Text
Title: B737-300 FLT CREW MISSES CTLR INSTRUCTION TO FLY RWY HDG AND FLIES PUBLISHED PROC ON MISSED APCH AT SLC.
Narrative: WE RECEIVED THE FOLLOWING ATIS DURING OUR DSCNT INTO SLC: WINDS 320 DEGS AT 4 KTS, 1/2 MI VISIBILITY AND MIST, SCATTERED AT 9500 FT, 29.86 ALTIMETER, SURFACE VISIBILITY 1 1/4 MI. WE CONTACTED SLC OPS TO GET AN UPDATE ON CONDITION AND TO MAKE THE IN-RANGE CALL. WE DECIDED TO REQUEST THE CAT IIIA TO RWY 34R DUE TO THE RAPIDLY CHANGING CONDITIONS. OUR REQUEST WAS DENIED DUE TO DEP TFC ON RWY 34R. WE WERE CLRED FOR THE ILS CAT I TO RWY 35. THE CAPT FLEW A HUD APCH USING COMPANY PROCS. ONCE WE REACHED MINIMUMS OF 200 HAT, THE RWY WAS NOT IN SIGHT. THE CAPT EXECUTED A GAR. I CALLED MISSED APCH ON TWR FREQ. I THEN TURNED MY ATTN TO BACKING UP THE CAPT BY READING THE MISSED APCH INSTRUCTIONS TO HIM. THE MISSED APCH CALLED FOR A CLB TO 5000 FT, THEN CLBING L TURN TO 9000 FT VIA 300 DEG HDG. DURING THE TURN, TWR ASKED US WHAT WE WERE DOING, AND I AGAIN TOLD THEM WE WERE FLYING THE PUBLISHED MISSED APCH. THEY TOLD US TO FLY RWY HDG, SO WE STARTED A TURN BACK TO THE R TO A 340 DEG HDG. DURING THE TURN TO THE R, HE CHANGED THE CLRNC TO A L TURN TO 260 DEGS AND TOLD US TO CONTACT DEP. I READ BACK THE CLRNC AND INCLUDED THAT WE WERE CLBING TO 9000 FT. ONCE WE CHKED IN WITH DEP, THEY RESEQUENCED US FOR ANOTHER ILS. WE AGAIN REQUESTED THE CAT IIIA ILS RWY 34R. THIS TIME, WE GOT CLRNC AS REQUESTED. WE FLEW AN UNEVENTFUL HUD APCH TO CAT IIIA MINIMUMS AND LANDED. ONCE CLR OF THE RWY, GND CTL ASKED US TO CALL THE TWR SUPVR. THEY TOLD THE CAPT THAT ON MISSED APCH THEY HAD INSTRUCTED US TO FLY RWY HDG. NEITHER THE CAPT NOR I HEARD THESE INSTRUCTIONS DUE TO HIGH COCKPIT WORKLOAD. THE CAPT WAS CALLING FOR FLAPS 15 DEGS LNDG GEAR UP AND I WAS ECHOING AND EXECUTING THE COMMAND. THE TWR SUPVR TOLD US THEY WERE PULLING AND REVIEWING THE TAPES. WE CONTINUED BOARDING FOR OUR NEXT FLT AND WAITED FOR A CALL FROM TWR. THE TWR SUPVR CALLED THE CAPT AND TOLD HIM 'THERE WAS NO PROB.' THE TWR HAD INSTRUCTED US TO FLY RWY HDG, BUT WE DIDN'T RESPOND. THIS CALL WAS MOST LIKELY MADE DURING THE CRITICAL PHASE OF FLT WHILE EXECUTING MISSED APCH. I BELIEVE THIS INCIDENT COULD HAVE BEEN AVOIDED IF WE HAD BEEN CLRED THE CAT IIIA TO RWY 34R. ADDITIONALLY, IF THEY DON'T WANT US TO FLY THE PUBLISHED MISSED APCH, THEN IT WOULD HELP IF THE CTLR WOULD GIVE CLBOUT PRIOR TO THE APCH WHEN THE COCKPIT WORKLOAD IS NOT AS HIGH.
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.