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B737-700 PIC admits to using the wrong approach plate for a non precision approach, using the VOR a plate versus the ATC assigned VOR runway 12R sidestep for approach to sjc.
| Attributes | |
| ACN | 623005 |
| Time | |
| Date | 200407 |
| Day | Sun |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : sjc.airport |
| State Reference | CA |
| Environment | |
| Flight Conditions | IMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : nct.tracon tower : sjc.tower |
| Operator | common carrier : air carrier |
| Make Model Name | B737-700 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | descent : approach landing : missed approach |
| Route In Use | approach : instrument non precision |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer oversight : pic |
| Qualification | pilot : atp technician : inspection authority |
| Experience | flight time total : 8000 flight time type : 6000 |
| ASRS Report | 623005 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain |
| Events | |
| Anomaly | inflight encounter : weather non adherence : clearance non adherence : published procedure other anomaly other |
| Independent Detector | other flight crewa |
| Resolutory Action | controller : issued new clearance flight crew : executed missed approach flight crew : became reoriented |
| Consequence | Other |
| Supplementary | |
| Problem Areas | Weather Airport Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
Narrative:
On flight to sjc, we were approximately 200 mi out when I, PNF, got the ATIS. The WX showed wind out of the south greater than 10 KTS (necessitating an approach to runway 12L. Runway 12L was closed). We looked at the available approachs and found the VOR a as the most suitable approach (both of us missed the VOR runway 12R) since the ILS to runway 12R was NOTAM'ed OTS. When we checked on with norcal approach, we were told to expect the VOR runway 12R sidestep, but we both remembered having read back the VOR a. There were 2 problems with the VOR a. The current WX was below minimums for the VOR a, and since it is an approach to any runway, it requires circling minimums. Again, we didn't have the minimums for the approach, we were legal to shoot it. It required both visibility and ceiling. When we were cleared for the approach, we were cleared for the VOR runway 12R sidestep. We still didn't pick up on our mistake and neither did approach control when we read back cleared for VOR a! We executed the approach, didn't break out and executed the missed approach. During the missed approach, we realized our mistake, rebriefed and flew the VOR runway 12R sidestep to runway 12L, broke out and landed uneventfully. Listening on company frequency, we heard a couple of other company aircraft making the same mistake that we did, missing the VOR runway 12R sidestep approach in the stack and thinking that the VOR a was the only option. These aircraft did not make the same error we did. They were holding, waiting for WX to improve so that they would be legal for the approach. Both were coordinating with dispatch to divert to smf when the captain jumped on the frequency and alerted them to find the VOR runway 12R approach in their plates and shoot that approach. Both aircraft flew the VOR runway 12R sidestep and landed at sjc versus smf. I don't know why we all made the same mistake, but maybe someone with more experience in causal factors might be able to find out why we all made the same error!
Original NASA ASRS Text
Title: B737-700 PIC ADMITS TO USING THE WRONG APCH PLATE FOR A NON PRECISION APCH, USING THE VOR A PLATE VERSUS THE ATC ASSIGNED VOR RWY 12R SIDESTEP FOR APCH TO SJC.
Narrative: ON FLT TO SJC, WE WERE APPROX 200 MI OUT WHEN I, PNF, GOT THE ATIS. THE WX SHOWED WIND OUT OF THE S GREATER THAN 10 KTS (NECESSITATING AN APCH TO RWY 12L. RWY 12L WAS CLOSED). WE LOOKED AT THE AVAILABLE APCHS AND FOUND THE VOR A AS THE MOST SUITABLE APCH (BOTH OF US MISSED THE VOR RWY 12R) SINCE THE ILS TO RWY 12R WAS NOTAM'ED OTS. WHEN WE CHKED ON WITH NORCAL APCH, WE WERE TOLD TO EXPECT THE VOR RWY 12R SIDESTEP, BUT WE BOTH REMEMBERED HAVING READ BACK THE VOR A. THERE WERE 2 PROBS WITH THE VOR A. THE CURRENT WX WAS BELOW MINIMUMS FOR THE VOR A, AND SINCE IT IS AN APCH TO ANY RWY, IT REQUIRES CIRCLING MINIMUMS. AGAIN, WE DIDN'T HAVE THE MINIMUMS FOR THE APCH, WE WERE LEGAL TO SHOOT IT. IT REQUIRED BOTH VISIBILITY AND CEILING. WHEN WE WERE CLRED FOR THE APCH, WE WERE CLRED FOR THE VOR RWY 12R SIDESTEP. WE STILL DIDN'T PICK UP ON OUR MISTAKE AND NEITHER DID APCH CTL WHEN WE READ BACK CLRED FOR VOR A! WE EXECUTED THE APCH, DIDN'T BREAK OUT AND EXECUTED THE MISSED APCH. DURING THE MISSED APCH, WE REALIZED OUR MISTAKE, REBRIEFED AND FLEW THE VOR RWY 12R SIDESTEP TO RWY 12L, BROKE OUT AND LANDED UNEVENTFULLY. LISTENING ON COMPANY FREQ, WE HEARD A COUPLE OF OTHER COMPANY ACFT MAKING THE SAME MISTAKE THAT WE DID, MISSING THE VOR RWY 12R SIDESTEP APCH IN THE STACK AND THINKING THAT THE VOR A WAS THE ONLY OPTION. THESE ACFT DID NOT MAKE THE SAME ERROR WE DID. THEY WERE HOLDING, WAITING FOR WX TO IMPROVE SO THAT THEY WOULD BE LEGAL FOR THE APCH. BOTH WERE COORDINATING WITH DISPATCH TO DIVERT TO SMF WHEN THE CAPT JUMPED ON THE FREQ AND ALERTED THEM TO FIND THE VOR RWY 12R APCH IN THEIR PLATES AND SHOOT THAT APCH. BOTH ACFT FLEW THE VOR RWY 12R SIDESTEP AND LANDED AT SJC VERSUS SMF. I DON'T KNOW WHY WE ALL MADE THE SAME MISTAKE, BUT MAYBE SOMEONE WITH MORE EXPERIENCE IN CAUSAL FACTORS MIGHT BE ABLE TO FIND OUT WHY WE ALL MADE THE SAME ERROR!
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.