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|
Attributes | |
ACN | 641591 |
Time | |
Date | 200412 |
Day | Mon |
Place | |
Locale Reference | airport : sea.airport |
State Reference | WA |
Altitude | msl single value : 3000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : s46.tracon tower : sea.tower |
Operator | common carrier : air carrier |
Make Model Name | Dash 8-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 16r |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 5800 flight time type : 1600 |
ASRS Report | 641591 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 10000 flight time type : 600 |
ASRS Report | 641589 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : published procedure other spatial deviation |
Independent Detector | atc equipment : msaw other controllera |
Resolutory Action | controller : issued alert flight crew : returned to original clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Weather Aircraft Environmental Factor Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We had flown into sea earlier that day and the RVR had been fluctuating up and down. It was the captain's leg. She decided to use the HUD and do a CAT III approach. The WX at the time was 3 mi visibility and the RVR for runway 16R was variable from 1600 ft to more than 6000 ft. We were on a right downwind leg on a vector for the ILS to runway 16R. We were at 4000 ft MSL. We were put on a base leg vector, heading 070 degrees and cleared to maintain 3000 ft MSL. As the PNF, I selected 3000 ft in the altitude alerter, pushed altitude select on the FGC. I made my '3000 ft' call and I verified that altitude select was showing on the advisory display. I immediately followed that with my '1000 ft to go, altitude select' call. The captain had the autoplt still engaged and she chose vertical speed as her means of descent and dialed it into the FGC and we started to descend. While she was doing that, we were cleared to 'maintain 3000 ft until established, turn right heading 130 degrees, cleared ILS runway 16R.' I read that back to the controller, verified and called that the localizer was alive and saw the autoplt capture the localizer as we continued our descent to the assigned altitude. At that time there was some confusion with the hgs system. The aiii mode had not been made available to us by the system and the captain mentioned that to me. I made a comment wondering why it might be out of parameters. I thought maybe the wind was too strong and I checked the FMS wind readout to see. Since the WX had improved and we didn't need to do a CAT III approach, the captain decided to continue. The problem with the aiii not being available caused a distraction at a very busy time on the approach. We were instructed by sea approach control to contact sea tower. The captain had since disengaged the autoplt and was hand flying, still using the HUD. We had been on top of a layer and were looking right into the sun and it made it difficult to read the instruments. (The captain commented to me, later after on the ground, that the bright sunlight made it hard for her to see the information in the HUD as well.) in the vicinity of the final approach fix, I noticed that we were low on the GS and paralleling it. I told the captain to check her altitude, that we were low and called out 'you're below the GS' or 'GS.' she was confused for a few seconds because (she later told me) she was so focused on flying using the HUD and that the altitude display information in the HUD is not very user friendly and difficult to read. She then initiated a climb back to intercept the GS. While she was in the process of doing that, we received a call from ATC asking us about our altitude and they issued a low altitude alert. I think I responded with 'correcting,' or something similar. We did not receive any GPWS warnings from our GPWS. The airplane was configured and stabilized and the captain elected to continue the approach. We landed without incident. To my knowledge there was no traffic conflicts with any other aircraft. Once on ground control, we were given a phone number to call. The captain called and was told that a pilot deviation report would be filed. There are a number of things I think that contributed to this situation. Usually, there is not just one thing you can point to, but instead, several links in the chain that lead you to a deviation. I think that when the captain selected vertical speed to initiate the descent to 3000 ft I believe she also pushed altitude select on the FGC, after I had already programmed it. One push selects it 'on.' if it is pushed a second time, it de-selects it or turns it 'off.' our procedure for yrs was for the PF to select altitude select, not the PNF. That has changed and now it's the PNF who selects it. A lot of people are in the old habit of selecting it themselves. If they do this after the PNF selects it, it basically turns it off and then it will not level off and capture the altitude in the alerter. When I programmed it, I made the required callouts and verified that altitude select was in the advisory display, but immediately after that is when she selected vertical speed, and I think that is when it was pushed. The 2 buttons (vertical speed and altitude select) are one right above the other. Everything really happened quickly. We were cleared to descend, cleared for the approach, had the distraction of the aiii mode not becoming available to us, got a handoff to the tower and intercepted final all in a very short amount of time. All this with the fact that the sun was extremely bright and right in our eyes, making it more difficult to read the instruments. The captain said the HUD is extremely difficult to read when looking into the sun. Also, our electronic flight instruments are all not adjusted to the same brightness level. We have the ability to adjust them, but not all the airplanes in our fleet are the same. On some aircraft, you can have it adjusted full bright and it is still very difficult to see when in the sun. When discussing it later with the captain, she brought up the fact that it is very easy to get completely focused on looking through the HUD and to forget about the other instruments, she told me that the altitude information in the HUD is lacking and difficult to use. Finally, I did not feel tired enough or fatigued enough that I felt I needed to utilize the fatigue policy our company has, however, I think being up since XA30, 2 days in a row and feeling tired probably played a role in this for both of us.
Original NASA ASRS Text
Title: DH8B FLT CREW ON ILS RWY 16R AT SEA UTILIZING HUD DISPLAY DSNDED BELOW GS AND WAS ALERTED BY ATC.
Narrative: WE HAD FLOWN INTO SEA EARLIER THAT DAY AND THE RVR HAD BEEN FLUCTUATING UP AND DOWN. IT WAS THE CAPT'S LEG. SHE DECIDED TO USE THE HUD AND DO A CAT III APCH. THE WX AT THE TIME WAS 3 MI VISIBILITY AND THE RVR FOR RWY 16R WAS VARIABLE FROM 1600 FT TO MORE THAN 6000 FT. WE WERE ON A R DOWNWIND LEG ON A VECTOR FOR THE ILS TO RWY 16R. WE WERE AT 4000 FT MSL. WE WERE PUT ON A BASE LEG VECTOR, HDG 070 DEGS AND CLRED TO MAINTAIN 3000 FT MSL. AS THE PNF, I SELECTED 3000 FT IN THE ALT ALERTER, PUSHED ALT SELECT ON THE FGC. I MADE MY '3000 FT' CALL AND I VERIFIED THAT ALT SELECT WAS SHOWING ON THE ADVISORY DISPLAY. I IMMEDIATELY FOLLOWED THAT WITH MY '1000 FT TO GO, ALT SELECT' CALL. THE CAPT HAD THE AUTOPLT STILL ENGAGED AND SHE CHOSE VERT SPD AS HER MEANS OF DSCNT AND DIALED IT INTO THE FGC AND WE STARTED TO DSND. WHILE SHE WAS DOING THAT, WE WERE CLRED TO 'MAINTAIN 3000 FT UNTIL ESTABLISHED, TURN R HDG 130 DEGS, CLRED ILS RWY 16R.' I READ THAT BACK TO THE CTLR, VERIFIED AND CALLED THAT THE LOC WAS ALIVE AND SAW THE AUTOPLT CAPTURE THE LOC AS WE CONTINUED OUR DSCNT TO THE ASSIGNED ALT. AT THAT TIME THERE WAS SOME CONFUSION WITH THE HGS SYS. THE AIII MODE HAD NOT BEEN MADE AVAILABLE TO US BY THE SYS AND THE CAPT MENTIONED THAT TO ME. I MADE A COMMENT WONDERING WHY IT MIGHT BE OUT OF PARAMETERS. I THOUGHT MAYBE THE WIND WAS TOO STRONG AND I CHKED THE FMS WIND READOUT TO SEE. SINCE THE WX HAD IMPROVED AND WE DIDN'T NEED TO DO A CAT III APCH, THE CAPT DECIDED TO CONTINUE. THE PROB WITH THE AIII NOT BEING AVAILABLE CAUSED A DISTR AT A VERY BUSY TIME ON THE APCH. WE WERE INSTRUCTED BY SEA APCH CTL TO CONTACT SEA TWR. THE CAPT HAD SINCE DISENGAGED THE AUTOPLT AND WAS HAND FLYING, STILL USING THE HUD. WE HAD BEEN ON TOP OF A LAYER AND WERE LOOKING RIGHT INTO THE SUN AND IT MADE IT DIFFICULT TO READ THE INSTS. (THE CAPT COMMENTED TO ME, LATER AFTER ON THE GND, THAT THE BRIGHT SUNLIGHT MADE IT HARD FOR HER TO SEE THE INFO IN THE HUD AS WELL.) IN THE VICINITY OF THE FINAL APCH FIX, I NOTICED THAT WE WERE LOW ON THE GS AND PARALLELING IT. I TOLD THE CAPT TO CHK HER ALT, THAT WE WERE LOW AND CALLED OUT 'YOU'RE BELOW THE GS' OR 'GS.' SHE WAS CONFUSED FOR A FEW SECONDS BECAUSE (SHE LATER TOLD ME) SHE WAS SO FOCUSED ON FLYING USING THE HUD AND THAT THE ALT DISPLAY INFO IN THE HUD IS NOT VERY USER FRIENDLY AND DIFFICULT TO READ. SHE THEN INITIATED A CLB BACK TO INTERCEPT THE GS. WHILE SHE WAS IN THE PROCESS OF DOING THAT, WE RECEIVED A CALL FROM ATC ASKING US ABOUT OUR ALT AND THEY ISSUED A LOW ALT ALERT. I THINK I RESPONDED WITH 'CORRECTING,' OR SOMETHING SIMILAR. WE DID NOT RECEIVE ANY GPWS WARNINGS FROM OUR GPWS. THE AIRPLANE WAS CONFIGURED AND STABILIZED AND THE CAPT ELECTED TO CONTINUE THE APCH. WE LANDED WITHOUT INCIDENT. TO MY KNOWLEDGE THERE WAS NO TFC CONFLICTS WITH ANY OTHER ACFT. ONCE ON GND CTL, WE WERE GIVEN A PHONE NUMBER TO CALL. THE CAPT CALLED AND WAS TOLD THAT A PLTDEV RPT WOULD BE FILED. THERE ARE A NUMBER OF THINGS I THINK THAT CONTRIBUTED TO THIS SIT. USUALLY, THERE IS NOT JUST ONE THING YOU CAN POINT TO, BUT INSTEAD, SEVERAL LINKS IN THE CHAIN THAT LEAD YOU TO A DEV. I THINK THAT WHEN THE CAPT SELECTED VERT SPD TO INITIATE THE DSCNT TO 3000 FT I BELIEVE SHE ALSO PUSHED ALT SELECT ON THE FGC, AFTER I HAD ALREADY PROGRAMMED IT. ONE PUSH SELECTS IT 'ON.' IF IT IS PUSHED A SECOND TIME, IT DE-SELECTS IT OR TURNS IT 'OFF.' OUR PROC FOR YRS WAS FOR THE PF TO SELECT ALT SELECT, NOT THE PNF. THAT HAS CHANGED AND NOW IT'S THE PNF WHO SELECTS IT. A LOT OF PEOPLE ARE IN THE OLD HABIT OF SELECTING IT THEMSELVES. IF THEY DO THIS AFTER THE PNF SELECTS IT, IT BASICALLY TURNS IT OFF AND THEN IT WILL NOT LEVEL OFF AND CAPTURE THE ALT IN THE ALERTER. WHEN I PROGRAMMED IT, I MADE THE REQUIRED CALLOUTS AND VERIFIED THAT ALT SELECT WAS IN THE ADVISORY DISPLAY, BUT IMMEDIATELY AFTER THAT IS WHEN SHE SELECTED VERT SPD, AND I THINK THAT IS WHEN IT WAS PUSHED. THE 2 BUTTONS (VERT SPD AND ALT SELECT) ARE ONE RIGHT ABOVE THE OTHER. EVERYTHING REALLY HAPPENED QUICKLY. WE WERE CLRED TO DSND, CLRED FOR THE APCH, HAD THE DISTR OF THE AIII MODE NOT BECOMING AVAILABLE TO US, GOT A HDOF TO THE TWR AND INTERCEPTED FINAL ALL IN A VERY SHORT AMOUNT OF TIME. ALL THIS WITH THE FACT THAT THE SUN WAS EXTREMELY BRIGHT AND RIGHT IN OUR EYES, MAKING IT MORE DIFFICULT TO READ THE INSTS. THE CAPT SAID THE HUD IS EXTREMELY DIFFICULT TO READ WHEN LOOKING INTO THE SUN. ALSO, OUR ELECTRONIC FLT INSTS ARE ALL NOT ADJUSTED TO THE SAME BRIGHTNESS LEVEL. WE HAVE THE ABILITY TO ADJUST THEM, BUT NOT ALL THE AIRPLANES IN OUR FLEET ARE THE SAME. ON SOME ACFT, YOU CAN HAVE IT ADJUSTED FULL BRIGHT AND IT IS STILL VERY DIFFICULT TO SEE WHEN IN THE SUN. WHEN DISCUSSING IT LATER WITH THE CAPT, SHE BROUGHT UP THE FACT THAT IT IS VERY EASY TO GET COMPLETELY FOCUSED ON LOOKING THROUGH THE HUD AND TO FORGET ABOUT THE OTHER INSTS, SHE TOLD ME THAT THE ALT INFO IN THE HUD IS LACKING AND DIFFICULT TO USE. FINALLY, I DID NOT FEEL TIRED ENOUGH OR FATIGUED ENOUGH THAT I FELT I NEEDED TO UTILIZE THE FATIGUE POLICY OUR COMPANY HAS, HOWEVER, I THINK BEING UP SINCE XA30, 2 DAYS IN A ROW AND FEELING TIRED PROBABLY PLAYED A ROLE IN THIS FOR BOTH OF US.
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.