37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 701555 |
Time | |
Date | 200606 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : atl.airport |
State Reference | GA |
Altitude | agl bound lower : 500 agl bound upper : 3500 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Turbulence Rain Thunderstorm |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : atl.tower |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff landing : missed approach |
Route In Use | arrival star : erlin.two |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : cfi pilot : atp pilot : commercial |
Experience | flight time last 90 days : 192 flight time total : 3703 flight time type : 1320 |
ASRS Report | 701555 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | inflight encounter : weather inflight encounter : turbulence non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : exited adverse environment flight crew : executed missed approach flight crew : diverted to alternate |
Consequence | Other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Upon arrival into the atlanta area through the erlin 2 arrival; we were instructed to hold over rome VOR with an efc 35 mins later. The captain and I discussed our fuel situation as the radar painted a strong line of thunderstorms between us and the airport. The captain's mental math left him comfortable (he seemed comfortable) with the situation assuming we got to our efc time and were then vectored in to land in atlanta. I was not so comfortable and was starting to think we might be better off just going to chattanooga (we could hear on the radio that other aircraft were spending a good amount of their efc in the holding pattern as opposed to the half-turn-and-you're-out kind of hold). However; the WX (ATIS) in atlanta did not seem to be an issue as the surface winds were favoring an eastern approach to runway 8L and the lowest cloud layer was at 5000 ft. With that WX in mind; I agreed with his reasoning. The fuel situation became a moot point as only 20 mins into the hold we were cleared to atlanta via radar vectors for the ILS runway 8L. We were approximately 15 mi in trail of another aircraft who was already penetrating the line of WX. Approach asked him for his ride conditions and they reported light to moderate turbulence through the line between the dalas and stutz waypoint. We experienced the same in addition to heavy rain as we were vectored south towards the approach. Joining the final outside of bahrr; we were cleared for the approach and 180 KTS to schel. The radar was not providing useful information as the same image was painting at both upper and lower tilt limitations. I assumed the radome was saturated with water from the heavy rain showers. Regardless; joining the final; we were in the clear with about 4-5 mi visibility. Coming up on a 10 mi final; we were queried by atl approach. I responded with our call sign and we were then instructed to contact tower. The approach controller's intonation made it sound like I had missed an earlier handoff. I asked the captain and he agreed that I hadn't. Switching to tower; we were immediately informed of surface winds of 290 degrees at 21 KTS gusting to 29 KTS and asked for our intentions. I looked to the captain for a response; knowing full well that we could not legally land the aircraft in more than a 10 KT tailwind. I then stated that 'that's too much.' perhaps due to the fact that another aircraft had just landed in front of us; the captain decided to continue on. I must have transmitted this intention to the tower. I'm not sure of the exact verbiage; but I am sure that we received a clearance to land and another wind advisory of 330 degrees at 21 KTS -- a 40 degree direction shift. Over the intercom; I again stated to the captain that the wind was too strong. He then instructed me to check the wind component chart in the speed card. Unnecessarily I grabbed the card even though I knew (I was sure) that the wind still exceeded the limitation set on the act. I had hoped that showing him the out-of-limits tailwind component would cause him to change his mind; now set on landing and led him to go around. I never got the speed card open to the correct page as there were more pressing issues. I told him at approximately 1500 ft AGL that we were not configured for landing. Flaps were at 20 degrees and the gear was still up. He then called for 'gear down; flaps 30 degrees; landing check to the line.' now back in IMC and heavy rain; my attention was away from the instruments and; therefore; the approach as I configured the aircraft. 'Flaps 45 degrees and below.' inside the OM; I finish configured the aircraft and the captain begins telling me to get a 'wind check.' my first request to atl tower goes unanswered. Now; more forcefully; the captain repeats; 'wind check! Wind check!' I cannot say anything over the radio as tower is in the middle of a transmission to another aircraft and we get an updated wind check. At approximately 500 ft AGL I state; 'sir; I recommend we go around.' without much hesitation; he agrees by pushing the toga button increasing power and pitching up. 'Set go around power; spoilers in; flaps 8 degrees.' when I reach for the thrust levers; I see that the N1 fans are already at approximately 88%. I push the power up TO94.8% to match the GA N1 bugs; check that the spoiler handle is forward and reset flaps to 8 degrees. While my head is down setting the power and reconfiguring the aircraft; my attention is again away from the instruments. I cue the microphone and stated; 'air carrier X is going around.' 'air carrier X turn left heading 060 degrees; climb and maintain 3500 ft.' I respond to the instructions and as my attention returns to the pfd; I see that the captain is in a climbing right turn away from the command bars. In disbelief; I xchk his pfd; confirm that they are the same then say; 'left turn! Left turn!' there is no response from the captain who is still in a 20 degree right bank (climbing) attitude. Tower 'air carrier X turn left heading 040 degrees; climb and maintain 3500 ft. Did you turn right?!?' I respond on the radio first; 'left turn 040 degrees;' then on the intercom; 'immediate left turn!' the captain then begins the left turn to the 040 degree heading. The appropriate published missed approach procedure is to climb straight ahead to 1500 ft then a climbing left turn out to the missed approach fix. The tower's modified instructions along with the published instructions are specifically designed to get the aircraft away from departures and a possible go around from the other runways. Climbing out; 'positive rate.' 'gear up; speed mode; heading mode.' I had already set the heading bug and he began a turn towards it. A moment later; we receive an overspd clacker and he orders; 'flaps up; after takeoff; autoplt on.' I complied with all. The remainder of the flight -- the diversion to chattanooga -- went without issue. Safely on the ground in chattanooga; the captain and I briefly discussed what had happened. I was concerned with the implications and disappointed in how we let the situation get so far out of hand; yet there was 1 thing I needed clarification on. In my memory; in the back of my head; I knew that the egpws was activated during this event; but I cannot place where or when (perhaps I was actively talking to the tower at the time). Regardless; I asked the captain. He confirmed that the egpws had activated briefly during the go around. He believed that the transition from approach/GS (approach) mode to go around/go around must have changed the threshold limits causing the egpws event and that this was a non event. Since I cannot place the egpws event in the timeline; I feel it is possible that our excessive descent rate required with the accelerated ground speed and constant ILS GS may have caused the activation during the go around roundout. Possible factors: 1) stress about the earlier potential fuel situation; the line of thunderstorms and the threat they could have posed; and the loss of the ability to see them (radar). 2) the excessive tailwind. 3) the late gear and flap confign. 4) the incorrect hand-flown missed approach procedure. Faults I find in my behavior: 1) my inability to unambiguously state my concerns about the excessive tailwind. 2) not recommending the go around at a much earlier point. 3) my distraction from the flight instruments. 4) my apparent distraction from the GPWS warning. I should have spoken up when tower initially gave us a wind report with a 20 KT tailwind. Going along with the approach and assuming that the captain knows what he is doing and will ultimately make the correct decision was the wrong decision. CRM training emphasizes this; but for me it took a serious incident to drive that fact home. My voice must be louder when I see something wrong and in no uncertain terms point out the problem. saying
Original NASA ASRS Text
Title: A CL65 FO ANALYZES HIS PERFORMANCE THROUGHOUT AN APCH TO ATL THAT INCLUDED HOLDING; CHANGING WX; DIVERSION ISSUES CONCLUDING WITH A NOT WELL FLOWN MISSED APCH AND AN EGPWS WARNING.
Narrative: UPON ARR INTO THE ATLANTA AREA THROUGH THE ERLIN 2 ARR; WE WERE INSTRUCTED TO HOLD OVER ROME VOR WITH AN EFC 35 MINS LATER. THE CAPT AND I DISCUSSED OUR FUEL SITUATION AS THE RADAR PAINTED A STRONG LINE OF TSTMS BTWN US AND THE ARPT. THE CAPT'S MENTAL MATH LEFT HIM COMFORTABLE (HE SEEMED COMFORTABLE) WITH THE SITUATION ASSUMING WE GOT TO OUR EFC TIME AND WERE THEN VECTORED IN TO LAND IN ATLANTA. I WAS NOT SO COMFORTABLE AND WAS STARTING TO THINK WE MIGHT BE BETTER OFF JUST GOING TO CHATTANOOGA (WE COULD HEAR ON THE RADIO THAT OTHER ACFT WERE SPENDING A GOOD AMOUNT OF THEIR EFC IN THE HOLDING PATTERN AS OPPOSED TO THE HALF-TURN-AND-YOU'RE-OUT KIND OF HOLD). HOWEVER; THE WX (ATIS) IN ATLANTA DID NOT SEEM TO BE AN ISSUE AS THE SURFACE WINDS WERE FAVORING AN EASTERN APCH TO RWY 8L AND THE LOWEST CLOUD LAYER WAS AT 5000 FT. WITH THAT WX IN MIND; I AGREED WITH HIS REASONING. THE FUEL SITUATION BECAME A MOOT POINT AS ONLY 20 MINS INTO THE HOLD WE WERE CLRED TO ATLANTA VIA RADAR VECTORS FOR THE ILS RWY 8L. WE WERE APPROX 15 MI IN TRAIL OF ANOTHER ACFT WHO WAS ALREADY PENETRATING THE LINE OF WX. APCH ASKED HIM FOR HIS RIDE CONDITIONS AND THEY RPTED LIGHT TO MODERATE TURB THROUGH THE LINE BTWN THE DALAS AND STUTZ WAYPOINT. WE EXPERIENCED THE SAME IN ADDITION TO HVY RAIN AS WE WERE VECTORED S TOWARDS THE APCH. JOINING THE FINAL OUTSIDE OF BAHRR; WE WERE CLRED FOR THE APCH AND 180 KTS TO SCHEL. THE RADAR WAS NOT PROVIDING USEFUL INFO AS THE SAME IMAGE WAS PAINTING AT BOTH UPPER AND LOWER TILT LIMITATIONS. I ASSUMED THE RADOME WAS SATURATED WITH WATER FROM THE HVY RAIN SHOWERS. REGARDLESS; JOINING THE FINAL; WE WERE IN THE CLR WITH ABOUT 4-5 MI VISIBILITY. COMING UP ON A 10 MI FINAL; WE WERE QUERIED BY ATL APCH. I RESPONDED WITH OUR CALL SIGN AND WE WERE THEN INSTRUCTED TO CONTACT TWR. THE APCH CTLR'S INTONATION MADE IT SOUND LIKE I HAD MISSED AN EARLIER HDOF. I ASKED THE CAPT AND HE AGREED THAT I HADN'T. SWITCHING TO TWR; WE WERE IMMEDIATELY INFORMED OF SURFACE WINDS OF 290 DEGS AT 21 KTS GUSTING TO 29 KTS AND ASKED FOR OUR INTENTIONS. I LOOKED TO THE CAPT FOR A RESPONSE; KNOWING FULL WELL THAT WE COULD NOT LEGALLY LAND THE ACFT IN MORE THAN A 10 KT TAILWIND. I THEN STATED THAT 'THAT'S TOO MUCH.' PERHAPS DUE TO THE FACT THAT ANOTHER ACFT HAD JUST LANDED IN FRONT OF US; THE CAPT DECIDED TO CONTINUE ON. I MUST HAVE XMITTED THIS INTENTION TO THE TWR. I'M NOT SURE OF THE EXACT VERBIAGE; BUT I AM SURE THAT WE RECEIVED A CLRNC TO LAND AND ANOTHER WIND ADVISORY OF 330 DEGS AT 21 KTS -- A 40 DEG DIRECTION SHIFT. OVER THE INTERCOM; I AGAIN STATED TO THE CAPT THAT THE WIND WAS TOO STRONG. HE THEN INSTRUCTED ME TO CHK THE WIND COMPONENT CHART IN THE SPD CARD. UNNECESSARILY I GRABBED THE CARD EVEN THOUGH I KNEW (I WAS SURE) THAT THE WIND STILL EXCEEDED THE LIMITATION SET ON THE ACT. I HAD HOPED THAT SHOWING HIM THE OUT-OF-LIMITS TAILWIND COMPONENT WOULD CAUSE HIM TO CHANGE HIS MIND; NOW SET ON LNDG AND LED HIM TO GO AROUND. I NEVER GOT THE SPD CARD OPEN TO THE CORRECT PAGE AS THERE WERE MORE PRESSING ISSUES. I TOLD HIM AT APPROX 1500 FT AGL THAT WE WERE NOT CONFIGURED FOR LNDG. FLAPS WERE AT 20 DEGS AND THE GEAR WAS STILL UP. HE THEN CALLED FOR 'GEAR DOWN; FLAPS 30 DEGS; LNDG CHK TO THE LINE.' NOW BACK IN IMC AND HVY RAIN; MY ATTN WAS AWAY FROM THE INSTS AND; THEREFORE; THE APCH AS I CONFIGURED THE ACFT. 'FLAPS 45 DEGS AND BELOW.' INSIDE THE OM; I FINISH CONFIGURED THE ACFT AND THE CAPT BEGINS TELLING ME TO GET A 'WIND CHK.' MY FIRST REQUEST TO ATL TWR GOES UNANSWERED. NOW; MORE FORCEFULLY; THE CAPT REPEATS; 'WIND CHK! WIND CHK!' I CANNOT SAY ANYTHING OVER THE RADIO AS TWR IS IN THE MIDDLE OF A XMISSION TO ANOTHER ACFT AND WE GET AN UPDATED WIND CHK. AT APPROX 500 FT AGL I STATE; 'SIR; I RECOMMEND WE GO AROUND.' WITHOUT MUCH HESITATION; HE AGREES BY PUSHING THE TOGA BUTTON INCREASING PWR AND PITCHING UP. 'SET GAR PWR; SPOILERS IN; FLAPS 8 DEGS.' WHEN I REACH FOR THE THRUST LEVERS; I SEE THAT THE N1 FANS ARE ALREADY AT APPROX 88%. I PUSH THE PWR UP TO94.8% TO MATCH THE GA N1 BUGS; CHK THAT THE SPOILER HANDLE IS FORWARD AND RESET FLAPS TO 8 DEGS. WHILE MY HEAD IS DOWN SETTING THE PWR AND RECONFIGURING THE ACFT; MY ATTN IS AGAIN AWAY FROM THE INSTS. I CUE THE MIKE AND STATED; 'ACR X IS GOING AROUND.' 'ACR X TURN L HDG 060 DEGS; CLB AND MAINTAIN 3500 FT.' I RESPOND TO THE INSTRUCTIONS AND AS MY ATTN RETURNS TO THE PFD; I SEE THAT THE CAPT IS IN A CLBING R TURN AWAY FROM THE COMMAND BARS. IN DISBELIEF; I XCHK HIS PFD; CONFIRM THAT THEY ARE THE SAME THEN SAY; 'L TURN! L TURN!' THERE IS NO RESPONSE FROM THE CAPT WHO IS STILL IN A 20 DEG R BANK (CLBING) ATTITUDE. TWR 'ACR X TURN L HDG 040 DEGS; CLB AND MAINTAIN 3500 FT. DID YOU TURN R?!?' I RESPOND ON THE RADIO FIRST; 'L TURN 040 DEGS;' THEN ON THE INTERCOM; 'IMMEDIATE L TURN!' THE CAPT THEN BEGINS THE L TURN TO THE 040 DEG HDG. THE APPROPRIATE PUBLISHED MISSED APCH PROC IS TO CLB STRAIGHT AHEAD TO 1500 FT THEN A CLBING L TURN OUT TO THE MISSED APCH FIX. THE TWR'S MODIFIED INSTRUCTIONS ALONG WITH THE PUBLISHED INSTRUCTIONS ARE SPECIFICALLY DESIGNED TO GET THE ACFT AWAY FROM DEPS AND A POSSIBLE GAR FROM THE OTHER RWYS. CLBING OUT; 'POSITIVE RATE.' 'GEAR UP; SPD MODE; HDG MODE.' I HAD ALREADY SET THE HDG BUG AND HE BEGAN A TURN TOWARDS IT. A MOMENT LATER; WE RECEIVE AN OVERSPD CLACKER AND HE ORDERS; 'FLAPS UP; AFTER TKOF; AUTOPLT ON.' I COMPLIED WITH ALL. THE REMAINDER OF THE FLT -- THE DIVERSION TO CHATTANOOGA -- WENT WITHOUT ISSUE. SAFELY ON THE GND IN CHATTANOOGA; THE CAPT AND I BRIEFLY DISCUSSED WHAT HAD HAPPENED. I WAS CONCERNED WITH THE IMPLICATIONS AND DISAPPOINTED IN HOW WE LET THE SITUATION GET SO FAR OUT OF HAND; YET THERE WAS 1 THING I NEEDED CLARIFICATION ON. IN MY MEMORY; IN THE BACK OF MY HEAD; I KNEW THAT THE EGPWS WAS ACTIVATED DURING THIS EVENT; BUT I CANNOT PLACE WHERE OR WHEN (PERHAPS I WAS ACTIVELY TALKING TO THE TWR AT THE TIME). REGARDLESS; I ASKED THE CAPT. HE CONFIRMED THAT THE EGPWS HAD ACTIVATED BRIEFLY DURING THE GAR. HE BELIEVED THAT THE TRANSITION FROM APCH/GS (APCH) MODE TO GAR/GAR MUST HAVE CHANGED THE THRESHOLD LIMITS CAUSING THE EGPWS EVENT AND THAT THIS WAS A NON EVENT. SINCE I CANNOT PLACE THE EGPWS EVENT IN THE TIMELINE; I FEEL IT IS POSSIBLE THAT OUR EXCESSIVE DSCNT RATE REQUIRED WITH THE ACCELERATED GND SPD AND CONSTANT ILS GS MAY HAVE CAUSED THE ACTIVATION DURING THE GAR ROUNDOUT. POSSIBLE FACTORS: 1) STRESS ABOUT THE EARLIER POTENTIAL FUEL SITUATION; THE LINE OF TSTMS AND THE THREAT THEY COULD HAVE POSED; AND THE LOSS OF THE ABILITY TO SEE THEM (RADAR). 2) THE EXCESSIVE TAILWIND. 3) THE LATE GEAR AND FLAP CONFIGN. 4) THE INCORRECT HAND-FLOWN MISSED APCH PROC. FAULTS I FIND IN MY BEHAVIOR: 1) MY INABILITY TO UNAMBIGUOUSLY STATE MY CONCERNS ABOUT THE EXCESSIVE TAILWIND. 2) NOT RECOMMENDING THE GAR AT A MUCH EARLIER POINT. 3) MY DISTR FROM THE FLT INSTS. 4) MY APPARENT DISTR FROM THE GPWS WARNING. I SHOULD HAVE SPOKEN UP WHEN TWR INITIALLY GAVE US A WIND RPT WITH A 20 KT TAILWIND. GOING ALONG WITH THE APCH AND ASSUMING THAT THE CAPT KNOWS WHAT HE IS DOING AND WILL ULTIMATELY MAKE THE CORRECT DECISION WAS THE WRONG DECISION. CRM TRAINING EMPHASIZES THIS; BUT FOR ME IT TOOK A SERIOUS INCIDENT TO DRIVE THAT FACT HOME. MY VOICE MUST BE LOUDER WHEN I SEE SOMETHING WRONG AND IN NO UNCERTAIN TERMS POINT OUT THE PROB. SAYING
Data retrieved from NASA's ASRS site as of January 2009 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.