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|
Attributes | |
ACN | 706370 |
Time | |
Date | 200608 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : mci.airport |
State Reference | MO |
Altitude | agl single value : 500 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : mci.tower tower : ont.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 1r Other |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 293 flight time type : 293 |
ASRS Report | 706370 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 305 |
ASRS Report | 706374 |
Events | |
Anomaly | non adherence : company policies non adherence : far other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Aiii hgs approach briefed to runway 1R at mci. WX was about 500 ft and 3 mi visibility. Intercepted GS at 3000 ft MSL and followed it down in hgs mode. Somewhere during the subsequent approach I lost awareness of our altitude in relation to the field elevation. Confign went from flaps 5 degrees; gear down; flaps 15 degrees; then flaps 30 degrees (briefed as final flaps). About the time I called for flaps 30 degrees we were breaking out and the flap confign warning went off (as flaps were in transit from 15 degrees to 30 degrees). I was totally surprised. While in the WX; I was thinking we were just approaching 1000 ft AGL! I continued the landing uneventfully and pondered this event until we reached home today. The report is being submitted now because I just realized we broke procedure and I want to call to attention the procedural breakdown I committed by not properly maintaining my situational awareness; not being configured for a 'stabilized approach;' and not going around in a 'messed up situation.' by the time I realized I was 'off' by 1000 ft in my 'mental altimeter;' we were in the round out and flare. My mistake to land! My first officer and I talked at length about callouts and our procedures to correct deviations. He did not realize how 'messed up' I was during this approach and watched it happen! He is an excellent pilot and I think this really surprised him and will give him an appreciation to not 'trust' any situation. Supplemental information from acn 706374: briefed an aiii hgs approach (not required) to runway 1R in mci. WX was improving (approach control) from ATIS report of 300 degrees; 2 mi. Vectored to final at 3000 ft MSL and asked to hold 170 KTS to the marker. Intercepted glide path with flaps 5 degrees (masi minimum speed approximately 160 KTS). About here I realize we are 'behind' the aircraft and point out we are 6 DME. After another mi or so; the captain calls for landing gear and flaps 15 degrees. Because we are remaining on the GS; the aircraft is not slowing much. At about this point; I start to fixate on the airspeed and the GS. I miss the 1000 ft call (key error). Somewhere around that point; the captain calls for flaps 30 degree. I initially move the flaps to 25 degrees and eventually to 30 degrees. At approximately 500 ft AGL; we break out of the WX and transition to a visual landing. Simultaneously; we received a 'pull up; too low' warning. I considered it; but failed to direct a go around. I also missed the 500 ft and 500 ft callouts. We landed long but had no trouble stopping the aircraft. I have flown with this captain previously for a month and a 3-DAY last week. He is an excellent pilot and I have never seen him come close to falling behind the aircraft! I think my mindset/comfort level allowed me to let this approach proceed farther than it should. Although not characteristic of this captain to 'press;' I never realized his situational awareness was out the window and was 1000 ft behind the aircraft. Shortly after his disappearance; though; my situational awareness followed! By missing my callouts; I contributed to his failing situational awareness instead of helping it. I should have directed a go around at 1000 ft and again on short final. In 6 yrs here; I have not experienced anything like this and it was a true 'wake up' call. I will never assume the PF is 'totally aware' and will be directive when required.
Original NASA ASRS Text
Title: A B737-700 CAPT AND AN HGS APCH INTO MCI LOSES SITUATIONAL AWARENESS AND IS STILL EXTENDING FLAPS TO LNDG SETTING WHEN THEY BREAK OUT AT 500 FT AGL.
Narrative: AIII HGS APCH BRIEFED TO RWY 1R AT MCI. WX WAS ABOUT 500 FT AND 3 MI VISIBILITY. INTERCEPTED GS AT 3000 FT MSL AND FOLLOWED IT DOWN IN HGS MODE. SOMEWHERE DURING THE SUBSEQUENT APCH I LOST AWARENESS OF OUR ALT IN RELATION TO THE FIELD ELEVATION. CONFIGN WENT FROM FLAPS 5 DEGS; GEAR DOWN; FLAPS 15 DEGS; THEN FLAPS 30 DEGS (BRIEFED AS FINAL FLAPS). ABOUT THE TIME I CALLED FOR FLAPS 30 DEGS WE WERE BREAKING OUT AND THE FLAP CONFIGN WARNING WENT OFF (AS FLAPS WERE IN TRANSIT FROM 15 DEGS TO 30 DEGS). I WAS TOTALLY SURPRISED. WHILE IN THE WX; I WAS THINKING WE WERE JUST APCHING 1000 FT AGL! I CONTINUED THE LNDG UNEVENTFULLY AND PONDERED THIS EVENT UNTIL WE REACHED HOME TODAY. THE RPT IS BEING SUBMITTED NOW BECAUSE I JUST REALIZED WE BROKE PROC AND I WANT TO CALL TO ATTN THE PROCEDURAL BREAKDOWN I COMMITTED BY NOT PROPERLY MAINTAINING MY SITUATIONAL AWARENESS; NOT BEING CONFIGURED FOR A 'STABILIZED APCH;' AND NOT GOING AROUND IN A 'MESSED UP SITUATION.' BY THE TIME I REALIZED I WAS 'OFF' BY 1000 FT IN MY 'MENTAL ALTIMETER;' WE WERE IN THE ROUND OUT AND FLARE. MY MISTAKE TO LAND! MY FO AND I TALKED AT LENGTH ABOUT CALLOUTS AND OUR PROCS TO CORRECT DEVS. HE DID NOT REALIZE HOW 'MESSED UP' I WAS DURING THIS APCH AND WATCHED IT HAPPEN! HE IS AN EXCELLENT PLT AND I THINK THIS REALLY SURPRISED HIM AND WILL GIVE HIM AN APPRECIATION TO NOT 'TRUST' ANY SITUATION. SUPPLEMENTAL INFO FROM ACN 706374: BRIEFED AN AIII HGS APCH (NOT REQUIRED) TO RWY 1R IN MCI. WX WAS IMPROVING (APCH CTL) FROM ATIS RPT OF 300 DEGS; 2 MI. VECTORED TO FINAL AT 3000 FT MSL AND ASKED TO HOLD 170 KTS TO THE MARKER. INTERCEPTED GLIDE PATH WITH FLAPS 5 DEGS (MASI MINIMUM SPD APPROX 160 KTS). ABOUT HERE I REALIZE WE ARE 'BEHIND' THE ACFT AND POINT OUT WE ARE 6 DME. AFTER ANOTHER MI OR SO; THE CAPT CALLS FOR LNDG GEAR AND FLAPS 15 DEGS. BECAUSE WE ARE REMAINING ON THE GS; THE ACFT IS NOT SLOWING MUCH. AT ABOUT THIS POINT; I START TO FIXATE ON THE AIRSPD AND THE GS. I MISS THE 1000 FT CALL (KEY ERROR). SOMEWHERE AROUND THAT POINT; THE CAPT CALLS FOR FLAPS 30 DEG. I INITIALLY MOVE THE FLAPS TO 25 DEGS AND EVENTUALLY TO 30 DEGS. AT APPROX 500 FT AGL; WE BREAK OUT OF THE WX AND TRANSITION TO A VISUAL LNDG. SIMULTANEOUSLY; WE RECEIVED A 'PULL UP; TOO LOW' WARNING. I CONSIDERED IT; BUT FAILED TO DIRECT A GAR. I ALSO MISSED THE 500 FT AND 500 FT CALLOUTS. WE LANDED LONG BUT HAD NO TROUBLE STOPPING THE ACFT. I HAVE FLOWN WITH THIS CAPT PREVIOUSLY FOR A MONTH AND A 3-DAY LAST WK. HE IS AN EXCELLENT PLT AND I HAVE NEVER SEEN HIM COME CLOSE TO FALLING BEHIND THE ACFT! I THINK MY MINDSET/COMFORT LEVEL ALLOWED ME TO LET THIS APCH PROCEED FARTHER THAN IT SHOULD. ALTHOUGH NOT CHARACTERISTIC OF THIS CAPT TO 'PRESS;' I NEVER REALIZED HIS SITUATIONAL AWARENESS WAS OUT THE WINDOW AND WAS 1000 FT BEHIND THE ACFT. SHORTLY AFTER HIS DISAPPEARANCE; THOUGH; MY SITUATIONAL AWARENESS FOLLOWED! BY MISSING MY CALLOUTS; I CONTRIBUTED TO HIS FAILING SITUATIONAL AWARENESS INSTEAD OF HELPING IT. I SHOULD HAVE DIRECTED A GAR AT 1000 FT AND AGAIN ON SHORT FINAL. IN 6 YRS HERE; I HAVE NOT EXPERIENCED ANYTHING LIKE THIS AND IT WAS A TRUE 'WAKE UP' CALL. I WILL NEVER ASSUME THE PF IS 'TOTALLY AWARE' AND WILL BE DIRECTIVE WHEN REQUIRED.
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.