37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 720790 |
Time | |
Date | 200612 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : zdv.artcc |
State Reference | CO |
Altitude | msl single value : 12400 |
Aircraft 1 | |
Controlling Facilities | artcc : zdv.artcc |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : vacating altitude descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 180 flight time total : 8500 flight time type : 1370 |
ASRS Report | 720790 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 250 flight time total : 8000 flight time type : 4000 |
ASRS Report | 720793 |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | aircraft equipment : gpws other flight crewa other flight crewb |
Resolutory Action | flight crew : took precautionary avoidance action |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
We were flying the localizer FMS runway 25 approach into ege and made several errors in planning and executing the approach. This was after taking a look at the approach earlier in the day by myself and then reviewing it with my first officer before leaving ZZZ. We received the 'terrain; terrain' warning; performed the escape maneuver and still had plenty of time to re-insert the approach into the box and uneventfully complete the approach and landing into ege. Our first and biggest mistake was setting 12400 ft into the alerter shortly after leaving rlg and starting a slow descent (opn des). The second mistake was mine. The plane would not slow down due to up and down drafts and in fact was accelerating toward flap limit speed. I clicked off the autoplt to bring the nose up; fully intending to reengage it as soon as possible and asked for 'gear down; final.' I had to ask twice; because my first officer thought I said I would reengage turning final. I clarified; saying 'gear down; final descent checklist.' this distraction was apparently enough to keep me from returning to automatic-flight and hand-flying to slow down. I fixated on the speed and drifted to just below 12000 ft when the GPWS went off. We never got an altitude alert going below 12400 ft. My first officer did not question why I turned off the autoplt; but said later he wondered why I would want to hand fly the approach. The confusion with the gear request satisfied him I was planning to reengage. No one caught the wrong altitude; in fact; that was the altitude we briefed. How could we make such a bad mistake? I do not think I have ever done anything like this before. Something bothered me during that initial transition but I didn't know what it was and did not say anything. That night; it really bothered me that we still had so much time before aqula after our event. I went back to the plate and discovered our mistake. I showed my first officer the plate the next day and had to have him focus on the transition between rlg and aqula. He immediately saw the problem. How could we miss such basic information of the transition altitudes? We both think it is the big print approach procedures sidebar. The emphasis is on getting configured and slowed and down to 12400 ft. It never mentions the step down fixes. We focused on the 12400 ft and never really looked closely at the transition phase of the actual plate. We did brief the details from aqula inbound. I remember looking at the transition altitude between voaxa and aqula and reading it as 12400 ft as we started down; that is what I expected to see. I never saw the 13.8 or the final 12.4. It was like we were briefing 2 separate approachs and we did not combine them properly. We loaded the approach on the ground in ZZZ; but we could not get the rlg via to come up. The missing fixes were entered; but altitudes were not inserted. I doubled checked the database dates and verified that it was current. Having the constraints would have helped; but with the autoplt off; we still might have gotten low. It would probably given us both more situational awareness. Supplemental information from acn 720793: the next morning; the captain had me look at the approach again and I described once again that I would descend to 12400 ft passing rlg. He then made me see the MEA's listed between rlg; voaxa; and aqula. It was then that I realized the terrain warning had probably been activated not because we went below 12400 ft but because we should have been at 13800 ft. And that we were still 500 ft low at wambl when we leveled off at 12400 ft and not 12900 ft as published.
Original NASA ASRS Text
Title: A320 FLT CREW HAS A TERRAIN WARNING DURING APCH TO EGE; AND EXECUTES THE AVOIDANCE MANEUVER.
Narrative: WE WERE FLYING THE LOC FMS RWY 25 APCH INTO EGE AND MADE SEVERAL ERRORS IN PLANNING AND EXECUTING THE APCH. THIS WAS AFTER TAKING A LOOK AT THE APCH EARLIER IN THE DAY BY MYSELF AND THEN REVIEWING IT WITH MY FO BEFORE LEAVING ZZZ. WE RECEIVED THE 'TERRAIN; TERRAIN' WARNING; PERFORMED THE ESCAPE MANEUVER AND STILL HAD PLENTY OF TIME TO RE-INSERT THE APCH INTO THE BOX AND UNEVENTFULLY COMPLETE THE APCH AND LNDG INTO EGE. OUR FIRST AND BIGGEST MISTAKE WAS SETTING 12400 FT INTO THE ALERTER SHORTLY AFTER LEAVING RLG AND STARTING A SLOW DSCNT (OPN DES). THE SECOND MISTAKE WAS MINE. THE PLANE WOULD NOT SLOW DOWN DUE TO UP AND DOWN DRAFTS AND IN FACT WAS ACCELERATING TOWARD FLAP LIMIT SPD. I CLICKED OFF THE AUTOPLT TO BRING THE NOSE UP; FULLY INTENDING TO REENGAGE IT ASAP AND ASKED FOR 'GEAR DOWN; FINAL.' I HAD TO ASK TWICE; BECAUSE MY FO THOUGHT I SAID I WOULD REENGAGE TURNING FINAL. I CLARIFIED; SAYING 'GEAR DOWN; FINAL DSCNT CHKLIST.' THIS DISTR WAS APPARENTLY ENOUGH TO KEEP ME FROM RETURNING TO AUTO-FLT AND HAND-FLYING TO SLOW DOWN. I FIXATED ON THE SPD AND DRIFTED TO JUST BELOW 12000 FT WHEN THE GPWS WENT OFF. WE NEVER GOT AN ALT ALERT GOING BELOW 12400 FT. MY FO DID NOT QUESTION WHY I TURNED OFF THE AUTOPLT; BUT SAID LATER HE WONDERED WHY I WOULD WANT TO HAND FLY THE APCH. THE CONFUSION WITH THE GEAR REQUEST SATISFIED HIM I WAS PLANNING TO REENGAGE. NO ONE CAUGHT THE WRONG ALT; IN FACT; THAT WAS THE ALT WE BRIEFED. HOW COULD WE MAKE SUCH A BAD MISTAKE? I DO NOT THINK I HAVE EVER DONE ANYTHING LIKE THIS BEFORE. SOMETHING BOTHERED ME DURING THAT INITIAL TRANSITION BUT I DIDN'T KNOW WHAT IT WAS AND DID NOT SAY ANYTHING. THAT NIGHT; IT REALLY BOTHERED ME THAT WE STILL HAD SO MUCH TIME BEFORE AQULA AFTER OUR EVENT. I WENT BACK TO THE PLATE AND DISCOVERED OUR MISTAKE. I SHOWED MY FO THE PLATE THE NEXT DAY AND HAD TO HAVE HIM FOCUS ON THE TRANSITION BTWN RLG AND AQULA. HE IMMEDIATELY SAW THE PROB. HOW COULD WE MISS SUCH BASIC INFO OF THE TRANSITION ALTS? WE BOTH THINK IT IS THE BIG PRINT APCH PROCS SIDEBAR. THE EMPHASIS IS ON GETTING CONFIGURED AND SLOWED AND DOWN TO 12400 FT. IT NEVER MENTIONS THE STEP DOWN FIXES. WE FOCUSED ON THE 12400 FT AND NEVER REALLY LOOKED CLOSELY AT THE TRANSITION PHASE OF THE ACTUAL PLATE. WE DID BRIEF THE DETAILS FROM AQULA INBOUND. I REMEMBER LOOKING AT THE TRANSITION ALT BTWN VOAXA AND AQULA AND READING IT AS 12400 FT AS WE STARTED DOWN; THAT IS WHAT I EXPECTED TO SEE. I NEVER SAW THE 13.8 OR THE FINAL 12.4. IT WAS LIKE WE WERE BRIEFING 2 SEPARATE APCHS AND WE DID NOT COMBINE THEM PROPERLY. WE LOADED THE APCH ON THE GND IN ZZZ; BUT WE COULD NOT GET THE RLG VIA TO COME UP. THE MISSING FIXES WERE ENTERED; BUT ALTS WERE NOT INSERTED. I DOUBLED CHKED THE DATABASE DATES AND VERIFIED THAT IT WAS CURRENT. HAVING THE CONSTRAINTS WOULD HAVE HELPED; BUT WITH THE AUTOPLT OFF; WE STILL MIGHT HAVE GOTTEN LOW. IT WOULD PROBABLY GIVEN US BOTH MORE SITUATIONAL AWARENESS. SUPPLEMENTAL INFO FROM ACN 720793: THE NEXT MORNING; THE CAPT HAD ME LOOK AT THE APCH AGAIN AND I DESCRIBED ONCE AGAIN THAT I WOULD DSND TO 12400 FT PASSING RLG. HE THEN MADE ME SEE THE MEA'S LISTED BTWN RLG; VOAXA; AND AQULA. IT WAS THEN THAT I REALIZED THE TERRAIN WARNING HAD PROBABLY BEEN ACTIVATED NOT BECAUSE WE WENT BELOW 12400 FT BUT BECAUSE WE SHOULD HAVE BEEN AT 13800 FT. AND THAT WE WERE STILL 500 FT LOW AT WAMBL WHEN WE LEVELED OFF AT 12400 FT AND NOT 12900 FT AS PUBLISHED.
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.