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|
Attributes | |
ACN | 740110 |
Time | |
Date | 200705 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : teb.airport |
State Reference | NJ |
Altitude | msl single value : 1500 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tower : teb.tower |
Operator | general aviation : personal |
Make Model Name | Beechjet 400 |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach |
Route In Use | approach : visual |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 60 flight time total : 5000 flight time type : 300 |
ASRS Report | 740110 |
Events | |
Anomaly | other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : became reoriented flight crew : returned to intended or assigned course |
Supplementary | |
Problem Areas | Company Flight Crew Human Performance |
Primary Problem | Company |
Narrative:
Navigation #1 fail en route to teb. VOR/DME a approach in use landing runway 19. Captain's leg. With navigation #1 inoperative; captain and first officer decided to have first officer fly the approach and return aircraft control to captain when approach completed overhead teb. In hindsight; this was poor decision making and was likely agreed to due to both pilots being tired. First officer was nearing the end of a 14 hour duty period. First officer was briefed 10 hours prior to show time; and between late notice and a new baby; had been awake nearly 20 hours; not eaten in 7 hours. In any case; the captain was handling radios and forgot to contact tower; and first officer relinquished control to captain overhead teb; thinking they were at a position to turn downwind. First officer was unable to see the airport. Checklist was still being performed and crew turned downwind overhead; completing the checklist. First officer now was PNF and asked captain if he called tower. No reply. First officer called tower; who was already asking us what was going on; and at this time; captain had begun a right turn to correct course. It was too late by now. We turned final; overshot and returned to course; landed. The next morning; after calling in fatigued (a minimum rest overnight was assigned; first officer refused); with adequate rest; it was clear to us that we created our own mess out of a simple instrument error. This goes to show how 2 tired pilots can over-complicate what should have been a routine flight with a simple VOR out. Recommendations: 1) call in fatigued before you deteriorate; even if coming in from a day off. 2) when the company knows an early show; with a time change is scheduled; do not wait until the last minute to notify a crew member.
Original NASA ASRS Text
Title: BE400 FLT CREW; CONDUCTING VOR APCH; INITIALLY FAILED TO CONTACT TWR; THEN OVERSHOT FINAL ON APCH. COURSE WAS CORRECTED AND FLT CONTINUED TO LNDG.
Narrative: NAV #1 FAIL ENRTE TO TEB. VOR/DME A APCH IN USE LNDG RWY 19. CAPT'S LEG. WITH NAV #1 INOP; CAPT AND FO DECIDED TO HAVE FO FLY THE APCH AND RETURN ACFT CTL TO CAPT WHEN APCH COMPLETED OVERHEAD TEB. IN HINDSIGHT; THIS WAS POOR DECISION MAKING AND WAS LIKELY AGREED TO DUE TO BOTH PLTS BEING TIRED. FO WAS NEARING THE END OF A 14 HR DUTY PERIOD. FO WAS BRIEFED 10 HRS PRIOR TO SHOW TIME; AND BTWN LATE NOTICE AND A NEW BABY; HAD BEEN AWAKE NEARLY 20 HRS; NOT EATEN IN 7 HRS. IN ANY CASE; THE CAPT WAS HANDLING RADIOS AND FORGOT TO CONTACT TWR; AND FO RELINQUISHED CTL TO CAPT OVERHEAD TEB; THINKING THEY WERE AT A POS TO TURN DOWNWIND. FO WAS UNABLE TO SEE THE ARPT. CHKLIST WAS STILL BEING PERFORMED AND CREW TURNED DOWNWIND OVERHEAD; COMPLETING THE CHKLIST. FO NOW WAS PNF AND ASKED CAPT IF HE CALLED TWR. NO REPLY. FO CALLED TWR; WHO WAS ALREADY ASKING US WHAT WAS GOING ON; AND AT THIS TIME; CAPT HAD BEGUN A R TURN TO CORRECT COURSE. IT WAS TOO LATE BY NOW. WE TURNED FINAL; OVERSHOT AND RETURNED TO COURSE; LANDED. THE NEXT MORNING; AFTER CALLING IN FATIGUED (A MINIMUM REST OVERNIGHT WAS ASSIGNED; FO REFUSED); WITH ADEQUATE REST; IT WAS CLR TO US THAT WE CREATED OUR OWN MESS OUT OF A SIMPLE INST ERROR. THIS GOES TO SHOW HOW 2 TIRED PLTS CAN OVER-COMPLICATE WHAT SHOULD HAVE BEEN A ROUTINE FLT WITH A SIMPLE VOR OUT. RECOMMENDATIONS: 1) CALL IN FATIGUED BEFORE YOU DETERIORATE; EVEN IF COMING IN FROM A DAY OFF. 2) WHEN THE COMPANY KNOWS AN EARLY SHOW; WITH A TIME CHANGE IS SCHEDULED; DO NOT WAIT UNTIL THE LAST MINUTE TO NOTIFY A CREW MEMBER.
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.