37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 751143 |
Time | |
Date | 200708 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : atl.airport |
State Reference | GA |
Altitude | msl bound lower : 5600 msl bound upper : 7000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : a80.tracon |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 27l other |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : atp pilot : private |
Experience | flight time last 90 days : 240 flight time total : 10000 flight time type : 3000 |
ASRS Report | 751143 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : relief pilot |
Qualification | pilot : commercial pilot : flight engineer pilot : instrument pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 201 flight time total : 7700 flight time type : 3065 |
ASRS Report | 750090 |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : overcame equipment problem |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
I was the first officer and PF on the above referenced flight. The flight was uneventful up to the incident in question in the atlanta traffic pattern. I briefed and selected the ILS prm runway 27L approach. As we got closer to the final approach course; it was becoming clear that if we didn't get a turn to intercept the final approach course soon; we would overshoot the course. I made the comment to the pilots that she better turn us quick or we're going to overshoot. Before the captain keyed the microphone to query the controller; she quickly told us to turn right to a 240 degree heading; descent from 7000 ft to 5000 ft; cleared to intercept runway 27L localizer. Her instructions began when we were just inside 1 mi to intercept and she was still giving us these instructions when we were approximately 1/2-1 mi overshot of the final. With our speed at 220 KIAS and on our turn to final; it appeared we rolled out about 1 mi left of course. She gave the instructions very quickly and in such a way that based on our apparent FMS position; it seemed clear to us that she realized that her delay in giving instructions had caused us to overshoot. At this point; I was worried about conflicts with runway 28 traffic; so I followed her instructions by turning right as quickly as possible to correct back towards the course; began the descent to 5000 ft; armed the localizer at the completion of her instructions; and rolled out on the heading she gave us. The FMS course was about 1 mi back to our right. I communicated to the captain to tell the controller we needed to come further right to intercept; because we were moving even further left away from the course. As he began to ask for the correction; she indicated in an obvious voice of concern that we were moving too far right. This was totally opposite to our FMS indications (FMS showed us left of track). She further stated that we were attempting to line up on runway 26R or that we must have loaded runway 26R into our computer; or something to that effect. All of the pilots quickly reconfirmed that we had the correct runway 27L approach loaded in the FMS. The captain stated to her that the correct approach was loaded; whereby she said we were still moving further right. She also said to stop our descent at 6000 ft versus 5000 ft. That instruction came when we were approaching 6000 ft. I quickly attempted to stop our descent but the aircraft continued a descent below 6000 ft to approximately 5500 ft. I then began a correction up to the assigned altitude. Simultaneously; the captain told the controller to 'give us a vector out of this approach; as there is an obvious conflict of information' or words to that effect. As we were departing; on a 290 degree directed heading; the relief officer stated that the localizer needle indicated the localizer course was left; yet the FMS course was still indicating far right. It became clear at that point that we had experienced a map shift on our FMS. As we exited the traffic pattern; we agreed that we would disregard FMS data and only use raw data on a subsequent approach due to the apparent FMS system malfunction. We were resequenced into the pattern and told to set up for an ILS runway 26R approach. We flew the ILS prm runway 26 approach and noted that the map shift was still in effect for that runway as well. Landing was uneventful. During this entire sequence of events; we never received any TCAS advisories or warnings. Supplemental information from acn 750090: the problem arose because of a malfunction (map shift) in combination with a slow recognition of the malfunction and finally less than optimal aircraft control. We were all thinking slowly (fatigue) but the PF got very distraction and it was difficult to help him understand our problem. In my judgement the gravest mistake was the PF not focusing on flying the aircraft while we were confused and attempting to sort out our problem.
Original NASA ASRS Text
Title: A B767 FLT CREW INBOUND TO ATL FLIGHT DEVIATED FROM CLEARED TRACK BECAUSE OF A MAP SHIFT.
Narrative: I WAS THE FO AND PF ON THE ABOVE REFED FLT. THE FLT WAS UNEVENTFUL UP TO THE INCIDENT IN QUESTION IN THE ATLANTA TFC PATTERN. I BRIEFED AND SELECTED THE ILS PRM RWY 27L APCH. AS WE GOT CLOSER TO THE FINAL APCH COURSE; IT WAS BECOMING CLEAR THAT IF WE DIDN'T GET A TURN TO INTERCEPT THE FINAL APCH COURSE SOON; WE WOULD OVERSHOOT THE COURSE. I MADE THE COMMENT TO THE PLTS THAT SHE BETTER TURN US QUICK OR WE'RE GOING TO OVERSHOOT. BEFORE THE CAPT KEYED THE MIKE TO QUERY THE CTLR; SHE QUICKLY TOLD US TO TURN R TO A 240 DEG HDG; DSCNT FROM 7000 FT TO 5000 FT; CLRED TO INTERCEPT RWY 27L LOC. HER INSTRUCTIONS BEGAN WHEN WE WERE JUST INSIDE 1 MI TO INTERCEPT AND SHE WAS STILL GIVING US THESE INSTRUCTIONS WHEN WE WERE APPROX 1/2-1 MI OVERSHOT OF THE FINAL. WITH OUR SPD AT 220 KIAS AND ON OUR TURN TO FINAL; IT APPEARED WE ROLLED OUT ABOUT 1 MI L OF COURSE. SHE GAVE THE INSTRUCTIONS VERY QUICKLY AND IN SUCH A WAY THAT BASED ON OUR APPARENT FMS POS; IT SEEMED CLEAR TO US THAT SHE REALIZED THAT HER DELAY IN GIVING INSTRUCTIONS HAD CAUSED US TO OVERSHOOT. AT THIS POINT; I WAS WORRIED ABOUT CONFLICTS WITH RWY 28 TFC; SO I FOLLOWED HER INSTRUCTIONS BY TURNING R AS QUICKLY AS POSSIBLE TO CORRECT BACK TOWARDS THE COURSE; BEGAN THE DSCNT TO 5000 FT; ARMED THE LOC AT THE COMPLETION OF HER INSTRUCTIONS; AND ROLLED OUT ON THE HDG SHE GAVE US. THE FMS COURSE WAS ABOUT 1 MI BACK TO OUR R. I COMMUNICATED TO THE CAPT TO TELL THE CTLR WE NEEDED TO COME FURTHER R TO INTERCEPT; BECAUSE WE WERE MOVING EVEN FURTHER L AWAY FROM THE COURSE. AS HE BEGAN TO ASK FOR THE CORRECTION; SHE INDICATED IN AN OBVIOUS VOICE OF CONCERN THAT WE WERE MOVING TOO FAR R. THIS WAS TOTALLY OPPOSITE TO OUR FMS INDICATIONS (FMS SHOWED US L OF TRACK). SHE FURTHER STATED THAT WE WERE ATTEMPTING TO LINE UP ON RWY 26R OR THAT WE MUST HAVE LOADED RWY 26R INTO OUR COMPUTER; OR SOMETHING TO THAT EFFECT. ALL OF THE PLTS QUICKLY RECONFIRMED THAT WE HAD THE CORRECT RWY 27L APCH LOADED IN THE FMS. THE CAPT STATED TO HER THAT THE CORRECT APCH WAS LOADED; WHEREBY SHE SAID WE WERE STILL MOVING FURTHER R. SHE ALSO SAID TO STOP OUR DSCNT AT 6000 FT VERSUS 5000 FT. THAT INSTRUCTION CAME WHEN WE WERE APCHING 6000 FT. I QUICKLY ATTEMPTED TO STOP OUR DSCNT BUT THE ACFT CONTINUED A DSCNT BELOW 6000 FT TO APPROX 5500 FT. I THEN BEGAN A CORRECTION UP TO THE ASSIGNED ALT. SIMULTANEOUSLY; THE CAPT TOLD THE CTLR TO 'GIVE US A VECTOR OUT OF THIS APCH; AS THERE IS AN OBVIOUS CONFLICT OF INFO' OR WORDS TO THAT EFFECT. AS WE WERE DEPARTING; ON A 290 DEG DIRECTED HDG; THE RELIEF OFFICER STATED THAT THE LOC NEEDLE INDICATED THE LOC COURSE WAS L; YET THE FMS COURSE WAS STILL INDICATING FAR R. IT BECAME CLR AT THAT POINT THAT WE HAD EXPERIENCED A MAP SHIFT ON OUR FMS. AS WE EXITED THE TFC PATTERN; WE AGREED THAT WE WOULD DISREGARD FMS DATA AND ONLY USE RAW DATA ON A SUBSEQUENT APCH DUE TO THE APPARENT FMS SYS MALFUNCTION. WE WERE RESEQUENCED INTO THE PATTERN AND TOLD TO SET UP FOR AN ILS RWY 26R APCH. WE FLEW THE ILS PRM RWY 26 APCH AND NOTED THAT THE MAP SHIFT WAS STILL IN EFFECT FOR THAT RWY AS WELL. LNDG WAS UNEVENTFUL. DURING THIS ENTIRE SEQUENCE OF EVENTS; WE NEVER RECEIVED ANY TCAS ADVISORIES OR WARNINGS. SUPPLEMENTAL INFO FROM ACN 750090: THE PROB AROSE BECAUSE OF A MALFUNCTION (MAP SHIFT) IN COMBINATION WITH A SLOW RECOGNITION OF THE MALFUNCTION AND FINALLY LESS THAN OPTIMAL ACFT CTL. WE WERE ALL THINKING SLOWLY (FATIGUE) BUT THE PF GOT VERY DISTR AND IT WAS DIFFICULT TO HELP HIM UNDERSTAND OUR PROB. IN MY JUDGEMENT THE GRAVEST MISTAKE WAS THE PF NOT FOCUSING ON FLYING THE ACFT WHILE WE WERE CONFUSED AND ATTEMPTING TO SORT OUT OUR PROB.
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.