37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 770263 |
Time | |
Date | 200801 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : avp.airport |
State Reference | PA |
Altitude | msl single value : 3700 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Turbulence Snow |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : avp.tracon |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 130 flight time total : 2900 flight time type : 1900 |
ASRS Report | 770263 |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude non adherence : clearance |
Independent Detector | aircraft equipment other aircraft equipment : stick shaker other flight crewa |
Resolutory Action | flight crew : overcame equipment problem flight crew : regained aircraft control flight crew : returned to assigned altitude flight crew : executed go around |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
On an ILS approach to runway 4 at avp; my first officer and I executed a go around/missed approach due to a stick shaker activation at what I estimate was about 3700 ft MSL. Upon the go around it was discovered that the flight spoilers had been left in the extended position. In the process of the go around; we climbed to about 4700 ft MSL before returning to the published altitude of 4000 ft MSL immediately. We were vectored around and landed without further incident. The factors that led up to this event were as follows: 1) we set up for and briefed 3 different approachs; 2 of these changes in the preceding 5 mins before commencing the approach. Each time; the controls were xferred between us as we descended into the terminal environment except for the final brief. On the final brief; I asked the first officer to review key altitudes and fixes. During one of these xfers; the fact that the spoilers were deployed was not communicated; and they remained deployed. During our postflt debrief; we could not determine which one of us had deployed the spoilers. The controls were xferred to me just outside the OM with the aircraft configured gear down flaps 30 degrees. As we approached the marker; I called for 'flaps 45; bug vref' the first officer complied. The aircraft captured the GS and we started down. As the first officer bugged vref; I noticed the low speed cue was unusually close to the bug. That is about the time the stick shaker activated; for approximately 1 second. There was light to moderate turbulence in the area and this was my first thought; then the shaker activated a second time for again about 1 second. I initiated the go around at this time. As I called for the flaps to be repositioned to flaps 8 degrees; we received a 'configuration spoilers' caution message (not sure why; no wow signal; but gear was in transit). I immediately stowed the flight spoilers and continued with reconfiguring the aircraft for the go around. During this time we climbed at about 3000 FPM and I stopped the climb at about 4700 ft MSL. The first officer informed ATC and we returned to 4000 ft MSL. We returned for another approach and landed without further incident. 2) the first officer had only 10-15 hours in the CRJ200 and was having difficulty setting up the approach in the FMS. We were missing several pieces of information including several waypoints and speeds after the last runway change. I was trying to direct him to get the approach setup and was also inputting information. Additionally; I have only about 130 hours PIC in this aircraft. 3) WX in the area was -sn; and I had to send several ACARS messages to dispatch to obtain current field braking/runway friction reports. 4) fatigue may have played a factor as this was the 3RD in a series of 'continuous duty overnight' (cdo) assignments. These usually have a cumulative negative effect on my performance during the 3RD and 4TH cdo as these usually conclude after my normal bedtime; provide for little sleep usually; 4 hours or less each night. The first officer was also on his 3RD cdo of the week. He said he did not feel tired during our postflt debrief. 5) on previous earlier in the week; I had experienced difficulty with the ILS runway 4 into avp. The aircraft was having trouble intercepting and maintaining GS. Large control wheel inputs by the autoplt were noticed on all approachs. It was as if a truck or other obstruction was in the way. The localizer seems to be offset about 10 degrees left of course. On touchdown; the localizer was showing full scale right deflection. Corrective measures. 1) our books require a hand to be kept on the flight spoilers while deployed. However; there are situations that require more than 1 hand and the hand is removed from the spoiler lever. As an first officer and PNF; I usually touch the spoilers lever on the before landing check right after arming the thrust reversers. However; this should be institutionalized and added to the flow and the checklist as in item both pilots should confirm.
Original NASA ASRS Text
Title: DISTRACTED BY MULTIPLE RWY CHANGES; CARJ FLT CREW GETS STALL WARNING WHEN THEY FAIL TO RETRACT SPOILERS WHILE PROGRAMMING CHANGES. FATIGUE A CONTRIBUTING FACTOR.
Narrative: ON AN ILS APCH TO RWY 4 AT AVP; MY FO AND I EXECUTED A GAR/MISSED APCH DUE TO A STICK SHAKER ACTIVATION AT WHAT I ESTIMATE WAS ABOUT 3700 FT MSL. UPON THE GAR IT WAS DISCOVERED THAT THE FLT SPOILERS HAD BEEN LEFT IN THE EXTENDED POS. IN THE PROCESS OF THE GAR; WE CLBED TO ABOUT 4700 FT MSL BEFORE RETURNING TO THE PUBLISHED ALT OF 4000 FT MSL IMMEDIATELY. WE WERE VECTORED AROUND AND LANDED WITHOUT FURTHER INCIDENT. THE FACTORS THAT LED UP TO THIS EVENT WERE AS FOLLOWS: 1) WE SET UP FOR AND BRIEFED 3 DIFFERENT APCHS; 2 OF THESE CHANGES IN THE PRECEDING 5 MINS BEFORE COMMENCING THE APCH. EACH TIME; THE CTLS WERE XFERRED BTWN US AS WE DSNDED INTO THE TERMINAL ENVIRONMENT EXCEPT FOR THE FINAL BRIEF. ON THE FINAL BRIEF; I ASKED THE FO TO REVIEW KEY ALTS AND FIXES. DURING ONE OF THESE XFERS; THE FACT THAT THE SPOILERS WERE DEPLOYED WAS NOT COMMUNICATED; AND THEY REMAINED DEPLOYED. DURING OUR POSTFLT DEBRIEF; WE COULD NOT DETERMINE WHICH ONE OF US HAD DEPLOYED THE SPOILERS. THE CTLS WERE XFERRED TO ME JUST OUTSIDE THE OM WITH THE ACFT CONFIGURED GEAR DOWN FLAPS 30 DEGS. AS WE APCHED THE MARKER; I CALLED FOR 'FLAPS 45; BUG VREF' THE FO COMPLIED. THE ACFT CAPTURED THE GS AND WE STARTED DOWN. AS THE FO BUGGED VREF; I NOTICED THE LOW SPD CUE WAS UNUSUALLY CLOSE TO THE BUG. THAT IS ABOUT THE TIME THE STICK SHAKER ACTIVATED; FOR APPROX 1 SECOND. THERE WAS LIGHT TO MODERATE TURB IN THE AREA AND THIS WAS MY FIRST THOUGHT; THEN THE SHAKER ACTIVATED A SECOND TIME FOR AGAIN ABOUT 1 SECOND. I INITIATED THE GAR AT THIS TIME. AS I CALLED FOR THE FLAPS TO BE REPOSITIONED TO FLAPS 8 DEGS; WE RECEIVED A 'CONFIG SPOILERS' CAUTION MESSAGE (NOT SURE WHY; NO WOW SIGNAL; BUT GEAR WAS IN TRANSIT). I IMMEDIATELY STOWED THE FLT SPOILERS AND CONTINUED WITH RECONFIGURING THE ACFT FOR THE GAR. DURING THIS TIME WE CLBED AT ABOUT 3000 FPM AND I STOPPED THE CLB AT ABOUT 4700 FT MSL. THE FO INFORMED ATC AND WE RETURNED TO 4000 FT MSL. WE RETURNED FOR ANOTHER APCH AND LANDED WITHOUT FURTHER INCIDENT. 2) THE FO HAD ONLY 10-15 HRS IN THE CRJ200 AND WAS HAVING DIFFICULTY SETTING UP THE APCH IN THE FMS. WE WERE MISSING SEVERAL PIECES OF INFO INCLUDING SEVERAL WAYPOINTS AND SPDS AFTER THE LAST RWY CHANGE. I WAS TRYING TO DIRECT HIM TO GET THE APCH SETUP AND WAS ALSO INPUTTING INFO. ADDITIONALLY; I HAVE ONLY ABOUT 130 HRS PIC IN THIS ACFT. 3) WX IN THE AREA WAS -SN; AND I HAD TO SEND SEVERAL ACARS MESSAGES TO DISPATCH TO OBTAIN CURRENT FIELD BRAKING/RWY FRICTION RPTS. 4) FATIGUE MAY HAVE PLAYED A FACTOR AS THIS WAS THE 3RD IN A SERIES OF 'CONTINUOUS DUTY OVERNIGHT' (CDO) ASSIGNMENTS. THESE USUALLY HAVE A CUMULATIVE NEGATIVE EFFECT ON MY PERFORMANCE DURING THE 3RD AND 4TH CDO AS THESE USUALLY CONCLUDE AFTER MY NORMAL BEDTIME; PROVIDE FOR LITTLE SLEEP USUALLY; 4 HRS OR LESS EACH NIGHT. THE FO WAS ALSO ON HIS 3RD CDO OF THE WK. HE SAID HE DID NOT FEEL TIRED DURING OUR POSTFLT DEBRIEF. 5) ON PREVIOUS EARLIER IN THE WK; I HAD EXPERIENCED DIFFICULTY WITH THE ILS RWY 4 INTO AVP. THE ACFT WAS HAVING TROUBLE INTERCEPTING AND MAINTAINING GS. LARGE CTL WHEEL INPUTS BY THE AUTOPLT WERE NOTICED ON ALL APCHS. IT WAS AS IF A TRUCK OR OTHER OBSTRUCTION WAS IN THE WAY. THE LOC SEEMS TO BE OFFSET ABOUT 10 DEGS L OF COURSE. ON TOUCHDOWN; THE LOC WAS SHOWING FULL SCALE R DEFLECTION. CORRECTIVE MEASURES. 1) OUR BOOKS REQUIRE A HAND TO BE KEPT ON THE FLT SPOILERS WHILE DEPLOYED. HOWEVER; THERE ARE SITUATIONS THAT REQUIRE MORE THAN 1 HAND AND THE HAND IS REMOVED FROM THE SPOILER LEVER. AS AN FO AND PNF; I USUALLY TOUCH THE SPOILERS LEVER ON THE BEFORE LNDG CHK RIGHT AFTER ARMING THE THRUST REVERSERS. HOWEVER; THIS SHOULD BE INSTITUTIONALIZED AND ADDED TO THE FLOW AND THE CHKLIST AS IN ITEM BOTH PLTS SHOULD CONFIRM.
Data retrieved from NASA's ASRS site as of May 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.