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Attributes | |
ACN | 810325 |
Time | |
Date | 200810 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : dts.airport |
State Reference | FL |
Altitude | msl bound lower : 2000 msl single value : 500 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : vps.tracon |
Operator | general aviation : corporate |
Make Model Name | Sovereign |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp pilot : cfi |
Experience | flight time last 90 days : 50 flight time total : 16000 flight time type : 400 |
ASRS Report | 810325 |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : crossing restriction not met altitude deviation : overshoot inflight encounter : weather non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : unable other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft ATC Human Performance |
Primary Problem | Ambiguous |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were en route to dts and shortly before being handed off from jax ARTCC to eglin approach control we were on vectors and then cleared direct to the airport. At that point; I punched dto to dts (1ST mistake). Shortly thereafter; we were handed off to eglin approach control and were cleared for the RNAV (GPS) runway 14 approach. The FMS had previously been programmed for this approach. The PNF then attempted to reprogram this approach and was unsuccessful. I; the PF; then attempted to reprogram the approach and was also unsuccessful. I then asked the PNF to enter ilope; the IAF; which he did and we proceeded to that fix to begin the approach. However; nozec; the FAF at 3.6 NM; was not entered into the FMS (another mistake). We crossed ilope approximately 500 ft above the prescribed altitude of 2000 ft. At this point we were descending and PNF was attempting to figure where the 3.6 mi fix was instead of programming it ito the FMS. Since the VNAV function was questionable at this point; I switched off the autoplt and began to fly the airplane by hand. During this time I failed to monitor the altitude and rate of descent and descended to approximately 1200 ft AGL prior to crossing nozec (1600 ft is the prescribed crossing altitude) prior to descent to MDA. When the PNF noted the altitude; I immediately arrested the descent and held this altitude until crossing what we expected to be nozec. I then began a 500 FPM rate of descent and we began to get ground contact. We broke out under a ragged ceiling at 900-1000 ft AGL with better than 5 mi visibility and approximately 2 mi from the end of the runway. We were configured to land and a landing was successfully accomplished with a strong crosswind from the left. At no time did we descend below MDA until the runway was in sight and the landing was assured. We canceled IFR with eglin approach once we were on the ground. In retrospect I feel the following mistakes were made and lessons well learned: 1) due to familiarity with this approach; both pilots were complacent; no adequate approach briefing was given. Had this not been the case; I believe that nozec would have been programmed into the FMS even if the rest of the procedure was not. 2) after first unsuccessful attempt to reprogram the correct approach procedure; a request for vectors or holding should have been made until the reprogramming issue was resolved. In lieu of this; a missed approach should have been called and initiated when the excessive descent became apparent. Either pilot could have called for this; failure to do so reflects poor CRM. 3) both pilots still fail to understand why neither was able to reprogram the FMS. A thorough examination of the FMS manual will be conducted to answer this question. Both crewmen are experienced in this aircraft and this problem had not been encountered prior to this occasion. 4) both pilots should not have been attempting to solve the FMS problem at the same time; before PF attempted to reprogram he should have turned control of the aircraft to PNF. At this point attention to the FMS became more important than flying the airplane. This should never have happened. Callback conversation with reporter revealed the following information: reporter was still uncertain as to why the approach could not be reinstalled. He stated that the flight crew was getting behind the airplane and felt it was most likely that both pilots were making errors out of haste. The event occurred because the flight was previously cleared direct to the airport by ARTCC and when that clearance was installed and executed in the FMS all prior waypoints were erased; including those associated with the previously installed RNAV runway 14 IAP.
Original NASA ASRS Text
Title: DIFFICULTIES IN INSTALLING A TARDY REPROGRAMMING OF THE RNAV APPROACH RESULTS IN CE68 FLIGHT CREW FAILING TO MAKE THE CROSSING RESTRICTION AT THE FAF.
Narrative: WE WERE ENRTE TO DTS AND SHORTLY BEFORE BEING HANDED OFF FROM JAX ARTCC TO EGLIN APCH CTL WE WERE ON VECTORS AND THEN CLRED DIRECT TO THE ARPT. AT THAT POINT; I PUNCHED DTO TO DTS (1ST MISTAKE). SHORTLY THEREAFTER; WE WERE HANDED OFF TO EGLIN APCH CTL AND WERE CLRED FOR THE RNAV (GPS) RWY 14 APCH. THE FMS HAD PREVIOUSLY BEEN PROGRAMMED FOR THIS APCH. THE PNF THEN ATTEMPTED TO REPROGRAM THIS APCH AND WAS UNSUCCESSFUL. I; THE PF; THEN ATTEMPTED TO REPROGRAM THE APCH AND WAS ALSO UNSUCCESSFUL. I THEN ASKED THE PNF TO ENTER ILOPE; THE IAF; WHICH HE DID AND WE PROCEEDED TO THAT FIX TO BEGIN THE APCH. HOWEVER; NOZEC; THE FAF AT 3.6 NM; WAS NOT ENTERED INTO THE FMS (ANOTHER MISTAKE). WE CROSSED ILOPE APPROX 500 FT ABOVE THE PRESCRIBED ALT OF 2000 FT. AT THIS POINT WE WERE DSNDING AND PNF WAS ATTEMPTING TO FIGURE WHERE THE 3.6 MI FIX WAS INSTEAD OF PROGRAMMING IT ITO THE FMS. SINCE THE VNAV FUNCTION WAS QUESTIONABLE AT THIS POINT; I SWITCHED OFF THE AUTOPLT AND BEGAN TO FLY THE AIRPLANE BY HAND. DURING THIS TIME I FAILED TO MONITOR THE ALT AND RATE OF DSCNT AND DSNDED TO APPROX 1200 FT AGL PRIOR TO XING NOZEC (1600 FT IS THE PRESCRIBED XING ALT) PRIOR TO DSCNT TO MDA. WHEN THE PNF NOTED THE ALT; I IMMEDIATELY ARRESTED THE DSCNT AND HELD THIS ALT UNTIL XING WHAT WE EXPECTED TO BE NOZEC. I THEN BEGAN A 500 FPM RATE OF DSCNT AND WE BEGAN TO GET GND CONTACT. WE BROKE OUT UNDER A RAGGED CEILING AT 900-1000 FT AGL WITH BETTER THAN 5 MI VISIBILITY AND APPROX 2 MI FROM THE END OF THE RWY. WE WERE CONFIGURED TO LAND AND A LNDG WAS SUCCESSFULLY ACCOMPLISHED WITH A STRONG XWIND FROM THE L. AT NO TIME DID WE DSND BELOW MDA UNTIL THE RWY WAS IN SIGHT AND THE LNDG WAS ASSURED. WE CANCELED IFR WITH EGLIN APCH ONCE WE WERE ON THE GND. IN RETROSPECT I FEEL THE FOLLOWING MISTAKES WERE MADE AND LESSONS WELL LEARNED: 1) DUE TO FAMILIARITY WITH THIS APCH; BOTH PLTS WERE COMPLACENT; NO ADEQUATE APCH BRIEFING WAS GIVEN. HAD THIS NOT BEEN THE CASE; I BELIEVE THAT NOZEC WOULD HAVE BEEN PROGRAMMED INTO THE FMS EVEN IF THE REST OF THE PROC WAS NOT. 2) AFTER FIRST UNSUCCESSFUL ATTEMPT TO REPROGRAM THE CORRECT APCH PROC; A REQUEST FOR VECTORS OR HOLDING SHOULD HAVE BEEN MADE UNTIL THE REPROGRAMMING ISSUE WAS RESOLVED. IN LIEU OF THIS; A MISSED APCH SHOULD HAVE BEEN CALLED AND INITIATED WHEN THE EXCESSIVE DSCNT BECAME APPARENT. EITHER PLT COULD HAVE CALLED FOR THIS; FAILURE TO DO SO REFLECTS POOR CRM. 3) BOTH PLTS STILL FAIL TO UNDERSTAND WHY NEITHER WAS ABLE TO REPROGRAM THE FMS. A THOROUGH EXAM OF THE FMS MANUAL WILL BE CONDUCTED TO ANSWER THIS QUESTION. BOTH CREWMEN ARE EXPERIENCED IN THIS ACFT AND THIS PROB HAD NOT BEEN ENCOUNTERED PRIOR TO THIS OCCASION. 4) BOTH PLTS SHOULD NOT HAVE BEEN ATTEMPTING TO SOLVE THE FMS PROB AT THE SAME TIME; BEFORE PF ATTEMPTED TO REPROGRAM HE SHOULD HAVE TURNED CTL OF THE ACFT TO PNF. AT THIS POINT ATTN TO THE FMS BECAME MORE IMPORTANT THAN FLYING THE AIRPLANE. THIS SHOULD NEVER HAVE HAPPENED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: REPORTER WAS STILL UNCERTAIN AS TO WHY THE APPROACH COULD NOT BE REINSTALLED. HE STATED THAT THE FLIGHT CREW WAS GETTING BEHIND THE AIRPLANE AND FELT IT WAS MOST LIKELY THAT BOTH PILOTS WERE MAKING ERRORS OUT OF HASTE. THE EVENT OCCURRED BECAUSE THE FLIGHT WAS PREVIOUSLY CLEARED DIRECT TO THE AIRPORT BY ARTCC AND WHEN THAT CLEARANCE WAS INSTALLED AND EXECUTED IN THE FMS ALL PRIOR WAYPOINTS WERE ERASED; INCLUDING THOSE ASSOCIATED WITH THE PREVIOUSLY INSTALLED RNAV RWY 14 IAP.
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.