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|
Attributes | |
ACN | 83327 |
Time | |
Date | 198803 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : spi |
State Reference | IL |
Altitude | agl bound lower : 100 agl bound upper : 2500 |
Environment | |
Flight Conditions | IMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | tracon : spi |
Operator | general aviation : corporate |
Make Model Name | Medium Transport |
Navigation In Use | Other |
Flight Phase | descent : approach landing : go around |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 75 flight time total : 6000 flight time type : 190 |
ASRS Report | 83327 |
Person 2 | |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : undershoot altitude deviation : overshoot non adherence : published procedure non adherence : clearance other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | other other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
In the in-range phase of the flight, as the PF briefed the approach, the PNF was facing aft in an attempt to set up the jumpseat so the 7 yr old could ride in the cockpit and observe the landing. The jumpseat was never successfully locked in position, but the child was permitted to situation on a shelf aft of the copilot's seat until directed to take a seat in the cabin for landing. While the child was basically well behaved, there were occasional questions and comments that may have interrupted the normal cockpit communications. The radios and instruments were all correctly set for the approach. The clearance was to fly an assigned heading until localizer intercept and to maintain 2500' until established. Unnoticed by either pilot, the aircraft flew through the localizer. When approach asked, 'are you receiving the localizer ok?', the PNF announced to the PF, 'you went through the localizer.' the PF made a heading change to capture the localizer. Shortly thereafter, the PNF said, 'better get it down, we're high on the G/south.' the PF argued that since the aircraft was not yet established on the localizer, descent below 2500' was not authority/authorized. During the debate, the aircraft flew through the localizer again and was not detected by either pilot until full needle deflection. The PF made another correction back to the localizer. The resultant approach was sloppy at best--a well established, stabilized approach was never achieved. The PNF failed to make most of the standard callouts on the approach. There were not callouts made for localizer intercept, G/south intercept, passing the marker, 100' to minimums or at minimums. The next cockpit communication was the PNF saying, 'we're below minimums, go around.' the PF executed a go around and leveled off at the assigned altitude. As the pilots discussed plans to make another approach to a different runway, the PF allowed the aircraft to climb to an altitude significantly above the assigned altitude. This error, too, went unnoticed by both pilots until it was called out by approach control. The altitude correction was made by the PF and a stabilized approach and landing followed. In post-flight discussion, the pilots determined that a misset, misinterpreted or malfunctioning flight director probably contributed to the altitude bust during the missed approach. The PF admitted to a sloppy approach, but at the same time questioned the lack of standard callouts by the PNF. The PNF speculated that fixation on the errors and corrections being made by the PF contributed to the failure to make the standard callouts.
Original NASA ASRS Text
Title: CPR MDT UNSTABILIZED APCH BOTH DIRECTION AND ALT RESULTED IN GO AROUND.
Narrative: IN THE IN-RANGE PHASE OF THE FLT, AS THE PF BRIEFED THE APCH, THE PNF WAS FACING AFT IN AN ATTEMPT TO SET UP THE JUMPSEAT SO THE 7 YR OLD COULD RIDE IN THE COCKPIT AND OBSERVE THE LNDG. THE JUMPSEAT WAS NEVER SUCCESSFULLY LOCKED IN POS, BUT THE CHILD WAS PERMITTED TO SIT ON A SHELF AFT OF THE COPLT'S SEAT UNTIL DIRECTED TO TAKE A SEAT IN THE CABIN FOR LNDG. WHILE THE CHILD WAS BASICALLY WELL BEHAVED, THERE WERE OCCASIONAL QUESTIONS AND COMMENTS THAT MAY HAVE INTERRUPTED THE NORMAL COCKPIT COMS. THE RADIOS AND INSTRUMENTS WERE ALL CORRECTLY SET FOR THE APCH. THE CLRNC WAS TO FLY AN ASSIGNED HDG UNTIL LOC INTERCEPT AND TO MAINTAIN 2500' UNTIL ESTABLISHED. UNNOTICED BY EITHER PLT, THE ACFT FLEW THROUGH THE LOC. WHEN APCH ASKED, 'ARE YOU RECEIVING THE LOC OK?', THE PNF ANNOUNCED TO THE PF, 'YOU WENT THROUGH THE LOC.' THE PF MADE A HDG CHANGE TO CAPTURE THE LOC. SHORTLY THEREAFTER, THE PNF SAID, 'BETTER GET IT DOWN, WE'RE HIGH ON THE G/S.' THE PF ARGUED THAT SINCE THE ACFT WAS NOT YET ESTABLISHED ON THE LOC, DSCNT BELOW 2500' WAS NOT AUTH. DURING THE DEBATE, THE ACFT FLEW THROUGH THE LOC AGAIN AND WAS NOT DETECTED BY EITHER PLT UNTIL FULL NEEDLE DEFLECTION. THE PF MADE ANOTHER CORRECTION BACK TO THE LOC. THE RESULTANT APCH WAS SLOPPY AT BEST--A WELL ESTABLISHED, STABILIZED APCH WAS NEVER ACHIEVED. THE PNF FAILED TO MAKE MOST OF THE STANDARD CALLOUTS ON THE APCH. THERE WERE NOT CALLOUTS MADE FOR LOC INTERCEPT, G/S INTERCEPT, PASSING THE MARKER, 100' TO MINIMUMS OR AT MINIMUMS. THE NEXT COCKPIT COM WAS THE PNF SAYING, 'WE'RE BELOW MINIMUMS, GO AROUND.' THE PF EXECUTED A GO AROUND AND LEVELED OFF AT THE ASSIGNED ALT. AS THE PLTS DISCUSSED PLANS TO MAKE ANOTHER APCH TO A DIFFERENT RWY, THE PF ALLOWED THE ACFT TO CLB TO AN ALT SIGNIFICANTLY ABOVE THE ASSIGNED ALT. THIS ERROR, TOO, WENT UNNOTICED BY BOTH PLTS UNTIL IT WAS CALLED OUT BY APCH CTL. THE ALT CORRECTION WAS MADE BY THE PF AND A STABILIZED APCH AND LNDG FOLLOWED. IN POST-FLT DISCUSSION, THE PLTS DETERMINED THAT A MISSET, MISINTERPRETED OR MALFUNCTIONING FLT DIRECTOR PROBABLY CONTRIBUTED TO THE ALT BUST DURING THE MISSED APCH. THE PF ADMITTED TO A SLOPPY APCH, BUT AT THE SAME TIME QUESTIONED THE LACK OF STANDARD CALLOUTS BY THE PNF. THE PNF SPECULATED THAT FIXATION ON THE ERRORS AND CORRECTIONS BEING MADE BY THE PF CONTRIBUTED TO THE FAILURE TO MAKE THE STANDARD CALLOUTS.
Data retrieved from NASA's ASRS site as of August 2007 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.