FLC WAS CONFUSED WHEN FLYING APCH. DIDN'T KNOW THAT DME WAS NOT FROM THE LOC. DSNDED TOO SOON ON APCH; BECAME REORIENTED AND VISUAL SO REMAINDER OF APCH NORMAL. RPTR SITES FATIGUE AND PLT EXPERIENCE AS CONTRIBUTING TO ERROR. DA50.
Synopsis
FLC WAS CONFUSED WHEN FLYING APCH. DIDN'T KNOW THAT DME WAS NOT FROM THE LOC. DSNDED TOO SOON ON APCH; BECAME REORIENTED AND VISUAL SO REMAINDER OF APCH NORMAL. RPTR SITES FATIGUE AND PLT EXPERIENCE AS CONTRIBUTING TO ERROR. DA50.
Narrative
THE MGR OF OUR FLT OP WAS OCCUPYING THE L SEAT OF OUR CORP FALCON 50; HE IS A MIDTIME PLT WITH VERY LITTLE JET ACFT EXPERIENCE. NORMALLY THIS DOES NOT POSE A PROB; BUT THIS TIME IT WAS A CONTRIBUTING FACTOR. THE PROB STARTED WHEN ON THE ARR HE WAS TO HAVE STOPPED AT 2400 FT; INSTEAD HE JUST CONTINUED TO DSND. I FINALLY GOT HIM TO START CLBING BACK UP AROUND 1700 FT. AT THIS TIME WE WERE ABOUT 8-9 MI FROM THE FAF. WE CLBED BACK TO THE PROPER ALT WHICH WAS 2400 FT. THIS ALL WOULD BE OK BUT NOW WE HAD LOST OUR POS AWARENESS. WE THOUGHT WE WERE CLOSER TO THE ARPT THAN WE REALLY WERE. THE PROB WAS WE HAD NOT REALIZED THAT THE FAF WAS A DME FIX OFF THE PSI VOR NOT DME DISTANCE FROM THE PKT LOC. THE CLUE SHOULD HAVE BEEN THAT WE WERE UNABLE TO RECEIVE ANY DME INFO OFF THE PKT LOC. WE HAD DISCUSSED THE FACT THAT WE WERE NOT RECEIVING THE DME AND AT THAT TIME THE DECISION WAS MADE TO USE THE FMS FOR DISTANCE FOR FAF. WE BECAME AWARE OF THE FACT THAT NOW WE WERE AT THE 9.5 MI FIX AND CONFIGURED THE ACFT FOR LNDG AND STARTED OUR DSCNT. AT THIS TIME WE CALLED THE TWR AND RPTED FAF INBOUND. THE TWR INFORMED US THAT HE SHOWED US ABOUT 2 MI OUTSIDE OF FAF AND HE HAD A LOW ALT ALERT ON US. IT WAS THEN THAT HE INFORMS US THAT THE FAF FIX WAS A DME FIX OFF THE PSI VOR AND NOT OFF THE PKT LOC. WE NOW HAD THE GND AND THE ARPT IN SIGHT SO WE CONTINUE ON WITHOUT FURTHER INCIDENT. AS YOU CAN SEE THAT THE MAIN PROB WAS THAT THE CREW MISSED THE FACT THAT THE FAF WAS DEPICTED ON THE CHART AS A DME FIX OFF THE PSI VOR AND NOT OFF THE PKT LOC. I DO FEEL AFTER REVIEWING THE APCH PLATE FOR DME LOC BACK COURSE RWY 27L AT PKT; THAT THE FAF IS POORLY DEPICTED. THE DISTANCE AND THE FIX IT IS OFF IS ONLY STATED IN ONE PLACE AND THAT IS IN VERY SMALL PRINT. ANOTHER FACTOR THAT WAS INVOLVED WAS THAT THIS WAS A VERY LONG DAY FOR THIS FLC. THEY HAD STARTED THEIR DAY SOME 16 HRS BEFORE THIS EVENT HAPPENED. THIS FLC DAY BEGAN IN PARIS; FRANCE AT XA00Z WHEN THEY DEPARTED FOR AMSTERDAM. THEY STAYED ABOUT 2 HRS IN AMSTERDAM BEFORE THEY DEPARTED FOR THE UNITED STATES WITH A STOP IN GANDER FOR FUEL. THE TIME OF THIS INCIDENT WAS XO00Z OR SOME 16 HR OF DUTY TIME. INTL DUTY TIME STARTS 2 HRS BEFORE ACTUAL DEP TIME. ALONE; THE ABOVE FACTORS ARE CAUSAL PROBS; BUT WHEN COMBINED TOGETHER THEY BECOME A VERY DANGEROUS SIT. I DO BELIEVE THAT THE LACK OF CREW COORD WAS A BIG FACTOR IN THE EVENTS THAT HAPPENED. FOR THIS REASON WE HAVE BEGUN AN IN-HOUSE REVIEW OF OUR CRM PROCS TO SEE WHERE WE ARE WEAK. WE ARE ALSO REVIEWING DUTY TIME LIMITATIONS.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.