AN ACR CREW FLEW THROUGH THE PUBLISHED GS INTERCEPT ALT.

Date: 1996-05 · Aircraft: L-1011 Tri-Star All Series

Anomalies: deviation-altitude-overshoot|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-published-material-policy

Synopsis

AN ACR CREW FLEW THROUGH THE PUBLISHED GS INTERCEPT ALT.

Narrative

WE ARE PLANNING AN ILS APCH TO RWY 16 IN ZURICH. THE DSCNT INTO ZURICH IS VERY STEEP AND WE ARE TOLD TO KEEP OUR SPD UP. AT 6000 FT APCHING GOLKE; I START TO SLOW AND APCH SAYS TO MAINTAIN 240 KTS. THIS IS UNCOMFORTABLY FAST AT THIS POINT IN OUR ARR. AFTER PASSING EKROW; WE ARE TOLD TO DSND TO 4000 FT. APCHING 4000 FT; APCH THEN GIVES US A TURN TO 130 DEGS TO INTERCEPT THE LOC AND CLRED FOR APCH. WE START TURNING AND START SLOWING DOWN AND ALMOST IMMEDIATELY WE GET A LOC CAPTURE. AFTER THE CAPTURE; THE ACFT ROLLS BACK AND STARTS A TURN TO THE L. I TURNED THE AUTOPLT OFF AND STARTED HAND FLYING AND TRIMMING AS WE CONTINUED TO DROP FLAPS AND SLOW DOWN. IN THE MEANTIME; WE WERE BOTH RETUNING THE ILS FREQ; TURNING THE FLT DIRECTOR OFF AND BACK ON; TRYING TO ORIENT OURSELVES BY THE INSTS AND LOOKING OUT TRYING TO SEE THE RWY. I WAS GETTING THE VERY UNCOMFORTABLE FEELING OF BEING TOO HIGH AND TOO FAST. WE THEN SAW THAT WE HAD FLOWN THROUGH THE LOC AND I STARTED A TURN TO REINTERCEPT. SHORTLY AFTER THIS; WE BOTH SPOTTED THE RWY. APCH CALLED AND SAID WE WERE BELOW THE GS. WE WERE 300-400 FT BELOW GS INTERCEPT ALT OF 4000 FT AND I IMMEDIATELY CLBED BACK UP AND CAPTURED THE LOC AND GS; THEN PROCEEDED ON TO A NORMAL LNDG. THE FOLLOWING IS A LIST OF FACTORS THAT CAUSED THIS SIT: 1) FATIGUE WAS ONE. I WAS PERSONALLY VERY TIRED AS I HAD NOT BEEN ABLE TO TAKE A NAP THE AFTERNOON BEFORE WE LEFT CVG. I HAD BEEN WITHOUT SLEEP FOR APPROX 20 HRS. 2) BEING AT A HIGH SPD WHEN THINGS WENT WRONG VERY MUCH COMPLICATED OUR SIT. IT GAVE US LESS TIME AND ADDED GREATLY TO OUR WORKLOAD. TO PREVENT SITS LIKE THIS IN THE FUTURE; I WOULD SUGGEST THE FOLLOWING POINTS: 1) DSCNTS FROM ALT INTO A TERMINAL AREA SHOULD BE PLANNED SO THAT A 2000 FPM RATE OF DSCNT WOULD BE ADEQUATE. 2) WE NEED PROGRAMMED SPD REDUCTIONS WITHIN 30 MI OF A TERMINAL FOR ALL OCCASIONS. I WOULD SUGGEST 210 KTS AT APPROX 20 MI AND 180 KTS AT APPROX 12 MI. 3) WE NEED TO ESTABLISH A PROGRAM WHERE CREW MEMBERS CAN TAKE A 30 MIN NAP ENRTE.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.