CAPT OF A CPR LEAR JET 35 DISCOVERED THAT HE HAD ALLOWED THE FO TO DSND BELOW PUBLISHED MINIMUMS DURING A VOR CIRCLING APCH DUE TO MISREADING THE APCH CHART'S PUBLISHED MDA AS AN AGL INSTEAD OF MSL ALT.

Date: 1998-12 · Aircraft: Learjet 35

Anomalies: deviation-altitude-overshoot|deviation-discrepancy-procedural-far|inflight-event-encounter-cftt-cfit|other-unspecified

Synopsis

CAPT OF A CPR LEAR JET 35 DISCOVERED THAT HE HAD ALLOWED THE FO TO DSND BELOW PUBLISHED MINIMUMS DURING A VOR CIRCLING APCH DUE TO MISREADING THE APCH CHART'S PUBLISHED MDA AS AN AGL INSTEAD OF MSL ALT.

Narrative

THE ILS SYS AT PALOMAR ARPT HAD BEEN DOWN FOR THE PRECEDING 2 MONTHS; AND THE ONLY AVAILABLE APCH WAS A VOR APCH. THE MINIMUMS ON THE CHART WERE 1000 FT MSL FOR CATEGORY B AND C; THE MINIMUMS BEING 672 FT ABOVE THE GND. THE CREW IN ERROR SET THE APCH MINIMUMS TO 672 FT INSTEAD OF 1000 FT; THEREBY BREAKING MINIMUM APCH ALTS BY 328 FT. DURING THE FIRST APCH WE WERE FORCED TO DECLARE A MISSED APCH; EVEN AT THE LOWER APCH ALT. DURING THE SECOND APCH; THE CREW REPEATED THE SAME ERROR; FAILING TO SET THE CORRECT ALT A SECOND TIME. CONTACT WITH THE ARPT WAS MADE DURING THE SECOND APCH; AND THE CREW LANDED THE ACFT SAFELY. THE ERROR WAS NOT REALIZED UNTIL I WAS PUTTING THE CHART AWAY. I DO NOT KNOW WHY I WOULD MAKE SUCH A FUNDAMENTAL ERROR. I HAVE MADE HUNDREDS OF APCHS; AND I AM NOT WEAK IN CHART INTERPS. WE RETURN TO FLT SAFETY EVERY 6 MONTHS FOR PLT RECURRENCIES; AND I RECEIVE EXCELLENT REVIEWS. NEITHER CREW MEMBER RECOGNIZED THE ERROR; EVEN THOUGH IT WAS REPEATED TWICE. PALOMAR DID CALL 'ALTIMETER ALERT' ONCE TO US; AND THEY GAVE US A NEW ALTIMETER SETTING. ONCE WE ADJUSTED THE ALTIMETERS; WE THOUGHT WE GAINED SOME MORE SPACE; AND WE DSNDED YET AGAIN ANOTHER HUNDRED FT TO THE MINIMUMS THAT WE BELIEVED THE NEW ALTIMETER SETTING AFFORDED US.

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