B737 FLC FLEW TOWARD RISING TERRAIN DURING AN ILS MISSED APCH INSTRUCTED BY A FOREIGN GOV; NON RADAR TWR; WHO BELIEVED THAT THEY WERE OVER THE ARPT ON THE MISSED APCH. HOWEVER; THEY WERE STILL 7 MI PRIOR TO THE MISSED APCH POINT.

2001-07 · NASA ASRS report 518936

Date: 2001-07 · Aircraft: B737 Undifferentiated or Other Model

Anomalies: deviation-track-heading-all-types|deviation-discrepancy-procedural-published-material-policy|inflight-event-encounter-cftt-cfit

Synopsis

B737 FLC FLEW TOWARD RISING TERRAIN DURING AN ILS MISSED APCH INSTRUCTED BY A FOREIGN GOV; NON RADAR TWR; WHO BELIEVED THAT THEY WERE OVER THE ARPT ON THE MISSED APCH. HOWEVER; THEY WERE STILL 7 MI PRIOR TO THE MISSED APCH POINT.

Narrative

DURING THE ILS DME RWY 7 AT SJO; A MISSED APCH WAS INITIATED ABOUT 7 NM PRIOR TO THE MISSED APCH POINT. ALT ON THE GS AT THIS POINT WAS VERY CLOSE BELOW THE MISSED APCH ALT. DURING THE INITIAL MISSED APCH CLB THE MISSED APCH ALT WAS CLBED THROUGH. A MISSED APCH WAS RPTED TO THE NON RADAR TWR. THE TWR MISUNDERSTOOD THE ACFT POS ON THE APCH AT WHICH THE MISSED APCH WAS EXECUTED AND ISSUED INSTRUCTIONS THAT PLACED THE ACFT OUT OF THE NORMAL PROTECTED MISSED APCH PATH TOWARDS RISING TERRAIN. SEVERAL ACFT WERE ON THE APCH AND THE CREW FOLLOWED THE TWR INSTRUCTIONS UNDER THE INCORRECT ASSUMPTION THAT TWR HAD RADAR AND WAS CLRING THE ACFT ABOVE THE MVA FOR THE SECTOR AND AWAY FROM OTHER TFC. AFTER CONTACTING DEP; PROPER ROUTING AND ALT CLRNCS WERE RECEIVED. DEP CTL COMPLAINED ABOUT THE ACFT POS AND THE CREW'S FAILURE TO FLY THE PROPER MISSED APCH PATH. AFTER EXPLAINING TO HIM THE CONFLICTING INSTRUCTIONS RECEIVED FROM THE TWR; THE DEP CTLR INSISTED THEY WERE CONSISTENT WITH FLYING THE PUBLISHED MISSED APCH. COMS CONFUSION; A POOR APCH BRIEFING; IMPROPER PREPARATION BEFORE THE APCH FOR A MISSED APCH PRIOR TO THE MISSED APCH POINT; AND MIS-PRIORITIZING OF TASKS DURING THE MISSED APCH; CONTRIBUTED TO THE GENERAL CONFUSION THAT CREATED THE SIT.

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

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