A BE30 PLT; WHILE FLYING THE QUIET BRIDGE VISUAL TO SFO; DEVIATED FROM THE PUBLISHED PROC; DRIFTING S OF INTENDED COURSE.

Date: 2001-12 · Aircraft: Super King Air 300

Anomalies: deviation-track-heading-all-types|deviation-discrepancy-procedural-published-material-policy|deviation-discrepancy-procedural-far|deviation-discrepancy-procedural-clearance

Synopsis

A BE30 PLT; WHILE FLYING THE QUIET BRIDGE VISUAL TO SFO; DEVIATED FROM THE PUBLISHED PROC; DRIFTING S OF INTENDED COURSE.

Narrative

AFTER DEPARTING FAT; WE WERE CLRED DIRECT TO SFO. THE FLT WAS UNEVENTFUL UNTIL WE CONTACTED THE LCL APCH CTLRS. AFTER A FEW TURNS AND CHANGES IN ALT; WE WERE THEN CLRED FOR THE QUIET BRIDGE VISUAL. THIS PROC REQUIRES THE PLT TO FLY VIA THE SFO 095 DEG RADIAL UNTIL REACHING 6 DME. AT THAT POINT; THE PLT IS THEN REQUIRED TO INTERCEPT THE FINAL APCH COURSE TO RWY 28L OR RWY 28R. WE WERE CLRED THE QUIET BRIDGE VISUAL RWY 28R. I AM NOT FAMILIAR WITH THE KING AIR; BUT HAVE OVER 6500 HRS FLYING LARGE TURBOPROPS AND JETS FOR THE AIRLINES. THE PLT NEVER REVIEWED NOR ASKED TO REVIEW THE BRIDGE VISUAL; SO I WAS UNDER THE IMPRESSION HE KNEW THE PROC. THE PLT CLAIMED HE WAS VERY FAMILIAR WITH SAN FRANCISCO INTL ARPT. FOR MY OWN REF; I HAD SET THE LOC FREQ AND CDI ON THE COPLT'S SIDE TO THE SFO ILS RWY 28R. WE INITIALLY WERE ON THE SFO 095 DEG RADIAL; BUT WITHIN MINS; FOUND OURSELVES S OF THE SFO 095 DEG RADIAL AND THE LOC TO RWY 28R. I WAS FIRST TO NOTICE OUR POS AND QUICKLY QUERIED THE PLT. HE THEN REALIZED HIS POS AND ADJUSTED THE ACFT'S FLT PATH TO INTERCEPT THE PROPER COURSE. AT SOME POINT THEREAFTER; THE TWR CLRED US TO LAND ON RWY 28L. THERE WERE SEVERAL FACTORS THAT LED TO THIS INCIDENT. FIRST; THE PLT NEVER REVIEWED NOR ASKED TO REVIEW THE QUIET BRIDGE VISUAL APCH. SECOND; THE PLT; DURING THE APCH; WAS TRYING TO LOAD A NEW FLT PLAN INTO THE GPS DURING A CRITICAL PHASE OF FLT. THE AUTOPLT WAS TURNED ON AND FLYING THE ACFT. AFTER LNDG; THE PLT STATED HE WAS IN HDG MODE WHICH WOULD EXPLAIN WHY THE ACFT DRIFTED OFF OF THE 095 DEG RADIAL. I BELIEVE THE ERROR MADE WAS DIRECTLY RELATED TO THE PLT'S LACK OF ATTN TO FLYING THE ACFT DURING THIS PHASE OF FLT. THIRD; THERE WAS A B747 4.5 MI AHEAD OF US AND THE CONCERN FOR WAKE TURB AND THE PROPER SEPARATION CONSUMED MOST OF MY ATTN. DURING A VISUAL APCH; IF THE PLT STATES HE HAS THE PRECEDING ACFT IN SIGHT; HE IS RESPONSIBLE FOR HIS OWN WAKE TURB SEPARATION. THIS INCIDENT REFLECTS HOW IMPORTANT GOOD OPERATING PROCS ARE AND HOW HUMAN FACTORS OFTEN LEAD TO MISTAKES THAT CAN LEAD TO PROBS. THE PLT SHOULD ALSO INSIST UPON REVIEWING ALL CHARTED PROCS; ESPECIALLY INTO LARGE METRO ARPTS. AS AN OBSERVER; I COULD HAVE BEEN INSISTENT ON REVIEWING THE PROC WHICH COULD HELP IN SITS SUCH AS THIS. BECAUSE THE PLT WAS ALSO A PERSONAL FRIEND WITH A LOT OF EXPERIENCE; I WAS UNDER THE IMPRESSION HE WAS IN COMPLETE CTL OF THE SIT. NEVER ASSUME ANYTHING. COMPLACENCY IS A RECIPE FOR DISASTER.

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