A B737 captain becomes disoriented on approach, resulting in an unstabilized approach that came close to a stall and a crossing restriction not being met.

Date: 2003-12 · Aircraft: B737-700

Anomalies: Deviation altitude crossing restriction not metDeviation altitude undershootDeviation discrepancy procedural published material policyDeviation discrepancy procedural FARInflight event encounter unstabilized approachInflight event encounter loss of aircraft control

Synopsis

A B737 captain becomes disoriented on approach, resulting in an unstabilized approach that came close to a stall and a crossing restriction not being met.

Narrative

Rewritten in plain English from NASA’s original all-caps telegraphic report — facts, figures, and terminology preserved.

I was pilot not flying. Approach gave us a vector of 150 degrees to join the final approach course for runway 11 at Oakland. The pilot flying (captain) selected 160 degrees in the course selector window. I remarked, 'Course should be 160 degrees, unless you wanted 150 degrees.'

We were then given 'Plaza at 1800 feet,' which is a mandatory altitude for the final approach fix on the approach chart. At this point he began configuring, gear down, flaps 15 degrees. He began his turn at 2500 feet and slowed the aircraft to a near stall (reference minus 15 knots) in a 30 degree bank. I made the altitude deviation call, 'Airspeed! Airspeed.'

He gave the airplane nearly maximum power and disconnected the autopilot. The power solved the airspeed, but we then began climbing. I told him, 'We can't climb here,' then, 'We have to cross Plaza at 1800 feet.' He leveled off, but did not descend. I called the deviation again, but by this time he had intercepted the localizer and thankfully, we broke out of the clouds and rejoined the glide slope for an uneventful landing. It was a classic attempt at a stall/spin on the base to final turn. I have no idea what caused his actions, other than getting disoriented in the clouds.

We climbed from an assigned altitude of 2000 feet to 2400 feet and crossed Plaza (required at 1800 feet) still at about 2400 feet, so we missed the restriction by not quite 500 feet. This is airspace under SFO and I was worried about ATC, but we did not hear anything about our (very short) altitude excursion.

I discussed what happened afterward with the captain, remarking, 'You scared me on final.' He explained what happened by explaining that a headwind changed to a tailwind (or vice versa) and the localizer button didn't arm. He didn't offer an explanation for the near stall and altitude bust from recovery. I think (hope) NorCal didn't notice; we didn't hear anything from them. The passengers sure noticed; I was buttonholed by both flight attendants and passengers while deplaning, who wanted to know, 'What happened back there?'

Show the original NASA report (verbatim, telegraphic)

I WAS PNF. APCH GAVE US A VECTOR OF 150 DEGS TO JOIN THE FINAL APCH COURSE FOR RWY 11 AT OAKLAND. THE PF (CAPT) SELECTED 160 DEGS IN THE COURSE SELECTOR WINDOW. I REMARKED 'COURSE SHOULD BE 160 DEGS; UNLESS YOU WANTED 150 DEGS.' WE WERE THEN GIVEN 'PLAZA AT 1800 FT' WHICH IS A MANDATORY ALT FOR THE FAF ON THE APCH CHART. AT THIS POINT HE BEGAN CONFIGURING; GEAR DOWN; FLAPS 15 DEGS. HE BEGAN HIS TURN AT 2500 FT AND SLOWED THE ACFT TO A NEAR STALL (REF MINUS 15 KTS) IN A 30 DEG BANK. I MADE THE ALTDEV CALL 'AIRSPD! AIRSPD.' HE GAVE THE AIRPLANE NEARLY MAX PWR AND DISCONNECTED THE AUTOPLT. THE PWR SOLVED THE AIRSPD; BUT WE THEN BEGAN CLBING. I TOLD HIM 'WE CAN'T CLB HERE;' THEN; 'WE HAVE TO CROSS PLAZA AT 1800 FT.' HE LEVELED OFF; BUT DID NOT DSND. I CALLED THE DEV AGAIN; BUT BY THIS TIME HE HAD INTERCEPTED THE LOC AND THANKFULLY; WE BROKE OUT OF THE CLOUDS AND REJOINED THE GS FOR AN UNEVENTFUL LNDG. IT WAS A CLASSIC ATTEMPT AT A STALL/SPIN ON THE BASE TO FINAL TURN. I HAVE NO IDEA WHAT CAUSED HIS ACTIONS; OTHER THAN GETTING DISORIENTED IN THE CLOUDS. WE CLBED FROM AN ASSIGNED ALT OF 2000 FT TO 2400 FT AND CROSSED PLAZA (REQUIRED AT 1800 FT) STILL AT ABOUT 2400 FT; SO WE MISSED THE RESTR BY NOT QUITE 500 FT. THIS IS AIRSPACE UNDER SFO AND I WAS WORRIED ABOUT ATC; BUT WE DID NOT HEAR ANYTHING ABOUT OUR (VERY SHORT) ALT EXCURSION. I DISCUSSED WHAT HAPPENED AFTERWARD WITH THE CAPT; REMARKING; 'YOU SCARED ME ON FINAL.' HE EXPLAINED WHAT HAPPENED BY EXPLAINING THAT A HEADWIND CHANGED TO A TAILWIND (OR VICE VERSA) AND THE LOC BUTTON DIDN'T ARM. HE DIDN'T OFFER AN EXPLANATION FOR THE NEAR STALL AND ALT BUST FROM RECOVERY. I THINK (HOPE) NORCAL DIDN'T NOTICE; WE DIDN'T HEAR ANYTHING FROM THEM. THE PAX SURE NOTICED; I WAS BUTTONHOLED BY BOTH FLT ATTENDANTS AND PAX WHILE DEPLANING; WHO WANTED TO KNOW 'WHAT HAPPENED BACK THERE?'

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