COPLT OF CRJ-700 RPTS THAT STRANGE BEHAVIOR OF CAPT THROUGHOUT A TRIP SEQUENCE CULMINATED IN A BIZARRE FAILURE TO PERFORM A VISUAL APCH TO SRQ; OVERFLYING THE FIELD AT 2000 FT. RPTR SUSPECTS SUBSTANCE ABUSE ALTERED THE CAPT'S ABILITY TO PERFORM HIS DUTIES.

2003-11 · NASA ASRS report 601526

Date: 2003-11 · Aircraft: Regional Jet 700 ER/LR (CRJ700)

Anomalies: conflict-airborne-conflict|deviation-altitude-undershoot|deviation-speed-all-types|deviation-track-heading-all-types|deviation-discrepancy-procedural-published-material-policy|deviation-discrepancy-procedural-clearance|inflight-event-encounter-unstabilized-approach

Synopsis

COPLT OF CRJ-700 RPTS THAT STRANGE BEHAVIOR OF CAPT THROUGHOUT A TRIP SEQUENCE CULMINATED IN A BIZARRE FAILURE TO PERFORM A VISUAL APCH TO SRQ; OVERFLYING THE FIELD AT 2000 FT. RPTR SUSPECTS SUBSTANCE ABUSE ALTERED THE CAPT'S ABILITY TO PERFORM HIS DUTIES.

Narrative

DURING DSCNT AND APCH INTO SRQ; ON THE NIGHT IN QUESTION; THE CAPT APPEARED TO BECOME DISORIENTED. THIS WAS THE LAST LEG OF A VERY LONG DAY. WHEN I QUESTIONED HIM AS TO WHETHER OR NOT HE HAD THE ARPT IN SIGHT; HE REPLIED IN THE AFFIRMATIVE; EVEN THOUGH WE WERE NOT IN A SAFE POS TO LAND HE CONTINUED THE APCH. 1) WE WERE TRAVELING AT 270 KIAS BELOW 10000 FT MSL. 2) WE OVERFLEW THE SRQ ARPT AT 250 KIAS AT 2000 FT MSL. THE FOLLOWING MEMO IS A RECORD OF THE EVENTS SURROUNDING AN INCIDENT ON THE EVENING OF NOV/FRI/03. DURING THE INCIDENT; THE CAPT COMPLETELY LOST SITUATIONAL AWARENESS WHILE ATTEMPTING A VISUAL APCH TO THE SARASOTA-BRADENTON ARPT IN NIGHT VMC. MY RECOLLECTION OF THE EVENTS IS ACCURATE TO THE BEST OF MY KNOWLEDGE AND THE ANALYSIS IS MY OWN INTERP OF THE INCIDENT AND ASSOCIATED EVENTS. THE FIRST DAY; THE CAPT WAS OVERLY CRITICAL OF MY PERFORMANCE. HE WAS IMPOLITE AND UNPROFESSIONAL IN HIS INTERACTIONS WITH ME. THE SECOND DAY; WE WERE SCHEDULED FOR A 12 HR 50 MIN DUTY DAY; WHICH INCLUDED 7 HRS 45 MINS OF FLYING. DUE TO THE WX AND DEICING REQUIREMENTS; WE ENDED THE DAY AFTER FLYING MORE THAN 9 HRS. OUR DUTY DAY ENDED UP BEING 14 HRS LONG. THROUGHOUT THE DAY; THE CAPT APPEARED TIRED. HE WAS YAWNING; RAMBLING ON HIS PA'S AND HAD DIFFICULTY STAYING AWAKE DURING OUR WAIT FOR DEICE IN CVG. THE WAIT FOR DEICE IN CVG WAS OVER 1 HR. AFTER WE HAD WAITED FOR ABOUT 1/2 HR; WE WERE FINALLY ABOUT #3 IN LINE FOR DEICE. WE MOVED FORWARD. AFTER WE STOPPED; CAPT DID NOT SET THE PARKING BRAKE; HE HELD THE BRAKES WITH HIS FEET. I WAS LOOKING AHEAD AT THE ACFT IN FRONT OF US AND NOTICED WE WERE MOVING CLOSER TO IT. WHEN I LOOKED OVER AT THE CAPT; I NOTICED HIS EYES WERE CLOSED. I IMMEDIATELY STEPPED ON THE BRAKES. HE APPEARED INSTANTLY MORE ALERT AND SIMPLY STATED 'THOSE BRAKES ARE CATCHY AREN'T THEY?' FINALLY; ON OUR DSCNT INTO SRQ; JUST BEFORE THE INCIDENT; WE WERE CLRED TO DSND TO 11000 FT; THEN RECLRED TO 6000 FT. THE CAPT HAD PUT A 400 FPM RATE OF DSCNT IN THE AUTOPLT. AS WE DSNDED THROUGH 10000 FT; WE HAD DECELERATED TO APPROX 260 KIAS. THE 'BANANA' ON THE MFG SHOWED THAT; AT OUR CURRENT RATE OF DSCNT; WE WOULD REACH 6000 FT APPROX 50 MI S OF SRQ. AS WE DSNDED; EVERY MIN OR SO THE CAPT INCREASED THE THRUST BY A SMALL AMOUNT. EVENTUALLY WE ACCELERATED TO 270 KIAS AND I STATED 'IT APPEARS WE ARE A LITTLE FAST; WE'RE DOING 270 KTS.' CAPT RESPONDED BY REDUCING THE THRUST TO IDLE AND STATED 'OH; I GUESS WE ARE.' HE THEN INCREASED OUR RATE OF DSCNT. THE CAPT WAS THE PF AND THE AUTOPLT WAS ENGAGED. SARASOTA APCH HAD VECTORED US TO A R DOWNWIND FOR RWY 32 ON A HDG OF 140 DEGS. WE WERE ABEAM THE ARPT AT ABOUT 6000 FT; AT AN AIRSPD OF 250 KTS; AND HAD JUST BEEN CLRED TO 2000 FT. I SAID 'CAPT; I'VE GOT THE ARPT OUT MY WINDOW HERE; WOULD YOU LIKE ME TO CALL IT?' HE GAVE A SHORT AFFIRMATIVE RESPONSE; 'YEAH; GO AHEAD.' I TOLD APCH WE HAD THE ARPT IN SIGHT AND THEY RESPONDED 'ACR X; TFC IS ON A 2 MI R BASE; CLRED FOR THE VISUAL; RWY 32.' I SAW THE TFC; BUT PER THE CAPT'S INSTRUCTIONS AT THE BEGINNING OF THE TRIP; I DID NOT RPT IT TO APCH. I RESPONDED WITH 'CLRED FOR THE VISUAL RWY 32.' I STATED 'IT SEEMS LIKE WE ARE A LITTLE HIGH' AND THE CAPT RESPONDED WITH 'UH-HUH.' WHEN WE WERE TURNED TO A POINT WHERE I WAS CERTAIN HE WOULD BE ABLE TO SEE THE ARPT I SAID; 'CAPT; THE RWY IS AT 2 O'CLOCK POS AND EXTREMELY LOW; DO YOU HAVE IT IN SIGHT?' HE RESPONDED WITH ANOTHER SHORT AFFIRMATIVE RESPONSE. ABOUT THE TIME WE REACHED THE NW HDG; THE ACFT LEVELED OFF AT 2000 FT. THE ONLY REASON WE COULD SEE THE ARPT IN THE TURN WAS BECAUSE WE WERE IN A DSCNT. AS SOON AS WE LEVELED OFF; THE RWY DISAPPEARED FROM VIEW AND WE PASSED OVER IT. AS WE WERE DIRECTLY OVERHEAD SRQ; THE APCH CTLR CALLED US AND ASKED US WHAT WE WERE DOING. I DID NOT KNOW WHAT THE CAPT WAS DOING SO I JUST SAID THAT WE WERE AT 2000 FT. HE TOLD US TO CLB TO 12000 FT. I SET 12000 FT IN THE ALT PRESELECTOR AND SAID 'TWELVE THOUSAND.' THE CAPT SAID 'OK; 12000 FT.' MEANWHILE; THE CTLR ASKED US 'DID YOU GOTO THE TWR; DID YOU GO AROUND?' THE CAPT SAID 'TELL HIM WE HAVE THE ARPT IN SIGHT.' I DID AND APCH GAVE US A R XWIND HDG; CLRED US FOR THE VISUAL APCH AND TOLD US TO CONTACT THE TWR. ON OUR FIRST CALL TO THE TWR; THE CTLR OBVIOUSLY THOUGHT THAT APCH HAD MADE THE MISTAKE. HE SAID HE DIDN'T KNOW WHY APCH HAD 'LEFT US UP THERE LIKE THAT.' HE INSTRUCTED US TO ENTER A R DOWNWIND AND THAT WE WERE #1; CLRED FOR THE VISUAL APCH AND CLRED TO LAND. HE THEN STATED 'NO; MAKE A HARD R TURN AND JOIN THE L DOWNWIND. YOU HAVE TFC AT YOUR 12 O'CLOCK POS IFR AT 1700 FT.' I SAW A ROTATING BEACON AHEAD OF US; BUT COULD NOT DETERMINE OUR DISTANCE FROM THE ACFT. AT THAT POINT; THE CAPT DISCONNECTED THE AUTOPLT AND ROLLED INTO A FULL 30 DEG BANKED TURN TO THE R. HE DID NOT ASK ME TO SET ANYTHING INTO THE FLT DIRECTOR; SO IT STILL DIRECTED US TO TURN TO THE XWIND HDG. FOR THE FIRST TIME; THE CAPT SLOWED THE ACFT BELOW 250 KTS. AT THIS POINT; HE APPEARED AWARE OF HIS SURROUNDINGS AND PERFORMED A NORMAL VISUAL APCH IN THE TFC PATTERN. WHEN WE REACHED 50 FT AGL; THE CAPT ABRUPTLY REDUCED THE THRUST COMPLETELY TO IDLE AND STARTED TO SLOWLY FLARE THE ACFT. FORTUNATELY; THE ACFT DID NOT ENTER A STALL; BUT FROM 20 FT AND DOWN; WE DID HAVE AN UNUSUALLY HIGH RATE OF DSCNT FOLLOWED BY A VERY FIRM TOUCHDOWN. I WANTED TO TALK TO THE CAPT ABOUT WHAT HAD JUST HAPPENED. WHILE I WAS PLACING MY HEADSET AND CHART BOOK BACK IN MY BAG; HE STARTED THE CONVERSATION. HE SAID SOMETHING LIKE 'SO; WHAT HAPPENED UP THERE?' I RECOUNTED THE EVENTS TO HIM AS IF HE HAD NOT BEEN IN THE ACFT. WHEN I GOT TO THE PART WHERE I TOLD HIM WE WERE CLRED FOR THE VISUAL APCH; HE INTERRUPTED ME AND SAID 'I GUESS SOMEHOW IN MY HEAD; WHEN WE GOT THAT CLRNC FOR THE VISUAL TO RWY 32; I THOUGHT IT WAS A HDG TO 32; I MEAN 320.' I TRIED TO CONTINUE TO TELL HIM ABOUT THE 2 TIMES I QUESTIONED HIS ACTIONS AND HE INTERRUPTED ME AGAIN STATING 'I FEEL IT'S OK TO MAKE MISTAKES; BUT IT'S IMPORTANT TO UNDERSTAND WHY WE MAKE THEM AND FIX THE PROB. I JUST CAN'T EXPLAIN THIS AS ME BEING TIRED. I CANNOT HAVE BEEN SO TIRED THAT I MADE THAT MISTAKE. THERE HAS TO BE SOMETHING ELSE.' CURIOUS ABOUT HIS LAST REMARK I SAID 'OK...?' HE SAID 'I'M NOT SAYING THERE'S ANY PROB ON YOUR PART; JUST THAT I NEED TO UNDERSTAND WHAT HAPPENED.' AFTER PERFORMING MY POSTFLT INSPECTION; I JOINED THE FLT ATTENDANTS IN THE GATE AREA AS WE WAITED FOR THE CAPT. HE SEEMED TO TAKE AN UNUSUALLY LONG TIME FINISHING UP; SO WE STARTED TALKING. THE LEAD FLT ATTENDANT ASKED IF THERE WAS A PROB. I SAID THAT THERE HAD BEEN A PROB WITH THE CAPT'S PERFORMANCE. THE AFT FLT ATTENDANT THEN STATED THAT SHE WITNESSED THE CAPT TAKING A PILL OF SOME SORT WHEN WE WERE ON THE GND IN ATL BEFORE DEPARTING FOR SRQ. SHE SAID THAT HE ACTED VERY NERVOUS AND TOLD HER THAT IT WAS AN ANTIBIOTIC. AS SOON AS WE GOT TO THE HOTEL; I CALLED SCHEDULING AND ASKED THEM TO CONNECT ME TO A CHIEF PLT. A FEW MINS LATER HE CALLED ME BACK AND I RECOUNTED THE MAJORITY OF THE CONTENT OF THIS RPT TO HIM OVER THE PHONE. THERE IS NO QUESTION IN MY MIND THAT THE CAPT ENDANGERED THE LIVES OF ALL 36 PAX AND 4 CREW ON OUR FLT THAT NIGHT. THE ACFT THAT WE WERE SUPPOSED TO BE FOLLOWING ON THE ORIGINAL VISUAL APCH COULD HAVE PERFORMED A GAR AND WE WOULD HAVE BEEN DIRECTLY IN ITS FLT PATH. THERE ALSO WAS THE POSSIBILITY OF A CONFLICT WITH THE ACFT E OF THE ARPT AS WE WERE RETURNING TO ATTEMPT THE VISUAL APCH THE SECOND TIME. IN ADDITION; HE DID NOT SEEM TO LAND THE ACFT IN THE STYLE NORMAL FOR THE CRJ-700. EITHER HE DID THIS ON PURPOSE; OR BY ACCIDENT -- THERE IS NO WAY TO KNOW. IF THE CAPT WAS ACTUALLY IN AN ALTERED STATE OF MIND; ANY ABNORMALITY DURING LNDG COULD HAVE ENDANGERED THE ACFT; PAX; AND CREW EVEN FURTHER. THIS IS DEFINITELY A COMPLEX SIT. HAD THE CAPT NOT BEEN SO CONFRONTATIONAL WITH ME ON PREVIOUS FLTS; I WOULD HAVE FELT FREE TO ACT MORE AGGRESSIVELY IN MY QUESTIONING OF HIM DURING THE VISUAL APCH. HOWEVER; HE HAS A HISTORY OF DOING THINGS HIS OWN WAY AND FIGHTING WITH DISSENTERS.HE IS A VERY EXPERIENCED CAPT AND I GAVE HIM THE BENEFIT OF THE DOUBT THROUGHOUT THE SIT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR DESCRIBED EVENTS SUBSEQUENT TO DATE OF THE RPT. HE CONTACTED THE COMPANY THE EVENING OF THE INCIDENT AND THEY DISPATCHED A NEW CAPT TO FLY THE RETURN FLT. THE ORIGINAL CAPT WAS RELIEVED OF DUTY AND REQUIRED TO TAKE A DRUG TEST AND SUBMIT TO A MEDICAL EVALUATION. RPTR ALSO ADVISED THAT THE CAPT HAD BEEN A LONG TERM CRM PROB FOR THE COMPANY. TO DATE; THE RPTR IS UNAWARE OF THE OUTCOME OF THOSE EVALUATIONS.

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

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