B767-300 EXPERIENCES ALTDEV ON ARR TO UUEE. RECOVERY RESULTS IN FLAP OVERSPD.
Synopsis
B767-300 EXPERIENCES ALTDEV ON ARR TO UUEE. RECOVERY RESULTS IN FLAP OVERSPD.
Narrative
RUSSIAN ATC KEPT ACFT HIGH ON STAR (KS25L) FOR TFC; THEN VECTORED N OF RWY TO LOSE ALT. ALT CHANGES WERE RAPID; AND CREW WORKLOAD WAS HIGH; COMPOUNDED BY METRIC CONVERSION AND CTLR ACCENT. ATC DIRECTED SPD REDUCTION FROM 250 KTS TO MINIMUM APCH SPD (180 KTS) WHILE IN TURNING DSCNT TO A 90 DEG LOC INTERCEPT (ILS RWY 25L). I (THE PF) EXTENDED SPD BRAKES AND EXTENDED FLAPS ON SPD SCHEDULE TO 20 DEGS; RESULTING IN A DSCNT RATE OF APPROX 2000 FPM. SIMULTANEOUSLY; ALT ASSIGNMENTS CONTINUED RAPIDLY IN 1000 FT INCREMENTS FROM 3300 M (9900 FT) ABOVE THE TRANSITION LEVEL OF 1500 M TO 600 M (1800 FT). CONCURRENTLY; ACFT DSNDED INTO SOLID LAYER AT 1200 M (3600 FT). CREW HAD BRIEFED TRANSITION ALT AND QFE (984 MILLIBARS) AT 3300 M AND SET THE STANDBY ALTIMETER TO QFE. ALL 3 PLTS WERE DISTR BY LATE ATC CLRNC FOR LOC INTERCEPT (ACFT OVERSHOT LOC BY FULL DEFLECTION); SIMULTANEOUS CLRNC TO 600 M AND APCH CLRNC AS IMC WAS ENCOUNTERED; AND THUS FAILED TO SEE QFE AS ACFT PASSED THROUGH 1500 M. STANDARDS INSTRUCTOR TRAINING FOR RUSSIAN AIRSPACE INCLUDES AN ADMONITION NOT TO SET QFE UNTIL ACFT ACTUALLY DSNDS BELOW TRANSITION ALT AS A LEVELOFF AT THAT ALT WOULD BE IN QNH; NOT QFE; AND COULD BE HUNDREDS OF FT OFF; AND CAPT HAD BRIEFED THIS STANDARD PREVIOUSLY ON FLT. AS ACFT ENCOUNTERED VMC AT 700 M (2000 FT AGL); I RETRACTED SPD BRAKES; THEN CLICKED OFF AUTOPLT AND AUTOTHROTTLE (AS I HAD BRIEFED). INSTANTLY THEREAFTER; ALL 3 CREW REALIZED ACFT WAS LOW ON GLIDE PATH; AND ATC QUERIED AS TO WHETHER WE WERE UTILIZING QFE. I LOOKED IMMEDIATELY AT TCAS REPEATER ON MY VSI AND SAW TFC AT 3 NM AHEAD AND 200 FT BELOW (TFC ON ILS APCH). I IMMEDIATELY ADDED SIGNIFICANT PWR (THROTTLES APPROX 75%); AND RAISED NOSE APPROX 5 DEGS FOR A SMOOTH CLB BACK TO GLIDE PATH. I NOTICED SPD INCREASING AND CALLED FOR FLAP RETRACTION; BUT WAS CONSUMED WITH CONFLICTING INFO FROM FLT DIRECTOR; WHICH INDICATED A DSCNT TO 600 M QFE (ABOUT 400 FT BELOW GLIDE PATH); AND THE FACT THAT ACFT RE-ENCOUNTERED IMC. CAPT GOT FLAPS TO 5 DEGS; BUT WAS DISTR AS WELL IN SITUATIONAL AWARENESS. AIRSPD CONTINUED TO 250 KTS BEFORE I HAD ACFT UP TO GLIDE PATH ALT. IMMEDIATELY I REDUCED THROTTLES FOR AIRSPD REDUCTION AND DIRECTED GEAR DOWN; AND FLAPS EXTENDED BACK ON SCHEDULE FOR LNDG SPD. VMC WAS RE-ATTAINED; AND WE MAINTAINED VISUAL SEPARATION WITH LNDG TFC. THE REMAINDER OF THE APCH AND LNDG WERE NORMAL. UPON SHUTDOWN; THE CREW WROTE THE ACFT UP FOR A FLAP OVERSPD. THE ALTDEV WAS CAUSED BY CREW WORKLOAD SATURATION; RESULTING IN A SINGLE; CRITICAL; MISSED STEP -- THE TRANSITION TO QFE. IF ONE OF THE 3 CREW HAD CAUGHT THIS ITEM; THIS INCIDENT WOULD NOT HAVE OCCURRED. NO PLT WAS NEGLIGENT -- ALL WERE PERFORMING THEIR DUTIES TO THE BEST OF THEIR ABILITY. UNFORTUNATELY; THE RAPIDITY OF SCAN REQUIREMENTS COUPLED WITH THE UNUSUAL NATURE OF OPERATING IN A QNH-QFE METRIC ENVIRONMENT OVERLOADED US. THE FLAP OVERSPD WAS CAUSED BY A MOMENTARY LOSS OF SITUATIONAL AWARENESS ON ALL 3 PLTS' BEHALF. THE RELIEF PLT NOTICED THE OVERSPD FIRST. I; THE PF; WAS OVERWHELMED BY 1) UNCERTAINTY AS TO THE THREAT PRESENTED BY THE TFC 200 FT BELOW; 2) THE TENDENCY TO FOLLOW BAD FLT DIRECTOR INFO; AND 3) RE-ENTRY INTO IMC. IN TERMS OF TRAINING; I HAD NOT EXPERIENCED THIS SITUATION BEFORE -- SUDDENLY; THE ACFT WAS IN JEOPARDY OF A MAJOR ALTDEV AT LOW ALT AND A POSSIBLE MIDAIR THREAT; YET I PERCEIVED SEMI-CONSCIOUSLY THAT A MAJOR CORRECTION (MAX PWR AND ATTITUDE) WOULD BE INAPPROPRIATE FOR THE CORRECTION OF THE FLT PATH. THUS; MY RESPONSE WAS AN INAPPROPRIATE COMPOSITE OF AN AGGRESSIVE AND SMOOTH RECOVERY. I AM TRAINED AND CONFIDENT IN MY PROC FOR A TCAS RA OR A CFIT INCIDENT; BUT HAVE NOT EXPERIENCED A SITUATION THAT INVOLVED BOTH OF THESE ELEMENTS YET DID NOT ACTUALLY PRESENT A CRISIS THREAT TO THE ACFT. I WOULD SUGGEST HAVING AIR CREWS ACTUALLY PRACTICE A SIMILAR EVENT IN A SIMULATOR IN ORDER TO DEVELOP THE SKILL OF NOT OVERCOMPENSATING WHEN THE SITUATION DOES NOT DICTATE SUCH. I SUPPOSE IT WAS A LIKEWISE OVERCOMPENSATION FOR ARELATIVELY INSIGNIFICANT DEV IN FLT PATH THAT CAUSED THE DEMISE OF ACR FLT X OVER JAMAICA; NY; IN 2001. I HAVE LEARNED A VALUABLE LESSON.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.