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Flight crew of medium large transport arriving bos in bad WX mistakes RVR value for descent altitude due to high cockpit workload.
| Attributes | |
| ACN | 153690 |
| Time | |
| Date | 199008 |
| Day | Fri |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : bos |
| State Reference | MA |
| Altitude | msl bound lower : 6500 msl bound upper : 7000 |
| Environment | |
| Flight Conditions | IMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : bos artcc : zan |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Navigation In Use | Other Other |
| Flight Phase | cruise other descent : approach landing : missed approach |
| Route In Use | enroute : on vectors |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
| Experience | flight time last 90 days : 200 flight time total : 8500 flight time type : 175 |
| ASRS Report | 153690 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : commercial pilot : instrument |
| Events | |
| Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance other anomaly other |
| Independent Detector | other flight crewa |
| Resolutory Action | flight crew : returned to intended course or assigned course |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
I was the PNF. The WX at bos was an intermittent RVR that necessitated a missed approach to a holding fix. Climb to 7000' MSL. Upon being vectored from the holding pattern for another approach. The approach controller kept issuing RVR reports; i.e., 5000, 2200, 1800, etc. I was talking with company coordinating a new alternate airfield, fuel, etc and was trying to monitor both radios when the control gave us a heading and mentioned the RVR at 2200'. The first officer thought he was cleared to 2200' and called out of 7000 for 2200'. At 6500' I was back on the radio and questioned the altitude and we began a climb back to 7000', after verification with the controller. In my opinion, the environment was approaching task saturation for a 2-M cockpit in a very busy approach control with bad WX, missed approachs, diverts, etc. This is the type of miscom that is bound to happen and fortunately was corrected before an incident occurred.
Original NASA ASRS Text
Title: FLT CREW OF MLG ARRIVING BOS IN BAD WX MISTAKES RVR VALUE FOR DESCENT ALT DUE TO HIGH COCKPIT WORKLOAD.
Narrative: I WAS THE PNF. THE WX AT BOS WAS AN INTERMITTENT RVR THAT NECESSITATED A MISSED APCH TO A HOLDING FIX. CLB TO 7000' MSL. UPON BEING VECTORED FROM THE HOLDING PATTERN FOR ANOTHER APCH. THE APCH CTLR KEPT ISSUING RVR RPTS; I.E., 5000, 2200, 1800, ETC. I WAS TALKING WITH COMPANY COORDINATING A NEW ALTERNATE AIRFIELD, FUEL, ETC AND WAS TRYING TO MONITOR BOTH RADIOS WHEN THE CTL GAVE US A HDG AND MENTIONED THE RVR AT 2200'. THE F/O THOUGHT HE WAS CLRED TO 2200' AND CALLED OUT OF 7000 FOR 2200'. AT 6500' I WAS BACK ON THE RADIO AND QUESTIONED THE ALT AND WE BEGAN A CLB BACK TO 7000', AFTER VERIFICATION WITH THE CTLR. IN MY OPINION, THE ENVIRONMENT WAS APCHING TASK SATURATION FOR A 2-M COCKPIT IN A VERY BUSY APCH CTL WITH BAD WX, MISSED APCHS, DIVERTS, ETC. THIS IS THE TYPE OF MISCOM THAT IS BOUND TO HAPPEN AND FORTUNATELY WAS CORRECTED BEFORE AN INCIDENT OCCURRED.
Data retrieved from NASA's ASRS site as of July 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.