B737 flight crew flew toward rising terrain during an ILS missed approach instructed by a foreign go...

Attributes
ACN	518936
Time
Date	200107
Day	Tue
Local Time Of Day	1801 To 2400
Place
State Reference	FO
Environment
Light	Night
Aircraft 1
Operator	common carrier : air carrier
Make Model Name	B737 Undifferentiated or Other Model
Operating Under FAR Part	Part 121
Navigation In Use	ils localizer & glide slope : 07 other
Flight Phase	descent : approach landing : missed approach
Route In Use	approach : instrument precision
Flight Plan	IFR
Person 1
Affiliation	company : air carrier
Function	flight crew : first officer
Qualification	pilot : commercial pilot : multi engine pilot : instrument
ASRS Report	518936
Person 2
Affiliation	company : air carrier
Function	flight crew : captain oversight : pic
Events
Anomaly	non adherence : published procedure other spatial deviation other spatial deviation
Independent Detector	other controllera
Resolutory Action	controller : issued alert controller : issued new clearance flight crew : executed missed approach none taken : detected after the fact
Consequence	faa : reviewed incident with flight crew
Supplementary
Problem Areas	Flight Crew Human Performance
Primary Problem	Flight Crew Human Performance
Air Traffic Incident	Pilot Deviation

Narrative:

During the ILS DME runway 7 at sjo, a missed approach was initiated about 7 NM prior to the missed approach point. Altitude on the GS at this point was very close below the missed approach altitude. During the initial missed approach climb the missed approach altitude was climbed through. A missed approach was reported to the non radar tower. The tower misunderstood the aircraft position on the approach at which the missed approach was executed and issued instructions that placed the aircraft out of the normal protected missed approach path towards rising terrain. Several aircraft were on the approach and the crew followed the tower instructions under the incorrect assumption that tower had radar and was clearing the aircraft above the MVA for the sector and away from other traffic. After contacting departure, proper routing and altitude clrncs were received. Departure control complained about the aircraft position and the crew's failure to fly the proper missed approach path. After explaining to him the conflicting instructions received from the tower, the departure controller insisted they were consistent with flying the published missed approach. Communications confusion, a poor approach briefing, improper preparation before the approach for a missed approach prior to the missed approach point, and mis-prioritizing of tasks during the missed approach, contributed to the general confusion that created the situation.

Original NASA ASRS Text

Title: B737 FLC FLEW TOWARD RISING TERRAIN DURING AN ILS MISSED APCH INSTRUCTED BY A FOREIGN GOV, NON RADAR TWR, WHO BELIEVED THAT THEY WERE OVER THE ARPT ON THE MISSED APCH. HOWEVER, THEY WERE STILL 7 MI PRIOR TO THE MISSED APCH POINT.

Narrative: DURING THE ILS DME RWY 7 AT SJO, A MISSED APCH WAS INITIATED ABOUT 7 NM PRIOR TO THE MISSED APCH POINT. ALT ON THE GS AT THIS POINT WAS VERY CLOSE BELOW THE MISSED APCH ALT. DURING THE INITIAL MISSED APCH CLB THE MISSED APCH ALT WAS CLBED THROUGH. A MISSED APCH WAS RPTED TO THE NON RADAR TWR. THE TWR MISUNDERSTOOD THE ACFT POS ON THE APCH AT WHICH THE MISSED APCH WAS EXECUTED AND ISSUED INSTRUCTIONS THAT PLACED THE ACFT OUT OF THE NORMAL PROTECTED MISSED APCH PATH TOWARDS RISING TERRAIN. SEVERAL ACFT WERE ON THE APCH AND THE CREW FOLLOWED THE TWR INSTRUCTIONS UNDER THE INCORRECT ASSUMPTION THAT TWR HAD RADAR AND WAS CLRING THE ACFT ABOVE THE MVA FOR THE SECTOR AND AWAY FROM OTHER TFC. AFTER CONTACTING DEP, PROPER ROUTING AND ALT CLRNCS WERE RECEIVED. DEP CTL COMPLAINED ABOUT THE ACFT POS AND THE CREW'S FAILURE TO FLY THE PROPER MISSED APCH PATH. AFTER EXPLAINING TO HIM THE CONFLICTING INSTRUCTIONS RECEIVED FROM THE TWR, THE DEP CTLR INSISTED THEY WERE CONSISTENT WITH FLYING THE PUBLISHED MISSED APCH. COMS CONFUSION, A POOR APCH BRIEFING, IMPROPER PREPARATION BEFORE THE APCH FOR A MISSED APCH PRIOR TO THE MISSED APCH POINT, AND MIS-PRIORITIZING OF TASKS DURING THE MISSED APCH, CONTRIBUTED TO THE GENERAL CONFUSION THAT CREATED THE SIT.

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.

B737 flight crew flew toward rising terrain during an ILS missed approach instructed by a foreign government, non radar tower, who believed that they were over the airport on the missed approach. However, they were still 7 mi prior to the missed approach point.