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System error and resulting potential conflict in the offing when the S80 first officer turns to the wrong heading on a missed approach to ILS runway 25L at lax, ca.
| Attributes | |
| ACN | 546528 |
| Time | |
| Date | 200205 |
| Day | Mon |
| Local Time Of Day | 0601 To 1200 |
| Place | |
| Locale Reference | airport : lax.airport |
| State Reference | CA |
| Altitude | msl single value : 1000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tower : lax.tower |
| Operator | common carrier : air carrier |
| Make Model Name | MD-80 Super 80 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | ils localizer & glide slope : 25l |
| Flight Phase | descent : approach landing : missed approach landing : go around |
| Flight Plan | IFR |
| Aircraft 2 | |
| Controlling Facilities | tower : lax.tower |
| Operator | common carrier : air carrier |
| Make Model Name | B757 Undifferentiated or Other Model |
| Operating Under FAR Part | Part 121 |
| Flight Phase | descent : approach |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| ASRS Report | 546528 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| ASRS Report | 546527 |
| Events | |
| Anomaly | inflight encounter : wake turbulence inflight encounter : weather non adherence : published procedure non adherence : far non adherence : required legal separation non adherence : clearance other anomaly other other spatial deviation |
| Independent Detector | atc equipment other atc equipment : radar aircraft equipment : tcas other controllera other flight crewa |
| Resolutory Action | controller : issued advisory controller : separated traffic flight crew : took precautionary avoidance action flight crew : returned to intended or assigned course flight crew : became reoriented |
| Consequence | other |
| Miss Distance | horizontal : 27000 vertical : 300 |
| Supplementary | |
| Problem Areas | ATC Human Performance Airspace Structure Weather Flight Crew Human Performance |
| Primary Problem | ATC Human Performance |
| Air Traffic Incident | Inter Facility Coordination Failure Operational Error Pilot Deviation |
Narrative:
Go around. At 1000 ft AGL on ILS runway 25L approach at lax, we were asked if we had the aircraft in front of us in sight. I responded that we were executing an instrument approach and did not. We were then given go around instructions of heading 250 degrees, climb and maintain 2000 ft. We heard heading 280 degrees instead. Leveling at 2000 ft, we were given an immediate left turn to 220 degrees. At that time we got a TA from an aircraft at 2-3 O'clock position and 300 ft above us at about 5 mi on TCASII. Once on heading 220 degrees, TA resolved and we turned back to heading 250 degrees as instructed and took vectors for a normal ILS runway 25L approach. First officer hand flying did a good job. In the funk of trying to figure out what happened to lose separation, we were distraction enough to miss the correct heading. Supplemental information from acn 546527: we were on final for runway 25L at lax and had been cleared to land by the tower. The WX at the time was marginal VFR and we were following a B757. The tower controller asked us if we had had the preceding B757 in sight. Captain said we didn't have him in sight for the instrument portion of the approach. The tower controller then said what I thought was approach clearance canceled, maintain 2000 ft, heading 280 degrees. I began a climb with a slight bank to the right when the captain pointed out traffic to our right on the TCASII. I started to level the wings when lax tower said make an immediate right turn to 220 degrees. I made the turn and continued the missed approach. Nothing further was said by ATC.
Original NASA ASRS Text
Title: SYS ERROR AND RESULTING POTENTIAL CONFLICT IN THE OFFING WHEN THE S80 FO TURNS TO THE WRONG HDG ON A MISSED APCH TO ILS RWY 25L AT LAX, CA.
Narrative: GAR. AT 1000 FT AGL ON ILS RWY 25L APCH AT LAX, WE WERE ASKED IF WE HAD THE ACFT IN FRONT OF US IN SIGHT. I RESPONDED THAT WE WERE EXECUTING AN INST APCH AND DID NOT. WE WERE THEN GIVEN GAR INSTRUCTIONS OF HDG 250 DEGS, CLB AND MAINTAIN 2000 FT. WE HEARD HDG 280 DEGS INSTEAD. LEVELING AT 2000 FT, WE WERE GIVEN AN IMMEDIATE L TURN TO 220 DEGS. AT THAT TIME WE GOT A TA FROM AN ACFT AT 2-3 O'CLOCK POS AND 300 FT ABOVE US AT ABOUT 5 MI ON TCASII. ONCE ON HDG 220 DEGS, TA RESOLVED AND WE TURNED BACK TO HDG 250 DEGS AS INSTRUCTED AND TOOK VECTORS FOR A NORMAL ILS RWY 25L APCH. FO HAND FLYING DID A GOOD JOB. IN THE FUNK OF TRYING TO FIGURE OUT WHAT HAPPENED TO LOSE SEPARATION, WE WERE DISTR ENOUGH TO MISS THE CORRECT HDG. SUPPLEMENTAL INFO FROM ACN 546527: WE WERE ON FINAL FOR RWY 25L AT LAX AND HAD BEEN CLRED TO LAND BY THE TWR. THE WX AT THE TIME WAS MARGINAL VFR AND WE WERE FOLLOWING A B757. THE TWR CTLR ASKED US IF WE HAD HAD THE PRECEDING B757 IN SIGHT. CAPT SAID WE DIDN'T HAVE HIM IN SIGHT FOR THE INST PORTION OF THE APCH. THE TWR CTLR THEN SAID WHAT I THOUGHT WAS APCH CLRNC CANCELED, MAINTAIN 2000 FT, HDG 280 DEGS. I BEGAN A CLB WITH A SLIGHT BANK TO THE R WHEN THE CAPT POINTED OUT TFC TO OUR R ON THE TCASII. I STARTED TO LEVEL THE WINGS WHEN LAX TWR SAID MAKE AN IMMEDIATE R TURN TO 220 DEGS. I MADE THE TURN AND CONTINUED THE MISSED APCH. NOTHING FURTHER WAS SAID BY ATC.
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.