Flight Crew Air Transport Pilot (ATP)
Workload; Situational Awareness; Communication Breakdown
Deviation - Altitude Excursion From Assigned Altitude; Deviation - Altitude Overshoot; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter CFTT / CFIT
Flight Crew Returned To Clearance
Airport; Company Policy; Human Factors; Procedure
Captain (pilot not flying) returned to the cockpit from rest break 1+15 before landing. First Officer (pilot flying) had finished his rest break at 4+05 before landing. Relief Pilot returned to cockpit from his 2nd rest break during initial descent phase 25 minutes before landing. Landing occurred after 9 plus hours of flying [dusk to dawn]. Upon returning to cockpit Captain reviewed NOTAMs and field report. Crew specifically discussed 1;380 meter displaced threshold due to construction on approach end Runway 28; and the ILS glidepath 28 and PAPI Runway 28 out of service. Notably; there was no change to the minimums to any approach to SBGL. Crew also checked the weather and noted low broken deck and 5;000 meter prevailing visibility; well above non-ILS minimums. Crew learned SBGL was landing Runway 28 from Brasilia Center about 45 minutes before landing and loaded Arena 1A Runway 28 arrival in FMC. At hand off to Curitiba Center at ARENA Intersection crew was cleared the Arena 1A arrival as expected. Crew verified step down fixes and airspeeds per the STAR; and specified a hard 2;500 FT at the last fix (EUJE) instead of 2500A3500B. Setting the lowest allowable altitude was intended to assist with transition to the RNAV Runway 28 approach; which began at EUJE. At hand off to Rio Approach Control crew was cleared to 'descend via the Arena 1A' for the RNAV Runway 28 approach. At some point the Approach Controller gave the local altimeter; which the pilot not flying (Captain) read back as 'QNH 1024'(hp); pilot not flying failed to check this against the ACARS weather printout which was (est.) 1014 hp. Failing to verify the altimeter setting was a significant error; as a habit pilot not flying (Captain) normally does verify ATC vs. ACARS weather at non-US destinations to compensate for heavily accented English and/or poor radios. The pilot flying (First Officer) briefed the RNAV Runway 28 approach during the descent while above 10;000 FT. As had been the case during previous flights using this arrival; it is difficult to keep autoflight/FMC in VNAV Path when reaching each step down fix. Nonetheless; Captain had flown the arrival previously without difficulty both as pilot flying and pilot not flying to a stabilized final. During the descent Rio Approach Control directed crew to slow prematurely to 170 KTS when passing about 7;000 FT which complicated energy management and required speed intervene to override FMC speeds. To comply; the pilot flying called for gear down passing through 5;000 FT when starting the turn at ERNA Intersection. Up to this point the arrival had gone normally. After rolling out of the 110 degree turn at ERNA; the aircraft was once again out of VNAV Path in a descent to the programmed ERNA crossing altitude of 2;500 FT. The pilot not flying (Captain); trying to be helpful; reengaged VNAV as the aircraft was on the path; but pilot not flying did not immediately speed intervene. Consequently; the autothrottles very quickly moved forward to attain the FMC programmed speed of 220 KTS. This caused the nose to pitch up; airspeed loss as throttles were disengaged and retarded; and an unstable condition for the pilot flying (First Officer) who clicked off the autopilot to regain control. The pilot flying (First Officer) resumed the descent to EUJE; but just over 2 NM prior to that fix at about 2;700 FT altitude the Controller stated that we needed to cross EUJE at 1;700 FT. The controller was using the EUJE crossing altitude published on the RNAV Runway 28 IAP; while the crew was using the min crossing altitude published on the STAR since we had been cleared to 'descend via' the Arena 1A arrival. The Captain had flown this arrival previously to ILS; VOR; and RNAV finals and had; for safety; always used the higher EUJE crossing altitude on the arrival without eliciting any comment from Rio Approach Control. The Captain reset the altitude window to 1;700 FT and directed the pilot flying to descend to meet the restriction; stating to the pilot flying; 'She's trying to tell you that you have 2 miles to descend 1;000 FT.' Captain assisted by deploying spoilers as pilot flying lowered the nose. While pilot flying (First Officer) met the 1;700 FT crossing restriction performing a hand flown descent; he overshot and descended 200-300 FT below (as indicated on the altimeter). The mandatory altitude from EUJE-to-FAF is 1;600 FT. At this point Captain took control of the aircraft and became the pilot flying until landing.Captain's decision to intervene was based on his knowledge of First Officer's normal flying skills vs. the observed fatigue-induced task saturation and channelized attention that resulted in an altitude deviation. Further; Captain realized he had contributed to the First Officer's task saturation by trying to assist for what he perceived as slower than normal situational awareness by First Officer (pilot flying) after passing ERNA. In retrospect; the appropriate response to the Controller's altitude clearance at EUJE should have been 'unable'; 'go around'; or 'going missed approach' (although we were not yet on the final approach segment). Captain's decision to continue approach was based on: 1) VMC conditions (hazy; 4 miles visibility and ground contact); and familiarity with the flat terrain/water from EUJE to Runway 28. (However; Captain was not familiar with a very small prohibited area (SB (P)-319) directly beneath the final approach; just inside the FAF. The Relief Pilot pointed this area out in the debrief. The altitude deviation occurred about 5 miles prior to this prohibited area.) 2) Deviation occurring 5-6 miles outside the FAF allowing plenty of time to recover by the FAF and still fly a stabilized approach. Had this deviation occurred in IMC or in unfamiliar terrain; Captain would have gone around. Failure to do so in this case may be attributable to either complacency (due to familiarity) and/or mission hacking. While neither was intentional or premeditated; both are unacceptable. Further; at the time of the altitude deviation and the Captain assuming control of the aircraft; the Relief Pilot suggested: 'We could go around...' Captain did not take this comment as directive; but still should have given it greater consideration. Between EUJE and FAF Captain climbed back to 1;600 FT until FAF and then descended via the VNAV path; but purposely stayed high to account for the displaced threshold; and verbalized this to the crew. Runway 28 was visually acquired at about four miles. As we neared the runway and saw the displaced threshold it was apparent that the Captain (pilot flying) had not compensated enough for the displaced threshold; resulting in a stabilized; shallow; dragged-in final. While the aircraft was continuously in a safe position to land with the runway in sight; this was non-standard. A safe touchdown occurred beyond the displaced threshold in the touchdown zone; followed by normal rollout and taxi-in. During taxi-in the Relief Pilot noted the altimeters reading about 250 FT above field elevation using 1024 hp. When crew reset the ACARS altimeter of 1014 hp (est.); the altimeters read field elevation. This means that we may have deviated up to 400 FT below the EUJE-to-FAF restriction of 1;600 FT due to two separate errors: (1) the Captain copying and reading back the wrong altimeter setting to Rio Approach Control; and; (2) the First Officer flying below the EUJE 1;700 FT restriction. This was a serious deviation and would have been avoided if the Captain had directed a go around or stated 'unable' when the controller made the radio call to cross EUJE at 1;700 FT. Fatigue; VNAV automation limitations (ergonomics); VNAV crew proficiency; ATC radio comprehension; and ATC STAR/IAP design and task saturation channelized attention during descent outside the FAF; resulting in an altitude deviation. 1) Captain accepted clearance for the RNAV Runway 28 approach because the aircraft was capable and we are encouraged to practice RNAV procedures when possible. However; given the temporary displaced threshold Captain should have requested the LOC Z Runway 28 approach; which has higher minima and the same crossing altitude restriction at EUJE (2500A3500B) as the Arena 1A STAR. This would have avoided both the altitude deviation and possibly mitigated the dragged-in final. 2) Captain asked the Station Operations Agent to confer with the SBGL Tower or Rio Approach Control Supervisor to ascertain their expectations regarding the EUJE crossing altitude differences between the Arena 1A arrival (STAR) vs. the RNAV Runway 28 approach (IAP). 3) Fleet Captain and training staff should address how they want crews to deal with an RNAV/VNAV approach to a temporary displaced threshold. The Training Department currently teaches crews to fly the VNAV path; and to not use VDP procedures or to drive toward the runway once reaching the DA/MDA. However; the only way VNAV path will work with a large displaced threshold (1;380 meters in this case) would be to adjust the FMC Runway XX crossing height upward (higher) to create a normal threshold crossing at the temporary displaced threshold. However; we have no procedures for making this adjustment. 4) Consider whether higher RNAV Runway 28 minimums would be appropriate during the period of construction and temporary displaced threshold to Runway 28. The current RNAV/VNAV minimums are 298 FT AGL; LNAV minimums are 302 FT AGL. These minimums occurred 1.7 NM from the temporary displaced threshold if the VNAV path is flown. Otherwise; crews might be restricted to using the ILS/LOC Z Runway 28; which has non-ILS minimums of 502 FT AGL. I believe the RNAV Runway 28 minimums should be no lower than the Localizer Z Runway 28 minimums while the temporary displaced threshold is in effect.
On RNAV (GNSS) Runway 28 to SBGL I observed altitude deviation from VNAV path. I did call deviations and suggested go around and that we have ample fuel for go around; but I haven't been assertive to the level I should have been.
Flight crew describes an arrival and RNAV 28 approach to a displaced threshold at SBGL. A mis-set altimeter and ATC adjustments to speed and altitude result in deviations below the initial approach fix altitude and the Captain assuming pilot flying duties.