Large Transport; Low Wing; 2 Turbojet Eng
Flight Crew Air Transport Pilot (ATP)
Training / Qualification; Communication Breakdown; Distraction; Confusion; Situational Awareness; Time Pressure; Workload
ATC Issue All Types; Deviation - Speed All Types; Deviation / Discrepancy - Procedural Published Material / Policy; Inflight Event / Encounter Weather / Turbulence
Flight Crew Executed Go Around / Missed Approach
Weather; Aircraft; Chart Or Publication; Human Factors; Procedure
Last leg of a 2 day trip into DCA; per current ATIS anticipated LDA 19 to DCA. Visibility was about 10 miles; but ceiling had varied between 1;600 FT and 2;400 FT. For about 2 months; the RNAV RNP 19 approach had been NOTAMed unusable; but that NOTAM was not included in our paperwork. About 150 miles out Captain queried Dispatch via free text to confirm RNAV RNP 19 availability as it was our preferred approach and requested an ANP. Dispatch responded with an ANP value of .11. We fully briefed both approaches. When switched to approach we noted that the River Visual 19 was in use. Queried Approach Controller on status of RNAV RNP 19; Controller responded that it was still unusable. Apparently there is a tree that extends into the protected approach area. Since weather was reported VFR we decided to backup the River Visual with vertical guidance from the RNAV RNP 19. Downwind I commented that there were multiple thin cloud layers and that the approach may not work. Captain concurred. I mentally went through MAP sequence. Since there is no published missed approach procedure; the brief was essentially to emphasize P56 avoidance. On final approaching HIXIT it initially looked like we would be able to descend VMC throughout the approach. We were configured early with landing checklist complete. Shortly after HIXIT; we noted a layer that would prevent continuing VMC; broke off the approach and executed a MAP. I TOGAed; disconnected the autopilot and began a climb; called for flaps 15; positive rate and gear up. At some point I called for 'set speed 200' but now not certain when I called it. Captain notified ATC who questioned the reason for the MAP; told us to turn toward the airport and gave us some initial altitude (I think 1;800 FT). Captain told him unable to maintain VMC and Controller then cleared us to climb to 3;000 FT and gave us two heading changes in succession. At some point the Captain called my airspeed fast and retracted the flaps but not before I exceeded the limit. I noted 240 KTS with flaps 15. I disconnected the autothrottles (A/T's) and reduced power. This description does not adequately communicate the confusion and I admit to being task saturated with poor situational awareness (SA) momentarily. We were vectored to an uneventful LDA 19 approach and landing and made the appropriate over speed entry in the log book. The flap over speed was caused by my momentary loss of SA during the missed approach. In replaying the event a dozen times I became increasingly concerned with a bunch of 'whys' that did not directly impact my S/A but contributed to the overall confusion. Though this was the first real life MAP I have ever flown in this aircraft type; I have had similar chaotic missed approaches at DCA in other aircraft. 1. Why was the RNAV RNP 19 not available if it wasn't NOTAMed? 2. Why did we get conflicting information on its status from NOTAMS; Dispatch; and the Controller? 3. Why does DCA ATC insist on using visual approaches when weather is marginal and/or weather in the area? Note a number of other aircraft were using the visual and we presume the layer moved in just before we commenced the approach. 4. Why is there no published missed approach for visual approaches. To me this is a huge issue system wide. It is truly a lot to ask for a busy controller to create a missed approach escape path and for pilots to immediately assimilate multiple altitude and heading assignments; especially with P56 in the DCA area. 5. Why do we have to disconnect a key automation feature of our sophisticated aircraft when we need it the most; during a high work load missed approach? 6. We are taught to TOGA with a missed approach. After the flight the Captain noted; and I concur; that this creates a high pitch up attitude that makes aircraft control more difficult; certainly appropriate in the final stages of an approach; but not on long final. 7. The question often arises in human factors of why pilots are so reluctant to executemissed approaches. They are clearly one of the highest workload maneuvers we do and despite the training in the simulator; we get very little real world practice. Real world MAPs rarely look like simulator MAPs. I hope these thoughts are helpful in preventing future such events.
Dispatch had previously told us the RNAV approach was legal; but Potomac said it was not. There was no mention of it in the NOTAMs. Around 1;800 FT we noticed a cloud layer below us beginning to obscure the river south of Rosslyn. Although we still had the river in sight below us; we agreed to discontinue the approach. I told DCA Tower that we were breaking off the approach and the First Officer initiated a Go-Around. ATC asked if we needed assistance and I responded that no; we had simply lost sight of the river. The First Officer called for Flaps 15 and Gear Up. ATC instructed us to continue toward the airport and maintain 3;000 FT. Because we were not technically on the RNAV approach and wanting to ensure separation from the prohibited airspace in P-56; I selected Heading Select on a heading directly toward the airport. I then set 3;000 FT; flaps 15 and raised the gear. When I directed my attention back to my flight instruments; I noticed that we had selected TOGA and were rapidly accelerating past 200 KTS. At first; I attempted to intervene and pitch the airplane up. But; as I saw were still accelerating toward 240 KTS and because I wanted to minimize any damage to the flaps; I advised the First Officer that we were over speeding the flaps and I selected flaps up. The workload of the situation prevented me from getting an accurate assessment of exactly where the flaps were when we reached which speeds. During this event; ATC was rapidly giving us multiple instructions. As I was focusing on keeping the airplane under control; it was very difficult to absorb the ATC instructions and I had to ask them to repeat themselves several times. Contributing factors: -Fatigue. We arrived the previous evening and did not get to the hotel until after 0100. -ATC pressing Visual approaches while the weather was not appropriate; both increasing the risk of go-arounds and eliminating any pre-established missed approach instructions. -ATC issuing multiple instructions during a critical phase of flight that seemed more focused on traffic volume than an orderly operation. -A Go-Around procedure that; while appropriate when you are slow; at the bottom of an approach and have 2;000 FT or more to climb; is a setup for flap overspeed when you are fully configured; still decelerating toward Vref; but already close to the missed approach altitude. -An aircraft design that causes the autopilot to disengage; dramatically increasing cockpit workload; at precisely the wrong time. An autopilot that remained engaged during a go-around would be useful. Otherwise; it would be helpful to develop a low-workload procedure for crews to discontinue an approach when that decision is made above a certain altitude. If we had selected Altitude Hold or Vertical Speed; the autopilot would have remained engaged; the airspeed would have remained within limits and this would have been a non-event.Although we were cleared for and accepted the River Visual approach; I do not recall the exact weather being reported at the airport and believe it is possible that the airport weather conditions were below those required for the River Visual to runway 19 at DCA. Prior to entering Potomac airspace; we had briefed both the RNAV and the LDA approaches. We were surprised when Potomac gave us vectors for the River Visual. But; since we had already briefed the other approaches; this was not an instrument approach and we were not changing runways. However; having flown the River Visual countless times; I neglected to actually review the chart. Yesterday; during a subsequent trip into DCA; I looked at the chart and noticed the published required ceiling for the approach is 3;500 FT. I believe my error in not re-reviewing the plate for an approach I fly on almost a weekly basis caused us to unintentionally accept an approach for which we may not have been legal. I believe the fact that Potomac was offering and multiple other aircraft were accepting the approach contributed to my complacency.
An Air Carrier crew executed an IMC go around after failing to remain VMC on the DCA River Visual and; because no missed approach procedure was specified; were extremely task saturated keeping up with the aircraft and ATC's instructions.