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Incidents related to Issue 10 incidents related to this issue.

Issue: pilots may be reluctant to assume control (Issue #26)
Description: Pilots may be reluctant to assume control from automation. Even when automation malfunctions or behaves contrary to their expectations they may persist in using it, possibly with time-consuming programming changes.This may lead to unsafe conditions.

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  2. Accession Number: 237133
    Synopsis: AUTOPLT FAILURE CAUSED WDB TO DSND AND EXCEED MAX SPD.
    Narrative: AFTER DEPARTING SFO WITH CAPT FLYING, I ENGAGED #1 AUTOPLT IN VERT SPD MODE AT APPROX 10000 FT. SET VERT SPD AT 1000 FPM CLB TO ACCELERATE TO TARGET CLB SPD OF 309 KTS. AT 309 KTS I ENGAGED IAS HOLD FUNCTION OF FLT GUIDANCE SYS AND FLT GUIDANCE SYS ANNUNCIATOR PANEL SO INDICATED. SPD CONTINUED TO BUILD, BUT FLT DIRECTOR PITCH COMMAND BAR OVERLAID THE ACFT INDICE ON THE ADI, INDICATING THAT THE IAS HOLD WAS STILL ENGAGED. AS SPD INCREASED, I TRIED TO REGAIN CTL OF AIRSPD WITH VERT SPD WHEEL. AT THIS POINT, 'VERT SPD' SHOWED IN FLT GUIDANCE SYS ANNUNCIATOR AND FLT DIRECTOR PITCH BAR OVERLAID THE ACFT INDICE. ALTHOUGH AUTOPLT OUT OF TRIM LIGHT DIDN'T ILLUMINATE, I WAS CONCERNED ABOUT DISCONNECTING AUTOPLT AFTER SUDDEN SPD BUILDUP. STABILIZER TRIM INDICATOR DIDN'T SEEM TO BE MOVING. I FEARED EXCESSIVE STRUCTURAL LOAD IF AUTOPLT WAS DISCONNECTED WITH ACFT OUT OF TRIM AT SPD IN EXCESS OF VMO. AS AIRSPD APCHED 390 KTS, I REDUCED THRUST TO NEAR IDLE AND DISCONNECTED AUTOPLT. THERE WAS NO OUT OF TRIM LURCH. NORMAL CLB WAS RESUMED ON AUTOPLT #2 AND SFO MM (SAM) WAS SUBSEQUENTLY NOTIFIED OF ELECTRO- MECHANICAL IRREGULARITY. SUPPLEMENTAL INFO FROM ACN 237134: NONE OF US HEARD THE AIRSPD CLACKER GO OFF AS WE PASSED VMO (BARBERPOLE ALS). MAINT WAS CALLED, THE #1 AUTOPLT WAS TAGGED OTS, AND A LOGBOOK ENTRY WAS MADE. WE WERE CLRED TO CONTINUE WITH THE #1 AUTOPLT INOP. THE REMAINDER OF THE FLT TO KONA AND BACK WAS UNEVENTFUL. THE PROB HERE IS THAT WE WERE SO ENGROSSED IN THE CAUSE OF THE PROB THAT NONE OF US THOUGHT ABOUT THE AIRSPD EXCURSION ABOVE VMO. THE AIR WAS VERY SMOOTH AND WE NEVER FELT ANY 'G' DURING THE ACCELERATION OR THE DECELERATION SO NONE OF US FELT THE OVERSPD WAS A CONCERN. CORRECTIVE ACTION MIGHT BE TO INCLUDE CLEAN OVERSPD PROCS IN THE FOM/FLT HANDBOOK TO INCLUDE THE NECESSITY FOR AN OVERSPD INSPECTION AND NOTIFICATION GIVEN TO MAINT OF THE OVERSPD. WE MAY ALSO WANT TO INCREASE CLACKER VOLUME SO WE HEAR IT BETTER. THE CLACKER WAS WORKING, BUT WAS NOT LOUD ENOUGH TO HEAR WITH ALL SYS AND ENGS RUNNING. WE ALSO NEED AN 'MRM' CODE FOR AN OVERSPD. SUPPLEMENTAL INFO FROM ACN 237135: THE ACFT EXCEEDED THE VMO BY APPROX 40 KIAS.

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  4. Accession Number: 357721
    Synopsis: B737-300 IN IMC UNDER AFDS CTL GETS OFF THE LOC AND NEVER RECOVERS. FLC FAILS TO TAKE CTL AND RECOVER. THEY ARE FINALLY CLRED FOR A VISUAL APCH TO A PARALLEL RWY ON THE FAR SIDE OF THE ARPT.
    Narrative: DEN APCH CLRED US TO MAINTAIN 210 KTS, 040 DEG HDG TO INTERCEPT ILS RWY 35L LOC, CLRED FOR APCH. CAPT THEN ARMED THE AUTOPLT/FLT DIRECTOR (AFDS) TO CAPTURE THE LOC AND GS. WITH THE HIGH GND SPD AND GREATER THAN NORMAL INTERCEPT ANGLE THE AFDS CAPTURED THE LOC, FLEW THROUGH THE COURSE MAKING THE L TURN TO GET BACK ON COURSE. ATC (APCH) ASKED US TO MAINTAIN 190 KTS. (I BELIEVE THIS WAS THE CLRNC) TO DYMON, THE OM (6.6 DME). THE AFDS ROLLED OUT ON A 335-340 DEG HDG TO GET BACK ON COURSE. THE ACFT FLEW THROUGH THE COURSE NWBOUND AND FAILED TO TURN TO TRACK INBOUND. I BROUGHT THIS TO THE CAPT'S ATTN AT WHICH TIME HE TRIED TO GET THE ACFT BACK ON COURSE USING THE AFDS. ATC CLRED US TO A LOWER ALT AND SHORTLY AFTER TOLD US WE WERE L OF COURSE AND TO TURN R TO INTERCEPT. THE CAPT HAD STILL NOT DISENGAGED THE AFDS AND HE WAS NOW PARALLELING THE LOC AND DSNDING. ATC STARTED TO GIVE US MISSED APCH INSTRUCTIONS L TURN 260 DEGS CLB AND MAINTAIN 8000 FT OR 9000 FT? (CAN'T REMEMBER) AND IN SAME BREATH ASKED IF WE COULD REINTERCEPT AND CONTINUE APCH? THE CAPT DISENGAGED AUTOPLT AND SAID THAT WE COULD CONTINUE. APCH TOLD US TO TURN R (CAPT IS STILL PARALLELING COURSE, I HAVE REMINDED HIM OF THIS 3-4 TIMES NOW) AND CONTACT TWR. TWR CLRED US TO LAND RWY 35L AND ASKED IF WE WERE TURNING TO REGAIN COURSE. AROUND THIS TIME WE HAD ACQUIRED VISUAL REF WITH THE TERRAIN AND IDENTIFIABLE PORTIONS OF ARPT (PARKING LOTS, TERMINAL, TWR). TWR ASKED IF WE HAD RWY 35L IN SIGHT. WE DID NOT AND STATED SO. TWR ASKED IF WE HAD RWY 34 IN SIGHT. WE DID HAVE RWY 34 IN SIGHT AND TWR THEN CLRED US TO LAND ON RWY 34. CONTRIBUTING FACTORS TO THIS WAS APCH HIGH SPD/LARGE INTERCEPT ANGLE, CAPT'S FAILURE TO DISENGAGE AFDS AND FLY MANUALLY, MY FAILURE TO GET CAPT'S ATTN TO TURN FURTHER R, FAILURE OF APCH CTL ASKING US IF WE CAN MAKE IT RIGHT AFTER THE MISSED CLRNC. I THINK THEY SHOULD HAVE MADE US MISS. AFTER THAT CLRNC WE THOUGHT THAT WE COULD REINTERCEPT AND WE COULD HAVE HAD WE BEEN AGGRESSIVE ENOUGH TO GET BACK ON COURSE. FAILURE ON TRAINING. NOT ENOUGH ON AFDS/FMC, TURNING IT OFF AND FLYING MANUALLY NEVER EMPHASIZED ENOUGH. WHAT STARTED OUT AS A PRECISION APCH AND FINISHED AS A NON PRECISION/VISUAL APCH SHOULD NEVER HAPPEN. AUTOPLT WAS TESTED ELECTRONICALLY ON THE GND WITH NO FAULTS DETECTED. NOTE: WE HAD GONE ABOVE GLIDE PATH (RWY 35L) AT SOME POINT NEVER TO REGAIN IT AND DID NOT USE EXCESSIVE (MORE THAN 1200 FPM) DSCNT RATES TO RE-ESTABLISH IT.

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  6. Accession Number: 372329
    Synopsis: WDB ACFT CLRED FOR ILS APCH AFTER PASSING INTXN WAS RECLRED TO ANOTHER RWY AFTER FMS AND LOC ILS CAPTURE. FLC DISTR BY REPROGRAMMING FMC AND HDG CHANGE DSNDED THROUGH 7000 FT AND WAS RECLRED TO 6000 FT. THEN WHILE DSNDING TO 6000 FT AND BEING DISTR BY TFC, FLC DSNDED THROUGH 6000 FT.
    Narrative: EXECUTING CIVET 1 ARR TO LAX. CLRED FOR ILS RWY 25L AFTER PASSING ARNES. APCH FLOWN IN AUTOFLT, APCH MODE, LOC AND GS CAPTURED. AT ABOUT (?) 8000 FT, SOCAL INSTRUCTED 'TURN R 10 DEGS, INTERCEPT ILS RWY 24R, DSND TO 7000 FT.' DURING THE CONFUSION OF TRYING TO LOCATE THE RWY 24R APCH PLATE, THE TURN WAS INITIATED BUT THE AUTOPLT FLT DIRECTOR SYS STILL HAD LOC AND GS CAPTURE, COMMANDING A DSCNT ON THE FLT DIRECTORS. WHILE TRYING TO SET UP TO INTERCEPT RWY 24L, DSNDED BELOW CLRED ALT. RECLRED TO 6000 FT, AND WHILE STILL FOLLOWING AUTOPLT FLT DIRECTOR SYS COMMANDS FOR RWY 25L, DSNDED 300 FT BELOW CLRED ALT. IN MY BELIEF, THIS INCIDENT OCCURRED BECAUSE OF THE DELAYED ABANDONMENT OF AUTOFLT COMMANDS UPON RECEIPT OF A DRASTIC CLRNC CHANGE AND THE RESULTANT CONFUSION AND INCREASED WORKLOAD. ALSO, SINCE WE HAD BEEN CLRED FOR THE RWY 25L APCH, OUR MINDSET WAS TO TRACK GLIDE PATH, EVEN THOUGH ONLY CLRED TO INTERCEPT RWY 24R. IN ANY EVENT, THIS EVENT DICTATES THE IMMEDIATE ABANDONMENT OF AUTOFLT UPON RECEIPT OF A CLRNC CHANGE THIS DRASTIC. WITH THE TIME INVOLVED IN REPROGRAMMING THE FMC AND RETUNING THE ILS, AUTOFLT DSCNT ON THE OLD APCH MUST BE CHKED. SUPPLEMENTAL INFO FROM ACN 372334: THE CTLR THEN CLRED US TO MAINTAIN 6000 FT MSL. AT THIS TIME AN ACFT WAS SPOTTED APPROX 5 MI AHEAD. WHILE I WAS DISTR WITH THE AIRPLANE AND THE OTHER PLT REPROGRAMMING THE FMC AND SELECTING THE LOC FREQ, THE ACFT DSNDED TO APPROX 5700 FT MSL WHEN A CLB WAS IMMEDIATELY INITIATED BACK TO 6000 FT MSL. WE WERE THEN CLRED FOR THE APCH WELL ABOVE SGS FOR RWY 24R ILS.

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  8. Accession Number: 379870
    Synopsis: AN ACR FLC IN AN MLG GOT OFF COURSE WHEN THEY FOLLOWED AN FMC COURSE THAT WAS IMPROPERLY DEPICTED ON THEIR SCREEN. THE CAPT ATTEMPTED TO REPROGRAM THE FMC INSTEAD OF USING THE AVAILABLE VOR INFO.
    Narrative: SHORTLY AFTER TKOF FROM BUR, WE WERE TOLD TO INTERCEPT A RADIAL THAT WAS ON THE SID (218 DEG RADIAL PMD). I, AS THE PF, SAW ON THE SID THAT THE RADIAL WAS SHOWN ON OUR RTE, SO I TURNED TOWARD THE LINE SHOWN ON THE EFIS SCREEN. IT TURNS OUT THAT THE FMC FOR SOME REASON LOADED THE SID INCORRECTLY, EVEN THOUGH IT WAS ENTERED CORRECTLY SO THE LINE SHOWN WAS THE WRONG RADIAL. DURING THIS TIME, THE CAPT WAS TRYING TO FIX THE BOX INSTEAD OF TUNING THE VOR. IN ANY CASE, THE CTLR NOTED OUR HDG WAS 40 DEGS FROM OUR INTERCEPT HDG GIVEN TO US BY HIM. WE TURNED APPROX 5- 8 MI BEFORE THE ASSIGNED RADIAL. HE TOLD US TO TURN BACK AND WE DID. TO PREVENT THIS FROM HAPPENING AGAIN, I WILL VERIFY THE RTE ON THE LEGS PAGE IN ADDITION TO THE RTE PAGE IN THE FMC. ALSO, I THINK TYPING IN THE BOX BELOW 10000 FT IS NEVER A GOOD IDEA.

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  10. Accession Number: 382700
    Synopsis: FLC OF MLG DSNDING ADJUSTED THE VERT SPD RATE WHICH TOOK THE AUTOPLT OUT OF CAPTURE MODE. DSNDED 350 FT BELOW ASSIGNED ALT.
    Narrative: WE WERE DSNDING TO ASSIGNED ALT OF 11000 FT. ZJX GAVE A FREQ CHANGE FOR COLUMBIA APCH PASSING 12000 FT. ACFT WAS IN AN IAS IDLE DSCNT. JUST AS THE AUTOPLT CAPTURED 11000 FT AND SWITCHED TO VERT SPD FOR THE LEVELOFF, THE CAPT ADJUSTED THE VERT SPD RATE WHICH UNKNOWINGLY TOOK THE AUTOPLT OUT OF CAPTURE MODE. THE ACFT CONTINUED TO DSND THROUGH THE ASSIGNED ALT OF 11000 FT. IT REACHED 10650 FT BEFORE THE DSCNT COULD BE STOPPED AND THE ACFT RETURNED TO 11000 FT. CONTRIBUTING FACTORS INCLUDED THE FREQ CHANGE JUST PRIOR TO LEVEL OFF AND THE CAPT'S POSSIBLE UNFAMILIARITY WITH THE ACFT (4-6 MONTHS IN TYPE). THE CAPT INITIALLY TRIED TO ARREST THE DSCNT THROUGH THE AUTOPLT CTLS VERSUS DISCONNECTING THE AUTOPLT AND TAKING MANUAL CTL WHICH MAY HAVE BEEN MORE EFFECTIVE. AS FO AND THE PNF, I ASSISTED WITH ACFT CTL ONLY WHEN IT WAS APPARENT THE CAPT WAS HAVING TROUBLE STOPPING THE DSCNT. NO COMMENTS WERE MADE BY THE CTLRS DURING THIS EVENT.

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  12. Accession Number: 392939
    Synopsis: A320 ACFT ON VECTOR HEADING FOR INTERCEPT AND ALT RESTR, ACFT ARMED FOR APCH CAPTURES GS PRIOR TO LOC INTERCEPT AND COMMENCES DSCNT BELOW ASSIGNED. TCASII RA ALERTS FLC TO ANOTHER ACFT ON APCH TO PARALLEL RWY. RPTR CAPT SAYS HE MAY HAVE PULLED INSTEAD OF PUSHING THE FCU (FLT CTL UNIT).
    Narrative: WHILE ON A 240 DEG VECTOR TO FINAL APCH COURSE TO RWY 21L AT DTW, WE WERE CLRED TO 'MAINTAIN 5000 FT UNTIL ROBBI, CLRED FOR THE ILS RWY 21 APCH.' THE FCU APPR (APCH) PUSH BUTTON WAS PUSHED AND THE AUTOPLT WAS ARMED TO CAPTURE THE LOC COURSE AND THE GS. THE GS WAS CAPTURED BEFORE THE LOC COURSE AND DSCNT FROM 5000 FT WAS INITIATED BY THE AUTOPLT. WHILE I ATTEMPTED TO DETERMINE IF WE HAD PASSED 'ROBBI,' WE FLEW THROUGH THE LOC COURSE (THE AUTOFLT SYS DID NOT CAPTURE THE LOC FOR REASONS UNKNOWN). AS I USED THE HEADING CTL KNOB OF THE FCU TO TURN BACK TO THE LOC COURSE, A TA FOLLOWED BY AN RA WAS GENERATED BY THE TCASII SYS FOR AN ACFT BELOW US ON THE PARALLEL APCH (RWY 21R). WE LEVELED OFF AT APPROX 4600 FT MSL AND CONTINUED THE TURN BACK TO THE LOC COURSE AND INTERCEPTED THE FAC. WHEN ESTABLISHED ON THE LOC (WELL ABOVE THE GS) AND AFTER THE TCASII AURAL 'CLR OF CONFLICT' MESSAGE WAS RECEIVED, I DISCONNECTED THE AUTOFLT SYS AND FLEW THE ACFT DOWN TO THE GS AND CONTINUED THE APCH TO A LNDG IN VMC. THE INCIDENT WAS INITIATED BY A FAILURE OF THE AUTOPLT TO CAPTURE THE LOC COURSE. THIS MAY HAVE RESULTED FROM MY POSSIBLY PULLING THE FCU HEADING CTL KNOB AFTER THE APCH PUSH BUTTON HAD BEEN PUSHED AND THE LOC AND GS ARMED FOR AUTOPLT CAPTURE. THIS WAS EXACERBATED BY MY FAILURE TO RECOGNIZE THE FAILURE TO CAPTURE THE LOC SOONER. THAT WAS BECAUSE I BECAME PREOCCUPIED WITH IDENTING 'ROBBI' (OUR 5000 FT RESTR). THE ILS RWY 21L HAS NO DME AND ROBBI WAS NOT DISPLAYED ON OUR EFIS NAV DISPLAY (A 'VIA' HAD NOT BEEN SELECTED ON THE FMGC APCH MENU). 'ROBBI' IS IDENTED BY THE CRL VOR/DME WHICH WAS NOT MANUALLY TUNED, AND BOTH VOR RECEIVERS WERE AUTO TUNED TO DXO VOR/DME. THE A320 FMGC IS PROGRAMMED TO ALLOW THE AUTOFLT SYS TO CAPTURE THE GS SIGNAL PRIOR TO THE LOC SIGNAL WHICH CAN CAUSE A DSCNT TO BE INITIATED BEFORE THE ACFT IS ESTABLISHED ON THE FAC. ANOTHER MISTAKE MADE WAS MY FAILURE TO DISCONNECT THE AUTOPLT IMMEDIATELY FOLLOWING THE TCASII RA. THIS RESULTED IN A SLOWER DIVERGENCE FROM THE RA TFC AND A SLOWER CORRECTION BACK ONTO THE GS, RESULTING IN A HIGH RATE OF DSCNT ONCE THE AUTOPLT WAS DISCONNECTED.

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  14. Accession Number: 394418
    Synopsis: B737-300 ACFT ON AUTOLAND APCH IN GOOD WX, RPTR CAPT SAW AND FELT INCREASED SINK RATE BELOW 100 FT. GS SIGNAL WAS DROPPING RAPIDLY AND THE AUTOPLT WAS FOLLOWING IT. RPTR DISCONNECTED AUTOPLT, ADDED PWR, RAISED NOSE AND LANDED. CAUSE OF SIGNAL VARIATION IS UNKNOWN.
    Narrative: VISUAL CONDITIONS, COUPLED APCH, INTENDING TO COMPLETE AN AUTOLAND FOR CURRENCY REQUIREMENTS. B747 DEPARTED ON RWY 14R AND TWR SAID THAT ILS CRITICAL AREA WAS NOT CLR AS WE PASSED INSIDE THE FAF. BY ABOUT 500-1000 FT AGL THE B747 WAS WELL CLR OF THE ATA. AS I WANTED TO GET THE AUTOLAND (IF POSSIBLE) I WAS LOOKING FOR OTHER ACFT/CARS/TRUCKS, ETC IN THE ILS CRITICAL AREA, NONE IN SIGHT. WE CONTINUED. NEAR THE 110 FT AGL RA ALT, THE FO AND I SPOTTED THE LARGE SKID MARKS LEFT BY THE B727 A COUPLE OF WKS BEFORE. I WAS WATCHING THE INTENDED POINT OF LNDG WITH CONCERN FOR ILS ZONE INTRUSION. I NOTICED THE INTENDED POINT OF LNDG MOVING UPWARD ON THE WINDSHIELD AND 'FELT' AN INCREASED SINK RATE. I GLANCED AT THE PFD AND SAW THE GS DROPPING RAPIDLY WITH THE ACFT FOLLOWING IT. ALT MUST HAVE BEEN LESS THAN 110 FT AGL AND GREATER THAN 65 FT AGL. I DISCONNECTED THE AUTOPLT AND AUTOTHROTTLES, ADDED PWR, RAISED THE NOSE, AND RE- ESTABLISHED A NORMAL LNDG PROFILE TO A NORMAL LNDG -- SOMEWHAT SHORTER THAN USUAL. GND CTL NOTIFIED AND SAID 2 SUBSEQUENT ACFT HAD THE SAME ENCOUNTER. I'M NOT SURE HOW I'D HAVE INTERPED THE EFIS HAD I BEEN CAT III CONDITIONS. VMC WAS EASY TO SPOT THE NEGATIVE TREND. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR CAPT HAS NO IDEA WHAT CAUSED THE SIGNAL INTERFERENCE IF THAT IS WHAT IT WAS AND TWR CTLR RPTED THE ILS SIGNAL HAD BEEN NORMAL. WHEN RPTR ACFT WAS 10 MI OUT ON THE ILS THE TWR RPTED THE ILS NOT CLEAN DUE TO A B747 TAKING OFF, BUT BY THE TIME RPTR WAS AT 1000 FT, EVERYTHING WAS STABLE. RPTR STATES THAT THE B737-300 IS NOTORIOUS FOR HAVING LOC DEFLECTIONS ON ILS APCHS, BUT HAS NEVER SEEN A GS DEFLECTION. IN HIS CASE HE PICKED UP VISUAL CLUES BELOW 100 FT OF INCREASING SINK AND CHKING THE PFD NOTED GS DROPPING RAPIDLY WITH AUTOPLT FOLLOWING IT. CAPT WAS KEYED TO DISCONNECTING THE AUTOPLT, NOT ONLY BECAUSE OF THE AUTOLAND, BUT ALSO BECAUSE OF BUSY TFC CONDITIONS AT ORD, BEING THAT AT ANY TIME HE MAY HAVE TO DEV BECAUSE OF ATC INSTRUCTIONS. HE SAYS THAT HAD THEY BEEN IN INST CONDITIONS WITH THIS OCCURRENCE, HE IS SURE THEY WOULD HAVE HIT SHORT OF THE RWY AND VERY HARD. HE NOTIFIED HIS ACR CHIEF PLT WHO NOTIFIED OTHER ACR'S.

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  16. Accession Number: 397650
    Synopsis: CAPT OF AN MD88 OVERSHOT DSCNT STAR ARR FIX DUE TO INADVERTENTLY OVERRIDING THE ALT CAPTURE MODE OF THE AUTOPLT WHEN CORRECTING FOR AIRSPD DESIRED.
    Narrative: ACR X WAS DSNDING TO CROSS LAMMA INTXN ON THE BITH07 ARR INTO MLB. THE CAPT (ME) WAS AT THE CTLS. I WAS USING VNAV FOR THE DSCNT. THE FMS WAS PROGRAMMED TO CROSS LAMMA AT 15000 FT AND 320 KTS. APPROX 500 FT PRIOR TO LEVEL OFF, THE SPD COMMAND BUG SLOWED TO 240 KTS, THE THROTTLES WENT TO IDLE, AND THE SINK RATE INCREASED TO APPROX 1800 FPM DOWN. I SELECTED VERT SPD ON THE MODE CTL PANEL, SELECTED 500 FPM DOWN, AND INCREASED THE SPD BUG BACK TO 320 KTS. HOWEVER, WHEN I DID THIS I INADVERTENTLY DISARMED THE ALT CAPTURE. APPROX 100 FT ABOVE LEVEL OFF THE FO SAID 'ALT CAPTURE ISN'T ARMED.' I ATTEMPTED TO LEVEL OFF USING VERT SPD, BUT THE ACFT WAS VERY SLOW TO RESPOND. FINALLY, APPROX 150 FT BELOW OUR ASSIGNED ALT, I DISCONNECTED THE AUTOPLT AND CLBED BACK TO 15000 FT. THE FO AND I ESTIMATED THE ACFT HAD DSNDED AS MUCH AS 250-300 FT BELOW 15000 FT DURING THIS MANEUVER. THE MAIN FACTOR HERE WAS, FIRST, MY FAILURE TO IMMEDIATELY NOTICE THE FACT THAT THE ALT CAPTURE MODE WAS OVERRIDDEN WHEN I SELECTED VERT SPD, AND SECONDLY, MY LESS THAN IMMEDIATE DECISION TO DISCONNECT THE AUTOPLT TO RETURN TO 15000 FT. ATC MADE NO COMMENT TO US, THERE WAS NO CONFLICT WITH OTHER ACFT.

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  18. Accession Number: 402690
    Synopsis: A DSNDING MD90 DSNDS BELOW THE ALT XING AS DESIGNATED FOR KAYOH INTXN WHEN THE FMS MALFUNCTIONS AND DISTRACTS THE CREW FROM THEIR DSCNT PROC.
    Narrative: WE WERE CLRED TO CROSS KAYOH AT 7000 FT AND PROCEED VIA EASTSIDE 3 ARR. THE CAPT WAS USING A VNAV DSCNT SETUP FOR THE EASTSIDE 3 FMS STAR AND VERIFIED BY BOTH PLTS. DURING OUR DSCNT TO 7000 FT THE CAPT NOTICED A MAP FAILURE AND ATTEMPTED TO UPDATE THE ACFT POS. I NOTICED OUR NAV DISPLAYS SHOWED THE RTE AS A DASHING BLUE LINE INSTEAD OF THE NORMAL PINK RTE LINE. THE AUTOPLT REMAINED ON IN THE 'HEADING HOLD' MODE AND VERT SPD. SINCE THE FMS WAS SET UP FOR THE STAR THE CAPT HAD RESET THE DIGITAL FLT GUIDANCE COMPUTER ALT TO 3300 FT FOR 'SNAKE INTXN.' I ATTEMPTED TO REGAIN OUR ARR SINCE WE WERE ON AN 'FMS STAR' WITH NO NAVAID BACKUPS. AFTER REACTIVATING THE RTE AND EXECUTING, THE NAV DISPLAY SHOWED A NORMAL DISPLAY. THE CAPT RE-ENGAGED NAV AND ATTEMPTED TO RE-ENGAGE VNAV. THE FMS DISPLAYED 'NO VERT NAV' AND 'NO PERFORMANCE DATA.' AS I WAS ENTERING THE PERFORMANCE DATA THE AUTOPLT AGAIN SWITCHED TO 'HEADING HOLD AND VERT SPD' MODE. AT THIS TIME ATC RADIOED ABOUT OUR ALT APPROX 5900 FT MSL. THE CAPT IMMEDIATELY DISCONNECTED THE AUTOPLT AND STARTED A CLB TO 7000 FT MSL. ATC ASKED IF WE WERE VMC, WHICH WE WERE, AND CLRED US TO PROCEED VISUALLY, MAINTAINING TERRAIN CLRNC AT 5000 FT OR ABOVE. THE REST OF THE FLT WAS UNEVENTFUL. TO PREVENT RECURRENCE I'LL NOTIFY ATC IMMEDIATELY WITH EQUIP FAILURES. ENSURE SOMEONE IS FLYING THE AIRPLANE WHILE THE OTHER PLT CORRECTS THE MALFUNCTION. PROVIDE A BETTER BACK UP FOR THE PF. SUPPLEMENTAL INFO FROM ACN 402691: I THEN NOTICED THE AUTOPLT HAD AGAIN GONE TO 'HEADING HOLD' AND WAS STILL IN 'VERT SPD' DSCNT AND I WAS 1200 FT OR 1300 FT BELOW 7000 FT AND 2 OR 3 MI E OF KAYOH. I KICKED OFF THE AUTOPLT AND STARTED A CLB BACK UP TO 7000 FT WHEN SOCAL CALLED AND SAID WE WERE CLRED TO DSND AND THEN SAID WE WERE TOO LOW AND TO CLB BACK TO...THEN HE ASKED IF WE WERE VFR. TO PREVENT A RECURRENCE, I'LL SET THE ALT WINDOW FOR THE BOTTOM ALT AT EACH WAYPOINT ON THE STAR.

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  20. Accession Number: 406350
    Synopsis: ACR FO APPARENTLY NOT ABLE TO GET PIC'S FOCUS TO THE ACTIVITY AT HAND. PIC UNABLE TO MEET ALT XING RESTRS, BEING PROMPTED BY THE FO TO COMPLETE COCKPIT RESPONSIBILITIES. FO BELIEVES WHAT HAPPENED IS FURTHER JUSTIFICATION FOR CRM REGS.
    Narrative: DSNDING INTO TORONTO, ONTARIO, ENRTE FROM CHARLOTTE, NC, WE WERE CLRED LATE FOR THE PROFILE DSCNT RWY 6 INTO TORONTO. DUE TO THE LATE CLRNC WE WERE STILL PRETTY HIGH FL240 OR HIGHER. WE ACCEPTED THE CLRNC AND STARTED COMING DOWN. WHEN CALCULATING OUR RATE OF DSCNT WE NEEDED TO MEET THE XING RESTR, I STARTED TO REALIZE THAT WE PROBABLY WOULD NOT MAKE THIS. I ASKED THE CAPT IF HE WANTED TO LET TORONTO KNOW THAT WE PROBABLY WOULD NOT MAKE THE RESTR (BTWN 10000-11000 FT AND 250 KTS). THE CAPT RESPONDED BY PLACING THE ACFT IN A 5500 FPM DSCNT WITH PWR AT IDLE AND FLT SPOILERS AT FULL EXTENSION. I ASKED THE CAPT AGAIN WITH 8 MI TO GO IF HE WANTED RELIEF FROM THE XING RESTR AND HE SAID 'NO.' WE CROSSED LINNG INTXN AT 12000 FT. THEN WE WERE VECTORED FOR THE ILS RWY 6R APCH INTO TORONTO. THE CAPT DID NOT PLACE THE LOC INTO HIS NAV TUNER. I CALLED 'LOC ALIVE' AND 'WE'RE THROUGH THE LOC' AND REALIZED HE DID NOT HAVE THE CORRECT FREQ IN HIS NAV TUNER. I TUNED IN THE CORRECT FREQ. THE CAPT WAS USING THE AUTOPLT TO FLY. THE CAPT WENT FULL SCALE ON THE LOC AGAIN. THE CAPT STARTED COMING BACK AND WAS ABOUT TO GO THROUGH THE LOC AGAIN WHEN I SAID, 'DO YOU HAVE THE RWY IN SIGHT, WE'RE ABOUT TO GO THROUGH THE LOC AGAIN.' HE COMMENTED BY SAYING, 'WELL, I'M TRYING TO USE THIS DAMNED AUTOPLT.' I STATED, 'WELL TURN IT OFF.' WE LANDED WITHOUT INCIDENT. I'M SURE THE TORONTO CTLRS WERE WONDERING WHAT WAS GOING ON. THE BOTTOM LINE IS THIS CAPT WAS WAY BEHIND THE ACFT. THE CAPT WAS NOT WILLING TO LISTEN TO HIS FO OR THE CTLR. I FEEL CRM MUST BECOME MANDATORY FOR COMMUTER AIRLINE CREWS. WE'RE IN GENERAL YOUNGER, MORE INEXPERIENCED CREWS FLYING TODAY'S MOST RECENTLY MADE JETS. WE NEED APPROVED CRM PROGRAMS.
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