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Incidents related to Issue 67 incidents related to this issue.

Issue: automation may demand attention (Issue #102)
Description: The attentional demands of pilot-automation interaction may significantly interfere with performance of safety-critical tasks. (e.g., "head-down time", distractions, etc.)

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  2. Accession Number: 50529
    Synopsis:
    Narrative: DESCENDING INTO SFO, CLRD TO 11,000', ACFT ON VERTICAL NAV ON FMC AND PROGRAMMED TO MAKE CROSSING RESTRICTION AND LATERAL NAV FLYING INBOUND COURSE, CTLR ISSUED "CLRD DIRECT BRIJJ (COMPASS LOCATOR), MNTN 16,000." BRIJJ WAS NOT A WAYPOINT IN THE FMC MEMORY, BUT ANTICIPATING WE MIGHT BE CLRD TO IT I HAD PREVIOUSLY PROGRAMMED IT INTO THE FMC TEMPORARY MEMORY BANK. I STARTED PRESSING BUTTONS TO HAVE THE FMC NAVIGATE US TO BRIJJ--THE ACFT STARTED TO TURN--AND I SELECTED ADF ON THE VOR TO COMPARE IT WITH THE FMC BEARING. THERE APPEARED TO BE ABOUT A 20 DEG DIFFERENCE IN BEARING FROM WHERE THE ACFT WAS HDG. I MENTIONED THIS TO THE COPLT AND HE BEGAN TO PULL UP THE WAYPOINT (BRIJJ). WE HAD SET IN TO CONFIRM IT. AT THIS POINT THE CTLR CALLED "OBSERVE YOU GOING 400' LOW, MAINTAIN 15,000 AND TURN LEFT HDG (?) FOR TFC." NEITHER OF US HAD SET THE NEW ALT IN THE MCP. CONTRIBUTING FACTORS--THIS WAS MY SECOND TRIP SERIES IN THE MLG--LESS THAN 35 HRS. THE FMC AND INDEED R-NAV WAS NOT FAMILIAR TO ME. COPLT WAS ALSO NEW IN ACFT--LESS THAN 1 MONTH. BASIC CAUSE--ALLOWING UNUSUAL EVENT (NAVAID DISAGREEMENT) TO DISTRACT ME FROM ROUTINE HABIT PATTERN (SETTING ALT WHEN CLRD). DIFFICULT TO KEEP NEW "TOYS" IN COCKPIT FROM DISTRACTING AND PREOCCUPYING YOU. I FEEL FMC IS TOO TIME INTENSIVE FOR USE IN TERMINAL AREA, ESPECIALLY WHEN NEW IN ACFT AS WELL AS TO THIS SYSTEM. I HAVE REVERTED TO USING THE BASIC FAMILIAR INSTRUMENTS AND NAV SYSTEMS BELOW 18,000' UNTIL I AM MUCH MORE COMFORTABLE IN THE ACFT.

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  4. Accession Number: 54493
    Synopsis: FAILED TO HOLD SHORT OF ACTIVE RWY PER TAXI INSTRUCTIONS.
    Narrative: ON DEP BOSTON THE RWY WAS INITIALLY 27. IT WAS CHANGED TO 9 AND THEN TO 15. DURING TAXI CLRNC AFTER PUSHBACK THE RWY WAS CHANGED TO 4R AND THE ENSUING CLRNC CALLED FOR HOLDING SHORT OF 4L. IN AN EFFORT TO REPROGRAM THE COMPUTER AND CALL FOR THE TKOF DATA FOR 4R I DID NOT PROVIDE THE CAPT WITH BACK UP SUPPORT REGARDING RWY 4L HOLD SHORT. WE TAXIED CLEAR OF 4L AND BELOW THE GLIDE PATH OF A LNDG LIGHT TWIN ACFT. I WAS ALERTED TO THE ERROR VIA A RADIO CALL FROM GROUND. THE LNDG ACFT DID NOT POSE A SAFETY PROBLEM AND NEITHER ACFT NEEDED TO TAKE EVASIVE ACTION. WE DID EXPEDITE THE TAXI AFTER THE CALL FROM GROUND. MY ROLE AS A COPLT WOULD HAVE PROVIDED THE PROPER BACK UP TO THE CAPT HAD I NOT BEEN PREOCCUPIED WITH THE COMPUTER AND GAINING THE NEW TKOF DATA. PRIORITIZING MY DUTIES IN A TWO MAN COCKPIT IS AN ONGOING NECESSITY.

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  6. Accession Number: 57895
    Synopsis: FLT CREW DID NOT COMPLY WHEN THEY WERE CLEARED TO PROCEED DIRECT ETC.
    Narrative: OUR FLT WAS BEING VECTORED OFF OUR FLT PLAN ROUTE, ALONG WITH A SPEED REDUCTION TO 250 KTS TO AID SEQUENCING INTO PIT. ATC WAS VERY BUSY ASSIGNING VARIOUS SPEEDS AND HDGS TO NUMEROUS ACFT WHEN WE WERE ASSIGNED A HDG OF 230 DEG, FOLLOWED A FEW MINUTES LATER BY A CLRNC TO PROCEED DIRECT TO ETG. DUE TO A DISTRACTION WHILE REPROGRAMMING THE FMC, THE TURN WAS NOT ACCOMPLISHED IMMEDIATELY. WE STAYED ON THE HDG, STRAIGHT AND LEVEL, FOR 2-3 MINUTES. THE ERROR WAS RECOGNIZED IN THE COCKPIT JUST AS ATC QUESTIONED IF WE WERE PROCEEDING DIRECT TO ETG, AS CLEARED. A TURN BACK ON COURSE WAS IMMEDIATELY ACCOMPLISHED. THE ERROR WAS DUE TO THE DISTRACTION OF PROGRAMMING THE FMC PRIOR TO TURNING THE ACFT ON COURSE.

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  8. Accession Number: 58628
    Synopsis: WDB OVERSHOT ALT DURING MISSED APCH AND CTLR CORRECTED.
    Narrative: DURING ENROUTE DESCENT FOR A VISUAL APCH TO RWY 36R AT DFW, THE WEATHER DROPPED BELOW VISUAL MINIMUMS AND WE WERE BEING VECTORED ON A HIGH DOWNWIND LEG WEST OF THE ARPT. WHEN THE ARPT SWITCHED TO FULL ILS (36L) APCHES WE WERE TURNED IN TO INTERCEPT THE LOCALIZER AT OR ABOVE 3000' MSL. WE WERE TOO FAR ABOVE THE GLIDESLOPE AT THIS POINT TO COMPLETE AN ILS IN IMC CONDITIONS SO THE CAPT WHO WAS HAND FLYING THE ACFT EXECUTED A MISSED APCH. WE WERE VERY CLOSE TO THE MISSED APCH ALT WHEN THE GO AROUND WAS EXECUTED AND THE ACFT WAS VERY LIGHT SO IT ONLY TOOK A FEW SECONDS TO CLIMB TO THE MISSED APCH ALT WHICH I HAD NOT SET IN THE ALT WINDOW. WE NORMALLY SET IT AT A LOWER ALT SO WE DON'T GET A NUISANCE ALERT DURING THE FINAL APCH PHASE. WE DID NOT REALIZE WE HAD CLIMBED ABOVE THE ASSIGNED ALT UNTIL WE WERE TOLD BY APCH TO DESCEND. I THINK WE WERE ABOUT 500' HIGH, BUT I'M NOT SURE BECAUSE I WAS SWITCHING RADIO FREQS AND ENTERING NAV DATA IN THE CDU. I THINK THIS INCIDENT WAS A RESULT OF A POOR SETUP BY APCH CONTROL ABOVE GLIDESLOPE AGGRAVATED BY A CREW WITH VERY LITTLE TIME IN THE ACFT AND MY ALLOWING MYSELF TO GET DISTRACTED BY THE RADIOS AND FLT MANAGEMENT COMPUTER WHEN I SHOULD HAVE BEEN BACKING UP THE CAPT.

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  10. Accession Number: 61855
    Synopsis: FAILED TO MAKE CROSSING RESTRICTION ON STAR ACCOUNT STRONG TAILWIND AND PREOCCUPATION WITH FEATURES OF THE AUTOPLT. SPEED RESTRICTION HAD BEEN LIFTED AND THE CAPT, PNF, FEELS HE SHOULD HAVE REQUESTED RELIEF FROM THE ALT. APPARENTLY NO CONFLICT BUT THE CTLR SEEMED UPSET WITH THE DEVIATION.
    Narrative:

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  12. Accession Number: 63447
    Synopsis: WDB LANDED ON THE WRONG PARALLEL RWY.
    Narrative: NEARING COMPLETION OF A 3 HR FLT. THE FLT WAS CLEARED FOR A NIGHT VISUAL APCH TO RWY 35R AT DFW. THE ACFT WAS HIGH ON DOWNWIND, W OF THE ARPT. TFC WAS LIGHT AND THE VISIBILITY WAS EXCEPTIONALLY GOOD. THE PLT FLYING (F/O) HAD APPROX 100 HRS IN THE ACFT. A SHORTENED APCH WAS COMMENCED WITH AN ANGLING LEFT TURN NEBND. THE FMS WAS PROGRAMMED FOR RWY 35R AND THE PF WAS USING THE MAP DISPLAY ON THE HSI FOR LINEUP AS THE RWY LIGHTS WERE NOT YET VISIBLE. JUST AS THE 36 L/R LIGHTS WERE COMING INTO VIEW, THE TWR OFFERED 35L AND THE CREW ACCEPTED (NO ILS ON 35L). AFTER FURTHER CHECKING THE HSI DISPLAY FOR LINEUP, THE PF LOOKED OUT AND SAW THE 36 L/R LIGHTS AND MISTOOK THE RWY PAIR AS RWY 35 L/R. THE LACK OF ILS INFO AND THE INTENSE LIGHTING OF A RELATIVELY NEW RWY (31L) ADDED TO THE CONFUSION. THE PF LINED UP ON 36L AND AS CLRNC TO LAND (ON 35L) HAD ALREADY BEEN GIVEN, A LNDG WAS MADE. NOTHING FURTHER WAS HEARD FROM THE TWR. JUST PRIOR TO TOUCHDOWN, BOTH PLTS REALIZED THE ERROR, BUT A GO-AROUND WAS NOT FEASIBLE AT THAT POINT. THE TWR OPERATOR THEN CLEARED THE ACFT TO TAXI ACROSS 36R AND TO THE GATE. THE FOLLOWING FACTORS WERE BELIEVED TO HAVE CONTRIBUTED TO THIS EVENT: A) F/O, PF, HAD MINIMUM TIME IN THE ACFT. B) CHANGING OF APCH FROM 35R TO 35L LATE ON FINAL, THUS INVOLVING A REPROGRAMMING OF FMS, DIVERTING NEEDED ATTN FROM OUTSIDE AT CRITICAL TIME. C) ATTEMPTING TO CALL RAMP FREQ ON FINAL TO GET GATE ASSIGNMENT AND ADVISE OF ETA FOR RIGHT CONNECTIONS EQUALS DISTRACTION. D) UNUSUALLY CLEAR VISUAL CONDITIONS AND FAMILIAR ARPT WHICH SEEMED TO UNDERMINE THE NORMAL LEVEL OF ALERTNESS OF CREW. E) MINIMUM NIGHTTIME STAFFING OF TWR. ONE MAN CONTROLLING TWR, GND CTL AND CLRNC DELIVERY DIVERTED HIS ATTN FROM LINE-UP. F) MOST IMPORTANTLY, PREOCCUPATION BY CREW ON FMS/INSTRUMENTATION LATE IN THE APCH WHEN OUTSIDE VIGILANCE WAS NECESSARY/MORE IMPORTANT. G) SINCE THE ACFT NEVER CAPTURED THE EXISTING ILS LOCALIZER (35L) THE RAW DATA AVAILABLE SEEMED TO INDICATE "LINED UP LEFT" WHICH WAS COMPATIBLE WITH THE SITUATION, THEREFORE DISREGARDED. IN CONCLUSION IT IS ALMOST INCOMPREHENSIBLE THAT 2 EXPERIENCED COMMERCIAL PLTS COULD LAND VFR AT A FAMILIAR ARPT, WITH NO ATC COMMENTS, ON THE WRONG RWY. THE HUMAN TENDENCY TO LET YOUR GUARD DOWN IN GOOD WX IN FAMILIAR SURROUNDINGS IS, RESULTANTLY, A VERY DANGEROUS FACTOR IN AVIATION. THE LESSON HERE IS THAT WE ALL NEED TO BE EXTRA VIGILANT DURING THESE PERIODS AND PERHAPS MORE EMPHASIS PLACED ON THIS REALM DURING OUR TRAINING FOR THESE SITUATIONS SEEM TO HAPPEN FREQUENTLY AND WE SEEM TO BE ILL PREPARED WHEN THEY DO OCCUR.

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  14. Accession Number: 63861
    Synopsis: MLG CREW TOOK CLRNC MEANT FOR ANOTHER ACFT AND LEFT THEIR ASSIGNED ALT.
    Narrative: ALL THE NEW COMPUTER EQUIPMENT IN OUR NEW AIRPLANES IS GREAT BUT UNTIL EVERYONE IS HIGHLY COMFORTABLE WITH THEM, THEY CAN CAUSE DISTRACTION. THE CAPT WAS QUALIFIED, ETC., BUT HAD NOT FLOWN THE MLG IN A COUPLE OF MONTHS. I HAD BEEN FLYING THE MLG MORE RECENTLY, SO WAS CALLED UPON TO HELP HIM OUT, WHICH IS FINE. COMING OUT OF CLT, WE WERE FLYING A 020 HDG TO INTERCEPT J-37 TO GORDONSVILLE. WE WERE AT 17000' AWAITING FURTHER CLIMB. WE BOTH WERE PAYING ATTN TO THE FMCS, SETTING IT UP TO INTERCEPT THE AIRWAY. I THOUGHT I RECEIVED CLRNC TO CLIMB TO FL230. I READ IT BACK AS "ACR FLT TO FL230". IT TOOK A FEW SECONDS TO PROGRAM THE FMCS AND THE ACFT STARTED TO CLIMB. AT 17600' THE CTLR SAID "ACR FLT MAINTAIN 17000', TURN RIGHT 20 DEG". HE THEN INSTRUCTED ANOTHER COMPANY FLT TO TURN RIGHT 20 DEG. ABOUT A MIN OR SO LATER HE RECLEARED US TO HDG 020 AND UP TO FL230. I ASKED HIM IF IT WAS NOT SO, THAT HE HAD CLEARED US TO FL230 PREVIOUSLY. HE SAID THAT THAT CLRNC HAD BEEN FOR ANOTHER COMPANY FLT. I THOUGHT I HAD CLRNC TO CLIMB BUT OBVIOUSLY I READ BACK ANOTHER FLT'S CLRNC. THE CTLR OBVIOUSLY DID NOT CATCH IT UNTIL WE HAD CLIMBED OUT OF OUR ASSIGNED ALT. THERE OBVIOUSLY WAS A TFC CONFLICT, THOUGH WE DO NOT KNOW HOW CLOSE AS WE NEVER DID SEE THAT TFC. THE CAPT HAD HEARD ME READ BACK THE CLRNC BUT APPARENTLY DID NOT HEAR THE ORIGINAL ISSUANCE. WE BOTH WERE EXPECTING A CLIMB CLRNC AND WE BOTH WERE DISTRACTED BY PROGRAMMING THE FMCS.

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  16. Accession Number: 63952
    Synopsis: ACR MLG EXCEEDED SPEED CROSSING RESTRICTION.
    Narrative: I WAS GIVEN A CROSSING RESTRICTION OF 30 MILES OUT OF BOSTON AT 10000' INDICATING 250 K ON THE 305 DEG R. THIS RESTRICTION WAS GIVEN AT A DISTANCE OF ABOUT 60 OR 70 MILES FROM BOSTON AT AN ALT OF ABOUT 23000' (I'M NOT SURE OF ALT). WHILE AT CRUISE, I HAD 100K OF TAILWIND GIVING ME A GROUNDSPEED OF 520 KTS. I KNEW WITH THAT SPEED I WOULD HAVE TO HURRY DOWN. THE POWER WAS REDUCED AND A VERTICAL SPEED OF 3300' DOWN WAS ESTABLISHED. I THEN PROCEEDED TO PROGRAM THE FMC WITH THE NEW WAYPOINT AND CROSSING RESTRICTION. BY THE TIME I FINISHED WITH THE PROGRAMMING OF THE FMC I WAS AT AN ALT OF 16000'. I HADN'T YET LOOKED AT THE DESCENT PAGE WHEN I LOOKED TO FIND THE DISTANCE FROM BOS. I WAS SHOWING ABOUT 55 MILES FROM KBOS (THE ARPT). IT WASN'T BUT A FEW SECONDS LATER THAT I REALIZED IN ACTUALITY I WAS ONLY 45 MILES FROM THE VOR. I THEN INCREASED THE VERTICAL SPEED AND EXTENDED THE SPEED BRAKES TO HELP ACCELERATE MY DESCENT. I MANAGED TO GET THE ACFT DOWN TO 10000 30 MILES FROM BOS, THE SPEED HOWEVER WAS INDICATING 310 K NOT 250 K. THE FACT THAT I HAD A FAST GROUNDSPEED AND WAS PREOCCUPIED WITH THE PROGRAMMING OF THE FMC HELPED TO CONTRIBUTE TO MY ERROR. I SHOULD HAVE BEEN MORE INVOLVED WITH THE ACFT. THERE ALSO WAS SOME CONFUSION WITH KBOS AND BOS AND THEIR DISTANCE FROM THE ACFT. KNOWING THE VOR IS ON THE FIELD, I FIRST LOOKED AT KBOS. THE DISTANCE KBOS WAS GIVING INCLUDED AN APCH TO 33L, IN FACT NOT THE DISTANCE OF THE ACFT FROM THE ARPT.

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  18. Accession Number: 68904
    Synopsis: ACR MLG FAILED TO MEET MANDATORY CROSSING ON VOR APCH.
    Narrative: WE WERE ON A VECTOR TO JOIN THE VOR 13L/R APCH TO JFK OUTSIDE THE ASALT FIX INBND TO JFK AND LNDG 13L/R. WE WERE DESCENDING DOWN TO THE ASSIGNED ALTITUDE OF 3000' IN A SWEEPING RT HAND. ARE OUT OVER THE WATER, AND TOLD NEW YORK APCH WE HAD NOT FLOWN THIS APCH BEFORE. HE GAVE US PLENTY OF TIME AND PUT US ON A HDG INBND TO "ASALT". WE JUST LEVELED OFF AT 3000' IN THE EVENING HAZE (WITH VISIBILITY 3-5 MILE ESTIMATED), AND INBND TO CRI. GOT DISTRACTED BY A BOGIE ACFT CALL AT OUR 12 O'CLOCK, "A VFR SMA HDG OUR WAY," AT APPROX 3500' MSL. DURING THIS DISTRACTION, AND THE UNFAMILIARITY OF THIS APCH WE PICKED UP THE LEAD IN FLASHER LIGHTS AT THE SAME TIME AND DID NOT DES TO CROSS THE VOR AT 1500' MSL, BUT JUST BELOW 3000'. WE THOUGHT, BUT NOT SURE IN THE CONFUSION, WE MIGHT HAVE BEEN CLRD A VISUAL. WE WERE SLOWED UP AND FOLLOWED THE LIGHTS INTO A GOOD APCH TO LAND ON 13L. THEREFORE OUR EVENT WAS NOT BEING AT 1500' MSL OVER THE CRI, BUT DESCENDING JUST AT CRI. NEW YORK APCH SAID NOTHING, BUT JFK ASKED IF WE WERE 3000 OVER CRI. WE SAID YES, BUT WERE DESCENDING AND THEN WE SAID WE SAW THE RWY. WE WERE A 2 MAN CREW ON AN MLG WITH FMC, AND WERE VERY BUSY LOOKING FOR VISUAL REFERENCES ON A VOR APCH WITH CIRCLING LEAD IN FLASHERS TO A RWY THAT REQUIRED A 90 DEGREE TURN TO FINAL FOLLOWING LIGHTS TO A VISUAL. PLUS WE HAD THE DISTRACTION OF THE OPPOSITE TFC CALL. ALSO SINCE THERE WAS NO RESTRICTION TO VISIBILITY, BUT HAZE 3-5, MILES. WE WERE VERY BUSY LOOKING FOR TFC, AND WHEN WE DID SEE IT, WE WANTED TO MAKE SURE HE WOULD NOT BE A FACTOR. SO WE WOUND UP LATE IN DESCENDING AND DID NOT CROSS THE CRI AT 1500'. WE KNOW THAT THE NY AREA IS VERY CONGESTED AND THE CTLRS VERY GOOD, BUT WITH AN "MCP" AUTOPILOT WITH ONE WORKING IT, AND THE OTHER LOOKING FOR TFC DETECTED OR NOT, PLUS VISUAL GROUND REFERENCES, WE WERE VERY AWARE OF SAFETY AND STAYING HI FOR NOISE THAT WE BECAME DISTRACTED ENOUGH TO MISS THE CROSSING ALTITUDE. NOTE: SOMETIMES AT CTLR'S DISCRETION THE ALTITUDES MAY BE WAVED. AT ASALT AND CARNARSIE VOR FLT MGT COMPUTER DISTRACTION WAS A FACTOR ALSO AS WE PUT IN "ASALT" CRI THEN "JFK" BUT DURING THE APCH THE "FMC" KEPT GIVING US "ROUTE DISCONTINUITY". WE TRIED TO RE-ENTER THIS SEVERAL TIMES AND WOUND UP PASSING "ASALT" INTXN STILL AT 3000'. FOLLOWING FACTORS LED UP TO BEING HIGH AT CARNARSIE VOR, BUT NO PROBLEM IN LANDING SAFELY: FMC ROUTE DISCONTINUITY, VOR APCH TO LEAD IN FLASHERS USING THE "MCP" TO EXECUTE THE APCH WITH A 90 DEGREE TURN TO FINAL, OPPOSITE VFR TFC AT 3500' AS POINTED OUT BY APCH, VISUAL LOOKOUT FOR OTHER ACFT, VISUAL CLUES TO THE ARPT (LACK OF DURING VOR PORTION), FIRST TIME SHOOTING APCH VOR 13L/R AT JFK, COMPLY WITH NOISE ABATEMENT AND THINKING OF STAYING HIGH AS LONG AS POSSIBLE SO THAT WHEN WE SAW THE LIGHTS JUST OUTSIDE CRI WE REALIZED THE LOWER CROSSING ALTITUDE RESTRICTION AND WE WERE NOT GOING TO BE ABLE TO COMPLY.

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  20. Accession Number: 85206
    Synopsis: RWY INCURSION RESULTED IN CRITICAL NMAC BETWEEN 2 ACR ACFT. PLT DEVIATION. SEE MULTIPLE REPORT #85210 AND 85363.
    Narrative: A RWY INCURSION OCCURRED AT SDF ARPT. BOTH CREW MEMBERS HAD GREATER THAN 72 HRS REST PREVIOUS TO COMING ON DUTY, SO CREW REST AND ON DUTY TIME WERE NO FACTOR. WE, ACR X, RECEIVED AND ACKNOWLEDGED "TAXI DOWN RWY 11 EBND AND HOLD SHORT OF RWY 1" CLRNC FROM GND CTLR. OUR ACFT THEN ENCROACHED ONTO RWY 1 WHILE ACR Y HAD BEEN GIVEN TKOF CLRNC. THE F/O WAS ACTIVELY ENGAGED (HEADS DOWN) IN RETRIEVING AND ENTERING ACARS CRT WT AND BALANCE DISPLAY SEQUENCED BY MANUALLY COPYING THE ACARS DATA ON THE WT AND BALANCE FORM 101 AND THEN ENTERING THE COPIED DATA ZFW ON THE ACFT PERFORMANCE PAGE OF THE CDU TO THEN BE VERIFIED AND EXECUTED. HIS DUTIES THEN CONTINUE TO ENTER THE TKOF PERFORMANCE PAGE AND MANUALLY ENTER THE V1 VR AND V2 SPD COMPUTER REDUCED TKOF THRUST N1 REDUCTION. WHILE TAXIING DOWN RWY 11 TOWARDS THE INTXN OF 11 AND 1I VIEWED (HEADS DOWN) THE ACARS ZFW DISPLAYED THAT WAS WASHED BY COCKPIT SUNLIGHT OF THE ACARS AND CONFIRMED THE ZFW ENTRY IN THE PERFORMANCE PAGE OF THE CDU PRIOR TO EXECUTION. I THEN LOOKED UP AND ASCERTAINED THAT I HAD PARTIALLY ENCROACHED UPON THE ACTIVE RWY AND OBSERVED ACR Y WITH LIGHTS ON APPROX 3000' DOWN RWY 1 ON TKOF ROLL. I THEN ELECTED TO CROSS THE ACTIVE RWY RATHER THAN BLOCK THE ACTIVE RWY FORCING EITHER AN ABORT OR COLLISION. TO AVOID POTENTIAL PROBS IN THE FUTURE I RECOMMEND: NO PROLONGED HEADS DOWN DATA RETRIEVAL OR ENTRY FROM CRT'S ACARS OR CDU'S TO OCCUR WHILE THE ACFT IS IN MOTION ON THE GND OR BELOW 10000', IE STERILE COCKPIT CONCEPT, WITH THE EXCEPTION OF THE ZFW ENTRY AND EXECUTION IN THE CDU AND THE MANUAL DISPLAY OF THE APPROPRIATE V SPD FLIP CHART PAGE. IT IS OBVIOUS THAT THE 2-M SAFETY CREW CONCEPT WAS VOIDED BY THE PROLONGED DATA RETRIEVAL AND DISPLAY AS BOTH HEADS WERE DOWN IN THE COCKPIT DURING AN EXTREMELY CRITICAL PHASE OF TAXI. NO ACFT SHOULD BE CLRED TO TAXI ON A RWY WHEN PARALLEL TXWYS ARE AVAILABLE UNLESS HOLD SHORT LINES, PROMINENT MARKINGS AND SIGNS ARE DISPLAYED ON INTERSECTING RWYS, AS ARE ALWAYS DISPLAYED ON TXWYS. I HAVE REFLECTED UPON AND REVIEWED THE CHAIN OF EVENTS, CAUSATIVE FACTORS AND PREVENTIVE ACTIONS THAT WOULD INHIBIT A RECURRENCE OF THIS TYPE OF INCIDENT AND WILL MOST LIKELY DO SO FOR THE REMAINDER OF MY LIFE. THE SAFETY CONCERNS OF THE INCREASED COCKPIT WORKLOAD (PARTICULARY IN THE 2-M ACFT) CANNOT BE EMPHASIZED ENOUGH. DON'T LET THE ACARS/SELCAL OR RADIO CALLS DISTRACT YOU FROM THE MORE IMPORTANT JOB OF STARTING/MONITORING THE ENGS, TAXIING THE ACFT AND ACCOMPLISHING THE CHKLIST. ACCOMPLISH THE 101 DATA ENTRY CALCULATIONS SAFELY AND AT THE APPROPRIATE TIME. SUPPLEMENTAL INFO FROM ACN 85210: WELL INTO THE TKOF ROLL, IT WAS EVIDENT THAT ACR X WAS NOT GOING TO HOLD SHORT OF OUR RWY. WE WERE NEAR V1 WHEN X ENTERED OUR RWY. ROTATION WAS AT VR AND WE WERE AIRBORNE ABOUT 200' AS WE PASSED X, WHO WAS JUST CLRING OUR RWY. THERE WAS NO REFERENCE TO ACR X BY GND OR TWR. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: VERY BRIEF CALL TO VERIFY THAT ACR Y WAS INDEED AN MLG TYPE.

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  22. Accession Number: 91422
    Synopsis: ACR MLG ALT DEVIATION HEADING DEVIATION FROM STAR INTO DFW.
    Narrative: APCHING DFW FROM THE SW, WE WERE ASSIGNED 11000' AND WERE TOLD TO DELETE THE SPDS ON THE STAR. PF WAS PREOCCUPIED WITH THE FMS AND GOT BEHIND THE AIRPLANE. IT CAME TIME TO SLOW IN ANTICIPATION OF THE DSNT. FOR SOME UNKNOWN REASON THE PF SELECTED A PITCH MODE ON THE FLT GUIDANCE SYS THAT WHEN SELECTED, THE AUTOPLT WILL SEEK THROUGH PITCH CTL TO MAINTAIN THE SPD AT THE TIME THE BUTTON WAS PUSHED. CONSEQUENTLY, THE ACFT STARTED TO DSND AND THE PF DISCONNECTED THE AUTOPLT BUT NOT BEFORE DSNDING 300'. THE PF OVERCORRECTED AND EXCEEDED THE ASSIGNED ALT THEN BY 300'. APCH THEN GAVE US A LOWER ALT BUT THE PF MISSED THE TURN ON THE STAR. THE PROB WAS THE PREOCCUPATION WITH PUSHING BUTTONS ON THE FMS AND NOT FLYING THE ACFT. ON ALL OCCASIONS THE PNF CALLED OUT THE ERRORS.

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  24. Accession Number: 95531
    Synopsis: ALT DEVIATION, CROSSING RESTRICTION NOT MET.
    Narrative: JUST AFTER PASSING OTT, WE WERE INSTRUCTED TO CROSS 30 MI E OF OTT AT AND MAINTAIN FL290. I THOUGHT THE CLRNC WAS FOR 50 MI E, AND THUS DID NOT START THE DSNT AT THE APPROPRIATE TIME. THE F/O MENTIONED AT LEAST TWICE THAT: "WE'RE APCHING 30 MI," BUT I WAS SO PREOCCUPIED WITH REPROGRAMMING THE FMC THAT HIS WARNINGS DIDN'T REGISTER WITH ME. AT 30 MI E, CENTER QUERIED US AND INSTRUCTED US TO BEGIN DSNT IMMEDIATELY. THE MAJOR REASON FOR THE INCIDENT WAS MY LACK OF EXPERIENCE IN THE ACFT AND EXCESSIVE ATTN TOWARD OPERATING THE FMC CORRECTLY.

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  26. Accession Number: 103884
    Synopsis: ACR LGT GETS INTO APCH TO STALL AND ALT EXCURSION WHEN AUTO THROTTLES DO NOT MAINTAIN SPEED.
    Narrative: DSNDED FROM FL410 OT ASSIGNED FL240 WITH CLRNC TO HOLD AT BUNKER INTXN ENRTE TO MSP. USED VERT SPD AND SPD INTERVENE ON MODE CONTROL PANEL. MSP ATC REQUESTED WE LEVEL AT FL330. WE DID SO. WE GOT ALT CAPTURE AND I WAS SATISFIED WE WERE AT FL330 AND CHKED AIRSPD. I WAS SATISFIED THAT IT WAS AT 220 KTS AS I HAD SELECTED. I THEN PROCEEDED TO VERIFY THAT THE FMC WAS PROPERLY PROGRAMMED TO HOLD AT BUNKER INTXN AS DIRECTED. WHILE CHKING FMC WE EXPERIENCED THE STICK SHAKER. I MANUALLY WENT TO FULL PWR AND NOTED AIRSPD TO BE QUITE LOW, APPROX 140 KTS. I TOOK ACFT OFF THE AUTOPLT AND PROCEEDED TO FLY THE ACFT OUT OF THE PENDING STALL. WE LOST 300-400' OF ALT AND COPLT INFORMED MSP ATC WE WERE OFF ALT AND CORRECTING. MSP ATC CLRED FLT TO FL290 AT THAT TIME AND WE PROCEEDED TO COMPLETE AIRSPD CORRECTION DURING OUR DSNT TO FL290. WE HAD 2 MORE DSNTS WHILE HOLDING AND WE TRIED TO RECREATE THE CIRCUMSTANCES THAT LED TO THE LOST OF AIRSPD PROB. THE ACFT AND SYSTEMS SEEMED TO FUNCTION NORMALLY. MY PERSONAL EVALUATION IS: THAT WHILE I WAS IN SPD INTERVENTION ON THE MODE CONTROL PANEL DURING THE INITIAL DSNT PHASE THE ACFT ENDED UP NOT BEING IN A SPD MODE WHEN WE LEVELED OFF AT FL330. THE ACFT SYS RESPONDED TO COMMANDS DURING DSNT FROM FL410, BUT FAILED TO MAINTAIN SELECTED AIRSPD WHEN AT FL330. SELECTED MODES WERE NOT CHANGED. ALT CAPTURE/ALT HOLD WAS VERIFIED. I REMAINED IN SPD INTERVENE AND CONSCIOUSLY VERIFIED AIRSPD INDICATOR ON THE SALMON AIRSPD BUG PRIOR TO SHIFTING MY ATTN TO THE FMC PANEL TO CHK HOLDING PROGRAMMING. I VISUALLY CHKED ALT CAPTURE/ALT HOLD ON PITCH MODE STATUS ON ADI. THOUGH I CHKED AIRSPD INTERVENE, AIRSPD INDICATOR, SALMONBUG, AND GENERAL COCKPIT ENVIRONMENT, I CANNOT ACTUALLY REMEMBER CHKING THE AUTOTHROTTLE STATUS/MODE ON THE SAME PRIMARY ADI INSTRUMENT WHEN I CHKED ALT CAPTURE/ALT HOLD. THAT THE PRESTALL STICK SHAKER IS A VALUABLE ASSIST TO SAFETY. THAT I, THE PF, FAILED TO PROPERLY MONITOR THE FLT INSTRUMENTS. THAT HOW THE ACFT GOT OUT OF SPD MODE IS NOT KNOWN TO ME. SUPPLEMENTAL INFO FROM ACN 103889: IN CLOSING DUE TO THE HIGH WORKLOAD IN THE COCKPIT (CAPT WAS REVIEWING THE HOLDING PATTERN AND I WAS PROGRAMMING THE COMPUTER) WE ALLOWED THE AUTOMATION TO FLY THE ACFT. THE CAPT HAD ENSURED THAT THE ACFT LEVELED PRIOR TO REVIEWING THE HOLD. AUTOTHROTTLES DID NOT ENGAGE AND SPD DECREASED TO STICK SHAKER.

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  28. Accession Number: 125527
    Synopsis: ACR WDB ALT DEVIATION UNDERSHOT ALT CROSSING RESTRICTION.
    Narrative: AT FL240 WE WERE CLEARED TO CROSS 20 NW SFO AT 250 KTS AND 11,000'. WE CROSSED THE 20 MI FIX AT 250 KTS BUT AT ABOUT 12,500'. WE WERE LEVEL AT 11,000 AT 16 MI NW SFO. NEW CAPT, LESS THAN 100 HRS IN TYPE. WE WERE SET UP ORIGINALLY FOR ANOTHER ARRIVAL FROM THE NW INSTEAD OF THE SE. THIS WAS WITH FAIRLY SHORT NOTICE. WITH THIS CHANGE IN ROUTING AND SUBSEQUENT DSNT CLRNC, THE CAPT BEING SOMEWHAT PREOCCUPIED WITH PROGRAMMING THE FMS, "GOT BEHIND". I WAS MONITORING THE SFO DME AND GIVING HIM THIS INFORMATION THAT WE WERE CLOSE IN AND NEEDED TO "GET DOWN". HE GOT THE FMS PROGRAMMED AND EXECUTED THE CLRNC, JUST A LITTLE LATE.

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  30. Accession Number: 130700
    Synopsis: ACR FLT CREW ASSIGNED HEADING, ALT AND SPEED CHANGE AT SAME TIME. FAILED TO TURN OR SLOW DOWN WHILE PROGRAMMING THE PERF (FMC).
    Narrative: WE WERE ASSIGNED A TURN FROM 260 TO 220 DEGS, AN ALT CHANGE AND AN AIRSPD CHANGE ALL AT ONCE. THE F/O WAS FLYING, THE ACFT WAS ON AUTOPLT AND THE PERF SYS WAS CONTROLLING THE AUTOPLT. PUT THIS OCCURRENCE TO PREOCCUPATION WITH FLT DECK AUTOMATED GADGETS AND LOSING SIGHT OF THE PRIMARY JOB: FLYING. WE WERE ASSIGNED 250 KTS AT 7000'. THEY SLOWED US TO 210 KTS AND THE F/O ENTERED THE COMMAND IN PERF. A COUPLE OF MINS LATER APCH SLOWED US AGAIN TO 170 KTS. THIS WAS WITH THE HDG AND ALT CHANGE ABOVE. THE CONFUSION OCCURRED WHEN WE SAW THE ACFT STILL DOING NEARLY 250 KTS! IT HAD NOT SLOWED. WE ENTERED THE ALT CHANGE, BEGAN DSNT AND WERE PLAYING THE "WHAT'S IT DOING NOW" GAME TO DETERMINE WHY IT HADN'T SLOWED DOWN AS COMMANDED. THE F/O FORGOT TO ACTIVATE HDG SELECT SO THE AIRPLANE DIDN'T TURN. THIS MADE THE CTLR UNHAPPY. I HAVE HAD MANY RUN-INS WITH THE PERF SYS. IT'S A COMPUTER DESIGNED TO BE SMOOTH AND EFFICIENT--MOSTLY EFFICIENT. IT HAS IDEAS OF ITS OWN AND OFTEN PUTS ITS OWN PRIORITIES AHEAD OF YOURS. TIME LOST TRYING TO DECIDE WHAT IT'S UP TO PUTS US BEHIND THE ACFT. I HATE PERF.

  31.  
  32. Accession Number: 134592
    Synopsis: ACR MLG LANDS WITHOUT CLRNC AT BNA.
    Narrative: ON SCHEDULED FLT FROM ORD TO BNA, VFR WX, LAST LEG OF A 4-LEG DAY WHICH BEGAN EARLY AM. CAPT AND F/O BOTH FRESH OUT OF IOE AND STILL LEARNING A GREAT DEAL ABOUT FMC OPERATION. FROM CRUISE ALT ATC ASSIGNS DSNTS WITH CROSSING RESTRICTIONS. FMC DOESN'T ACCEPT CROSSING INPUTS CAUSING MUCH CREW DISTR AND HEADS DOWN FLYING. AS A RESULT ACFT IS LEFT HIGH AND FAST AS CREW ID BECOMING OVERLOADED APCHING ARPT. FMC CONTINUES TO PERPLEX CREW AND FLT CREW IS APCHING 10000' WELL ABOVE 250 KTS (F/O FLYING, CAPT ON RADIOS). AFTER SLOWING, BNA APCH CALLS VFR TFC NEAR ARPT, WHICH FURTHER DISTRACTS CREW. BNA APCH CLRED ACFT FOR CLOSE IN VIS TO 20R (JOINED FINAL INSIDE OM). NEITHER CREW MEMBER RECALLS BEING HANDED OFF TO TWR. APCH IS CONTINUED TO A NORMAL LNDG, AND UPON TAXI-IN, CREW REALIZES THEY NEVER CONTACTED THE TWR NOR RECEIVED LNDG CLRNC. GND CTLR SAYS IT'S OK, AND CAPT APOLOGIZES TO TWR SUPVR AFTER PARKING VIA PHONE. FAILURE TO CONTACT TWR WAS SIMPLY CAUSED BY THE CREW'S OVERLOADED COCKPIT. THEY WERE BOTH BEING DISTRACTED BY THE FMC SOME 80 MI OUT. THE PLANE WAS CAUGHT HIGH AND FAST, SO EXTRA MEASURES HAD TO BE TAKEN TO SLOW AND DSNT. BNA APCH MAY VERY WELL HAVE NEGLECTED TO HDOF CREW TO TWR, AND CREW WAS ALSO BUSY LOOKING FOR VFR TARGET NEAR SAME ALT.

  33.  
  34. Accession Number: 136613
    Synopsis: ACR WDB RWY TRANSGRESSION UNAUTH LNDG AT THE END OF EXTENDED OVERWATER OPERATION.
    Narrative: LNDG AT SFO ARPT WITHOUT LNDG CLRNC. THE RELIEF PLT BELIEVED WE HAD BEEN CLEARED FOR THE APCH AND LNDG. I DID NOT HEAR THIS, I HEARD CLEARED FOR THE APCH. AS WE MADE THE HIGH SPEED TURN OFF I ASKED THE F/O TO ASK FOR CLRNC TO CROSS THE RWY 28L. AT THAT POINT HE SWITCHED FROM APCH CTL FREQ TO TWR FREQ AND I REALIZED WE HAD NOT HAD CLRNC TO LAND. THE WX WAS 1600 TO 2800 RVR, THIN OVERCAST, FOG. WE SET UP FOR A CAT I APCH WITH MINIMUMS OF 300' AGL. I HAVE LESS THAN 100 HRS IN COMMAND ON THE WDB SO THAT IS THE REASON FOR THE HIGH MINIMUMS. THE PLAN WAS TO USE ONE AUTOPLT OUT OF THE THREE. WE USED THE RIGHT AUTOPLT SO I WOULD HAVE A FLT DIRECTOR THROUGHOUT THE APCH. WE PLANNED TO DISCONNECT THE AUTOPLT NO LATER THAN 200' DECISION HEIGHT. THE APCH WAS INTERRUPTED BY 4 AUTOPLT DISCONNECTS. AS A RESULT THE COPLT WAS CONTINUALLY DISTRACTED BY TRYING DIFFERENT AUTOPLT COMBINATIONS WHILE I WAS CONCENTRATING ON MORE OR LESS HAND FLYING THE APCH. THIS WAS A NON STOP FLT ORIGINATING IN HKG. THE CREW WAS TIRED. IN VIEW OF THIS, THE SOLUTION WOULD HAVE BEEN TO HAVE ONE PERSON OUT OF THE 4 BACKING UP THE COPLT ON THE RADIO TO MAKE SURE THE PROPER CLRNCS WERE RECEIVED.

  35.  
  36. Accession Number: 171919
    Synopsis: MLG CROSSED SJC VOR HIGHER THAN SID ALT ASSIGNED.
    Narrative: WAS ON LOUPE 7 DEP OUT OF SJC. DEP CTL CLRED US TO FL230 AND I THOUGHT THEY SAID TO PROCEED DIRECT TO SJC VOR AND CROSS AT OR ABOVE 12000' TO MAINTAIN FL230. PASSING 14000' DEP CALLED AND ASKED WHY WE WERE ABOVE 12000' PASSING THE VOR. I STATED I THOUGHT THEY CLRED US TO FL230 AND TO BE AT OR ABOVE 12000' AT THE VOR. THEY CLAIMED NO VIOLATION WAS BEING FILED. IF ATC WOULD GIVE US AN SID OR STAR AND LET US FLY IT AS PUBLISHED AND NOT CONTINUALLY AMEND CLRNCS, IT MIGHT HELP PREVENT INCIDENTS SUCH AS THIS ONE. ON RNAV EQUIPPED ACFT, ONE HAS TO SPEND TIME IN THE FMS TO CHANGE THE PROGRAM THAT WAS SET UP IN THE PREFLT AND THIS DISTRACTS THE CREW INTO THE COCKPIT INSTEAD OF HAVING OUR HEADS AND EYES OUTSIDE LOOKING FOR TFC AT LOWER ALTS, ESPECIALLY BELOW 18000' IN HIGH DENSITY ARPTS. SUPPLEMENTAL INFO FROM ACN 172262: THERE WAS NO DOUBT IN EITHER OF OUR MINDS THAT WE WERE CLRED TO CROSS THE VOR ABOUT 12000'.

  37.  
  38. Accession Number: 172798
    Synopsis: ACR MLG ALT DEVIATION OVERSHOT DURING CLIMBOUT FROM LNDG GO AROUND AT SNA WITH ACR OBSERVING.
    Narrative: RWY 19R, WIND 220/18, LNDG SNA, CLR DAY, GUSTY WINDS. APPROX 100' AGL, AIRSPD LOSS OF APPROX 20 KIAS. ABRUPTLY APPLIED PWR AND WHILE ENGS SPOOLED UP LOST ANOTHER 50'. AT T/D, GUSTING WIND INCREASED SPD TO BUG +10. TOUCHED DOWN ON LEFT MAIN ABOUT THE SAME TIME ENGS REACHED FULL SPOOL. ACFT THEN SETTLED ON RIGHT MAIN GEAR WITH NOSE HIGH ATTITUDE. ELECTED TO GO AROUND (5000' RWY GIVE VERY LITTLE ROOM FOR ERROR). HIT THE TO/GA SWITCHES, APPLIED MAX PWR AND HAND-FLEW THE ACFT TO 2000'. ELECTED TO LEAVE FLAPS AT 15 DEGS AND RETURN TO LAND AND WAS CLRED TO 3000'. WHILE REPROGRAMMING FMC AND SELECTING MODE TO RE-ENGAGE AUTO THROTTLES, FLEW THREW 3000 TO 3400'. DSNDING BACK TO 3000'. RETURNED TO THE ARPT FOR NORMAL LNDG. FACTORS CONTRIBUTING TO ALT EXCURSION: NOISE ABATEMENT PROC AT SNA IS DIFFICULT ENOUGH W/O THROWING IN TURMOIL CREATED BY GAR. ACI IN JUMP SEAT, HENCE ADDED STRESS FOR SMOOTHE, PROC WAS INCREASED. THEN CONCENTRATION ON AUTOMATION RATHER THAN JUST FLYING ACFT WAS ENOUGH DISTR TO FLY THROUGH THE ALT.

  39.  
  40. Accession Number: 176490
    Synopsis: ALT OVERSHOT DURING DESCENT.
    Narrative: THIS ALT DEV OF 450' BELOW ASSIGNED ALT OF 12000' MSL OCCURRED DUE TO CAPT'S ALTIMETER STILL BEING SET AT 29.92. THE ACFT WAS BEING FLOWN BY USE OF FMS, WHICH LEVELED AT 12000' ON THE CAPT'S ALTIMETER. CHAIN OF EVENTS. DIRECTED BY CLEVELAND ARTCC TO DSND TO 11000'. CAPT'S DUTIES WERE DIVIDED BTWN MAINTAINING FLT PATH OF THE ACFT AND REPROGRAMMING THE FMS FOR OPTIMUM SPDS AND REQUIRED ALT. F/O (MYSELF) STARTED SILENT ITEMS OF DSNT CHKLIST. POOR RECEPTION OF ROC ATIS ON A VOR FFEQ RESULTED IN ATIS RECEPTION APPROX 50 MI CLOSER TO THE ARPT THAN USUAL AND WELL INTO THE ENRTE DSNT. F/O WENT OFF ARTCC RADIO TO OBTAIN ATIS. F/O RSUMED MONITOR OF ARTCC FREQ, ACCEPTED A FREQ CHANGE, THEN ACKNOWLEDGED ARTCC DIRECTIVE TO AMEND ALT CLRNC TO 12000' DUE TO TFC. CAPT AND F/O STARTED DISCUSSING RWY TO BE USED AT ROCHESTER DUE TO POOR WX AND WET RWYS. F/O WENT TO PERFORMANCE MANUAL AT CAPT'S REQUEST TO CHK LNDG DISTANCE. DSNT CHKLIST STILL NOT FULLY ACCOMPLISHED. THIS IS REAL KEY. HAD THIS CHKLIST BEEN COMPLETED AT APPROX 18000' MSL (NORMAL AIRLINES OPERATION) BOTH PRIMARY ALTIMETERS WOULD HAVE BEEN PROPERLY SET. CLEVELAND ARTCC CTLR CALLED TFC. F/O ACKNOWLEDGED AND ADVISED CTLR OF IMC CONDITIONS. CLEVELAND ARTCC QUERRIED US ON ALT WE WERE CLRED TO. THIS PROMPT MADE F/O AWARE OF DSNT BELOW ASSIGNED ALT (F/O'S ALTIMETER WAS SET AT 29.40; CAPT'S STILL AT 29.92). F/O INFORMED CAPT OF ALTIMETER SETTING ERROR. CAPT IMMEDIATELY CORRECTED THE ALTIMETER SETTING AND ACTUAL ACFT ALT. PROB WAS DETECTED AT 11700'. CREW REACTION TIME ALLOWED THE ACFT TO READ 11550'. CAUSES. POOR RECEPTION OF ATIS ON SEC FREQ TRIED BY F/O IN POOR WX. ROCHESTER ATIS BROADCAST NEEDS TO BE UPGRADED. SHOULD BE CLRLY AVAILABLE 100-150 MI FROM ARPT. CREW DID NOT MAKE THE DSND CHKLIST A PRIORITY OVER APCH SELECTION. BOTH OF US GOT A REAL WORLD REFRESHER COURSE IN SETTING PRIORITIES. CAPT'S CONCENTRATION WAS DIVIDED BTWN COMPUTER PROGRAMMING AND FLYING THE AIRPLANE. THE BUTTON PUSHING REQUIRED BY AN FMS IS A BIG CONTRIBUTOR TO CREW OVERLOAD AND POOR SITUATIONAL AWARENESS. USE OF COMPUTERIZED NAV NEEDS TO BE DEEMPHASIZED IN AIRLINE OPS.

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  42. Accession Number: 180082
    Synopsis: ACR MLG FLT CREW MAKES WRONG RWY APCH AT DFW.
    Narrative: WE WERE APCHING DFW FOR THE SW ON THE ACTON ARR. ATIS INFORMED US TO PLAN OF A VIS APCH TO 18R. WHEN WE TURNED N (ON DOWNWIND) WE WERE GIVEN DSNT AND A FREQ CHANGE. THE FMS AND MCP WERE SET FOR 18R. THE NEW CTLR TOLD US TO EXPECT 17L AND A SHORT FINAL. THE TIME INVOLVED WITH REPROGRAMMING EVERYTHING TOOK ME UNTIL BASE LEG, WHILE THE COPLT FLEW THE ACFT (DSNDING FROM 11000 TO 3000'). UPON TURNING BASE, THE CTLR ASKED IF WE HAD THE FIELD IN SIGHT. THE COPLT SAID HE DID AND THEN THE CTLR CLRED US FOR A VIS TO 17L AND SWITCHED US TO TWR. AT THIS POINT WE BEGAN CONFIGURING THE ACFT FOR LNDG AND RUNNING THE LNDG CHKLIST. WHEN WE CAME UPON TWR'S FREQ HE OFFERED US 17R AND WE ACCEPTED IT. AS WE ROLLED OUT ON FINAL, I WAS BUSY REPROGRAMMING THE RADIOS AND FMS FOR THE THIRD TIME AND DID NOT NOTICE THE COPLT HAD LINED UP ON 18R. APPROX 1 MI LATER I FINISHED SETTING UP THE COCKPIT AND SAW ON THE NAV DISPLAY THAT ACFT WAS DISPLACED TO THE RIGHT OR W OF COURSE. AFTER CHKING FREQS AND COURSES VERY QUICKLY, I LOOKED OUTSIDE AND STARTED TO TELL THE COPLT HE HAD LINED UP ON THE WRONG RWY. AT THAT MOMENT THE TWR CALLED TO CONFIRM WE HAD THE ARPT IN SIGHT--WE WERE APCHING THE OM--AND WE TURNED TOWARD 17R. THE REMAINDER OF THE APCH WAS UNEVENTFUL. CONTRIBUTING FACTORS WERE THE FADING DAYLIGHT AND THE COPLT HAD BEEN OUT OF THIS COCKPIT FOR 2 MONTHS WHILE TRANSITIONING TO ANOTHER AFT WHICH LEFT HIM A LITTLE BEHIND AND PREOCCUPIED. THERE WERE NO OTHER ACFT ON APCH TO EITHER SIDE OF DFW. CHANGING APCHS AND RWYS INSIDE OF 10 MI (EVEN IN VMC) IN THIS HIGH WORKLOAD 2-M COCKPIT ACFT REPRESENTS A CHALLENGE, EVEN WHEN BOTH PLTS ARE EXPERIENCE AND CURRENT, MUCH LESS IF ONE IS NOT.

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  44. Accession Number: 189654
    Synopsis: ACR FLC IN NEW MODEL WDB HAS ALT DEV ALT OVERSHOT ALT EXCURSION DUE TO WRONG ALTIMETER SETTING.
    Narrative: I WAS THE FO AND WAS RESPONSIBLE FOR COMPUTER ENTRIES AND RADIO COM. WE WERE CLRED OUT OF FL230 TO 10000 FT BY TOKYO CENTER. WE WERE GIVEN A XING RESTRICTION OF AT OR BELOW 15000 FT AT MELON INTXN. IN SHORT ORDER, WE WERE GIVEN REVISED CLRNC TO 11000 FT THEN HANDED OFF TO TOKYO NARITA APCH WHO THEN GAVE A CLRNC TO HOLD AT ARIES INTXN. WE WERE PERHAPS 20 DME FROM THE FIX. AN ALREADY BUSY ARR WAS MADE MORE SO BY THE FOLLOWING FACTORS: 1) WX - TSTMS, TURB. CAPT WAS CLOSELY MONITORING RADAR. 2) WX AT DEST - RPTED AT MINS. CREW DURING DSCNT WAS DISCUSSING POSSIBLE DIVERT TO OSHKA. INTL OFFICER FELL OUT OF LOOP WHILE GETTING OSHKA WX AND MONITORING ATIS. NEW ATIS INDICATED RWY CHANGE. 3) I WAS OVERLY OCCUPIED WITH COMPUTER DUTIES - HOLDING, NEW ARR, NEW APCH. I DID NOT MONITOR DSCNT CLOSELY ENOUGH. 4) LANGUAGE - THE CTLR WAS DIFFICULT TO UNDERSTAND. I REQUIRED REPEATS OF SEVERAL OF THE TRANSMISSIONS. I ALSO HAD TO ASK FOR EFC. 5) WE WERE DSNDED LATE - CAPT ELECTED TO HAND FLY THE ACFT TO MAKE THE XING RESTRICTION. THE AUTO PLT OFF ALARM DISTRACTED ME FOR A FEW MOMENTS AT A CRITICAL TIME ABOUT 17000 FT (TA 14000 FT). I HAD COMPLETED THE DSCNT CHKLIST TO 18000 FT (OR TRANS ALT). AFTER THE AUTOPLT OFF ALARM I WENT BACK TO THE COMPUTER AND WAS SO ENGAGED WHEN NARITA APCH TOLD US WE WERE BELOW ALT AND TO CLB AND TURN. THE CAPT REACTED IMMEDIATELY. WE HAD FAILED TO RESET ALTIMETERS FROM 29.92 TO 29.19 AT TRANSITION ALT. NOBODY WAS THINKING DSCNT CHKLIST. IT IS EXTREMELY DIFFICULT TO MAINTAIN COCKPIT AWARENESS AND SCAN IN FMC ACFT WHEN RAPID CHANGE IS REQUIRED. PARTICULARLY WITH THE HEAD DOWN KEYPAD. CONTRIBUTING FACTORS: 1) HIGH WORKLOAD ACFT WITH RELATIVELY LOW TIME CREW DSNDING INTO AREA OF HVY WX. 2) LAST MIN HOLDING INSTRUCTIONS TOOK THE FO OUT OF THE LOOP WHILE REPROGRAMMING THE COMPUTER. 3) I NOW BACKING FO UP ON GETTING THE TRANSITION ALT CHKLIST COMPLETED. 4) CAPT NOT DOUBLECHKING TO SEE THAT ALL THE CHKLIST ITEMS HAD BEEN COMPLETED. LESSONS TO BE LEARNED: 1) ALL CREW MEMBERS NEED TO INSURE CHKLIST IS COMPLETE (INCLUDING THE ONE WHO IS FLYING). 2) ALL CREW MEMBERS NEED TO BE IN THE LOOP DURING APCH, PARTICULARLY WHEN WX, LANGUAGE DIFFERENCES, AND LAST MIN CLRNCS COULD COMPLICATE THE APCH.

  45.  
  46. Accession Number: 189654
    Synopsis: ACR FLC IN NEW MODEL WDB HAS ALT DEV ALT OVERSHOT ALT EXCURSION DUE TO WRONG ALTIMETER SETTING.
    Narrative: I WAS THE FO AND WAS RESPONSIBLE FOR COMPUTER ENTRIES AND RADIO COM. WE WERE CLRED OUT OF FL230 TO 10000 FT BY TOKYO CENTER. WE WERE GIVEN A XING RESTRICTION OF AT OR BELOW 15000 FT AT MELON INTXN. IN SHORT ORDER, WE WERE GIVEN REVISED CLRNC TO 11000 FT THEN HANDED OFF TO TOKYO NARITA APCH WHO THEN GAVE A CLRNC TO HOLD AT ARIES INTXN. WE WERE PERHAPS 20 DME FROM THE FIX. AN ALREADY BUSY ARR WAS MADE MORE SO BY THE FOLLOWING FACTORS: 1) WX - TSTMS, TURB. CAPT WAS CLOSELY MONITORING RADAR. 2) WX AT DEST - RPTED AT MINS. CREW DURING DSCNT WAS DISCUSSING POSSIBLE DIVERT TO OSHKA. INTL OFFICER FELL OUT OF LOOP WHILE GETTING OSHKA WX AND MONITORING ATIS. NEW ATIS INDICATED RWY CHANGE. 3) I WAS OVERLY OCCUPIED WITH COMPUTER DUTIES - HOLDING, NEW ARR, NEW APCH. I DID NOT MONITOR DSCNT CLOSELY ENOUGH. 4) LANGUAGE - THE CTLR WAS DIFFICULT TO UNDERSTAND. I REQUIRED REPEATS OF SEVERAL OF THE TRANSMISSIONS. I ALSO HAD TO ASK FOR EFC. 5) WE WERE DSNDED LATE - CAPT ELECTED TO HAND FLY THE ACFT TO MAKE THE XING RESTRICTION. THE AUTO PLT OFF ALARM DISTRACTED ME FOR A FEW MOMENTS AT A CRITICAL TIME ABOUT 17000 FT (TA 14000 FT). I HAD COMPLETED THE DSCNT CHKLIST TO 18000 FT (OR TRANS ALT). AFTER THE AUTOPLT OFF ALARM I WENT BACK TO THE COMPUTER AND WAS SO ENGAGED WHEN NARITA APCH TOLD US WE WERE BELOW ALT AND TO CLB AND TURN. THE CAPT REACTED IMMEDIATELY. WE HAD FAILED TO RESET ALTIMETERS FROM 29.92 TO 29.19 AT TRANSITION ALT. NOBODY WAS THINKING DSCNT CHKLIST. IT IS EXTREMELY DIFFICULT TO MAINTAIN COCKPIT AWARENESS AND SCAN IN FMC ACFT WHEN RAPID CHANGE IS REQUIRED. PARTICULARLY WITH THE HEAD DOWN KEYPAD. CONTRIBUTING FACTORS: 1) HIGH WORKLOAD ACFT WITH RELATIVELY LOW TIME CREW DSNDING INTO AREA OF HVY WX. 2) LAST MIN HOLDING INSTRUCTIONS TOOK THE FO OUT OF THE LOOP WHILE REPROGRAMMING THE COMPUTER. 3) I NOW BACKING FO UP ON GETTING THE TRANSITION ALT CHKLIST COMPLETED. 4) CAPT NOT DOUBLECHKING TO SEE THAT ALL THE CHKLIST ITEMS HAD BEEN COMPLETED. LESSONS TO BE LEARNED: 1) ALL CREW MEMBERS NEED TO INSURE CHKLIST IS COMPLETE (INCLUDING THE ONE WHO IS FLYING). 2) ALL CREW MEMBERS NEED TO BE IN THE LOOP DURING APCH, PARTICULARLY WHEN WX, LANGUAGE DIFFERENCES, AND LAST MIN CLRNCS COULD COMPLICATE THE APCH.

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  48. Accession Number: 202041
    Synopsis: ACR TAXIES ONTO ACTIVE WITHOUT CLRNC.
    Narrative: I TAXIED ONTO THE ACTIVE RWY BELIEVING WE HAD A CLRNC FOR TKOF. I ASKED THE FO TO CONFIRM THAT CLRNC AND WAS INFORMED THAT IT WAS THE FIRST CONTACT WITH THE TWR AND WE WERE CLRED FOR TKOF. CONTRIBUTING FACTORS: 1) TIRED CREW (MIN LAYOVER) 2) EARLY DEP. 3) FMS NEEDED REPROGRAMMING DURING TAXI (A DISTRACTING SITUATION). 4) EXTRANEOUS COCKPIT CONVERSATION. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATES FLT WAS CLRED TO TAXI TO RWY 5 WHICH INDICATED CLRNC TO INTERSECTING RWY. HOWEVER, THE FMS DUMPED SOME FLT INFO AND CREW DISTRACTED TRYING TO REPROGRAM. WHEN CAME TO INTERSECTING RWY, CAPT ASKED FO TO GET CONFIRMATION FOR XING. WHEN ARRIVING AT ACTIVE RWY CAPT REALLY THOUGHT CLRNC WAS CLRNC FOR TKOF. ATTRIBUTES PROBLEM TO FATIGUE AS HOTEL WAS POOR AND SO WAS THE QUALITY OF SLEEP. BOTH PLTS CLRED FINAL BEFORE RWY ENTRY. GND CTLR WAS ALSO CLRNC DELIVERY AND POSSIBLY LCL AS WELL. NEVER RECEIVED INSTRUCTIONS TO SWITCH FROM GND TO TWR SO DID ON THEIR OWN JUST PRIOR TO CONTACTING AS TAXI ONTO RWY. NO OTHER MOVING TFC ON THE ARPT AT THAT TIME.

  49.  
  50. Accession Number: 209413
    Synopsis: CAPT OF MLG ACR ACFT ALLOWED THE ACFT TO UNDERSHOOT DURING DSCNT CAUSING AN ALT XING RESTRICTION NOT TO BE MET. THERE WAS NO KNOWN CONFLICT WITH OTHER TFC.
    Narrative: PROBLEM: MISSED XING RESTRICTION ALT. SUCCESSIVE DSCNTS AND XING RESTRICTIONS WITH EACH CHANGING CTLR. HAD BEEN CLRED TO FL190, TO CROSS 30 NM S OF SIE VOR AT 15000 FT. RESTRICTION HAD BEEN PROGRAMMED INTO FMC COMPUTER, BUT I MUST NOT HAVE PROPERLY ENGAGED THE COMPUTER. WHEN CHANGED TO FREQ 127.70, THE CTLR QUERIED OUR CLRNC TO 15000 FT. I CONFIRMED IT -- BELIEVING I STILL HAD APPROX 30 MI TO GO -- BUT IN FACT, I WAS ABOUT 3 MI FROM THE XING. CTLR SAID OK -- JUST DSND TO 15000 FT, WHICH I DID. CONTRIBUTING FACTORS: REPEATED DIFFICULTY HAD BEEN EXPERIENCED WITH SETTING LOWER ALTS INTO THE FMC TO SATISFY EACH NEW RESTRICTION. SOMETIMES WITHOUT SUCCESS. OFTEN WHEN MAKING DSCNTS WITH RAPIDLY CHANGING PARAMETERS, THE AUTOMATED COCKPIT BECOMES UNWIELDY -- AND BECOMES A DISTR TO FLYING THE ACFT. HUMAN PERFORMANCE CONSIDERATIONS: FLT WAS LAST LEG OF A 4-DAY TRIP -- ACCUMULATING 25+ HRS IN THE LAST 80 HRS. A LAYOVER OF ABOUT 3 HRS WAS EXPERIENCED BTWN PREVIOUS AND CURRENT FLT. A CERTAIN AMOUNT OF FATIGUE WAS FELT -- PLUS ANGER AT KNOWING CREW WAS SUBJECT TO POSSIBLE DRUG TEST ON ARR -- COMBING WITH FRUSTRATION AND INABILITY TO MANAGE THE FMC -- ADDED TO THE DISTR OF ADHERING TO THE CLRNC.

  51.  
  52. Accession Number: 218329
    Synopsis: AN MLG ACR MISSED A XING ALT.
    Narrative: AT FL290, APPROX 10 NM SW OF EKN, CLRNC WAS RECEIVED TO CROSS 30 NM SW OF MGW AT FL240. PNF ACKNOWLEDGED CLRNC AND PF ENTERED RESTRICTION IN FMC. (FLT WAS OPERATING IN VNAV AND LNAV MODES OF AUTOPLT.) AFTER ENTRY IN FMC, PF NOTICED A 'BYPASS' ANNUNCIATION IN FMC ROUTING IN ASSOCIATION WITH THE ENTRY OF '30 SW OF MGW' FIX. THIS WAS DUE TO IMPROPER ENTRY OF THIS FIX BTWN MGW AND 'ROTON' INTXN. AS OPPOSED TO WHERE IT REALLY WAS, BTWN EKN AND 'TYGAR' INTXN. PF WAS ATTEMPTING TO RESOLVE THIS PROBLEM WHEN IT BECAME APPARENT THAT INITIATION OF DSCNT WAS NECESSARY TO MEET RESTRICTION. PF ATTEMPTED TO USE VERT SPD TO INITIATE DSCNT BUT ACFT REMAINED AT FL290. IT WAS THEN NOTICED THAT ALT 'SET' WINDOW WAS STILL AT FL290, DISALLOWING AUTOPLT TO DSND. ALT WAS RESET TO FL240, DSCNT WAS INITIATED CONCURRENT WITH INQUIRY FROM CTR AS TO ABILITY TO MEET RESTRICTION. WE RESPONDED 'UNABLE' AND FLT WAS GIVEN A 50 DEG R TURN, PRESUMABLY TO AVOID A POTENTIAL CONFLICT. AT FL250, FLT WAS CLRED DIRECT MGW TO RESUME ROUTING. THIS SITUATION OCCURRED BECAUSE OF PF'S FAILURE TO FOLLOW HIS OWN SOP IN SUCH A CIRCUMSTANCE WHICH IS TO 1) RESET ALT, 2) MAKE A QUICK DETERMINATION IF ACFT IS NEAR THE REQUIRED DSCNT POINT AND INITIATE A DSCNT USING VERT SPD OR LEVEL CHANGE IF NECESSARY, 3) MAKE APPROPRIATE ENTRIES IN FMC AND USE VNAV FOR DSCNT IF APPROPRIATE. PF DID THESE OUT OF SEQUENCE AND BECAME DISTRACTED BY AN FMC IRREGULARITY, THUS OVERSHOOTING DSCNT POINT.

  53.  
  54. Accession Number: 236228
    Synopsis: ALTDEV DUE TO PROGRAMMING FMS AND NOT MONITORING ALT.
    Narrative: WE WERE DSNDING INTO DAY OUT OF FL180 TO 11000 FT. WE WERE GIVEN A CLRNC TO GO DIRECT TO DAY VOR. WE WERE ATTEMPTING TO PUT DIRECT TO DAY VOR IN THE FMC WHEN I NOTICED OUR ALT AT 7700 FT DSNDING, AIRSPD AT 280 KTS. I KICKED OFF THE AUTOPLT AND BEGAN A CLB, ASKING THE FO TO CHK WITH ATC ON OUR CLRED ALT. I CHKED THE ALT WINDOW ON THE FLT MODE PANEL AND INSTEAD OF 11000 FT I SAW 7700 FT. WHEN WE WERE CLRED TO 11000 FT, I SET THAT IN THE ALT WINDOW, SAID '11000 FT,' AND POINTED TO IT. THE FO POINTED AND RESPONDED. '11000 FT.' SOMEHOW THE ALT GOT CHANGED (OR CHANGED ITSELF) AND WE DID NOT NOTICE IT UNTIL PASSING BELOW 8000 FT, DUE TO BEING DISTRACTED BY PROGRAMMING THE FMC.

  55.  
  56. Accession Number: 246157
    Synopsis: DSCNT PROC DELAYED, SO CTR CTLR GIVES FLC A WAKE UP CALL TO START ON DOWN. ALT XING RESTRICTION.
    Narrative: WE WERE AT 27000 FT ON POLAR 1 ARR TO DTW IN A FOREIGN MADE MLG. WE WERE GIVEN CLRNC TO CROSS CETUS AT AND MAINTAIN 23000 FT. WE SET ALL PARAMETERS IN OUR FCU AND PROGRAMMED FOR AN APPROPRIATE DSCNT. HOWEVER, IN THIS MLG, ONE CAN'T PREPROGRAM THE EXECUTE. AS THE APPROPRIATE TIME CAME TO DSND, WE WERE BUSY DOING OTHER TASKS SUCH AS COPYING ATIS AND CONFIGURING THE COMPUTER FOR OUR APCH. WE OVERFLEW THE DSCNT POINT AND HAD TO BE REMINDED BY CTR TO START DOWN. THIS IS A REAL TRAP IN THE MLG'S VERT NAV CAPABILITY. I WAS WELL AWARE OF IT AND STILL GOT DISTRACTED. THE SOFTWARE SHOULD BE MODIFIED TO PREPROGRAM THE EXECUTE SO THIS WILL NOT HAPPEN.

  57.  
  58. Accession Number: 252461
    Synopsis: FLC OF A WDB ACR ACFT BECAME DISTRACTED BY A MALFUNCTIONED AUTO THROTTLE CTL INPUT AND FAILED TO TURN AS REQUIRED BY SID RESULTING IN LESS THAN LEGAL SEPARATION TO ANOTHER DEPARTING ACFT ON SEPARATE PARALLEL RWYS.
    Narrative: WE DEPARTED ON RWY 25R AT LAX AND OUR CLRNC WAS FOR A LOOP 9 DEP TO MAINTAIN 2000 FT. THE LOOP 9 DEP CALLS FOR A TURN TO A HDG OF 235 DEGS UPON XING THE SANTA MONICA VOR (SMO) 160 DEG RADIAL. THIS IS AN AUTOMATED AIRPLANE SO WE WERE USING THE FLT DIRECTOR AND AUTO THROTTLES. THE TKOF WAS NORMAL. WE LEVELED AT 2000 FT, AND THE AUTO THROTTLES CAME BACK AND SET THE THRUST TO MAINTAIN 250 KIAS. JUST PRIOR TO XING THE SMO 160 DEG RADIAL, LAX DEP CTL ISSUED US A CLB CLRNC. IN ACCORDANCE WITH OUR FLT MANUAL PROC, I COMMANDED THE FO TO PUSH THE FLT LEVEL CHANGE BUTTON ON THE MODE CTL PANEL AND SET 250 KTS IN THE SPD WINDOW: 'FLCH 250.' PUSHING THE 'FLCH' BUTTON CAUSES THE AUTO THROTTLES TO MOVE THE THRUST LEVERS TO CLB THRUST, AND IT ALSO CAUSES THE PITCH COMMAND BARS TO COMMAND AN ANU PITCH THAT WILL MAINTAIN THE SELECTED SPD (IN THIS CASE 250 KTS). FOR SOME REASON, THE AUTO THROTTLES DID NOT RESPOND. THEY REMAINED AT THEIR PRESENT THRUST SETTING AND THE ACFT DID NOT GO INTO A CLB MODE. WE WERE DISTRACTED BY THIS MALFUNCTION AND WERE LATE IN INITIATING OUR TURN TO 235 DEGS. BECAUSE OF OUR LATE TURN AND BECAUSE OF THE FACT THAT WE WERE ALSO LATE IN STARTING OUR CLB, WE CAME CLOSE ENOUGH TO TFC THAT HAD DEPARTED RWY 24L THAT WE GOT AN RA ON OUR TCASII SYS. THE FO MADE VISUAL CONTACT WITH THE TFC AND ESTIMATED THAT OUR LATERAL SEPARATION WAS AROUND 6000 FT AND THE TCASII READOUT INDICATED A VERT SEPARATION OF 400 FT. WE MANUALLY SET THE THROTTLES TO CLB THRUST, AND AS SOON AS WE INITIATED THE TURN AND STARTED THE CLB THE RA ENDED.

  59.  
  60. Accession Number: 358711
    Synopsis: MD80 WAS DSNDING AND AS THEY APCHED FL270, THE CAPT WAS REPROGRAMMING THE FMS WHICH CANCELED THE ALT CAPTURE AND THE RATE OF DSCNT INCREASED. ACFT DSNDED TO FL269 AND TRIGGERED A TCASII RA ON A DC10, OPPOSITE DIRECTION TFC, AT FL260.
    Narrative: ZDC CLRED US TO FL270. DURING DSCNT PF PROGRAMMED THE FMS TO DSND AT 250 KIAS AND 1500 FPM. JUST PRIOR TO LEVELING AT FL270, THE PF NOTED THAT THE IAS WAS 260 KIAS WHILE DSCNT RATE WAS 400 FPM WITH THROTTLES ADVANCING. AT THAT TIME THE PF BEGAN TO REPROGRAM THE FMS WHICH CANCELED THE ALT CAPTURE FUNCTION OF THE AUTOPLT. WHILE 'HEADS DOWN' AND TASK SATURATED WITH THE FMS THE ACFT INCREASED ITS RATE OF DSCNT AND DSNDED THROUGH FL270. AT THAT TIME THE PNF TOOK CTL OF THE ACFT AND BEGAN A CLB BACK TO FL270. AT ABOUT THE SAME TIME A DC10 (?) TRIGGERED AN RA ON THE TCASII. ACR Y TFC WAS OPPOSITE DIRECTION AT FL260. THE ACR Y FLT RPTED A NEAR MISS TO THE CTR CTLR. THE CTLR QUERIED OUR FLT LEVEL TO WHICH WE RPTED FL270 WHICH WAS WHERE WE WERE AT. WE BELIEVE THAT THE INCREASING DSCNT RATE IN COMBINATION WITH THE 1000 FT CLRNC TRIGGERED AN RA. WE BELIEVE THE MISS DISTANCE WAS AT LEAST 900 FT VERT.

  61.  
  62. Accession Number: 358890
    Synopsis: ALTDEV ALT OVERSHOT IN DSCNT WHEN FO INADVERTENTLY DISARMS ALT AUTO CAPTURE BY SELECTING 'VERT SPD' ON AUTOPLT MODE SELECTOR.
    Narrative: FLT TO BOS, ZNY ISSUED CLRNC FOR DSCNT, TO SLOW TO 300 KTS, TO CROSS A FIX N OF JFK AT FL240. WE HAD A TAILWIND OF 80-90 KTS. FO PROGRAMMED FMS FOR XING RESTR. DSCNT WAS BEGUN. ACFT WAS ON VERT NAV PATH TO XING RESTR. TAILWIND WAS MAKING IT DIFFICULT FOR ACFT TO MAINTAIN BOTH VNAV PATH AND AIRSPD. ACFT MAINTAINED PATH AND SPD INCREASED TO 313 KTS. AS ACFT APCHED FL240, CTR ISSUED CLRNC TO FL230. FO SET NEW ALT IN AUTOPLT ALT SELECT WINDOW. FO NOTICED SPD HAD INCREASED ABOVE 300 KTS, AND SELECTED VERT SPD MODE OF AUTOPLT TO REDUCE SPD. APPARENTLY SELECTING VERT SPD DISARMED ALT CAPTURE FOR FL230. AT 200 FT ABOVE FL230 I NOTICED ACFT WAS DSNDING AT 3300 FPM AND WOULD NOT LEVEL OFF AT FL230. I ANNOUNCED THIS TO FO WHO BEGAN TO LEVEL OFF ACFT. ACFT DSNDED ABOUT 400 FT BELOW FL230 BEFORE RETURNING TO FL230. PREOCCUPATION WITH FMS PROGRAMMING AND ACFT NOT ABLE TO MAINTAIN BOTH AIRSPD AND DSCNT PATH WITH TAILWIND LED TO SELECTION OF AUTOPLT VERT SPD MODE AND LOSS OF ALT ARM AND CAPTURE DURING AUTOPLT DSCNT.

  63.  
  64. Accession Number: 359070
    Synopsis: DC9-41 WAS CLBING TO FL240. 1000 FT TO GO CALL WAS MADE AND PNF LOOKED UP AS THEY WERE CLBING THROUGH FL242.
    Narrative: WE WERE INSTRUCTED TO LEVEL AT FL240, THE AAD WENT OFF AS WE PASSED THROUGH FL230. I THEN CALLED OUT 'OUT OF FL230 FOR FL240.' THE PF ACKNOWLEDGED 'ROGER.' I THEN CONTINUED WITH MY PAPERWORK, AND AFTER A FEW SECONDS, I GLANCED UP AND SAW THE ALTIMETER AT FL242 AND THE ACFT STILL CLBING. I CALLED THE DEV AND IMMEDIATELY PUNCHED OFF THE AUTOPLT AND PITCHED THE ACFT OVER TO CORRECT THE ALT. THE FO, PF, HAD GOTTEN DISTR WITH REPROGRAMMING THE LORAN. NO MENTION WAS MADE ABOUT ALT BY ATC.

  65.  
  66. Accession Number: 360911
    Synopsis: AN ACR CAPT RPTS THAT THE AUTOFLT SYS ON THE MD88 HAS SOME 'ERRATIC AND POTENTIALLY HAZARDOUS' CHARACTERISTICS ASSOCIATED WITH THE VNAV AND AUTOTHROTTLE FUNCTIONS. THE RPTR ALSO COMPLAINS ABOUT A NAV PROGRAM IN THE FMC.
    Narrative: THE VNAV CAPTURE FUNCTION OF AUTOPLT IS POTENTIALLY HAZARDOUS DURING CONDITIONS OF HIGH ACFT CLB PERFORMANCE (IE, LIGHT GROSS WT AND/OR LOW TEMP). IT IS NOT UNCOMMON FOR THE AUTOTHROTTLES TO PULL BACK PWR BELOW CLEAN SPD WHILE IN A TURN, AT 3000 FT MSL WITH LEVEL OFF AT 6000 FT MSL. EVEN CLBING AT 250 KTS PASSING THROUGH 10000 FT ENRTE TO 12000 FT IT IS NOT UNCOMMON FOR THE AUTOTHROTTLES TO PULL BACK PWR AND THEN JAM IT ON AGAIN TO ACCELERATE. THIS ERRATIC NATURE OF THE AUTOTHROTTLES REQUIRES THE PLT'S FULL ATTN, OR WILL BE MISSED WHILE PERFORMING OTHER FLT DUTIES AND RESULT IN AIRSPD FALLING BELOW SAFE LEVELS. THE INCLUSION OF THE 6000 FT INITIAL CLB ALT IN THE FMS FOR THE REDSS ONE DEP INHIBITS VNAV WHEN, WHILE ON VECTORS, WE ARE GIVEN CLRNC TO A HIGHER ALT. PLEASE REMOVE THIS RESTR FROM THE FMS DATA BANK FOR THE DEP. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THIS RPTR SAID THAT SINCE HE HAS STARTED OPERATING THIS ACFT IN LINE OPS HE HAS DISCOVERED THAT IT DOES NOT ALWAYS SMOOTHLY AND CORRECTLY CAPTURE THE SELECTED ALT. THE MD88 AUTOTHROTTLES WILL START REDUCING THRUST WELL BEFORE THEY SHOULD AS THE ACFT APCHS ITS ALT HE SAID. ALSO HE COMPLAINED THAT IN SOME EXTREME CASES THE AUTOTHROTTLES WOULD ALLOW THE AIRSPD TO DECREASE TO A CRITICAL LEVEL IF HE WERE NOT WATCHFUL. HE ALSO COMPLAINED THAT IF THE LEVEL OFF ALT WAS AROUND 10000 FT OR SLIGHTLY ABOVE, THE AUTOTHROTTLES WOULD REDUCE AS THE ALT WAS CAPTURED AND THEN GO BACK TO FULL PWR AFTER LEVELING AT OR PASSING 10000 FT. LASTLY, THE RPTR COMPLAINED ABOUT A RECENT CHANGE IN THE SOFTWARE THAT WAS ANTICIPATING A NORMAL CLRNC THAT IS OFTEN GIVEN ON A DEP. HOWEVER, THE ALT RESTR IS NOT ALWAYS GIVEN YET, WITH THE SOFTWARE CHANGE, THE FMC ALWAYS TRIES TO MEET THE RESTR.

  67.  
  68. Accession Number: 363330
    Synopsis: B737-300 MAX GROSS TKOF RWY 35R CLBING TO 10000 FT. COMPLETING AFTER TKOF CHKLIST AND VECTORED TO 100 DEGS PLUS TA GIVEN. AUTOPLT WOULD NOT ENGAGE AND NOTED ALT 10150 FT CLBING. DSNDED TO 9900 FT WHEN CTLR QUESTIONED ALT. TCASII TA AND RA AND SAW TFC VISUALLY 500 FT ABOVE. WHEN CLR OF TFC CLRED TO 16000 FT.
    Narrative: WE WERE MAKING A MAX GROSS WT TKOF ON RWY 35R AT COS USING IMPROVED CLB, BLEEDS OFF, FLAPS 1 DEG. THE CLRNC WAS RWY HEADING CLB TO 10000 FT MSL. AFTER LIFT-OFF I PROCEEDED ON RWY HEADING AND THE TWR TOLD US TO TURN TO 010 DEGS AND CONTACT DEP CTL. THE ACFT WAS BEING CLEANED UP AS WE CONTACTED DEP. HE GAVE US A TURN TO 100 DEGS TO INTERCEPT THE 349 DEG RADIAL OFF PUB. I CALLED FOR THE AFTER TKOF CHKLIST AND RESET THE BLEEDS AS WE LEVELED AT 10000 FT TURNING TO 100 DEGS. DEP CTL ADVISED US OF VFR TFC AT 2 O'CLOCK. THE COPLT WAS LOOKING FOR TFC AS I ATTEMPTED TO ENGAGE THE AUTOPLT. IT WOULD NOT ENGAGE SO I ATTEMPTED IT AGAIN WITHOUT SUCCESS. I LOOKED BACK AT THE ALTIMETER AND NOTICED WE WERE AT 10150 FT IN A CLB. I IMMEDIATELY PUSHED THE NOSE DOWN TO REGAIN 10000 FT. AT THIS TIME DEP CTL ASKED IF WE WERE CLBING BECAUSE OF A POSSIBLE CONFLICT WITH THE VFR TFC. BY THIS TIME WE WERE AT EXACTLY 9900 FT SO WE TOLD HIM WE WERE AT 10000 FT. WE THEN PICKED UP THE TFC VISUALLY AND ON TCASII, WHICH SHOWED HIM AT 500 FT ABOVE US CLOSING. SOON AFTERWARD WE GOT A TA FOLLOWED BY AN RA FROM THE TCASII. WE STAYED AT 9900 FT UNTIL HE PASSED BECAUSE WE HAD HIM VISUALLY. DEP CTL THEN GAVE US A CLB TO 16000 FT AND CONTACT ZDV. LOOKING BACK I SHOULD HAVE EITHER ENGAGED THE AUTOPLT EARLIER TO REDUCE THE WORKLOAD OR WAITED TILL WE HAD BEEN CLRED TO CLB TO 16000 FT. THERE IS JUST TOO MUCH GOING ON IN THE ATA ESPECIALLY WHEN VFR ACFT ARE FLYING OVER THE TOP.

  69.  
  70. Accession Number: 363356
    Synopsis: COMPLAINT REGARDING THE AUTOMATED ATIS VOICE AT VARIOUS LOCATIONS.
    Narrative: THE PRESENT COMPUTER GENERATED VOICE THAT IS BEING USED FOR THE AUTOMATED ATIS INFO IS NOT CLR AND UNDERSTANDABLE. IE, 'WHISKEY' IS PRONOUNCED 'WILKY' AND 'VICTOR' IS 'WICTOR.' SOME OF THE WX PHENOMENA AND OBSERVATIONS ARE ALSO MISPRONOUNCED. THIS REQUIRES LISTENING TO THE ATIS INFO 2 OR MORE TIMES. DURING AN ARR INTO A HIGH DENSITY AREA IT RESULTS IN DIVERTING ONE'S ATTN FROM FLYING AND ATC FOR LONGER THAN NECESSARY. I BELIEVE THIS IS A 'MACINTOSH' COMPUTERIZED VOICE OF WHICH THERE ARE SEVERAL ACCEPTABLE ONES TO CHOOSE FROM. A SUFFICIENT NUMBER OF MY FELLOW PLTS AT ACR HAVE EXPRESSED THE SAME OPINION. I WOULD LIKE TO RECOMMEND THAT THE VOICE BE CHANGED BEFORE IT CONTRIBUTES TO AN INCIDENT DUE TO A MISUNDERSTANDING OR MISSING AN ATC FUNCTION WHILE OFF THE FREQ. THIS PROB IS MORE OF A DISTR TO THE GA PLT IN A SINGLE PILOTED ACFT.

  71.  
  72. Accession Number: 363470
    Synopsis: LGT ACFT OVERSHOT ASSIGNED ALT ON CLB BY 300 FT AND RETURNED BACK IMMEDIATELY. FLC RPTR'S STATE THAT, BECAUSE THE COURSE WAS NOT DISPLAYED AND FMC PROGRAMMING REQUIRED THEIR ATTN, IT CONTRIBUTED TO A HIGH WORKLOAD AND DISTR FROM ALT.
    Narrative: DEPARTED IAH, WE WERE ISSUED A CLB TO 15000 FT, CLRNC WAS RADAR VECTORS TO FIRST FIX. ABOUT 30 MI W, WE WERE CLRED ON COURSE AND A FREQ CHANGE. DUE TO THE FACT THAT THE COURSE PRIOR TO THE FIX WAS NOT DISPLAYED, THIS CREATED TOO MUCH OF A WORKLOAD WITH THE EFIS/COCKPIT LOAD. WE HAD ALTDEV OF 300 FT HIGH AND CORRECTED BACK TO 15000 FT IMMEDIATELY.

  73.  
  74. Accession Number: 363986
    Synopsis: FLC OF A300 MAKING A GAR DUE TO TFC ON THE RWY IS ASSIGNED 2000 FT. BECAUSE OF NOT USING TOGA PWR FLC IS DISTR AND CLBS ABOVE ASSIGNED ALT.
    Narrative: LOCATION: SJU. THE CAPT WAS FLYING A VISUAL STRAIGHT-IN APCH TO SJU RWY 8. THE WX WAS CAVOK BUT THERE WAS HVY INBOUND TFC DUE TO UNSCHEDULED CLOSURE OF RWY 10. THE APCH WAS HAND FLOWN WITH THE ILS RWY 8 TUNED AND THE FLT DIRECTOR IN LAND. AT ABOUT 1000 FT, THE CAPT DISENGAGED THE AUTOTHROTTLES. WE WERE SPACED VERY TIGHTLY BEHIND LIGHT ACFT TFC ON A R BASE. TWR INSTRUCTED S-TURNS TO INCREASE SPACING AND ASKED THE LIGHT ACFT TO LAND LONG AND TAKE THE HIGH SPD, BUT IT DIDN'T WORK AND AT ABOUT 500 FT, THEY TOLD US TO GAR. THE CAPT MANUALLY PUSHED UP THE PWR, CALLED FOR FLAPS AND THEN GEAR AS WE CLBED OUT TO 2000 FT AS INSTRUCTED BY THE TWR. HOWEVER, HE DID NOT USE THE TOGA LEVERS AND, AS A RESULT, THE FMA REMAINED IN APCH MODE. AT ABOUT 1000 FT IN THE CLB, I TOLD HIM HE HAD TO TOGA TO GET THE FMA TO DO WHAT HE WANTED AND HE INDICATED HE DIDN'T WANT TO HAVE THE PWR GO UP THAT HIGH. DURING ATTEMPTS TO GET THE FMA TO DISENGAGE FROM THE APCH MODE IN A STEADY CLB, WE BOTH NOTICED WE WERE GOING THROUGH 2000 FT. THE CAPT HAD BEGUN A TURN AS INSTRUCTED BY TWR, AND REALIZING THE ALT TREND, HE LOWERED THE NOSE AND DSNDED BACK TO 2000 FT. AT THE TOP OF CLB I THINK WE REACHED 2500 FT. WE BOTH SHUT OUR FLT DIRECTORS OFF AND GOT BACK TO BASIC FLYING. TWR DID NOT COMMENT ON THE DEV AND WE SUBSEQUENTLY COMPLETED A NORMAL APCH AND LNDG. SUPPLEMENTAL INFO FROM ACN 364350: MADE A MISTAKE AND LEARNED FROM THIS EPISODE AND HOPE IT WILL PREVENT OTHER INCIDENTS.

  75.  
  76. Accession Number: 364180
    Synopsis: MLG ACFT ON SID DEP. PF, FO, TRIED TO ENGAGE LNAV UNSUCCESSFULLY AND BY THE TIME THE FLC WAS ABLE TO RECONFIGURE THE FLT DIRECTOR FOR DME, THE ACFT HAD EXCEEDED THE DME LIMITATION FOR THE SID.
    Narrative: ON THE SAN JOSE 8 DEP, A TURN IS SUPPOSED TO BE INITIATED AT 1.8 DME TO A 110 DEG HDG. I ATTEMPTED TO ENGAGE LNAV AT 1.8 DME AND IT DIDN'T ENGAGE. AFTER RECONFIGURING FLT DIRECTOR TO RESTORE VOR/DME INFO, 20 DEGS OF L TURN HAD BEEN ACCOMPLISHED AND THE DME WAS 3.4. THE TURN RATE WAS INCREASED AND AIRSPD DECREASED TO ACCOMPLISH THE TURN. THE MANEUVER EXCEEDED THE 4 DME TURN WITHIN DEPICTED ON THE SID TO APPROX 5.4 DME.

  77.  
  78. Accession Number: 365306
    Synopsis: CAPT OF A L1011 OVERSHOT DSCNT XING RESTR ALT AND MADE SUCH AN ABRUPT CORRECTION THAT 2 FLT ATTENDANTS WERE INJURED. IN ADDITION, SINCE THE WRONG WAYPOINT HAD BEEN ENTERED INTO THE FMC, RPTR WAS NOT ON THE PRESCRIBED STAR ARR TRACK.
    Narrative: ACFT WAS CLRED TO LOGEN INTXN WHEN FO WAS ABSENT FROM COCKPIT FOR PERSONAL BIOLOGICAL REASONS. ACFT WAS LEVEL AT FL240. FO RETURNED TO COCKPIT AND WAS INFORMED OF CLRNC DIRECT TO LOGEN. UPON INSPECTION OF LATITUDE/LONGITUDE OF WAYPOINT THAT ACFT WAS PROCEEDING TO, DETERMINED WRONG WAYPOINT SELECTED. AT THAT TIME, ATC ISSUED DSCNT TO FL200. ALT SET, AND ANNUNCIATED, IN ALT SELECTOR. FO COMMENCED VERIFYING AND INPUTTING PROPER WAYPOINT LATITUDE/LONGITUDE. AT FL210, THE REQUIRED '1000 FT TO GO, OUT OF FL210 FOR FL200' WAS MADE BY THE FO AND 'ROGERED' BY THE CAPT. BEFORE THE FINALIZATION OF THE CORRECT WAYPOINT WAS COMPLETED, A RADICAL PULL-UP WAS INITIATED BY THE CAPT. WHEN QUESTIONED WHY, THE CAPT STATED THAT THE ACFT AUTOPLT FAILED TO CAPTURE THE SET ALT, FL200. THE ACFT DSNDED BELOW FL200 BY 400-450 FT BEFORE RETURNING TO THE CLRED ALT. FOR UNKNOWN REASONS, THE ACFT DID NOT LEVEL OFF. AFTER, THE ACFT WAS LEVELED OFF MANUALLY, (THE AUTOPLT WAS DISCONNECTED BY CAPT DURING HIS ATTEMPT TO RE-LEVEL THE ACFT) AND THE ALT SET KNOB WAS RESET TO FL200. 2 FLT ATTENDANTS WERE SHAKEN UP AND SUSTAINED MINOR INJURIES THAT WERE BROUGHT TO THE ATTN OF THE FLC WITHIN 10 MINS OF THE INCIDENT. NO ATC COMMENTS WERE MADE ABOUT ALT BUST.

  79.  
  80. Accession Number: 367239
    Synopsis: MD80 SUPER 80 FLC DISTR BY WX FAIL TO RESET ALTIMETERS TO 29 PT 92. THE RESULT IS 400 FT OVERSHOOT ON THE CLB. THE AUTOPLT HAD DISCONNECTED FURTHER ADDING TO THE CONFUSION. THE OVERSHOOT CAUSED A TCASII ALERT ON ANOTHER ACFT.
    Narrative: DURING CLB WITH FO FLYING IN THE MIDDLE OF TSTMS, WE BECAME OVERLOADED AND FAILED TO LEVEL OFF AT FL200. JUST PRIOR TO LEVELOFF (THE 7TH ALT ASSIGNED) THE AUTOPLT DISCONNECTED. I WAS DISTR BY A TCASII TA AND BY WX RETURNS ON THE RADAR. I DISCOVERED LATER THAT I HAD FAILED TO RESET MY ALTIMETER TO 29.92 AT FL180. THE NET RESULT WAS AN ALT OVERSHOOT OF APPROX 400 FT. THIS IS A PERFECT EXAMPLE OF HOW MULTIPLE DISTRS, COUPLED WITH PLT ERROR (FAILURE TO SET ALTIMETER AND TO MAKE THE 1000 FT BELOW CALL) AND A MECHANICAL MALFUNCTION (AUTOPLT), CAN LEAD TO NONCOMPLIANCE. SUPPLEMENTAL INFO FROM ACN 367240: AT THAT TIME CTR CALLED TFC AT 11 O'CLOCK AND FL210. I RPTED THE TFC IN SIGHT THEN IMMEDIATELY RECEIVED A TCASII TA AT FL195.

  81.  
  82. Accession Number: 368610
    Synopsis: ACR MLG FLC FAIL TO EXECUTE AN ALT XING RESTR. THEIR AUTOTHROTTLE SYS WAS INOP. THE FO, PF, RECEIVED DSCNT CLRNC WHILE THE PIC WAS TELLING COMPANY ABOUT IT, FAILING TO SET THE ALT IN THE ALT SYS AND FAILING TO ADVISE PIC. CTLR ASSISTED WITH VECTORS.
    Narrative: WHILE TALKING TO COMPANY ABOUT ARR AND MECHANICAL PROB WITH AUTOTHROTTLES, FO (WHO WAS FLYING) RECEIVED CLRNC TO CROSS DIGGIN AT 12000 FT. FO FAILED TO SET 12000 FT IN ALT SYS, OR INFORM ME OF CLRNC WHEN I CAME BACK FROM COMPANY RADIO. WITH AUTOTHROTTLES BROKEN, FMS PERFORMANCE WAS OFF, SO SYS DID NOT ADVISE FOR DSCNT. CTR ASKED US ABOUT OUR DSCNT AT THE SAME TIME WE HAD STARTED DOWN. ASKED FOR A TURN IN HOLDING FOR ALT LOSS, WAS GIVEN HDG VECTORS INSTEAD.

  83.  
  84. 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.

  85.  
  86. Accession Number: 374100
    Synopsis: CAPT OF AN SF340 MISTAKENLY TAXIED ONTO A RWY WHEN HE FAILED TO FOLLOW TAXI INSTRUCTIONS DURING TAXI OUT FOR TKOF.
    Narrative: CLRED TO TAXI TXWY KK TO FOLLOW ACR MD80 DIRECT TXWY B TO RWY 22R. TAXIING OUT TXWY KK, GND INSTRUCTED US TO TURN L ON TXWY A, TAKE TXWY J AND THEN TURN L ON TXWY B. RUNNING THE TAXI CHKLIST, FO HAD HIS HEAD DOWN SETTING UP THE MGMNT FLT DIRECTOR (IN SF340) FOR SPDS AS I BRIEFED BY LEADING V SPDS AND TORQUE SETTINGS (CHKLIST REQUIRES CAPT TO BRIEF WHILE TAXIING) REQUIRING MY HEAD TO BE INSIDE AND DOWN ALSO. I MISSED THE L TURN ON TXWY B AND BEGAN TO TURN L ONTO RWY 4L. I WAS ACROSS THE HOLD SHORT LINE AND COMMITTED PRIOR TO OBSERVING MY ERROR. ALTHOUGH THE CHKLIST REQUIREMENT IS QUESTIONABLE, I'VE FOLLOWED IT THOUSANDS OF TIMES WITHOUT ERROR. A FEW SECONDS OF DISTR BY BOTH PLTS SET US UP FOR THIS ERROR. GND THEN CLRED US ON RWY 4L TO L TURN ONTO TXWY H, R ON TXWY B TO CONTINUE TO RWY 22R. ALTHOUGH THERE WERE NO ACFT ON RWY 22R/4L, THE POTENTIAL FOR PROBS WAS OBVIOUS.

  87.  
  88. Accession Number: 375020
    Synopsis: AN ACR MLG FLC CLBED ABOVE THEIR CLRED ALT. THE FLC SUSPECTS A MALFUNCTION IN THE AUTOFLT GUIDANCE SYS, BUT COULD NOT VERIFY THIS. THE SYS OPERATED PERFECTLY FOR THE REMAINDER OF THE FLT.
    Narrative: ATC CLRNC 'CLB TO 6000 FT MSL, L TURN 220 DEGS TO INTERCEPT COL 350 DEG RADIAL.' AS PNF, I DIVERTED ATTN TO FMC TO SET UP COURSE INTERCEPT FOR PF. HE WAS FLYING MANUALLY. I HAD SET 6000 FT IN ALT WINDOW AND THEN BEGAN TO SET UP COURSE INTERCEPT. FOR SOME UNKNOWN REASON, I HAD TO REPEAT THE SETUP AND WHILE ATTEMPTING SECOND TIME, PF QUERIED '6000 FT?' I LOOKED UP AND CONFIRMED '6000 FT' AND NOTICED WE WERE LEVELING AT 7000 FT MSL. PF BEGAN IMMEDIATE CORRECTION TO 6000 FT AND STATED THAT THE COMMAND BARS INDICATED CLB UNTIL HE FINALLY QUERIED '6000 FT?' AS WE APCHED 7000 FT MSL. WE HAVE NO EXPLANATION WHY COMMAND BARS COMMANDED CLB. HE ALSO STATED, AUTOTHROTTLES DID NOT RETARD. HIS CORRECTION BACK TO 6000 FT WAS IMMEDIATE. UPON REACHING 6000 FT, DEP CLRED US TO HIGHER (I THINK 12000 FT) AND WE BEGAN CLB. PASSING 6400 FT ATC REQUESTED OUR ALT AND WE RESPONDED 6400 FT CLBING TO 12000 FT. ATC SAID NOTHING FURTHER, NOR DID WE. MISTAKES: 1) PNF DIVERTED ATTN TO FMC TOO LONG AT ONE TIME. 2) PF DIDN'T MONITOR ALTIMETER AS WELL AS COMMAND BARS. IF ALT WARNING AND AUTOTHROTTLES MALFUNCTIONED, IT NEVER HAPPENED AGAIN FOR ENTIRE FLT (NO EXPLANATION). WE WONDER IF SAME WOULD HAVE OCCURRED WITH AUTOPLT FLYING.

  89.  
  90. Accession Number: 375574
    Synopsis: MLG ACFT ON STAR WITH XING RESTR WAS RECLRED DIRECT TO ANOTHER FIX. NEXT CTLR CLRNC REVERTED BACK TO THE ORIGINAL CLRNC, BUT FLC HAD ALREADY SET IN THE NEW FIX ON THE FMC, SO CTLR CLRED THEM TO A POINT CLOSE TO THE ORIGINAL XING FIX. FLC ERRONEOUSLY SET IN WRONG ALT.
    Narrative: ON THE SINCA 3 ARR INTO ATL WE HAD PROGRAMMED THE FMC TO CROSS CANUK AT 250 KTS AND 12000 FT. WE WERE SUBSEQUENTLY CLRED DIRECT TO HUSKY INTXN WITH NO ALT OR AIRSPD RESTR. THE NEXT CTLR TOLD US TO CROSS CANUK AT 250 KTS AND 12000 FT. WE TOLD HER WE WERE DIRECT TO HUSKY, SO SHE THEN RECLRED US TO CROSS 40 MI SE OF ATL AT 12000 FT AND 250 KTS. WE PROGRAMMED THE FMC TO CROSS 11 MI SE OF HUSKY (45 MI SE OF ATL) AT 250 KTS AND 11000 FT. WE SET OUR MCP TO 11000 FT. I BELIEVE WE READ BACK 11000 FT BUT I AM NOT SURE. THE CTLR CAUGHT OUR DSCNT THROUGH 12000 FT AND WE CLBED IMMEDIATELY BACK TO 12000 FT. END OF EVENT. I FEEL IT WAS NOT NECESSARY TO AMEND THE ORIGINAL SINCA ARR IN THE FIRST PLACE (ATC COM GAP BTWN CTLRS). HOWEVER, OUR INATTN TO THE ALT WAS CAUSED BY: 1) FAILURE TO MONITOR THE ACFT BY FOCUSING ENTIRELY ON THE FMC, 2) NOT DOUBLECHKING THE PUBLISHED ARR PLATE FOR CONTINUITY, AND 3) AUTOMATIC AIRPLANE COMPLACENCY.

  91.  
  92. Accession Number: 377700
    Synopsis: MD80S ACR ACFT ON STAR INTO LGB, RPTR FO MISSED TURN POINT AND DEVIATED SLIGHTLY S OF COURSE. CAPT REMINDED HIM OF THE PROPER TRACK AND CORRECTION WAS MADE JUST AS APCH CTLR INTERVENED AND PROVIDED A VECTOR.
    Narrative: I WAS THE FO FLYING THE KAYOH 3 STAR INTO LONG BEACH. WE WERE INBOUND TO THE HDF VOR WITH THE AUTOPLT ENGAGED IN HEADING SELECT MODE. THE HDF DME WAS NOT WORKING AND I MISSED STATION PASSAGE WHICH REQUIRED A TURN TO INTERCEPT THE 257 DEG RADIAL OUTBOUND. THE CAPT BROUGHT THIS TO MY ATTN AND I STARTED A R TURN TO INTERCEPT. DURING THE TURN APCH CTL ASKED IF WE WERE FOLLOWING THE STAR. THE CAPT RESPONDED THAT WE WERE S OF COURSE CORRECTING. APCH GAVE US A VECTOR TO INTERCEPT WHICH WE DID. NOTHING FURTHER WAS SAID ABOUT OUR EXCURSION. MY SITUATIONAL AWARENESS WAS DEGRADED BY NOT HAVING DME AVAILABLE AND NOT COMPENSATING FOR IT. I LET MYSELF LOOK AT THE APCH PLATE TOO LONG AT THE WRONG TIME. GOOD THING THE CAPT WAS PAYING ATTN.

  93.  
  94. Accession Number: 380820
    Synopsis: AN ACR B737 FLC CLB ABOVE THEIR ASSIGNED ALT WHILE ENTERING DATA INTO THE FMS FOR A DSCNT AND AN INCREASED AIRSPD.
    Narrative: UPON RECEIVING DSCNT CLRNC WITH PLT DISCRETION WE ALSO RECEIVED A RESTR TO MAINTAIN 320 KTS OR MORE INTO LAX. I WAS REPROGRAMMING THE FMS TO COMPLY WITH THIS CLRNC WHILE IN VNAV. THE ACFT ACCELERATED TO 320 KTS AND BEGAN A SHALLOW CLB. I WAS HEAD DOWN SO I AM NOT SURE EXACTLY WHAT THE CAPT WAS DOING WITH THE MCP, BUT WHEN I LOOKED UP WE WERE 200 FT OFF ALT. CAPT DISENGAGED AUTOPLT AND MAX DEV WAS APPROX 300 FT.

  95.  
  96. Accession Number: 387160
    Synopsis: FLC OF B757 HAS PROB WITH FLT DIRECTOR REMAINING IN ALT HOLD MODE AFTER INTERMEDIATE LEVELOFF. PITCH BARS INDICATED A CLB. DURING TROUBLESHOOTING THE PROB THEY HAD AN ALT EXCURSION OF 400 FT.
    Narrative: ON CLBOUT FROM FLL THE FLT DIRECTOR STAYED IN AN 'ALT HOLD' MODE AFTER AN INTERMEDIATE LEVELOFF. HOWEVER, THE PITCH BARS GAVE A CLB INDICATION. AUTOTHROTTLES CLICKED OFF AND 'PWR MODE' WAS LOST. COULD NOT RESTORE FLT DIRECTOR OUT OF 'ALT HOLD' MODE BACK INTO 'VNAV.' WHILE WORKING ON PROB, EXCEEDED ALT OF 11000 FT BY 400 FT. TURNED EVERYTHING OFF AND FLEW RAW DATA TO 11000 FT. I WAS FINALLY ABLE TO RESTORE 'VNAV' AFTER 2 RESET ATTEMPTS. DID NOT GET AUTOTHROTTLES BACK UNTIL COMING OUT OF CLB MODE AT 25000 FT.

  97.  
  98. Accession Number: 388130
    Synopsis: MD88 ACFT GIVEN LAST MIN HOLDING INSTRUCTIONS AND DSCNT CLRNC. RPTR CAPT OUT OF LOOP INSERTING THE HOLDING IN FMS, FO RESPONDS TO ATC DSCNT CLRNC TO 12000 FT. CTLR SHORTLY TELLS FLC THEY WERE ONLY CLRED TO 13000 FT AND FLC RETURNS TO ALT.
    Narrative: WE HAD BEEN CLRED FOR THE MACEY ARR INTO ATL TO CROSS THE MACEY INTXN AT 250 KTS AND 13000 FT. 2 MI PRIOR TO MACEY INTXN, ZTL ABRUPTLY GAVE US INSTRUCTIONS TO HOLD AT MACEY AS PUBLISHED, AND PROVIDED US WITH AN EFC TIME. AS THE FO BEGAN THE TURN TO ENTER HOLDING, I LOADED THE HOLDING DATA INTO THE FMS. I COMPLETED LOADING THE HOLDING DATA AS WE WERE NEARLY THROUGH OUR TURN TO THE OUTBOUND HDG. I NOTICED OUR ALT WAS 12400 FT AND WE WERE DSNDING. I ASKED THE FO IF WE HAD RECEIVED CLRNC TO DSND. HE STATED THAT ZTL HAD GIVEN US CLRNC TO DSND TO 12000 FT, THAT HE READ BACK LEAVING 13000 FT FOR 12000 FT, AND THAT ZTL SAID 'ROGER.' SHORTLY AFTER LEVELING AT 12000 FT, ZTL SAID WE WERE SUPPOSED TO BE AT 13000 FT. CTR GAVE US A WBOUND VECTOR, AND INSTRUCTED US TO CLB BACK UP TO 13000 FT. I ASKED ZTL IF THERE WAS A PROB WITH WHAT HAD HAPPENED, AND IF WE HAD A LOSS OF SEPARATION WITH ANY ACFT. ZTL SAID THERE WAS NO PROB AND NO LOSS OF SEPARATION OCCURRED. AT THIS POINT, I DO NOT KNOW FOR CERTAIN IF ZTL GAVE US CLRNC TO DSND TO 12000 FT AS THE FO SAID OR NOT. WHILE I WAS LOADING THE HOLDING DATA INTO THE FMS, I HEARD THE FO TALKING WITH CTR, BUT I DID NOT PICK UP ANY SPECIFICS AS I WAS CONCENTRATING ON CORRECTLY LOADING THE HOLDING DATA INTO THE FMS. AFTER DISCUSSING THE SIT WITH THE FO, I TOLD HIM IF THERE IS EVEN A REMOTE QUESTION IN A CREW MEMBER'S MIND AS TO CLRNC, TO ASK THE CTLING AGENCY TO CONFIRM THE CLRNC. I THINK IF THE WORD 'CONFIRM' IS USED IN THE XMISSION, IT ALERTS THE CTLR AND CREW TO BE ESPECIALLY AWARE OF THE CLRNC ISSUED. RECEIVING HOLDING INSTRUCTIONS 2 MI FROM THE HOLDING FIX IS ALSO A CONTRIBUTING FACTOR, AS IT PROVIDES INADEQUATE TIME TO PROPERLY SET UP TO ENTER HOLDING.

  99.  
  100. Accession Number: 389660
    Synopsis: CLBING ACR B737 OVERSHOT ASSIGNED ALT OF 10000 FT BY 400 FT.
    Narrative: ON DEP WE WERE LEVELING AT 10000 FT MSL WITH AUTOPLT OFF IN A VERY LIGHT ACFT. DEP CLRED US TO A FIX THAT WAS NOT ON THE FMC. FO WAS GIVING A DEP MESSAGE TO COMPANY ON THE OTHER FREQ. I BECAME DISTR BY THE FMC AND ALLOWED THE ACFT TO CLB. AS ALT ALERT HORN SOUNDED, I EASED THE NOSE DOWN BUT STILL GAINED 400 FT MORE IN AN EFFORT TO MAKE A REASONABLY SMOOTH PUSHOVER. OAK DEP ASKED ABOUT OUR ALT. THERE WERE NO APPARENT CONFLICTS. LESSON: DON'T GET DISTR AND FORGET TO FLY THE AIRPLANE! SUPPLEMENTAL INFO FROM ACN 389805: I HEARD THE ALT ALERT HORN SOUND AND INFORMED THE CAPT TO CORRECT THE ACFT'S ALT AS WE WERE ABOUT 400 FT HIGH.

  101.  
  102. Accession Number: 389761
    Synopsis: FO, PF, IN A B767 ALLOWS A SPD OF 300 KTS WHILE IN DSCNT TO 8000 FT. FO CITES DISTR WITH AN UNRULY PAX IN CABIN THAT INTERFERED WITH THE COCKPIT COORD.
    Narrative: MOMENTARILY EXCEEDED 250 KIAS BELOW 10000 FT MSL, APPROX 300 KTS AT 8000 FT. THE LAST 30 MINS OR SO LEADING UP TO THE EVENT WERE EVENTFUL DUE TO A DISRUPTIVE PAX. PAX WAS A FOREIGN MALE. UNKNOWN TO US, HE HAD BEEN DENIED BOARDING ON 2 PREVIOUS FLTS TO LGA DUE TO HIS BEHAVIOR WITH ALCOHOL. THIS WAS THE LAST FLT OF THE DAY TO LGA. THE GATE AGENT BOARDED THIS PAX STILL IN A QUESTIONABLE STATE OF SOBRIETY, WITHOUT CONSULTING THE CAPT, AGAINST COMPANY RULES. HE DID HOWEVER, TELL THE FLT ATTENDANTS NOT TO SERVE HIM ALCOHOL. STARTING ABOUT 40 MINS OUT, THE HEAD FLT ATTENDANT WAS IN AND OUT OF THE COCKPIT CONTINUOUSLY ADVISING OF PROBS WITH THIS PAX YELLING AT THE OTHER PAX, SOLICITING ALCOHOL FROM OTHER PAX, NOT SITTING IN HIS SEAT AS ORDERED. FINALLY, CAPT DIRECTED ME TO GO BACK AND GET HIM SEATED (HE WAS IN 1ST CLASS). I FOUND HIM IN THE AFT GALLEY (AT REARMOST PART OF ACFT) BOTHERING 2 FEMALE FLT ATTENDANTS. I ESCORTED HIM TO HIS SEAT AND DIRECTED HIM TO REMAIN SEATED FOR THE REMAINDER OF THE FLT. HE HAD A LEG INJURY (WAS A WHEELCHAIR ON/OFF PAX), ACTED STRANGELY, POSSIBLY INEBRIATED OR ON DRUGS, AND WAS DEFIANT. MINS AFTER I RETURNED TO THE COCKPIT AND WAS TRYING TO SET THE FMS UP FOR THE APCH TO RWY 22 AT LGA, THE FLT ATTENDANT SAID HE WAS UP AGAIN AND CAUSING TROUBLE. I WENT BACK TO THE CABIN AGAIN, HAD HIM SIT DOWN AND FASTENED HIS SEAT BELT, AND ADVISED HIM THAT HE COULD BE ARRESTED FOR SUCH DISRUPTION TO THE FLC. WHILE ON THE STAR TO LGA, I WAS ESSENTIALLY FLYING SOLO AS THE CAPT WAS SPENDING 100% OF HIS TIME WITH COMPANY DISPATCHER, LGA STATION OPS, AND FLT ATTENDANTS -- THEY DECIDED TO HAVE POLICE MEET THE ACFT. I WAS CLRED TO 'CROSS SOMTO AT OR BELOW 13000 FT AND DSND TO 11000 FT, MAINTAIN 310 KTS OR GREATER.' THE FMS VNAV MODE WAS PROGRAMMED AND THE DSCNT STOPPED AT 13000 FT. THE DSCNT MODE WAS THEN CHANGED TO FLT LEVEL CHANGE AND WE WERE NOW CLRED ON DOWN TO 7000 FT. SIMULTANEOUSLY, OUR RWY ASSIGNMENT WAS CHANGED TO RWY 31. WHILE TRYING TO REPROGRAM FMS FOR RWY 31, AND AMID ALL THE COMMOTION AND WITHOUT A COPLT DOING ANY PNF DUTIES, I NOTICED THE SPD WAS STILL ABOUT 300 KIAS WHILE DSNDING TOWARDS 8000 FT. I IMMEDIATELY AND QUICKLY CORRECTED. THE CAPT HAD NO IDEA WHAT WAS GOING ON UNTIL WE WERE ON DOWNWIND.

  103.  
  104. Accession Number: 392704
    Synopsis: B777B DEPARTS LAX, CA, WITH THE FMS NOT PROGRAMMED. DURING CLBOUT IT SUFFERS LOSS OF SEPARATION BECAUSE THE FLC IS BUSY TRYING TO PROGRAM THE FMS PROPERLY. FLC IS DISTRACTED WITH PERSONAL PROBS.
    Narrative: THIS IS A CLASSIC CASE OF HOW TO HAVE AN ACCIDENT WITH THE GLASS COCKPIT. I WAS THE REGULAR PLT, BUT FLYING AS RELIEF. THE COPLT WAS FLYING, LAX TO LHR FLT ON JAN/SAT/98. THE CAPT WAS UNDER STRESS. HE JUST COMMITTED HIS CLOSE RELATIVE TO A MENTAL INSTITUTION. HE STATED HE THOUGHT SOMETHING WAS WRONG WITH HIS HEART. HE TOLD ME TO KEEP AN EYE ON THE COPLT BECAUSE ON PREVIOUS TRIPS HE WOULD LOSE HIS SIT AWARENESS. THERE WAS A LOT OF CONFUSION ON COCKPIT SETUP. TWO MECHS HAD TO CLR TWO STATUS MESSAGES. THE FUELER WAS HAVING TROUBLE BALANCING THE FUEL. THEN THE DATA MODE DEFAULTED TO THE #2 RADIO. BUT FINALLY WE GOT GOING. WE DEPARTED ON THE LOOP DEP OUT OF LAX. THE COPLT MISSED THE L TURN AT 2 MI AND HAD TO BE DIRECTED TO TURN BY THE CAPT. AT THIS POINT THE CAPT REALIZED THAT THE DEP WAS NOT INSTALLED. HE PUT IN LAX AND HIT (NAV) AND ASKED THE COPLT TO FLY THE SID WHILE HE TRIED TO FIGURE OUT WHAT WAS WRONG WITH THE COMPUTER. THE COPLT FLEW STRAIGHT TO THE VOR AND THEN KEPT GOING STRAIGHT. I TOLD HIM HE HAD TO TURN R. HE ASKED IF HE COULD PUT ON THE AUTOPLT, THE CAPT SAID NO, JUST FLY THE PLANE. HE TURNED BACK R AND THEN TURNED OUTBOUND. AT THIS POINT ZLA TOLD US TO CLB TO FL260 AND TFC AT 3 O'CLOCK POS. THE NEXT THING WE GOT WAS TCASII 'DSND NOW.' WE SAW THE OTHER ACFT PASS IN FRONT. THE COPLT DID NOT REACT TO THE TCASII RA AND HAD TO BE TOLD BY BOTH OF US TO DSND. IT APPEARED ZLA WAS NEVER AWARE OF THE CONFLICT. THE PROB WAS THAT THE CAPT INSTALLED LAX AS DEST INSTEAD OF LHR. AS A RESULT, THE PREVIOUS FLT'S INBOUND ARR WAS STILL SHOWING TO LAX. THIS IS WHAT THE COPLT THOUGHT WAS THE OUTBOUND COURSE. THIS PUT HIM S OF THE OUTBOUND RADIAL AND CAUSED THE TFC CONFLICT. WHY ZLA DID NOT CATCH IT IS BEYOND ME. LESSONS: 1) THE PLT WHO INSTALLS INFO INTO THE COMPUTER, MUST HAVE EACH PAGE CHKED BY THE OTHER PLT. 2) THE PF SHOULD ALWAYS BACK UP WITH RAW DATA. 3) DO NOT DO COMPUTER WORK THAT'S COMPLICATED BELOW 18000 FT. 4) IF YOU ARE STRESSED OUT AND NOT FEELING WELL, GO ON SICK LEAVE.

  105.  
  106. Accession Number: 395563
    Synopsis: A320 ACFT ARRIVING FOR APCH HAD DUAL FMGC TIMEOUTS WHICH CAUSED LOSS OF AUTOPLTS, AUTOTHRUST, FLT DIRECTORS AND NAV DISPLAYS. PNF, CAPT BECAME DISTR IN RESETTING THE FMGC'S AND FLC LANDED WITHOUT TWR CLRNC.
    Narrative: FLYING DIRECT TO FAF IN A320 ACFT, BOTH FMGC'S TIMED OUT CAUSING LOSS OF AUTOPLTS, AUTOTHRUST, FLT DIRECTORS, AND ALL NAV DISPLAY. NOTIFIED ATC OF LOSS AND RECEIVED VECTORS FOR VISUAL APCH. I WAS PF AND AM NEW IN THIS TYPE ACFT, SO ALL THE LOSSES OF DATA AND AIDS FORCED ME TO CONCENTRATE HEAVILY ON FLYING ACFT MANUALLY. CAPT HANDLED RADIOS AND WORKED ON GETTING FMGC'S BACK ON LINE. PROCEEDED TO LAND NORMALLY WITHOUT A CHANGE IN ACFT STATUS. UPON TAXIING CLR OF RWY, I CALLED TWR TO SAY WE WERE CLR, BUT RADIO WAS STILL TUNED TO APCH. I SUSPECT WE LANDED WITHOUT TALKING TO TWR OR GETTING CLRNC. WHEN WE CALLED GND CTL NO ONE SAID ANYTHING TO US, AND WE DID NOT PUSH THE ISSUE. APPARENTLY CAPT WAS ENGROSSED WITH MALFUNCTION AND FAILED TO CALL TWR PRIOR TO LNDG, AND WITH MY EXTRA CONCENTRATION ON FLYING MANUALLY, I FAILED TO CATCH IT. I THINK CHKLISTS FOR EVEN NORMAL OPS SHOULD HAVE 'LNDG CLRNC RECEIVED' AS PART OF THE LNDG/FINAL CHKLIST. I AM NOT AWARE OF ANY AIRLINES DOING THIS NOW.

  107.  
  108. Accession Number: 397720
    Synopsis: FLC OF A BAE146 LANDED WITHOUT CONTACTING TWR FOR CLRNC. THEY NOTICED THEIR ERROR WHEN AFTER LNDG ATTEMPTING TO OBTAIN TAXI INSTRUCTIONS AND DISCOVERED THAT THEY WERE STILL ON APCH CTL FREQ.
    Narrative: CLRED FOR VISUAL APCH IN DES MOINES, FOR RWY 31R. AUTOPLT FLEW THROUGH FINAL APCH COURSE, EVEN THOUGH IT SHOWED IT HAD CAPTURED THE LOC. CAPT AND I WERE TRYING TO FIGURE OUT WHAT AND WHY THE AUTOPLT HAD DONE WHAT IT DID. AS APCH WAS CLRING US FOR THE VISUAL APCH WE WERE NOT SURE IF THEY HAD TOLD US TO CONTACT THE TWR OR NOT. EITHER WAY AFTER WE LANDED I REALIZED WE WERE STILL ON APCH FREQ. I IMMEDIATELY SWITCHED FREQ AND TWR SAID 'CLRED TO YOUR GATE WITH ME.' NO FURTHER MENTION WAS MADE AS TO WHY WE DID NOT REPLY WHEN HE CLRED US TO LAND OR IF HE DID CLR US TO LAND. WE ASSUMED HE DID CLR US TO LAND BECAUSE NOTHING MORE WAS SAID. ON APCH IN DSM WE WERE FOLLOWING A CPR JET THAT WAS 5-10 MI AHEAD AND WAS WELL CLR BY THE TIME WE LANDED. NO OTHER PLANES WERE WAITING FOR TKOF OR CONFLICTS IN THE AREA EXISTED. THE CAPT AND I WERE DISTRACTED BY THE AUTOPLT AND WHEN WE DECIDED TO FORGET ABOUT IT AND CONCENTRATE ON THE JOB AT HAND (CHKLISTS, SETTING AND CALLING SPDS) WE HAD FORGOTTEN TO SWITCH FREQS. I WAS PNF ON REDUCED REST OVERNIGHT PREVIOUSLY WITH APPROX 5 HRS SLEEP. FATIGUE MAY HAVE BEEN A FACTOR IN MY ALERTNESS. APCH DID NOT QUERY TO SEE IF WE WERE STILL ON FREQ.

  109.  
  110. Accession Number: 405080
    Synopsis: ATIS NOT UP TO DATE. FLC OF A320 IS GIVEN PARALLEL APCH TO EXPECT VISUAL APCH IN MARGINAL WX. GIVEN RWY CHANGE AT THE LAST MIN. CREW DSNDED BELOW THEIR CLRED ALT BEFORE BECOMING VISUAL.
    Narrative: SFO ATIS FEW 1200 FT, VISIBILITY 10 MI, PARALLEL CHARTED VISUAL APCHS IN USE, LNDG RWY 28L. ABOUT 15 MI OUT, AFTER ESTABLISHED ON SFO 095 DEG RADIAL INBOUND, INQUIRED ABOUT RWY ASSIGNMENT AND REPLY WAS RWY 28R. FO SPENT NEXT FEW MINS ENTERING DATA AND CLRING MAP DISPLAY. STARTED OUT ON GS BUT DESPITE IDLE PWR AND 1/2 SPOILERS (FRENCH LOGIC ALLOWS ONLY 1/2 SPOILERS IF AUTOPLT ON), WENT WELL ABOVE GS. THE 'FEW' CLOUDS ALL HAPPENED TO BE HUGGING THE W SIDE OF SAN FRANCISCO BAY BTWN US AND SFO. WE CONTINUED TO GET LOWER ALT ASSIGNMENTS BY ATC WITHOUT SFO BEING IN SIGHT. ANOTHER ACFT ON THE PARALLEL 'TIPP TOE' APCH RPTED US IN SIGHT AND PROMISED TO MAINTAIN VISUAL SEPARATION. STILL ABOVE GS, I DISCONNECTED AUTOPLT AND AUTOTHROTTLE AND DIRTIED UP. ABOUT 8-10 MI OUT, FO SAID HE COULD SEE REILS, BUT I WASN'T CONFIDENT ENOUGH TO RPT FIELD IN SIGHT AND TAKE A VISUAL. APCHING BRIJJ (AT APPROX 6 MI FINAL) WE WERE CLRED TO 2000 FT. MY MAJOR CONCERNS WERE UNSEEN ACFT TO OUR L AND BEING TOO HIGH. INSIDE BRIJJ, FO SAID '2000 FT ASSIGNED' AS WE PASSED 1700 FT. I BELIEVE WE ENTERED THE THIN CLOUDS ABOUT 2000 FT. AS I STARTED TO ADD PWR, THE FIELD BECAME CLRLY VISIBLE, ALONG WITH THE OTHER TFC WHICH WAS NOW 2-3 MI AHEAD OF US. AS THE FO WAS POINTING OUT MY ALTDEV, ATC WAS ASKING IF WE COULD MAINTAIN VISUAL WITH THE ACFT AHEAD. AS WE CAME OUT OF THE CLOUDS, WE ANSWERED YES AND WERE CLRED FOR THE VISUAL. ALTHOUGH THE ALT ALERTER WAS SET TO 2000 FT, NEITHER THE FO NOR I RECALL HEARING IT. THE SFO ATIS FOR THE PREVIOUS 3 HRS (WE HAD BEEN GETTING IT ON ACARS) HAD BEEN SAYING ARRS RWY 28L ONLY AND THE NOTAMS SAID RWY 28R CLOSED AFTER XA00 (OUR ARR TIME). HOW CAN AN ACR PLT EXPECT TO MAINTAIN BASIC VFR CLOUD CLRNC, AT NIGHT, WITH ANY CLOUDS AT 1200 FT. I ACKNOWLEDGE MY SCREW UP IN BUSTING MY ALT. I ALSO SHOULD HAVE TOLD ATC 'FIELD NOT IN SIGHT AND NOT EXPECTED TO COME INTO SIGHT.' BUT, IT IS ALMOST IMPOSSIBLE TO COMMUNICATE WITH A BUSY APCH FACILITY. ALL YOU CAN USUALLY DO IS RESPOND, TERSELY, TO INSTRUCTIONS. SUPPLEMENTAL INFO FROM ACN 405081: CURRENT ATIS STATED THAT RWY 28R WAS CLOSED. WE PROGRAMMED THE FMS WITH THE QUIET BRIDGE VISUAL RWY 28R RECOMMENDED ALTS, DME'S, BUT HAD RWY 28L PROGRAMMED INSTEAD OF RWY 28R. WE ASSUMED WE WOULD FLY THE RWY 28R CHARTED VISUAL APCH WITH THE EXCEPTION THAT WE WOULD CONDUCT A VISUAL APCH TO RWY 28L ONCE WE ACQUIRED THE FIELD. WE HAD A DISCONTINUITY PROGRAMMED AFTER THE LAST DME FIX. AT APPROX 8-10 MI OUT, THE APCH CTLR TOLD US THAT TFC AT OUR 10 O'CLOCK POS HAD US VISUALLY AND WOULD MAINTAIN SEPARATION FROM US AND THAT HE WAS LNDG ON RWY 28L. WE THEN REALIZED THAT SFO WAS USING BOTH RWYS AND THEY WANTED US TO LAND ON RWY 28R. I HAD THE SFO 095 DEG RADIAL HARD-TUNED, SO, AS THE PNF, I SELECTED ILS RWY 28R ON THE FMS SO THE CAPT WOULD HAVE FINAL GUIDANCE TO RWY 28R. THIS ACTION ELIMINATED THE MANUALLY INPUTTED DME RECOMMENDED ALTS THAT HE HAD ENTERED FOR THE QUIET BRIDGE. IT TOOK ME A WHILE TO GET RWY 28R ENTERED BECAUSE I SELECTED THE MODESTO 2 ARR AND HAD TO ERASE A LOT OF WAYPOINTS INSTEAD OF SELECTING 'NO STAR.' THINGS WERE HAPPENING FAIRLY QUICKLY BY THIS TIME. I WAS CONCENTRATING ON ENTERING THE CORRECT ILS IN THE FMS AND WAS NOT FOCUSING ON THE ALTIMETER AS I WOULD HAVE BEEN HAD WE NOT BEEN GIVEN A RWY CHANGE LATE IN THE GAME. I NORMALLY PROGRAM THE 'SECONDARY FLT PLAN' WITH THE PARALLEL RWY, IF THERE IS ONE, BUT DECIDED NOT TO IN THIS CASE BECAUSE THE ATIS SPECIFICALLY STATED THAT RWY 28R WAS CLOSED.

  111.  
  112. Accession Number: 409414
    Synopsis: LGT CREW MAY HAVE LANDED WITHOUT GETTING TWR CLRNC.
    Narrative: ACR FLT XXX PIT-ABE, ON BASE TURNING FINAL TO RWY 24 VISUAL APCH, COMPONENT FAILURE ACCOMPANIED WITH LOSS OF AUTOTHROTTLES PLUS NUMEROUS WARNING FLAGS AND AURAL WARNINGS, DISTR CREW ON THE FINAL APCH. THE FLT MAY HAVE LANDED WITHOUT TWR CLRNC. THE FLT WAS CLRED FOR THE VISUAL APCH, NOT SURE IF HANDED OFF TO TWR. UPON LNDG, CALLED TWR BY PHONE. THEY SAID NO PROB AT ALL, NO TFC. THE AUTOTHROTTLE SYSTEM FAILURE OCCURRED AT A CRITICAL TIME ON THE APCH INTERRUPTING THE CREW'S NORMAL PROCS. THIS DISTR PREVENTED THE FLC FROM DOUBLECHKING WITH THE TWR AND HDOF. THERE WAS NO TFC CONFLICT AND SAFETY WAS NOT COMPROMISED. CTLR INTERACTION WITH OTHER CTLRS COULD POSSIBLY PREVENT THIS OCCURRENCE IN THE FUTURE BY XCHKING (APCH CTLR AND ALSO TWR CTLR) WITH EACH OTHER TO VERIFY IF A HDOF HAS BEEN ACCOMPLISHED OR NOT, AND CONTINGENCY PLANS FOR WHEN THE HDOF HAS FAILED.

  113.  
  114. Accession Number: 409993
    Synopsis: THE FLC OF A B747-400 HAS PROBS TRYING TO BAL THE FUEL AS THEY FLY IN RCTP FOREIGN AIRSPACE.
    Narrative: DURING FLT #YY NRT-HKG ON JUL/XX/98, WE HAD A MAJOR FUEL IMBALANCE SIT WHICH IF NOT DETECTED, COULD HAVE RESULTED IN THE FLAMEOUT OF ENGS #1 AND #4. THERE WAS PLENTY OF ACCESSIBLE FUEL IN TANKS #2 AND #3 WHICH WOULD HAVE ALLOWED A RESTART AND POSITIVE FUEL FLOW FOR CONTINUED FLT. THE CAPT AND FO HAD DIFFERENT FUEL PUMP CONFIGNS IN MIND AT ENG START, BOTH OF WHICH WOULD HAVE BEEN ACCEPTABLE. HOWEVER ONLY HALF OF EACH CONFIGN WAS ESTABLISHED. 3 OUT OF 4 EICAS MESSAGE ADVISORIES WERE NEVER RECEIVED. HUMAN FACTORS AND DISTRACTIONS ALSO WERE INVOLVED RESULTING IN THE IMBALANCE. AT ENG START, I PUSHED THE APPLICABLE FUEL PUMPS ON FOR TANK TO ENG CONFIGN. AS THE FUEL LOAD WAS 121000 LBS, EITHER THE TANK TO ENG OR THE FUEL-OVERRIDE #2 AND #3 PUMPS ALONG WITH #1 AND #4 XFEEDS OPEN, ARE ACCEPTABLE CONFIGNS. MY CAPT WAS THINKING OF THE OVERRIDE/XFEED CONFIGN AND I WAS USING TANK TO ENG. THUS WE ENCOUNTERED HALF THE SET UP OF EACH. THE CHKLIST HAS A CHALLENGE OF 'XFEEDS #1 AND #4' OF WHICH THERE ARE TWO POSSIBLE RESPONSES. MY CAPT RESPONDED 'OPEN' WHICH WAS TRUE AND I SHOULD HAVE STOPPED AND ASKED: WHY? RATHER, BECAUSE THIS RESPONSE IS ACCEPTABLE, I CONTINUED ON. WE SHOULD HAVE RECEIVED 3 EICAS ADVISORY MESSAGES WARNING OF THIS NON STANDARD CONFIGN, BUT NEVER DID AND PUSHING THE RECALL BUTTON DISPLAYED NO APPLICABLE MESSAGES AS WELL (1) FUEL TANK/ENG, 2) XFEED CONFIGN, 3) XFEED FUEL IMBALANCE #1 AND #4). THE 4TH ADVISORY DID DISPLAY HALFWAY THROUGH THE FLT (LOW FUEL QUANTITY). AT THAT TIME WE PLACED THE OVERRIDE PUMPS #2 AND #3 ON, WHICH FED FUEL INTO ENGS #1 AND #4. THE REST OF THE FLT WAS UNEVENTFUL WITH A NORMAL LNDG IN HKG. I NOTED THE FUEL QUANTITY TOTALS ON THE FLT PLAN EVERY WAYPOINT WHICH SHOWED A CONSISTENT 2500 LBS UNDER BURN. THE LOGBOOK ARR FUEL WAS LOGGED AND A MECH BRIEFED. HUMAN FACTORS CONTRIBUTING TO THE IMBALANCE WERE: 1) CAPT AND FO THINKING OF DIFFERENT FUEL CONFIGN SCENARIOS BEFORE ENG START UP, 2) DISTRACTIONS OF A COMPLEX SID FROM NRT ALONG WITH EXTENSIVE BRIEFING FOR APCH AND LNDG INTO THE NEW HONG KONG ARPT, 3) THE CHKLIST WAS FOLLOWED BUT DID NOT ADDRESS THIS SCENARIO, 4) THIS WAS MY FIRST TIME IN THE COCKPIT FOR TKOF IN 7 MONTHS. MECHANICAL FACTORS WERE: 1) NOT RECEIVING 3 EICAS ADVISORY MESSAGES, 2) MAIN PUMPS #1 AND #4 HAVING A HIGHER OUTPUT PRESSURE THAN #2 AND #3 MAIN PUMPS RESULTING IN FUEL DEPLETION (TANKS #1 AND #4) IF #1 AND #4 XFEEDS OPEN, 3) XFEED CONFIGN EICAS MESSAGE DISPLAYED AFTER COMPLETE ENG SHUTDOWN IN HKG. OTHER ITEMS TO NOTE ARE 1) THE L FMC WAS RELOADED WITH DATA DUE TO PREVIOUS FAILURE JUST BEFORE OUR FLT, 2) WE HAVE A TEMPORARY PROC OF TURNING ON THE ENG BLEED VALVES JUST BEFORE START, 3) THE FUEL LOAD OF 121000 LBS ALLOWED FOR EITHER FUEL CONFIGN SET UP, 4) LATE FLAP RETRACTION DUE TO NOISE ABATEMENT REQUIREMENTS IN NRT, 5) COCKPIT OPERATING MANUAL DOES NOT SOLVE THIS PARTICULAR 'LOW FUEL QUANTITY' SIT IN TANKS #1 AND #4. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THE FUEL LEVEL WAS EVEN AT 120000 LBS TOTAL. THE EICAS MESSAGE INDICATED THE FUEL TANKS OF EACH WING TANK SHOULD BE TO EACH RESPECTIVE ENG. THEY GOT A FUEL IMBALANCE LIGHT AND NOTED THAT TANKS #1 AND #4 DIFFER BY 6000 LBS. ONE TANK GOT LOW ENOUGH TO SHOW FUEL QUANTITY. THEY CARRIED EXTRA FUEL, BUT THEY DID NOT CHK THE FUEL PANEL TO ASSURE HOW FUEL WAS BEING USED. WHEN IT WAS DECIDED TO REBALANCE THE FUEL, NO ONE PERSON WAS IN CHARGE. EACH PLT DECIDED WHICH TECHNIQUE THEY WOULD USE AND EACH PLT WAS DOING SOMETHING DIFFERENT THAN THE OTHER. THE L FMC WAS INOP WHICH DISTRACTED THE FLC. SOMEHOW, THE FUEL BEGAN TO COME WITHIN BAL RANGE IN TIME FOR NORMAL UNEVENTFUL LNDG AT DEST.

  115.  
  116. Accession Number: 410170
    Synopsis: FLC OF A B737 UNDERSHOT XING FIX ON DSCNT STAR DUE TO COMPLACENCY IN STARTING THE DSCNT AND DISTR OF ENTERING FMC DATA FOR LNDG. NO CONFLICT NOTED.
    Narrative: I DID NOT DSND TO FL270 FROM FL330 (AT MY DISCRETION) UNTIL TOO LATE. I HAD PREVIOUSLY ENTERED 24000 FT IN THE FMC AT TURLO BUT WAS BUSY PROGRAMMING THE ARR RWY AND WHEN I SWITCHED BACK TO THE DSCNT PAGE, I FOUND THAT I WAS LATE TO START THE DSCNT. I BEGAN A MAX RATE DSCNT +6000 FPM AND ESTIMATE THAT TURLO WAS CROSSED AT ABOUT FL270. I LEVELED AT FL240 APPROX 3 MI PAST THE TURLO FIX. THE CAUSAL FACTOR WAS DISTR/INATTENTION. I SHOULD HAVE WAITED UNTIL AFTER I DSNDED TO FL240 BEFORE I ENTERED MORE FMC DATA. NO ACFT SEPARATION COMPROMISED. NO OTHER ACFT WERE NOTED WITHIN 15 MI ON TCASII.

  117.  
  118. Accession Number: 411189
    Synopsis: A TAXIING ACR MLG PASSES OVER THE HOLD SHORT LINE FOR RWY 8 AT ABQ. THE ACFT WAS AT TXWY A3 AND THE FO CLAIMS THAT THERE IS AN ARPT PROB WITH THE ILLUSION OF THE TXWYS AT C, A1, A2 AND A3 BEING SIMPLY EXITS FROM THE RAMP AND NOT ACCESS TXWYS TO THE RWY. SAYS THERE SHOULD BE WARNING SIGNS REGARDING A POSSIBLE RWY INCURSION IN THIS AREA.
    Narrative: DURING TAXI FOR TKOF, CAPT TAXIED PAST HOLD SHORT LINE APPROX 10-12 FT. CALLED TWR AND TOLD THEM WE WERE READY FOR TKOF. NO TFC CONFLICTS. TWR CLRED US ONTO RWY AND SUBSEQUENT TKOF WAS UNEVENTFUL. PROB AROSE DUE TO 2 MAN COCKPIT (ADVANCED FMS) AND SHORT TAXI, ALONG WITH THE FACT THAT TXWY A IS PART ON SAME CONCRETE AS TERMINAL RAMP. FO WAS BUSY READYING COCKPIT FOR DEP AND READING CHKLIST. ARPT LAYOUT IS VERY CONFUSING. THERE IS NO BOUNDARY BTWN THE TERMINAL RAMP AND TXWY A. INCURSION OCCURRED AT TXWY A3. THE PERCEPTION IS THAT TXWYS C, A3, A2, AND A1 ARE EXITS FROM RAMP, NOT ONTO RWY 8/26 AT ABQ. THERE NEEDS TO BE A PHYSICAL BARRIER OR BETTER SIGNS DEMARKING TXWY A AND THE TERMINAL RAMP. AT THE VERY LEAST, SOME WARNING SIGNS AT TXWYS A1, A2, A3, AND C WARNING OF DANGER OF POSSIBLE RWY INCURSION DUE TO POOR DESIGN OF ARPT. PROCS SHOULD BE STUDIED FOR HIGHER WORKLOAD COCKPITS IN 2 MAN CREWS. MAYBE A PROC THAT REQUIRES THE ACFT TO BE STOPPED WHILE TAXIING WHEN DATA IS ENTERED IN FMS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: FO ADMITS TO BEING BUSY WITH THE CHKLIST DURING THE TAXI OUT. HE STATED THAT THE HOLD LINES WERE VISIBLE BUT FELT THAT THE ILLUSION THAT ONE EXPERIENCES ABOUT THE RAMP VERSUS THE RWY WAS CAUSAL. THE ACCESS TXWYS ARE VERY SHORT AND THE PERCEPTION IS THAT THOSE TXWYS ARE EXITS TO A PARALLEL TXWY WHICH, IN REALITY, IS RWY 8. HE DOESN'T KNOW IF THE CAPT FILED A COMPANY RPT OR NOT.

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  120. Accession Number: 411385
    Synopsis: CL65 CREW LANDED WITHOUT GETTING LNDG CLRNC FROM THE TWR.
    Narrative: FORGOT TO CONTACT TWR, DUE TO THE FOLLOWING REASONS: 1) ATC TOLD US TO CONTACT TWR WHEN JOINING FINAL, BUT IT WAS ISSUED ON DOWNWIND (CLRED FOR THE VISUAL APCH). 2) THERE WAS A LOT OF NOISE COMING FROM THE CABIN, WE WERE CONCERNED THAT THE FLT ATTENDANT MAY NOT MAKE IT TO HER JUMP SEAT IN TIME. DEBRIEF -- THE FLT ATTENDANT RPTED THAT SHE DID MAKE IT TO HER SEAT, BUT IT WAS VERY CLOSE. ALSO, SHE RPTED THAT SHE GOT THE CORRECT SIGNALS FROM ME, THE CAPT, AND THAT IT WAS HER FAULT SHE SERVED ON THIS SHORT FLT. SHE KNOWS THAT I (THE CAPT) USED THE CORRECT SIGNALS AND THAT SHE WAS ALSO BRIEFED ON THE COMPANY'S STANDARD SIGNALS SINCE THERE WAS A RECENT CHANGE. SHE APOLOGIZED AND SAID IT WOULD NOT HAPPEN AGAIN. 3) WE WERE THINKING GAR NOT LNDG, BUT WHEN SHE MADE IT TO HER JUMP SEAT WE KNEW WE COULD LAND SINCE THE NOISE OF THE JUMP SEAT CONFIRMED IT. 4) AFTER 13 1/2 HRS OF DUTY, WE HAD FLOWN 6 PREVIOUS FLTS, NOW OVER 8 HRS 30 MINS AND NOW ON OUR 7TH FLT. WE WERE TIRED AND THIS VERY SHORT FLT (16 MINS, 5 AIRBORNE) DID NOT HELP. THIS INCIDENT WAS COUPLED WITH MANY INGREDIENTS, EVEN THOUGH THERE WAS NO INCIDENT INVOLVING OTHER ACFT OR ANY OTHER PROB NOTED BY ATC. I HAVE BEEN FLYING SINCE 1982 (16+ YRS) AND NOTHING LIKE THIS HAS EVER HAPPENED. I AM VERY CONCERNED BECAUSE IT ONLY TAKES 1, 2, OR 3 MORE FACTORS AND THERE IS A MAJOR ACCIDENT, AND PEOPLE DIE, BUT THEY WILL JUST BLAME THE PLTS. SUPPLEMENTAL INFO FROM ACN 411243: FACTORS WHICH I FEEL ARE RELEVANT: 1) CAPT WAS PREOCCUPIED WITH PROGRAMMING FMS AND WAS DISTR. 2) CAPT PREOCCUPIED WITH MONITORING MY FLYING, INSTRUCTING ME AS TO WHAT HE THOUGHT I SHOULD DO IN ORDER TO DSND AND SLOW (NONE OF WHICH ARE REQUIRED -- APCH WAS STABILIZED ON GS AND LOC). 3) WHEN TURNING FINAL (AT ABOUT 4 MI) LOUD NOISE FROM GALLEY WAS HEARD. FLT ATTENDANT WAS UP AFTER THE FINAL SIGNAL FOR HER TO BE SEATED. WE WERE THINKING POSSIBLE GAR. 4) WE WERE ON THE 7TH LEG OF THE DAY, WHICH WAS A 13 1/2 HR DUTY DAY. CREW FATIGUE WAS DEFINITELY A FACTOR.

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  122. Accession Number: 412020
    Synopsis: A CLBING B737-300 OVERSHOT ITS ASSIGNED ALT OF 5000 FT BY 1000 FT. FO WAS IN TRAINING.
    Narrative: I LEVELED OUT AT 6000 FT INSTEAD OF 5000 FT AS ASSIGNED IN ATC CLRNC. I HONESTLY DON'T KNOW IF I MISREAD THE ACARS CLRNC AND MISDIALED THE INITIAL ALT OR IF I WAS DISTR WHILE SETTING UP AND 6000 FT WAS LEFT FROM PRIOR LEG. AT ANY RATE, 6000 FT WAS MISTAKENLY SET AND NOT CHALLENGED LATER. THIS WAS AN IOE TRIP AFTER FINISHING TRAINING. I MAY HAVE BEEN TOO FOCUSED ON PROPER PROGRAMMING OF FMC AND NOT ENOUGH ON BASICS. ALSO, A SHORT TAXI/HIGH WORKLOAD TAXI OUT HELPED TO KEEP US FROM CATCHING A BASIC ERROR. LONG AND SHORT IS -- ALL BASIC CLRNC INFO MUST BE DOUBLECHKED AND CONFIRMED EVERY TIME. SUPPLEMENTAL INFO FROM ACN 411744: DURING CLBOUT THE STUDENT, FO IN TRAINING, SET 6000 FT IN THE ALT WINDOW. THE STUDENT HAD BEEN ON A SIMILAR FMC ACFT THAT HAD EFIS. ON CLBOUT FROM DCA, WHILE LEVEL AT 6000 FT, THE CTLR ASKED ABOUT OUR ASSIGNED ALT. DUE TO PREVIOUS INCORRECT LATERAL NAV ENTRIES, COCKPIT ATTN WAS DIVERTED FROM ALT READINGS/CHKS NORMALLY ACCOMPLISHED. BUSY, SHORT TAXI PATH INVOLVING HIGH WORKLOAD DURING BRIEFING. RADIO CONFUSION ABOUT XING RWY 33. GLARE ON ALT WINDOW LCD READOUT, MAKING IT DIFFICULT TO READ. SHORT TAXI RTE, TEACHING ENVIRONMENT DURING HIGH WORKLOAD. TWR RUSHING OUR ACFT TO FILL AN 'ARR SLOT' FOR OUR DEP RESULTING IN CHKLISTS BEING ACCOMPLISHED QUICKLY. ACARS DEP INFO BEING LOCATED WELL BEHIND THE PLT'S NORMAL FIELD OF VISION AND REQUIRING INFO TO BE READ SIDEWAYS. STUDENT'S INCORRECT ENTRY (LATER CORRECTED) IN THE LATERAL DATA NAV BASE REQUIRING SEVERAL CORRECTIVE ENTRIES BY BOTH PLT AND DIVERTING ATTN DURING CLBOUT. RECOMMENDATIONS: STUDY FEASIBILITY OF ACARS DATA BEING PLACED/REPEATED TO PLT'S NORMAL FIELD OF VISION.

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  124. Accession Number: 412260
    Synopsis: G3 FLC CONDUCTING GPS APCH TO MMU ARPT DID NOT IMMEDIATELY DSND FROM 4000 FT TO 2000 FT AND NEEDED TO BE PROMPTED BY THE CTLR BECAUSE OF OPPOSITE DIRECTION TFC.
    Narrative: ON IFR FLT PLAN FROM ISP TO MMU, ACFT AT 4000 FT PROCEEDING DIRECT TO SAX VOR (APPROX 260 DEG HDG) AT 200 KIAS. FINAL CTLR ISSUED A TURN TO HDG 240 DEGS, DSND TO 2000 FT, CLRED GPS RWY 23 APCH. THE PF TURNED THE ACFT TO 240 DEGS AND BEGAN SETTING UP THE FMS FOR THE GPS APCH. THE PNF DIALED IN 2000 FT IN THE ALT SELECT WINDOW AND ASKED THE PF WHAT HDG THE CTLR HAD ASSIGNED. THE PNF THEN READ BACK THE CLRNC. THE ACFT REMAINED AT 4000 FT BECAUSE THE PF DID NOT HEAR OR ACKNOWLEDGE THE ALT CHANGE. AFTER ABOUT 60 SECONDS, THE CTLR CAME BACK AND REISSUED A DSCNT TO 2000 FT STATING THERE WAS AN ACR AT OUR 12 O'CLOCK POS AND 5 MI. THE PF IMMEDIATELY DSNDED THE ACFT TO THE CORRECT ALT, THE REST OF THE FLT WAS UNEVENTFUL. THIS EVENT OCCURRED BECAUSE: 1) THIS PF DID NOT HEAR THE ALT CHANGE BECAUSE HE WAS PROGRAMMING THE FMS. 2) THE PNF DID NOT CONFIRM WITH THE PF THAT A DSCNT WAS GIVEN. 3) A REQUESTED WX GRAPHIC BECAME AVAILABLE ON THE FMS SCREEN AT THE SAME TIME AS THE CLRNC WAS ISSUED AND DISTR BOTH CREW MEMBERS. PREVENTING THE SAME PROB FROM HAPPENING AGAIN: 1) THE PF DEVOTE MOST OF HIS ATTN ON FLYING THE ACFT AND FOLLOWING ATC INSTRUCTIONS. 2) THE PNF INSURE THE PF FOLLOWS ATC INSTRUCTIONS.

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  126. Accession Number: 412360
    Synopsis: EMB145 CREW DSNDED BELOW CLRED ALT UNTIL THE GPWS ACTIVATED.
    Narrative: DURING VECTOR FOR ILS APCH, VOR AND ILS EQUIP WERE BEING USED AS PRIMARY FLT INSTS AND FMS WAS BEING USED AS BACKUP DISPLAYED ON THE MULTI-FUNCTION DISPLAY. THE CAPT (MYSELF) WAS FLYING THE ACFT. DURING INITIAL CONTACT I THOUGHT THE CTLR SAID TO EXPECT THE ILS TO RWY 28L. THE FO HEARD TO EXPECT RWY 28R CORRECTLY. WE EACH PROGRAMMED OUR FMS EQUIP ACCORDINGLY. WHEN I DISCOVERED WE WERE GOING TO RWY 28R, I ASKED THE FO TO SET MY FMS TO THE PROPER APCH AND I SET MY VHF RADIOS TO THE PROPER FREQ. WE WERE DSNDING TO 3000 FT AT THE TIME. WE WERE GIVEN FURTHER DSCNT TO 2500 FT, BUT THE ALT PRESELECT WAS NOT SET PROPERLY AND WE DSNDED TO 2000 FT, AT WHICH TIME OUR ACFT GPWS TOLD US WE WERE TOO LOW, GEAR NOT DOWN, 1000 FT AGL. I ASKED ATC WHAT ALT I SHOULD BE AT. HE CLBED US TO 3000 FT AND WE FINISHED THE APCH WITHOUT INCIDENT. THIS PROB I THINK WAS DUE TO SPENDING TIME PROGRAMMING THE FMS, WHICH WAS NOT NEEDED TO START WITH, AND NOT FOLLOWING PROPER PROCS FOR SETTING THE ALT PRESELECT AND CONFIRMING BTWN THE 2 PLTS.

  127.  
  128. Accession Number: 412420
    Synopsis: B737-500 CREW EXCEEDS 250 KTS BELOW 10000 FT IN IAH AIRSPACE.
    Narrative: APCHING IAH FROM THE NW, WE HAD BEEN CLRED FOR THE COAST ARR, DIRECT TO HOAGI AND ASKED TO KEEP THE SPD UP UNTIL REACHING 10000 FT, AND NOT TO SLOW TO 250 KTS UNTIL THEN. 6000 FT HAD BEEN SET IN THE ALT WINDOW AS THE LOWEST ALT ON THE COAST ARR WHEN WE WERE INITIALLY CLRED FOR THE COAST ARR. WHEN ASKED TO KEEP THE SPD UP, THE FO (HE WAS FLYING) DISENGAGED VNAV AND SELECTED VERT SPD. THIS TOOK PLACE APCHING HOAGI AND JUST PRIOR TO HDOF TO APCH. (AIRSPD 310 KTS, VERT SPD 2000 FPM.) WE HAD THE COMPUTER SET UP FOR THE COAST ARR AND RWY 26. WHEN WE CHKED IN WITH APCH, HE CLRED US DIRECT TO VETTE FOR THE RWY 14L APCH. WE HAD NOT YET REACHED 10000 FT AT HOAGI. BY SELECTING DIRECT TO VETTE AND RWY 14, WE REMOVED THE COAST ARR AND OUR 10000 FT PROTECTION. WHILE THE FO WAS REPROGRAMMING THE COMPUTER, I WAS RETUNING THE ILS AND CHANGING THE INBOUND COURSE ON THE MCP. WE BOTH LOOKED UP AT THE SAME TIME AND WE WERE DOING 310 KTS AT 9000 FT. THE FO DISCONNECTED THE AUTOPLT AND ARRESTED THE DSCNT AND AIRSPD.

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  130. Accession Number: 412670
    Synopsis: A DSNDING B737-300 FAILS TO CROSS THE DALAS INTXN AT THE REQUIRED ALT OF 12000 FT. CAPT THOUGHT IT WAS A 13000 FT ALT ASSIGNMENT, THE FO PF THOUGHT 12000 FT.
    Narrative: WE WERE FLYING THE ROME 2 ARR PROC TO ATL. RECEIVED A CLRNC TO CROSS ERLIN AT 13000 FT. LATER WERE GIVEN A CLRNC DIRECT TO DALAS (11 MI BEYOND ERLIN). THIS CLRNC DID NOT ALLOW US TO CROSS ERLIN SO WE WERE GIVEN 12 MI W OF DALAS AT 13000 FT. SO WE COULD MAKE THIS RESTR, I WAS TRYING TO PROGRAM A FIX FOR THE RESTR WHEN I NOTICED THE FO HAD DIALED 12000 FT INSTEAD OF 13000 FT. WE WENT TO 12500 FT THEN BACK TO 13000 FT. MY FO REMEMBERS THE RESTR TO BE 12000 FT. I REMEMBER 13000 FT. THE CTLRS WERE VERY BUSY, WE WERE VERY BUSY AS WELL. COULDN'T GET A WORD IN TO CONFIRM THE ALT. WE WERE THEN XFERRED TO APCH AND RECEIVED A NEW CLRNC TO 10000 FT. WE DIDN'T SAY ANYTHING, THE CTLRS DIDN'T SAY ANYTHING. THEY WERE PROBABLY TOO BUSY TO NOTICE. THIS IS A CLASSIC EXAMPLE OF AUTOMATION- DISTR DEVELOPING INTO A POSSIBLE BUSTED ALT. I DO INDEED BELIEVE AUTOMATED COCKPIT, AT LEAST NAV, IS GREAT. BECAUSE WE HAD AN AUTO-COCKPIT, THE CTLR KNEW THIS AND GAVE US DIRECT, WHICH SHORTENED OUR RTE A LITTLE BUT PUT OUR ABILITY TO MAKE THE RESTR IN DOUBT. WE WERE BUILDING THE NEW FIX TO CHK IF WE WERE GOING TO MAKE THE RESTR WHEN CONFUSION DEVELOPED AND THINGS WENT 'SOUTH' FROM THERE. SUPPLEMENTAL INFO FROM ACN 411964: OUR FMC WAS PROGRAMMED TO LATERALLY NAV THE ROME 2 ARR PROFILE AS WELL AS THE VERT PROFILE TO COMPLY WITH THE ERLIN RESTR OF 13000 FT AT 250 KTS AS DICTATED ON THE PLATE FOR A PLANNED LNDG TO THE E. AT 40 NM FROM THE RMG VOR, WE WERE CLRED DIRECT TO DALAS INTXN AND INSTRUCTED TO CROSS 10 NM W OF DALAS AT 12000 FT. AT THE TIME OF THIS CLRNC, WE WERE LEVEL AT FL240. AS MY CAPT BEGAN TO REPROGRAM OUR FMC, I ENTERED 12000 FT IN THE ALT WINDOW OF OUR MCP AND BEFORE I STARTED MY DSCNT, I REQUESTED THAT THE PNF/CAPT VISUALLY CONFIRM MY ALT ENTRY. TO MY RECOLLECTION, HE CONFIRMED THE 12000 FT ENTRY. WHILE MY CAPT WAS BUSY WITH THE FMC, I BEGAN A RAPID VERT SPD CTLED DSCNT TO CROSS 10 MI W OF DALAS AT 12000 FT. ATC FURTHER COMPLICATED OUR SIT BY ISSUING A SPD REDUCTION TO 250 KTS. AFTER ASSESSING OUR SIT, I DETERMINED WE COULD MEET THIS RESTR, PROVIDED THE SPD BRAKE WAS DEPLOYED AND AN IMMEDIATE 3000-4000 FPM DSCNT RATE WAS INITIATED. PASSING THROUGH 13000 FT AND 14 NM W OF DALAS INTXN, MY CAPT SUDDENLY TOOK CTL OF THE ACFT AND LEVELED OFF AT 13000 FT, AS OPPOSED TO OUR ASSIGNED ALT OF 12000 FT. DUE TO THE FACT THAT IT WAS VMC, AND MY SITUATIONAL AWARENESS CONFIRMED THAT NO OTHER ACFT WERE IN OUR VICINITY, I ELECTED NOT TO OVERRIDE MY CAPT'S ACTIONS. CONTRIBUTING FACTORS: BOTH PLTS RELATIVELY INEXPERIENCED IN ATL AIRSPACE, HVY NAV AND COM WORKLOAD, CAPT'S CONFUSION BTWN PAST AND CURRENT CLRNC, PNF DISTR BY LAST MIN AUTOMATION WORKLOAD, END RESULT BEING AN ASSIGNED ALT DISAGREEMENT BTWN THE PF AND PNF.

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  132. Accession Number: 414290
    Synopsis: PLT OF BE20 LINED UP WITH THE WRONG RWY DURING AN ILS APCH DUE TO USING AN OUTDATED CHART. HE, THE TWR CTLR AND THE CREW OF A B737 WAITING TKOF, NOTICED HIS MISTAKE IN TIME FOR A SIDESTEP TO THE ASSIGNED PARALLEL RWY.
    Narrative: DSNDING INTO ONT ON THE ZIGGY 3 ARR, WE WERE GIVEN RADAR VECTORS FOR THE ILS RWY 26L ONT. WE INTERCEPTED THE ILS RWY 26L LOC AND PROCEEDED INBOUND ON THE ILS. I WAS VERY BUSY RUNNING CHKLISTS AND DOUBLECHKING THAT I HAD THE EFIS SET UP CORRECTLY, AS THIS WAS MY THIRD FLT AND FIRST ILS IN THIS NEW AIRPLANE. ON SHORT FINAL, TWR CLRED A FLT FOR TKOF ON RWY 26R. I LOOKED UP TO VERIFY I WAS ON THE CORRECT RWY AND TO SEE THE B737. WHEN I DID THIS, I REALIZED I WAS LINED UP FOR RWY 26R INSTEAD OF RWY 26L. AT THIS POINT, ON SHORT FINAL, I STILL HAD PLENTY OF ROOM TO SIDESTEP TO RWY 26L AND LAND. THE TWR CTLR AND B737 CREW REALIZED I WAS LINED UP FOR RWY 26R AT ABOUT THE SAME TIME I DID AND THERE WAS NO CONFLICT BTWN AIRPLANES. AFTER LNDG, I VERIFIED THAT I HAD INDEED HAD THE ILS RWY 26L APCH PLATE OUT AND THE LOC FREQ OF 109.7 IN THE NAV RADIO. AFTER DISCUSSING THIS WITH THE TWR, I LEARNED THAT THE FREQ FOR THE ILS RWY 26L HAD BEEN CHANGED TO 111.35 SOMETIME IN THE PRECEDING 6 MONTHS AND THAT I HAD USED AN OUT-OF-DATE APCH PLATE. THIS PROB CAME ABOUT BECAUSE I WAS IN A NEW AIRPLANE EQUIPPED WITH EFIS AND FMS THAT I WAS JUST BECOMING FAMILIAR WITH. I SPENT TOO MUCH TIME CHKING TO MAKE SURE I HAD THE EFIS SET UP CORRECTLY AND NEGLECTED TO IDENT THE LOC. AFTER LNDG, I FOUND THAT WHEN I HAD REVISED MY APCH PLATES I HAD NOT REMOVED THE OLD ONE AND JUST INSERTED THE NEW ONES BEHIND THEM. BECAUSE THE 3 OF US INVOLVED (MYSELF, THE TWR CTLR AND THE B737 CREW) WERE AWARE OF WHAT WAS HAPPENING AROUND US, SAFETY WAS NEVER COMPROMISED DURING THIS EVENT, BUT I HAVE LEARNED THAT LITTLE THINGS, SUCH AS CURRENT APCH PLATES OR IDENT A FREQ, CAN KEEP THINGS FROM GETTING TO THAT POINT IN A HIGH WORKLOAD ENVIRONMENT.

  133.  
  134. Accession Number: 417040
    Synopsis: FLC OF AN ACR MLG FAILED TO DSND IN SUFFICIENT TIME TO MAKE ALT XING RESTR DUE DISTR OF REPROGRAMMING THE FMC FOR THE XING RESTR AND AT AN INCREASED AIRSPD. THERE WAS NO COMMENT FROM CTR CTLR.
    Narrative: WELL INTO MINKS 1 STAR INTO LGA, PRIOR TO KERNO INTXN, ZDC ASKED US TO START DSCNT TO CROSS KERNO INTXN AT FL260 AND TO PICK UP THE AIRSPD ASAP AS WE DSNDED TO 320 KIAS. THIS WAS EXPLAINED BY CTLR THAT HE NEEDED THE INCREASED SPD 'REAL SOON' SO THEREFORE THE EARLY DSCNT. ACFT WAS TAKEN OUT OF VNAV AND USED VERT SPD AND MACH SPD CTL, SO AS TO PICK UP SPD, DURING THE TIME JUST PRIOR TO HDOF TO CTLR (NYC). SEVERAL EXCHANGES OCCURRED AND SOME CONFUSION EXISTED OVER OTHER ITEMS. UPON CONTACTING ZNY WE REALIZED WE WERE AT FL270 AT KERNO AND THROTTLED BACK AND DSNDED TO FL260 WITHIN 1.5 MI OF KERNO. NOTHING WAS SAID BY CTR AS HE ISSUED LOWER AT THAT POINT.
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