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Incidents related to Issue 41 incidents related to this issue.

Issue: understanding of automation may be inadequate (Issue #105)
Description: Pilots may not understand the structure and function of automation or the interaction of automation devices well enough to safely perform their duties.

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  2. Accession Number: 59060
    Synopsis: WDB DESCENDING OVERSHOT THE ASSIGNED ALT BY 2000'. REPORTER SO BELIEVES AUTOMATICS, FMS ALT SELECT NOT PROPERLY PROGRAMMED. FURTHER BELIEVES THAT CAPT DID NOT UNDERSTAND HOW THE EQUIPMENT WORKED. CAPT REPORTS 70 MILE TRACK DEVIATION ON
    Narrative: DURING CRUISE FLT ON A DIRECT ROUTING BETWEEN CAPE CANAVERAL, FL AND FREEPORT, BAHAMAS, WE WERE GIVEN A DESCENT FROM FL370 TO FL350. THE COPLT WAS OUT OF THE COCKPIT SO THE CAPT ACKNOWLEDGED THE DESCENT AND COMMENCED SAME. I MADE THE REQUIRED ADJUSTMENTS TO THE CABIN PRESSURIZATION SYSTEM AND THEN PROCEEDED TO MAKE A COMPANY POSITION REPORT ABEAM VRB. I HEARD THE AUTOPLT DISCONNECT ALARM SOUND AND LOOKED FORWARD TO THE CAPT'S ALTIMETER WHICH INDICATED A DESCENT THROUGH FL330. SIMULTANEOUSLY, MIA CENTER WAS ASKING US WHAT OUR ALT WAS. THE CAPT REPORTED 330 AND WE WERE GIVEN A FURTHER DESCENT TO FL310. I BELIEVE THE PROBLEM WAS DISCOVERED BY ATC. WHEN WE WERE GIVEN THE FURTHER DESCENT TO FL310, I NOTICED THAT THE ALT ALERT/SELECT WINDOW STILL SHOWED FL370. I ALSO NOTICED THAT THE CRUISE ALT ENTERED INTO THE FMS READ FL350 WHICH LEADS ME TO SUSPECT THAT A PROBABLE CAUSE FOR THIS FAILURE TO LEVEL OFF AT FL350 WAS A MISCONCEPTION THAT THE FMS WILL STOP A CLIMB OR DESCENT AT THE CRUISE ALT ENTERED IN THE FMS RATHER THAN THE ALT SELECTED ON THE ATL ALERT SELECT PANEL. SUPPLEMENTAL INFO FROM ACN 59101: VNAV STARTED NORMAL DESCENT, BUT CONTINUED THROUGH FL350 (RAPIDLY). ATC AND CREW CAUGHT OVERSHOOT ABOUT SAME TIME. ATC THEN CLEARED US TO CONTINUE DESCENT TO FL310, WHICH WAS ACCOMPLISHED WITHOUT VNAV MODE. ON NEXT LEG FMS GENERATED 70 MILE ERROR IN LNAV. COMPLETED LEG ON VOR ONLY AND WROTE UP FMS.

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  4. Accession Number: 69684
    Synopsis: ACR MLG ALT DEVIATION OVERSHOT CRS ALT, DUE TO MISSET AUTOPLT AND ALT ALERT.
    Narrative: I WAS FLYING AS THE CAPT WITH A NEW F/O AND HE WAS FLYING THE ACFT ON AUTOPLT. (BY 'NEW' I MEAN NEW TO THE COMPANY AND ACFT). AS WE WERE CLIMBING TO AND APPROX 600' BELOW OUR ASSIGNED ALT OF FL310, CENTER CLEARED US TO DESCEND PLTS DISCRETION TO FL240 AND CONTACT CENTER ON A NEW FREQ. I READ BACK THE CLRNC BUT HAD THE WRONG FREQ. THE F/O RESET THE ALT ALERT/AUTOPLT TO FL240 WHILE STILL IN THE CLIMB TO 310. AS I WAS LOOKING DOWN SETTING THE CORRECT FREQ AND TALKING TO CENTER, THE F/O CONTINUED THE CLIMB AND FAILED TO LEVEL OFF. AS WE WERE PASSING 316 THE LAST THING BEFORE SWITCHING TO THE NEW FREQ WAS THE HELPFUL QUESTION FROM CENTER, 'FLIGHT XX BEFORE YOU GO, VERIFY YOUR ASSIGNED ALT OF 310 OR 330?' I ACKNOWLEDGED THAT WE WERE CORRECTING TO 310 THANKED HIM FOR HIS HELP AND TOOK CONTROL OF THE ACFT TO DESCEND BACK TO 310. AT THAT POINT THE F/O ASKED, WHAT HAPPENED? MEANING, WHY DIDN'T THE AUTOPLT LEVEL OFF AT 310? I EXPLAINED THAT BY RESETTING THE ALT TO 240 BEFORE THE AUTOPLT HAD CAPTURED THE ASSIGNED ALT, IT WILL OF COURSE NOT LEVEL OFF. FURTHERMORE, WE WOULD NOT GET AN ALERT THAT WE HAD PASSED THROUGH 310 BECAUSE THE ALT ALERT WAS ALSO RESET TO 240. I THEN SUGGESTED AS TECHNIQUE, TO NOT RESET THE ALT UNTIL THE AUTOPLT HAS CAPTURED CRUISE ALT. CONTRIBUTING FACTORS. F/O UNFAMILIAR WITH THE ADVANCED AUTOPLT FEATURES. DISTRACTION OF THE FREQ CHANGE AND GETTING THE WRONG FREQ AT THE TIME LEVEL OFF IS OCCURRING. BEING CLEARED TO A LOWER ALT BEFORE REACHING THE ASSIGNED ALT. DEVIATION FROM COMPANY POLICY ON CREW COORDINATION (THE F/O SHOULD NOT HAVE RESET THE ALT IN THE FIRST PLACE, THE PLT NOT FLYING HANDLES THE RADIOS AND RESETS THE ALT CLRNCS).

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  6. Accession Number: 134620
    Synopsis: ACR WDB OVERSHOOTS ALT IN DESCENT, ABRUPT PULL-UP CAUSES MINOR INJURY TO A PASSENGER.
    Narrative: F/O FLYING ON AUTOPLT, DSNDING FROM FL370 TO 330, LNDG ORD. I WAS LOOKING OVER ARR ROUTES AND RWYS WHEN I HEARD AUTOPLT DISENGAGE. LOOKED AT ALT, FL325. F/O WITH VERY POSITIVE BACK PRESSURE MANUALLY LEVELED THE ACFT AT FL330. MIGHT BE A LACK OF UNDERSTANDING OF THE SYS; I.E., MOVING PITCH CTL WHEEL WHILE IN THE CAPTURE MODE, WHICH DISENGAGES AUTOCAPTURE AND HOLD. ALSO THERE MAY HAVE BEEN A LITTLE COMPLACENCY. NOT CHKING AUTO FUNCTIONS WITH RAW DATA. MY OBSERVATIONS WHILE THE F/O IS FLYING IS A LACK OF RESPONSIBILITY FOR HIS ACTIONS. MAKE THE F/O ANSWER FOR HIS ACTIONS. SUPPLEMENTAL INFO FROM ACN 135029: CAPT FAILED TO ARM THE ALT DSNT WINDOW. I FEEL HE IS STILL USED TO FLYING THE WDB A, WHERE YOU DON'T HAVE TO PULL OUT ON THE ALERT KNOB, BUT ON THE WDB B YOU HAVE TO SELECT THE NEW ALT AND PULL OUT ON THE KNOB TO ARM IT. CREW ATTN WAS DIVERTED AND NO ALT WARNING SOUNDED, AND THE CREW HAD TO MAKE AN ABRUPT LEVEL OFF. 1 PAX WAS INJURED ABOUT THIS TIME IN THE FLT. PARAMEDICS MET THE ACFT. SUPPLEMENTAL INFO FROM ACN 134889: I WAS AT THE F/E TABLE COPYING ATIS INFO AND ACCOMPLISHING COMPANY REQUIRED PAPERWORK IN PREPARATION FOR OUR DSNT INTO ORD. AS I WAS WRITING, I FELT A SLIGHT "G" SENSATION. IT SIMPLY FELT LIKE A MOMENTARY BUMP OF TURB. WHEN I TURNED FORWARD TO HAND THE PLTS THE PAPERWORK, THE CAPT WAS MAKING A COMMENT ABOUT THE BUMP, BUT I MISSED IT BECAUSE I WAS STILL MONITORING ATIS ON MY HEADSET. LATER I WAS INFORMED THAT THE AUTOPLT HAD FAILED TO CAPTURE THE ENRTE DSNT ALT. OUR PLTS DETECTED THE FAILURE AND RETURNED THE ACFT TO FL330.

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  8. 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.

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  10. Accession Number: 364789
    Synopsis: B737-300 GOT A TCASII RA WITH A C182RG WHILE FLYING S OF THE ASSIGNED RTE. THE CTLR WAS MORE CONCERNED WITH GETTING THE B737 BACK ON COURSE THAN WITH THE CONFLICT. B737 DSNDED BELOW ASSIGNED ALT TO SATISFY THE RA.
    Narrative: I WAS FLYING WITH A BRAND NEW FO (3RD TRIP). WE WERE CLRED TO FLY THE 'ZIGGY' ARR INTO ONT. I INSTRUCTED THE FO TO START THE R TURN TO THE INBOUND RADIAL, BUT HE WAS CONFUSED WHILE USING THE LNAV FUNCTION OF THE AUTOPLT. I STARTED THE R TURN FOR HIM AND AT ABOUT THE SAME TIME WE RECEIVED A TCASII ALERT AND THE APCH CTLR ADVISED US WE HAD MISSED THE TURN ONTO THE COURSE. HE HAD A PERTURBED SOUND IN HIS VOICE (AS EXPECTED). AT THAT MOMENT WE GOT THE RA ALERT TO 'DSND.' HE THEN CANCELED OUR APCH RWY 26R CLRNC AND INSTRUCTED US TO MAINTAIN 5000 FT. WE HAD BEEN CLRED TO 4000 FT SO WE WERE DSNDING ALMOST 2600 FPM. AT THAT MOMENT I WAS NOW MORE CONCERNED ABOUT MISSING THE TFC THAT, ACCORDING TO OUR TCASII, WAS INDICATING 5000 FT I DON'T KNOW WHY THE CTLR ASSIGNED US THE SAME ALT, THAT PLAINLY COULD HAVE CAUSED AN ACCIDENT. THE CTLR NEVER DID ACKNOWLEDGE THE FACT THAT THE SINGLE ENG WAS EVEN THERE! DID HE KNOW?? IF SO, WHY DIDN'T HE ISSUE IT AS ADVISORY TFC?? IF SO, WHY DID HE ISSUE AN ALT THAT WOULD CAUSE MORE CONFLICT? WE DSNDED DOWN TO ABOUT 4600 FT MSL TO COMPLY WITH THE RA ALERT. I TOLD THE CTLR WE HAD TFC TO AVOID, AND ALL HE SAID WAS, 'WELL YOU'RE 4 MI S OF THE ARR!' HE STILL DID NOT MAKE MENTION OF THAT ACFT. WE REJOINED THE LOC AND LANDED UNEVENTFULLY. I WILL BE MORE AGGRESSIVE IN TAKING THE ACFT SOONER IN THE FUTURE. SUPPLEMENTAL INFO FROM ACN 365031: WE RECEIVED A TA/RA AND VISUALLY ACQUIRED A C182RG AT 2 O'CLOCK POS.

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  12. Accession Number: 367140
    Synopsis: ACR FO RPT ON HIS PIC'S ATTITUDE AND FLYING TECHNIQUE DURING ONE PARTICULAR ALTDEV.
    Narrative: ATC INSTRUCTED OUR FLT TO DSND IMMEDIATELY (FROM FL370) TO FL310 FOR TFC, EXPEDITE DSCNT. I ACKNOWLEDGED, 'ACR FLT XYZ LEAVING FL370 FOR FL310, WHERE IS TFC.' ATC'S DEPICTION ON THE TFC INDICATED THIS WAS FOR TFC SEPARATION (20 NM AT 9 O'CLOCK) AS OPPOSED TO AN IMPENDING MIDAIR. CAPT USED VERT SPD TO DO THE DSCNT. OUR PROC IS NOT TO USE 'VERT SPD' FOR ANYTHING BUT NON PRECISION APCHS BECAUSE IT CAN TAKE YOU AWAY FROM YOUR SELECTED ALT AS WELL AS TOWARDS IT. THIS CAPT HAD BEEN DIFFICULT TO FLY WITH OVER THE PAST 3 DAYS (THIS WAS THE LAST DAY OF A EWR-BOGOTA-QUITO-BOGOTA-EWR PAIRING). HE WAS CONSTANTLY, A) TALKING IN STERILE PERIOD, B) INVENTING NON STANDARD PROCS WITH PRESSURIZATION, FMC, ETC. HAD I NOT FORCIBLY PROTESTED HE WOULD HAVE HAD FLT ATTENDANT IN THE JUMP SEAT TO OBSERVE LNDG AT NIGHT IN QUITO. IN SHORT, I HAD A HEADACHE FROM MONITORING THIS IDIOT. I OBSERVED AUTOPLT NOT ACQUIRING FL310. I CALLED OUT 'IT'S NOT STOPPING AT FL310.' 200 FT BELOW I VERBALIZED MORE FORCEFULLY AND TOLD HIM TO CLB. HE ALLOWED ACFT TO DSND TO FL306 AND THEN GRADUALLY 'VERT SPEEDED' IT BACK TO FL310. HE LET IT STAY AT FL306 FOR 20-30 SECONDS (SEEMED LIKE AN ETERNITY). POSSIBLY HE WAS MISTAKENLY CONCERNED ABOUT PAX COMFORT PERCEPTIONS IN AN ABRUPT CORRECTION. IN SIMILAR SITS MY PRIORITY IS TIMELY CORRECTION, EVEN AT THE EXPENSE OF A SPILLED CUP OF COFFEE. I FINALLY SHOUTED, 'CLB, CLB, GET THIS BLANKETY BLANK ACFT BACK TO FL310!!' MY MISTAKE WAS NOT TAKING THE CTLS 200 FT BELOW BY PUNCHING OFF THE AUTOPLT. I WAS JUST TOO WORN DOWN BY 30 DAYS OF DEALING WITH OVER-SIZED EGO AND CONSTANTLY RIDING HARD ON HIS 'HIP-POCKET' PROCS. I ASKED HIM IF HE KNEW WHY THE EVENT HAPPENED AND HE REPLIED 'I DON'T KNOW.' IT WAS BECAUSE HE MANIPULATED 'VERT SPD' AFTER 'ALT ACQUIRE.' I HAD FLOWN WITH THIS INDIVIDUAL ONCE IN OCT 1995 WHEN HE MADE IT INTO THE SELECT GROUP OF THOSE 'I BID AROUND.' HE HAS NOW GRADUATED TO THE SMALLER GROUP THAT, IF I SEE THEM IN THE COCKPIT AND MY FAMILY IS PASS RIDING, I PULL MY FAMILY OFF THE ACFT.

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  14. Accession Number: 367190
    Synopsis: MD80 SUPER 80 DSNDED 300 FT BELOW ASSIGNED ALT WHEN AUTOPLT FAILED TO CAPTURE ALT. AUTOTHROTTLES WERE INOP.
    Narrative: UPON DSNDING FROM FL350 TO FL240 THE FO TURNED OFF THE AUTOTHROTTLES. AUTOPLT TRIED TO LEVEL OFF BUT IT APPEARED THAT IT WAS GOING TO GO BELOW FL240. AUTOPLT WAS TURNED OFF, AND ACFT WAS HAND FLOWN TO LEVELOFF. I BELIEVE THIS WAS DUE TO TURNING OFF AUTOTHROTTLE DURING LEVELOFF. THE AUTOPLT COULD NOT LEVEL SMOOTHLY OR AT ASSIGNED ALT WITHOUT AUTOTHROTTLE ON.

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  16. Accession Number: 368850
    Synopsis: AN ACR B757 CAPT RPTS MAKING A FIRM LNDG AT SNA. HE WAS NEW TO THE ACFT AND CONCERNED ABOUT THE SHORT RWY AND UNUSED TO USING AUTOBRAKES.
    Narrative: DURING CHKOUT IT IS NOT POSSIBLE TO SAY FOR CERTAIN MY IOE. IT IS DIFFICULT TO SAY FROM AN EXPERIENCE STANDPOINT IF THE LNDG WAS FIRM OR NOT. I CAN SAY THAT IN VIEW OF THE SHORT, VERY SHORT RWY AVAILABLE THAT I WAS CONCERNED TO FOLLOW ACR PROCS. THE ACFT WAS STABILIZED IN THE SLOT AND ON SPD AND OFF AUTOPLT AS SOON AS THE RWY WAS VISIBLE BELOW THE OVCST, ABOUT 1000 FT. I WAS CONCERNED ABOUT THE UNUSUALLY SHORT RWY ABOUT 4800 FT BEYOND GS AND THEREFORE USED AUTOBRAKES #4 AND WAS DETERMINED TO NOT FLOAT WHILE LOOKING FOR THE PERFECT LNDG. IN ACCORDANCE WITH NORMAL PRACTICE IN A SHORT FIELD SIT I BROKE THE DSCNT AND TOUCHED DOWN FINE, BUT LACK OF EXPERIENCE WITH THE APPLICATION OF THE AUTOBRAKES #4 COUPLED WITH THE CONCERN OVER A TAILSTRIKE, CAUSED THE NOSE TO COME DOWN TO THE RWY FASTER THAN I WOULD HAVE LIKED. WHILE TRYING TO STOP THE SUDDEN NOSE PITCH-DOWN, I APPLIED ADDITIONAL BACK PRESSURE CAUSING THE NOSEWHEEL TO POSSIBLY BOUNCE ONCE THEREBY CAUSING A ROCKING SENSATION IN THE ACFT. IN RETROSPECT, I SHOULD HAVE BRIEFED THE PAX OF THE DIFFERENT LNDG TECHNIQUE REQUIRED FOR THE LNDG JUST AS WE DO FOR THE TKOF FROM SNA. ALSO I NOW HAVE MORE EXPERIENCE IN WORKING WITH AUTOBRAKES POS #4 AND WILL BETTER ANTICIPATE THE PITCHDOWN CHARACTERISTIC CAUSED BY THE BRAKE APPLICATION IN ORDER TO PREVENT NOSE BOUNCE.

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  18. Accession Number: 371330
    Synopsis: DC10 CREW OVERSHOT THEIR ASSIGNED ALT IN DSCNT WHEN THE FO, PF, ACTIVATED THE AUTOPLT VERT SPD CTL WHEEL, THEREBY DISCONNECTING THE AUTOPLT'S ALT AUTO CAPTURE FEATURE. FO WAS NEW TO DC10 OP. THE SO ALERTED THE REST OF CREW TO THE OVERSHOOT.
    Narrative: CTR CLRED ACFT FROM FL370 TO FL330. FO FLYING, AND THIS WAS HIS FIRST FLT AFTER IOE. I, CAPT, WAS LOOKING AT THE ARR PLATE DURING DSCNT (BDF3). WE DSNDED TO FL323 BEFORE THE FE CALLED ALT. I HAD SET AND ARMED FL330, CALLED THE SETTING AND THE FO HAD ACKNOWLEDGED THE SETTING AS PER COMPANY POLICY. I BELIEVE THE FO MOVED THE VERT SPD WHEEL AFTER ALT CAPTURE WAS ANNUNCIATED, WHICH ON THE DC10 REMOVES ALT PROTECTION IN AUTOPLT MODE. THE CTR SAID NOTHING, AND WE QUICKLY CLBED BACK TO FL330. I DO NOT BELIEVE THE ALT TRANSGRESSION WAS UNOBSERVED.

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  20. Accession Number: 371630
    Synopsis: FLC OF ACR FAILS TO MAKE XING RESTR DUE TO INABILITY TO QUICKLY LOCATE THE INTXN. RECEIVED VECTOR UPON INFORMING ATC AND WHILE COMPUTING APCH SPDS FLC DSNDED BELOW ASSIGNED ALT.
    Narrative: FO FLYING LEG FROM PVD-BWI. GIVEN CLRNC TO CROSS TROYZ INTXN ON V378 AT 12000 FT. AFTER FINDING THE LOCATION FOR TROYZ (NON FMS EQUIPPED) WE WERE LATE IN GETTING DOWN. FO DEPLOYED SPD BRAKE, TOOK AUTOPLT OUT OF PMS MODE TO CWS MODE AND WAS MAKING RAPID DSCNT. I NOTIFIED ZNY THAT WE WERE UNABLE TO MEET THE RESTR. CTR TURNED US TO THE R. MY ATTN WAS DISTR WHILE GETTING APCH SPDS AND WHEN I LOOKED UP WE WERE DSNDING THROUGH 12000 FT. I TOLD THE FO '12000 FT, 12000 FT.' AND BEFORE HE COULD ARREST THE DSCNT, WE REACHED 11600 FT. PRIMARY FACTORS WERE A CLRNC THAT REQUIRED AN IMMEDIATE DSCNT AND THE FO TAKING THE AUTOPLT OUT OF A MODE THAT WOULD HAVE LEVELED THE ACFT AT 12000 FT.

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  22. Accession Number: 379502
    Synopsis: NAV ERROR. FO ON A B727-200 RPTS ON THE INACCURACY OF THE OMEGA SYS IN USE THAT DAY FROM BOS TO ARUBA. BY THE TIME THEY ARRIVED AT ZMA CTL AREA THEY WERE SOME 85 MI W OF PLANNED COURSE. FO CITES THE CAPT AS BEING PARTLY RESPONSIBLE FOR NOT INSURING A LAND DEP POINT FOR AN ACCURACY CHK OF THE OMEGA.
    Narrative: TO BEGIN WITH, THE FLT PLAN RTE NEEDS TO BE STATED. I FEEL THE INITIAL FAILURE TO FLY THE FLT PLAN RTE MAY HAVE LED TO THE EVENT. DEP POINT: BOS. ARR POINT: ARUBA. FLT PLAN/CLRNC: LOGAN 1 LUCOS SEY 067 SEY DIRECT HTO DIRECT RANCO DIRECT KUPEC A554 LAMER DIRECT SEKAR DIRECT PTA UW7 BEROX A567 TNCA. THE ACFT LONG RANGE NAV SYS IS OMEGA. A STANDARD PRACTICE WHEN USING OMEGA IS TO POSITIVELY FIX THE POS BY OVERFLYING A VOR OR NDB PRIOR TO GOING ON AN OCEANIC RTE. THIS IS WHERE I BELIEVE THE PROB INITIALLY OCCURRED. UPON REACHING LUCOS INTXN ON THE LOGAN 1 DEP FROM BOS, ZBW CLRED THE FLT DIRECT TO RANCO INTXN. THE CAPT OF THE FLT ACCEPTED THIS CLRNC. I QUESTIONED WHETHER WE SHOULD ACCEPT THIS BECAUSE WE NEEDED TO GO OVER A GATE AND POSITIVELY FIX OUR POS WITH THE OMEGA. WHAT FOLLOWED WAS A RATHER INTENSE DISCUSSION OVER WHAT WAS THE CORRECT AND PROPER PROC WHEN FLYING WITH OMEGA. THE CAPT'S ARGUMENT WAS THAT HIS MAP AND PLOTTER SHOWED THAT THE OMEGA COURSE AND DISTANCE WERE INDEED CORRECT. I COULD NOT ARGUE WITH THIS EXCEPT TO SAY THAT WITHOUT A POSITIVE FIX ON THE OMEGA, THE SYS TENDED TO WANDER. AFTER WE BEGAN TO GO DIRECT RANCO, I COUPLED THE AUTOPLT TO THE OMEGA. UPON REACHING RANCO, WE TRIED TO TRIANGULATE THE POS WITH BEARINGS FROM HTO AND SIE VORS. THESE BEARINGS SHOWED THE ACFT TO BE A LITTLE W AND S OF COURSE, COMPARED TO THE OMEGA. WE CORRECTED FOR THESE INDICATIONS AND THEN PROCEEDED TO FLY DIRECT KUPEC-A554 ETC. IT MUST BE STATED HERE THAT AFTER RANCO, THE FLT LOSES RADAR CONTACT AND MUST MAKE POS RPTS. THE OMEGA AND AUTOPLT APPEARED TO BE OPERATING PROPERLY. EACH POS CAME WITHIN 2-3 MINS OF WHAT THE COMPUTER FLT PLAN SHOWED. WE GAVE OUR POS RPTS ACCORDING TO THE INFO OFF THE OMEGA AND XCHKED WITH THE FLT PLAN. APCHING LAMER INTXN ON A554, THE FLT WAS SUPPOSED TO CONTACT ZMA. AFTER INITIAL CONTACT, ZMA ASKED FOR AN IDENT. THEY PROCEEDED TO TELL US WE WERE 5 MI SE OF LETON INTXN. LETON IS APPROX 90 MI W OF LAMER. AT THIS POINT WE RPTED AN OMEGA VLF NAV FAILURE. WE WERE ABLE TO CONTINUE THE FLT VIA VOR NAV TO THE DEST. IN SUMMARY: I FEEL THE PROB AROSE BY NOT TAKING A POSITIVE FIX. BY NOT BEING IN RADAR CONTACT, THE FLT WAS NOT ABLE TO BE CORRECTED FOR COURSE ERROR. I BELIEVE THE OMEGA SYS IS TOO INACCURATE AND SHOULD NOT BE USED FOR LONG RANGE NAV. I BELIEVE THE CAPT'S LACK OF KNOWLEDGE ON THE OMEGA SYS ENHANCED A BAD JUDGEMENT ON HIS PART, IE, PROCEED DIRECT RANCO WITHOUT A POSITIVE FIX. I ALSO FEEL HIS INABILITY TO LISTEN TO THE CREW AND THEREFORE EXERCISE CRM CONTRIBUTED TO THIS EVENT.

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  24. Accession Number: 380520
    Synopsis: B737-300 ACFT ON STAR ARR. RPTR CAPT HAD FMC SET FOR NEXT DSCNT BUT WHEN DEVIATING AROUND WX IN HDG SELECT THE FMC CHANGED MODES TO LEVEL CHANGE AND COMMENCED DSCNT. RPTR CAUGHT IT AFTER 400 FT AND RETURNED TO ALT.
    Narrative: ON THE COAST 2 STAR INTO IAH, I WAS LEVEL AT 10000 FT AND 2 MI NW OF MACED INTXN. THE COAST 2 IS AN FMC ARR. I HAD THE AUTOPLT FLYING IN LNAV AND VNAV WITH 6000 FT SET IN THE MCP ALT WINDOW. THE WX WAS BROKEN CLOUD COVERAGE WITH NUMEROUS CUMULO NIMBUS ON THE ARR COURSE. I REQUESTED PERMISSION TO DEVIATE AROUND THE BUILDUPS AND PERMISSION WAS GRANTED. WHEN I SELECTED HDG SELECT TO GO L OF COURSE, THE FLT DIRECTOR COMMAND BARS WENT OUT OF VIEW AND THE MODE ANNUNCIATOR SHOWED CTL WHEEL STEERING PITCH. THIS CONFUSED ME AND I TRIED TO ENGAGE A PITCH MODE TO GET THE FLT DIRECTOR BACK AS I WENT AROUND THE BUILDUPS. AT THIS TIME, I SAW THE 6000 FT IN THE MCP WINDOW AND SELECTED LEVEL CHANGE. THE FLT DIRECTOR RETURNED AND THE ACFT STARTED TO DSND. SINCE THERE IS AN ALT RESTR AT MACED OF 10000 FT, I DISENGAGED THE AUTOPLT AND RETURNED THE ACFT TO 10000 FT. IT HAD DSNDED TO ABOUT 9600 FT. IT IS AN APPROVED PROC IN OUR OPS MANUAL TO PUT IN THE CORRECT ALT ON AN FMC ARR (IN THIS CASE 6000 FT), HOWEVER, THIS PRACTICE CAN GET PLTS IN TROUBLE IF THEY NEED TO DEVIATE FOR WX AND REFER TO MCP ALT FOR THE ALT THEY ARE CLRED TO, WHICH IS WHAT I DO ROUTINELY. IN THE FUTURE, I WILL NEVER PUT IN THE LOWER ALT UNTIL I AM AT THE DSCNT POINT FOR THE NEXT ALT.

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

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  28. Accession Number: 385322
    Synopsis: AN A320 ACFT ON VECTORS FOR ILS APCH. FLC HAS DIFFICULTY GETTING ACFT OUT OF 'MANAGED' MODE AND ACFT TURNS OPPOSITE DIRECTION FROM HDG DESIRED. FLC WAS ABLE TO CORRECT THE PROB. LOW TIME CAPT MAY HAVE CONTRIBUTED TO LACK OF UNDERSTANDING MANAGED VERSUS MANUAL MODES.
    Narrative: WE WERE BEING VECTORED WITH THE AUTOPLT ENGAGED FOR AN ILS APCH TO RWY 21R AT DTW. ON BASE LEG, TURNING R TO FINAL, WE WERE GIVEN HDG 120 DEGS AND WHILE TURNING TO THAT HDG, GIVEN HDG 160 DEGS TO INTERCEPT THE LOC. I SELECTED HDG 160 DEGS AND PUSHED THE 'LOC' PUSH BUTTON TO ARM THE FMGC FOR THE INTERCEPT. THE FLT DIRECTOR THEN IMMEDIATELY COMMANDED A L TURN AND THE AUTOPLT FOLLOWED IT. AFTER A SLIGHT 'REACTION TIME' DELAY WHILE I WENT THROUGH THE GLASS COCKPIT TROUBLESHOOTING SEQUENCE (WHAT'S IT DONE? WHY'S IT DOING THAT? HOW DO I MAKE IT STOP?), I PULLED THE HDG KNOB AND TURNED IT TO THE R, WHICH SHOULD HAVE CAUSED THE GUIDANCE SYS TO EXIT WHATEVER MODE IT HAD GONE INTO AND TURN TO THE SELECTED HDG. THIS DID NOT WORK, HOWEVER, AND THE ACFT CONTINUED IN THE L TURN. I THEN DISENGAGED THE AUTOPLT, DISREGARDED THE FLT DIRECTOR AND TURNED THE ACFT BACK TO THE R. THIS ALL TOOK PLACE IN JUST A FEW SECONDS, BUT IT WAS ENOUGH TO CAUSE AN OVERSHOOT ON WHAT WAS ALREADY A TIGHT INTERCEPT. ALSO, BECAUSE OF THE COMPRESSED SEQUENCE OF EVENTS, I DID NOT OBSERVE THE ANNUNCIATIONS ON THE FMA PANEL AND DON'T KNOW WHAT MODE THE FLT GUIDANCE SYS WENT INTO THAT CAUSED THE L TURN. WHEN WE GOT THINGS SORTED OUT WITH THE CTLR AND WERE ON AN INTERCEPT HDG FROM THE OTHER SIDE OF THE LOC, THE FLT DIRECTOR CONTINUED TO COMMAND A L TURN, IN SPITE OF REPEATED ATTEMPTS BY THE FO TO SELECT A HDG TO THE R. THE SELECTED HDG SHOWED IN THE WINDOW BUT THE 'MANAGED NAV' DOT WOULD NOT GO OUT. WE ARMED FOR THE APCH BY PUSHING THE 'APPR' PUSH BUTTON AND THE FLT DIRECTOR THEN SUCCESSFULLY CAPTURED THE LOC AND SEEMED TO RETURN TO NORMAL OP. AFTER LNDG WE WROTE UP THE FLT GUIDANCE SYS, BUT AS I WRITE THIS, I AM AT A LOSS TO EXPLAIN WHAT HAPPENED. THE L TURN SHOULD NOT HAVE BEEN COMMANDED, AND THE MANAGED NAV MODE SHOULD HAVE BEEN DISENGAGED BY SELECTING A HDG TO THE R. THE HDG SELECTED WAS ONLY ABOUT 40 DEGS OR 50 DEGS R OF THE PRESENT HDG, SO IT WAS NOT A CASE OF SELECTING A HDG CHANGE OF OVER 180 DEGS AND HAVING THE ACFT TURN THE SHORTEST DIRECTION. WITH ONLY 100 HRS IN THE ACFT, I DO NOT CONSIDER MYSELF AN AUTH, SO I AM GOING TO BRING THIS SIT UP TO THE 'EXPERTS.'

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  30. Accession Number: 386989
    Synopsis: AN MD11 MAKES AN APCH INTO SUBIC BAY, PHILIPPINES, AND PROGRAMS THE FMS IN ERROR. THE FLC ASSUMES THAT THE ACFT WILL FOLLOW AN OUTBOUND RADIAL, HOWEVER THE NAV SYS WILL NOT DO THAT AND THEY FLY OFF COURSE. APCH CTLR GETS THEM BACK ON COURSE.
    Narrative: THE PROB AROSE DUE TO CONFUSION BTWN FMS AND HARD VOR INFO RECEIVED. THE CAPT AND FO ARE NEW IN ACFT TYPE NEITHER ONE EVER HAVING FLOWN THE MD11. THE PROB WAS DISCOVERED WHEN THE FO QUESTIONED THE (TO) POINT ON FMS INFO. ACFT WAS NOT NAVING TO THE VOR AND OUTBOUND ON THE OUTBOUND RADIAL AS PROGRAMMED (OR THOUGHT TO BE). APCH QUESTIONED WHAT WE WERE DOING ON THE WRONG RADIAL WHEN WE SIMULTANEOUSLY FIGURED OUT WHERE WE WERE. CORRECTED OUR FLT PATH AND THE CAPT CONTINUED THE APCH AND LNDG WITHOUT FURTHER COMPLICATIONS. BOTH CREW MEMBERS ARE NEW IN THE ACFT AND FLYING IN UNFAMILIAR SURROUNDINGS. BUSY TIME OF FLT -- IE, CAPT WAS DOING AN APCH CHKLIST WHEN IT WOULD BE BETTER TO PAY ATTN. BACK SIDE OF CLOCK -- BOTH CREW MEMBERS TIRED.

  31.  
  32. Accession Number: 387216
    Synopsis: AN ACR B737 FLC HAD THE L STALL WARNING VANE BROKEN OFF BY THE JETWAY OPERATOR. THIS WAS DISCOVERED DURING TAXI OUT AND THE FLC RETURNED FOR MAINT, BUT THE MAINT TECHNICIANS IMPROPERLY USED THE MEL TO KEEP THE ACFT IN SVC.
    Narrative: WHEN DOING RECALL DURING TAXI FLOW AND CHKLIST WE NOTED A L ALPHA VANE LIGHT ILLUMINATED AND ALSO AN INTERMITTENT STICK SHAKER ON THE CAPT'S SIDE. AFTER CHKING CIRCUIT BREAKERS, WE CALLED MAINT CTL FOR HELP. WE PULLED AND RESET SEVERAL CIRCUIT BREAKERS, BUT CONDITION REMAINED. WE THEN RETURNED TO THE GATE AND AFTER BLOCK-IN, I OPENED MY WINDOW TO DISCOVER OUR ALPHA VANE HAD BEEN BROKEN OFF BY THE JETWAY PRIOR TO OUR ORIGINAL DEP. I INFORMED OUR MAINT CTLR AND THE LINE MECHS OF THE PROB. THE LINE MECHS SAID THEY FIGURED WE COULD MEL THE L STALL WARNING SYS AND BE ON OUR WAY. I TALKED TO OUR MAINT CTLR AND WAS TOLD WE COULD INDEED MEL THE L STALL WARNING SYS AND THE GPWS (WINDSHEAR WARNING). THE MECH SIGNED OFF OUR LOGBOOK AND I ENTERED A DELAYED PLACARD INSTALLATION IN REF TO THE MEL FOR THE STALL WARNING AND GPWS. WE DEPARTED EWR FOR CMH AND DURING LEVELOFF THE AUTOTHROTTLES DIDN'T REDUCE THE PWR FROM THE CLB SETTING. WE CALLED TO INFORM THEM OF THE SIT, THEN DURING DSCNT FLOW WE GOT AN AUTOSLAT FAIL LIGHT. WHEN WE BLOCKED IN AT CMH A TECHNICIAN CAME ON BOARD AND INFORMED US THAT WE SHOULD ALSO HAVE HAD SEVERAL OTHER MELS FOR OUR GIVEN PROB. MEL AAAA ANGLE OF ATTACK SENSOR, MEL BBBB AUTOTHROTTLE, MEL CCCC SPD BUG COMMAND, MEL DDDD AUTOSLAT, AND MEL EEEE L ANGLE OF ATTACK HEAT IN ADDITION TO THE MELS ALREADY IN PLACE. WHILE DISCUSSING THE PROB WITH THE CMH TECHNICIAN HE INFORMED THE FO AND I THAT A SIMILAR INCIDENT HAPPENED A COUPLE OF WKS EARLIER. AN ACFT HAD EXPERIENCED THE LOSS OF AN ALPHA VANE ENRTE TO CMH AND MAINT CTL TRIED TO HAVE THEM MEL JUST THE STALL WARNING AND GPWS. THE CMH TECHNICIAN CONVINCED THEM THAT THEY NEEDED THE OTHER MELS ALSO. IT SEEMS TO ME THAT A PROB EXISTS IN MAINT CTL THAT HAS YET TO BE RECTIFIED. IN SUMMARY, THE PROB STARTED WITH A CARELESS JETWAY OPERATOR IN EWR AND WAS FURTHER COMPLICATED BY IMPROPER MEL APPLICATION. IN ADDITION THE PROPER MEL AAAA WAS EXTREMELY HARD TO FIND AS IT IS LOCATED UNDER THE AUTOFLT SECTION OF THE TABLE OF CONTENTS.

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  34. Accession Number: 390899
    Synopsis: FO OF AN AIRBUS A320 OVERSHOT XING ALT DURING SID DEP RESULTING IN ATC PROVIDING THE NEXT 1000 FT HIGHER ALT THAT WAS ALSO OVERSHOT. THE PROB WAS DUE TO THE CAPT'S UNFAMILIARITY WITH THE FMS TO OBTAIN DESIRED RESULTS AND THE FO DISCONNECTING THE AUTOPLT TO FLY THE ACFT MANUALLY. BOTH CREW MEMBERS WERE UNFAMILIAR WITH THE SID.
    Narrative: CLBING OUT OF SJC ON RWY HDG, DANVILLE 1 DEP, CTLR CLRED US TO FL230, TURN R DIRECT TO SJC AT OUR DISCRETION TO MAKE XING AT SJC AND MAINTAIN 250 KTS. ACCORDING TO OUR CALCULATIONS WE COMMENCED TURN TO MAKE SURE WE WOULD BE AT 12000 FT OVER SJC, THINKING THAT THE RESTR TO MAINTAIN 12000 FT HAD BEEN DELETED WHEN WE WERE CLRED TO FL230. ACFT CLBING OUT IN MANAGED NAV AND EXPEDITE CLB, VERT ASCENT WAS QUITE HIGH. ONCE WE ASCERTAINED THAT WE WOULD MAKE THE 12000 FT MANAGED VERT WAS SELECTED, BUT ACFT OVERSHOT THE 12000 FT ALT. PF WAS THE FO. HE DISCONNECTED THE AUTOPLT IN ORDER TO RECOVER TO 12000 FT. I QUESTIONED THE CTLR ON WHETHER WE WERE TO CROSS SJC AT 12000 FT, OR AT OR ABOVE 12000 FT AND CLB TO FL230. HE CONFIRMED THAT WE WERE TO CROSS AT 12000 FT, BUT SINCE WE WERE ALREADY ABOVE 12000 FT TO CONTINUE CLB TO 13000 FT. THE FO HAD HIS HANDS FULL, TRYING TO HAND FLY THE ACFT MAINTAINING 13000 FT AND THE RESTR AIRSPD OF 250 KTS. WHEN ACFT WAS IN EXPEDITE CLB, AIRSPD AND ALT RESTRS IN THE MCDU WERE NEGATED. DUE TO MY RECENCY OF EXPERIENCE IN THIS ACFT, NOT BEING USED TO THIS PARTICULAR DEP, AND BEING REQUESTED TO ACCOMPLISH SEVERAL COMMANDS WITH THE CONFUSION OF AN ALT CLRNC WITH OR WITHOUT THE SAME XING RESTR AS ON THE DEP, WAS SOMEWHAT OVERWHELMING TO THIS SHORT PERIOD OF TIME. MAYBE IN THE FUTURE THE CTLR COULD CONFIRM THE XING ALT THEN ADVISE OF A NEW CLRNC ALT.

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  36. Accession Number: 393530
    Synopsis: FLC OF LTT SF340 COMMUTER DURING CLB IS CLRED TO DSND TO A LOWER ALT. FO SETS THE NEW ALT IN THE PRESELECTOR. SINCE THEY ARE ABOVE THE NEW ALT THE ACFT CONTINUES TO CLB. THEY CLB 1600 FT BEFORE THE ERROR IS CAUGHT. AS THEY DSND ATC CALLS TO QUERY ALT.
    Narrative: DURING OUR CLB TO 15000 FT (WE HAD NOT YET LEVELED OFF) THE CTLR ISSUED A CLRNC FOR US TO DSND TO 11000 FT AT PLT'S DISCRETION. THE FO SELECTED 11000 FT IN THE ALT PRESELECTOR (USED BY THE AUTOPLT AND FLT DIRECTOR SYS TO LEVEL OFF THE ACFT). I LET MYSELF BECOME DISTRACTED AND DID NOT PAY ATTN TO THE FO'S ACTIONS. THE ACFT CONTINUED ITS CLB (SINCE 11000 FT WAS SELECTED IN THE ALT PRESELECT, AND WE WERE AT AN ALT ABOVE 11000 FT, THE AUTOPLT WOULD NEVER LEVEL US OFF). WHEN I LOOKED UP FROM READING THE MEL BOOK, WE WERE CLBING THROUGH 15600 FT. I IMMEDIATELY INITIATED A DSCNT TO 11000 FT. I BROKE A BASIC RULE, FLY THE AIRPLANE FIRST. ANYTHING ELSE COULD HAVE BEEN ACCOMPLISHED ONCE IN CRUISE FLT OR ON THE GND. I ALSO ASSUMED THAT THE FO HAD A BETTER UNDERSTANDING OF THE AUTOPLT. I SHOULD HAVE BEEN PAYING ATTN, I AM THE CAPT AND WAS THE PF.

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  38. Accession Number: 396750
    Synopsis: FLC OF B767 IS ISSUED A XING RESTR WHICH THEY FAIL TO MEET. FMS PROGRAMMING WAS INCORRECT.
    Narrative: GIVEN A XING RESTR TO DSND TO FL310 FROM FL390 BY 70 MI W OF JNC. ACFT HAD JUST PASSED JNC AND SO JNC WAS NOT IN THE FMS ANYMORE. I LOOKED AT THE FLT PLAN AND LOOKED ON THE WRONG LINES TO FIGURE WHERE 70 MI FROM JNC WOULD BE IN RELATIONSHIP FROM THE NEXT POINT ON THE FLT PLAN (HELPR). I SET UP THE DSCNT TO ARRIVE EARLY. WELL, MY CALCULATION WAS INCORRECT AND I WAS STILL BTWN FL330-320 WHEN AT 70 MI W OF JNC. CTR CALLED AND INFORMED ME OF THE SIT AFTER THE FACT. THEY SAID THAT THERE WAS NO CONFLICT. I LEARNED HOW TO PROPERLY FIGURE THESE PROBS OUT FOR FUTURE USE. I LEARNED A GOOD LESSON. I'M FAIRLY NEW TO THE B767 AND FMS WORK. IT WON'T HAPPEN AGAIN.

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

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  42. Accession Number: 399600
    Synopsis: MLG ACFT IN CRUISE WAS OFF COURSE DUE TO MISPROGRAMMING FMC. CTR CTLR INTERVENED AND ISSUED NEW CLRNC.
    Narrative: WE HAD JUST PASSED HPW. ZDC SAID WE WERE OFF COURSE, TO TURN L 180 DEG HDG. WE DID AND THERE WAS NO TFC CONFLICT. HE ASKED IF WE HAD BEEN CLRED TO ARGAL, WE SAID YES. I TOLD HIM WE HAD OUR RELEASE, PDC CLRNC SAID AFTER HPW, ARGAL 4 TO RDU. I CHKED THE RTE ON THE FMCS AND IT SHOWED AFTER HPW, ARGAL 4. THE FO WAS NEW. WHEN ENTERING THE RTE LGA-RDU1, HE WENT TO DEP ARR PAGE AND RE-ENTERED ARGAL 4. WHEN THE TRANSITION CAME UP, IT SHOWED 'ACTIN.' HE PUSHED 'EXEC.' THIS DROPPED OUT THE HPW TRANSITION TO THE ARGAL 4 AND LEFT A RTE DISCONTINUITY. HE WENT BACK TO THE RTE PAGE AND BROUGHT ARGAL TO HPW. THIS WAS WRONG BECAUSE IT DROPPED OUT THE HPW TRANSITION. WHEN I CHKED OUR RTE, IT LOOKED CORRECT BECAUSE AFTER HPW, ARGAL 4 WAS SHOWN, AND THAT WAS CORRECT ON THE RTE PAGE. THE ERROR COULD HAVE BEEN FOUND ON THE LEGS PAGE. THE FO COULD HAVE TOLD ME HE WAS UNSURE ABOUT ENTERING THE RTE.

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  44. Accession Number: 399890
    Synopsis: B767-200 ACFT ON STAR ARRIVAL WAS GIVEN A NEW STAR. FLT CREW PROGRAMMED FMS FOR THE NEW ARRIVAL, BUT DIDN'T MAKE THE CROSSING RESTRICTION ON THE NEW ARRIVAL.
    Narrative: APPROACHING CIVIT INTXN OUR ARRIVAL WAS CHANGED FROM THE CIVET TO THE MITTS ARRIVAL WITH INSTRUCTIONS FOR INTERCEPTING THE RWY 24R LOCALIZER. THE FMS WAS PROGRAMMED (I THOUGHT) FOR THE MITTS AND WE WERE CLRED FOR THAT ARRIVAL. APPROACHING MITTS INTXN, MY CO-PLT ADVISED ME THAT IT LOOKED AS IF THE ACFT WAS NOT PROPERLY DSNDING. I CHECKED THE HSI AT THE SAME TIME AS A FLT ATTENDANT ENTERED THE COCKPIT AND I MISINTERPRETED THE DISPLAY AS BEING OK. IT WASN'T. WE CROSSED MITTS ABOUT 600 FT HIGH. I REESTABLISHED THE CORRECT VERT PATH AND NOTICED THAT THE 'EXEC' LIGHT ON THE FMS WAS ILLUMINATED. THIS ARRIVAL IS A RELATIVELY NEW AND NOT OFTEN USED PROC. THIS INCIDENT RESULTED FROM THE LAST MINUTE CHANGE IN ARRIVAL, A POSSIBLE ERROR IN PROGRAMMING THE FMS, AN INTERRUPTION IN THE COCKPIT, AND MY UNFAMILIARITY WITH THE PROC.

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  46. Accession Number: 400910
    Synopsis: AN ACR MD80 FLC DSNDED BELOW THEIR ASSIGNED ALT WHEN THE FLC INADVERTENTLY SWITCHED THE MODE OF THE AUTOFLT SYS AFTER IT HAD GONE TO THE CAPTURE MODE AT A HIGH RATE OF DSCNT. THE CAPT FAILED TO MONITOR THE EFFECTS OF THE CHANGE HE INITIATED IN THE SYS AND THE FO DID NOT MONITOR THE ACFT DURING A CRITICAL PHASE OF FLT.
    Narrative: WE WERE BEING VECTORED FOR A VISUAL APCH TO RWY 21 AND WERE QUITE HIGH. WE WERE BEING STEPPED DOWN FROM 9000 FT TO 7000 FT, BEING ASSIGNED HEADINGS AND LOOKING FOR THE ARPT. AFTER SETTING AND CONFIRMING THAT 7000 FT HAD BEEN SET, BOTH PLTS TURNED OUR ATTN BACK OUTSIDE THE ACFT. SPOILERS AND SLATS EXTENDED WE WERE DSNDING RAPIDLY. I NOTICED THE ACFT WAS IN VERT SPD MODE AND AIRSPD WAS SLOWING. I REACHED UP AND SWITCHED THE ACFT TO IAS SINCE I THOUGHT THE VERT SPD MODE WAS LEFT OVER FROM THE INTERMEDIARY DSCNT TO 9000 FT AND THEN WHEN WE WERE RECLRED TO 7000 FT THE ACFT WAS ALREADY CAPTURING 9000 FT. WHAT I BELIEVE WAS ACTUALLY HAPPENING WAS WE WERE DSNDING SO FAST THAT THE ACFT WAS ALREADY CAPTURING 7000 FT, SO WHEN I HIT IAS I INADVERTENTLY CANCELED THE ALT CAPTURE. SINCE OUR ATTN WAS DIVERTED OUTSIDE, THE ACFT DSNDED THROUGH 7000 FT AND WE DID NOT CATCH IT UNTIL WE WERE ALREADY DSNDING THROUGH 6700 FT. WHEN WE REALIZED IT I IMMEDIATELY CLICKED OFF THE AUTOPLT, STOPPED THE DSCNT AND BEGAN A CLB BACK TO 7000 FT. ABOUT THAT TIME APCH QUERIED US ABOUT WHAT ALT WE WERE DSNDING TO AND I RESPONDED WE WERE LEVELING AT 7000 FT. HE THEN RECLRED US FOR 6000 FT. THERE DID NOT APPEAR TO BE ANY TFC CONFLICT AND APCH DID NOT MAKE ANY FURTHER MENTION OF OUR DSCNT.

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  48. Accession Number: 401142
    Synopsis: AN ACR B757 FLC EXPERIENCES A MAP SHIFT THAT WAS APPARENTLY CAUSED WHEN THE IRS SYS WERE NOT ALLOWED TO UPDATE THEMSELVES DUE TO FLC MISOP OF THE NAV RADIOS.
    Narrative: ON THE PDZ2 ARR IN THE VICINITY OF THE ARNES INTXN WE EXPERIENCED A MAP SHIFT ON THE FO'S FMC. CAPT WAS IN EXPANDED ILS AND THE FO WAS IN AUTO MODE. FO SWITCHED TO MANUAL MODE AND DEV TO ASSIGNED CLRNC OCCURRED. CALLED DISPATCH DESK IMMEDIATELY AFTER ARR AND TOLD DISPATCHER OF THE ABOVE. CAPT WAS TUNED TO LAX RWY 25L LOC. NO REF ON THE FO'S RECEIVER AT TIME OF SHIFT.

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  50. Accession Number: 401200
    Synopsis: AN ACR CL65 FO RPTS THAT THE CAPT HAD PROGRAMMED THE FMC TO FLY THE WRONG RTE BY ENTERING A DIRECT RTE VS THE STAR RTE TO THEIR DESTINATION.
    Narrative: CAPT WAS FLYING THIS LEG FROM CVG-MCO. ROUTING TOOK US FROM SZW VOR TO PIE VOR AND THEN THE MINEE 3 ARR INTO MCO. THIS IS AN UNUSUAL ROUTING FOR US, AND CAPT HAD MANUALLY PROGRAMMED THE FMS FOR THIS FLT. MY SUSPICION IS THAT AFTER PIE VOR, HE SIMPLY TYPED IN MINEE, AND SO THE FLT PLAN IN THE FMS HAD US FLY FROM PIE DIRECT TO MINEE INTXN AND THEN TO MCO. HE SHOULD HAVE SELECTED MCO ARRS, AND THEN SELECTED THE MINEE 3 ARR. THAT WAY, THE FMS WOULD HAVE PLANNED US TO FLY THE CORRECT ROUTING FOR THE MINEE ARR. WE DID NOT CATCH HIS ERROR AND AFTER PIE VOR, CTR ASKED US TWICE ABOUT OUR ROUTING. HE SAID THAT A COMPANY AIRPLANE HAD MADE THE SAME MISTAKE THE NIGHT BEFORE, AND THEY HAD ALMOST HAD A CONFLICT. WE DID NOT HAVE ANY CONFLICT (AS FAR AS I KNOW) AND NO EVASIVE ACTION WAS TAKEN. SUPPLEMENTAL INFO FROM ACN 401203: CTR TOLD US TO DSND TO CROSS PIE VOR AT FL210. BY THE TIME WE CROSSED PIE VOR WE WERE STILL DSNDING THROUGH FL225 ON THE WAY TO FL210. I QUERIED THE CAPT ABOUT THE XING RESTR ABOUT 10 MI BEFORE PIE VOR, AND HE REPLIED THAT HE WAS NOT AWARE OF ANY XING RESTR. HE DID NOT HEED MY ADVICE ON THE MATTER. ATC WAS BUSY AT THE TIME, SO I COULD NOT VERIFY THE SIT WITH THEM ON THE RADIO. THE NEXT TIME THIS OCCURS, I WILL BE MUCH MORE ASSERTIVE IN VERIFYING MY OPINIONS ABOUT THESE MATTERS.

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  52. Accession Number: 401425
    Synopsis: LGT ACFT ON STAR ARR AND DSNDING TO CAPTURE GS. RPTR FO, PNF, WAS INSTRUCTED BY CAPT TO RESET ALT ABOVE ACFT SO HE COULD CONTINUE IN 'OPEN DSCNT' TO CAPTURE GS, BUT THE FMA REVERTED TO VERT SPD. CAPT WANTED OPEN DSCNT SO WHEN RPTR SET IT THE ACFT REVERTED TO OPEN CLB, PWR INCREASING FOR CLB AND SPD INCREASED, OVERSPEEDING THE FLAP SETTING.
    Narrative: CAPT WAS HAND FLYING, AUTOTHRUST 'ON.' WHILE STEPPING DOWN ON THE CIVIT 4 ARR AT LAX AND TRANSITIONING TO THE ILS FROM ABOVE THE GS WE EXPERIENCED A FLAP OVERSPD. WITH 5000 FT SET IN THE ALT WINDOW AND IN 'OPEN DSCNT,' SLOWING AS ASSIGNED BY ATC AND DSNDING TO CAPTURE THE GS, THE PF TOLD ME TO SET THE ALT ABOVE OUR PRESENT ALT (SO THE ACFT WOULD CONTINUE DSNDING PAST 5000 FT TO CAPTURE THE GS). I DID THIS AND THE FMA REVERTED TO VERT SPD. I TOLD THE CAPT I'D GIVE HIM 1000 FT VERT SPD DOWN TO CAPTURE THE GS, THIS WAY THE FLT DIRECTOR WOULD MATCH WHAT WE WERE DOING. HE SAID HE DIDN'T LIKE THAT MODE, AND TO GIVE HIM OPEN DSCNT INSTEAD, SO I PULLED THE ALT KNOB TO DO SO, FORGETTING THAT I HAD SPUN THE ALT KNOB UP TO SOMETHING ABOVE OUR PRESENT ALT, AND NOT CHKING THE FMA AFTER DOING SO. IF I HAD CHKED THE FMA, I WOULD HAVE SEEN 'OPEN CLB.' THIS CAUSED THE ENGS TO SPOOL UP TOWARDS CLB PWR, RAPIDLY ACCELERATING US TO VFE +10 KTS. CONTRIBUTING TO THIS WAS OUR ENTRY INTO A CLOUD BUILDUP, FURTHER INCREASING OUR AIRSPD. ALSO, THE THROTTLES ON THIS ACFT DON'T MOVE IN THE AUTOTHROTTLE MODE (ONE LESS CLUE AS TO ENG THRUST TRENDS). THIS COULD BE PREVENTED BY 1) CONTINUING TO STEP THE ALT DOWN UNTIL GS CAPTURE, 2) NEVER TOUCHING THE FLT CTL UNIT UNTIL TOLD TO DO SO BY THE PF, 3) ALWAYS CHKING THE FMA'S (FLT MODE ANNUNCIATOR) AFTER AN FCU INPUT.

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  54. Accession Number: 402700
    Synopsis: A COMMUTER FLC ALLOWS THEIR ACFT TO DSND BELOW THE GS WHEN THEY FAIL TO REALIZE THAT THE GS AUTO CAPTURE IS NOT FUNCTIONING.
    Narrative: I WAS THE PF (THE FO) AND THE CAPT WAS THE PNF. AT ABOUT 10 DME ON THE RWY 28R LOC AT PDX WE WERE 'CLRED FOR THE APCH' AND TO MAINTAIN 2500 FT UNTIL ESTABLISHED ON THE LOC. I WAS ALREADY DSNDING AND IN THE DSCNT MODE OF THE AUTOPLT PRIOR TO THE CLRNC AND SELECTED THE 'APCH' MODE ON THE AUTOPLT ONCE CLRED FOR THE APCH. THE AUTOPLT WAS ALREADY CAPTURED ON THE LOC AND THE GS WAS ARMED. THE AUTOPLT CONTINUED TO DSND BELOW THE GS AND THEREFORE DID NOT CAPTURE IT. I DID NOT UNDERSTAND FULLY THE MODE OF THE AUTOPLT AND THAT IT WOULD NEVER CAPTURE ONCE SELECTING 'APCH.' I ASSUMED IT WAS CAPTURED WHEN I SAW THAT WE WERE A DOT BELOW AND CALLED FOR GEAR DOWN, BEFORE LNDG CHKLIST. THE CAPT PROCEEDED WITH THE CHKLIST AND WHEN HE RETURNED TO THE INSTS WE WERE 2 DOTS LOW AT 1900 FT. I PUT TOO MUCH EMPHASIS ON OTHER INSTS AND TOO MUCH TRUST OF THE AUTOPLT THAT IT HAD CAPTURED THE GS. THE CAPT CALLED FOR IMMEDIATE PWR AND TO CLB. ATC THEN ISSUED A LOW ALT RPT. WE RETURNED TO THE GS, BROKE OUT OF THE CLOUDS AND LANDED VISUALLY. I WAS LOW TIME IN THE ACFT AND GOT TOO BUSY MONITORING OTHER INSTS ASSUMING THE AUTOPLT WAS CAPTURED. WE THOROUGHLY DISCUSSED THOSE ISSUES AND THE MODES OF THE AUTOPLT WHEN WE RETURNED TO THE GATE. NO GPWS WARNINGS WERE RECEIVED AND ATC ACTED ACCORDINGLY IN THE INTEREST OF SAFETY AFTER WE REALIZED THE DEV. SUPPLEMENTAL INFO FROM ACN 402958: THE FO WAS LOW TIME IN THE ACFT AND TOTAL TIME. THOUGH A QUICK LEARNER, WITH AN EXCELLENT ATTITUDE, EXPERIENCE WAS A FACTOR WITH THE SIT. FAILURE TO OBSERVE AND CORRECT GS DEV OCCURRED WHILE ASSUMING THE AUTOPLT WAS COUPLED.

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  56. Accession Number: 402840
    Synopsis: FLC OF A B737-500 OVERSHOT ASSIGNED HOLDING FIX DURING ENRTE DSCNT DUE TO DISTR OF PROGRAMMING THE FMC FOR THE FIX. ATC WAS NOTIFIED OF THE MISTAKE AND THE CREW RETURNED TO THE FIX IMMEDIATELY.
    Narrative: FO WAS PF, SAT-IAH. DURING THIS LEG, CTR GAVE US A HOLD 70 MI OUT OF R234, IAH WHILE WERE ON THE GLAND 7 STAR. WE WERE APPROX 13 MI FROM THIS POINT (NOT A CHARTED FIX) WHEN WE RECEIVED THE HOLD. I SET RAW DATA ON MY SIDE AND PROCEEDED TO ASSIST THE FO IN SETTING UP A HOLD ON THE FMC. I WAS ENGROSSED IN HELPING THIS SETUP (AND ATTEMPTING TO KEEP FO'S FINGERS FROM PUNCHING THE WRONG BUTTONS) THAT I FLEW PAST THE HOLDING POINT. I NOTIFIED ATC AND QUICKLY RETURNED TO THE FIX. WE EXECUTED THE HOLD VIA THE NOW SET UP FMC, FOLLOWING IT WITH RAW DATA TO ENSURE ACCURACY. FO WAS UNABLE TO ACCOMPLISH SOME IMPORTANT TASKS RELATING TO FMC WORK ON THE B737-500. MY ERROR WAS IN ATTEMPTING TO 'TEACH' THIS FO, RATHER THAN SIMPLY PAYING ATTN TO THE RAW DATA AND 'FLYING THE AIRPLANE.'

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

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  60. Accession Number: 407350
    Synopsis: B747 CREW ENTERS WARNING AREA WITHOUT CLRNC IN ZOA AIRSPACE.
    Narrative: HAVING BEEN OFF FOR OVER 50 DAYS AND HAVING ONLY USED THE LITTON-92 FOR NAV 4 TIMES IN THE PAST I ARRIVED EARLY AND WITH THE FO COMPLETED A THOROUGH PREFLT LOADING AND RECHK OF THE WAYPOINTS IN THE NEW LITTON-92 INERTIAL NAV SYS. TKOF WAS AT XX25Z AND WAS ASSIGNED THE MOLEN TWO (MOLEN2.MOLEN) DEP. THE FO CONTACTED BAY DEP CTL AND AFTER WESLA INTXN I TRANSITIONED TO THE SFO 287 DEG RADIAL (V199) OUT TO MOLEN INTXN. WE WERE HANDED OFF TO ZOA. JUST AS I WAS TUNING THE 156 DEG RADIAL OF ENI WE WERE THEN CLRED DIRECT TO KENNT INTXN. I SWITCHED ON THE AUTOPLT AND PRESSED THE DIR KEY ON THE LITTON-92 THEN TYPED THE FIRST LETTER OF THE WAYPOINT. THE CDU DISPLAYED KENNT ON LINE 4 (HERE IS MY ERROR), I THEN PRESSED ENT AND WAS ASKED TO CONFIRM 'K' N 48 DEG 38.46 E 21 DEG 14.00 SLAVIC. SO I REPEATED THE PROCESS WITH THE SAME RESULTS, DURING THIS TIME ZOA CALLED AND ASKED IF WE WERE PROCEEDING TO KENNT. NOW I HAD JUST SPENT ABOUT 40 MINS GOING THROUGH EVERY WAYPOINT ON OUR RTE. I ANSWERED THAT I WAS GETTING SOME WAYPOINT IN YUGOSLAVIA. I THEN BEGAN TYPING IN KENNT ON THE DIRECT PAGE, WHICH IS COMPLICATED BY THE FACT THAT ALL THE KEYS ON THE LITTON-92 HAVE AT LEAST TWO AND SOME THREE DIFFERENT FUNCTIONS. AT THIS TIME ZOA CALLED SAYING THAT WE WERE GOING TO ENTER A WARNING AREA AND TO TURN TO A HDG OF 010 DEGS. I IMMEDIATELY TURNED THE ACFT. AFTER BEING HANDED OFF TO THE HIGH ALT SECTOR I ASKED THE CTLR IF WE HAD ENTERED THE WARNING AREA HE RESPONDED NO WE HAD NOT. AFTER ABOUT 45 MINS WE RECEIVED A SELCAL FROM SAN FRANCISCO COMMERCIAL RADIO ASKING THAT WE CALL ZOA. I USED THE SATELLITE PHONE ON THE ACARS AND ASKED CHICAGO DISPATCH TO PATCH US THROUGH. I WAS CONNECTED WITH A SUPVR WHO INFORMED ME THAT HE DIDN'T HAVE ANY DETAILS AND ASKED THAT I CALL BACK WHEN I ARRIVED AT MY DEST. I INFORMED HIM THAT I WOULD NOT BE LNDG UNTIL LATE. THE SUPVR THEN ASKED THAT I CALL BACK IN 1 HR AND HE WOULD HAVE THE DETAILS FOR ME. I CALLED BACK AS REQUESTED AND THE SUPVR INFORMED THAT WE HAD GONE 5 MI INTO W-260. I ASKED IF THERE HAD BEEN ANY TFC CONFLICTS CAUSED BY THIS AND WAS TOLD THAT THERE WAS NO CONFLICTING TFC.

  61.  
  62. Accession Number: 407480
    Synopsis: B737. ACFT FMC AUTOMATION DID NOT DO WHAT THE CAPT EXPECTED.
    Narrative: WE WERE IN CRUISE AT FL260 WITH A PLT'S DISCRETION DSCNT TO FL240, ASSIGNED 280 KTS. THE CAPT WAS FLYING WITH VNAV AND LNAV ENGAGED. ZMP TOLD US TO MAINTAIN 300 KTS. THE CAPT DESELECTED VNAV AND SET 300 KTS IN THE AIRSPD WINDOW. THE THROTTLES ADVANCED AND HE ASSUMED HE WAS ACCELERATING TO 300 KTS IN ALT HOLD. HOWEVER, WHEN VNAV IS DESELECTED AND THE ALT IN THE MCP WINDOW IS NOT THE SAME AS ON THE CRUISE PAGE (BECAUSE WE HAD A PLT'S DISCRETION TO FL240) OF THE FMC, THE AUTOPLT REVERTS TO CTL WHEEL STEERING PITCH. WHEN THE THROTTLES ADVANCED, THE AIRPLANE BEGAN A SLOW PITCH UP AND CLB. WE CLBED APPROX 700 FT BEFORE THE CAPT BEGAN A DSCNT TO FL240. THIS GOES BACK TO SOMEONE HAS TO BE FLYING THE AIRPLANE. THERE WERE SIGNIFICANT NOTAMS AT MSP INTL ARPT DUE TO RWY CONSTRUCTION, AND I WAS REVIEWING THEM AND REFERRING TO THE ARPT DIAGRAM. THE CAPT WAS REVIEWING THE ARR. THE AIRPLANE DID EXACTLY WHAT HE TOLD IT TO DO, BUT NOT WHAT HE WAS EXPECTING IT TO DO. WE LEARNED THAT AFTER YOU PUSH BUTTONS, MAKE SURE THE AIRPLANE IS DOING WHAT YOU INTEND IT TO DO. THIS WAS A VERY UNIQUE SIT, BECAUSE YOU WILL NOT GET AN ALTDEV LIGHT OR HORN BECAUSE THE MODE CTL PANEL ALT IS SET LOWER AND YOU ARE CLBING. SUPPLEMENTAL INFO FROM ACN 407474: 4TH DAY OF 4 DAY TRIP, SLEPT POORLY THE NIGHT BEFORE. ZMP OR APCH CHANGED STARS AND RWYS 60 MI E OF ARPT. TOLD 'PLT DISCRETION DSND TO MAINTAIN 24000 FT.' ALT WINDOW WAS SET TO 24000 FT. FMC PITCH MODE IN ALT HOLD. THEN TOLD BY ATC TO INCREASE SPD TO 300 KTS OR GREATER. I HIT VNAV BUTTON TO OPEN WINDOW OF IAS/MACH AND SELECTED 310 KTS. WE WERE 280 KTS. AFTER TOUCHING THAT VNAV BUTTON ADI-FMC PITCH WENT BLANK AND 'CTL WHEEL STEERING PITCH' ACTIVATED. BECAUSE OF THE THRUST INCREASING, NOSE STARTED CLBING UNBEKNOWNST TO ME UNTIL 26700 FT. I DSNDED BACK DOWN. WE WERE BOTH BUSY GETTING OUT MAPS, CHARTS, ETC, AND NEVER NOTICED THE CLB OR CTL WHEEL STEERING PITCH. 'CLASSIC OVER DEPENDENCE ON AUTOMATION' DOING WHAT I EXPECTED BUT NOT FAMILIAR WITH THE COMPLEXITY OF MY REQUEST.

  63.  
  64. Accession Number: 407534
    Synopsis: A CRJ65 DEVIATES FOR WX AND INCURS A NAV DEV IN ZDC AIRSPACE.
    Narrative: THE FLT DEPARTED THE GATE WITH ALL NORMAL PREFLT OPS COMPLETED. A GND STOP AT PHL REQUIRED US TO SHUT DOWN OUR ENGS AND WAIT 2 HRS ON THE TXWY. THE FMS WAS CHKED SEVERAL TIMES AND CONCURRED WITH THE FLT PLAN AND CLRNC. ON DEPARTING WE WERE REQUIRED TO DEVIATE SEVERAL TIMES DUE TO SEVERE WX. ATC QUESTIONED US SAYING 'WHERE ARE YOU?' AND STATED THAT WE WERE NOT CLRED DIRECT TO FKN. SO WE CHKED THE FMS ONLY TO FIND THE CCV (CAPE CHARLES) HAD DROPPED OUT AND ONLY FKN WAS REMAINING AS THE NEXT POINT. CCV WAS REPROGRAMMED AND WE WERE ABEAM THE FIX (15 MI TO THE W). ACCORDING TO THE MECHS, WHEN DEVIATING IF YOU GET CLOSE TO OR ABEAM A FIX IT WILL DROP OUT. EVIDENTLY THAT IS WHAT HAPPENED. NEITHER OF US REMEMBER IT DROPPING OUT. WE CONTINUED ON WITH THE REST OF OUR FLT PLAN AND NOTHING ELSE WAS EVER SAID BY ATC. THE FOLLOWING DAY THE FMS WAS PROGRAMMED AND FOUND TO BE GIVING ERRONEOUS ROUTES OF FLT. THE MECHS REPROGRAMMED THE DATA ONCE WE RETURNED TO RDU. WE FLEW THREE MORE FLTS AND IT SEEMED TO BE FUNCTIONING PROPERLY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR TALKS ABOUT HOW THE WAYPOINT DROPPED OUT OF THE FLT PLAN RTE AND THE NEXT WAYPOINT IN THE FLT PLAN BECAME THE ACTIVE WAYPOINT. RPTR WAS NOT CERTAIN IF THE FMS WAS SUPPOSED TO WORK THIS WAY, HOWEVER, SOME MECHS ON THE SUBSEQUENT FLTS INDICATED THAT IS THE WAY THE FMS WORKS. RPTR FELT THAT ANY NAV DEV SHOULD HAVE BEEN TAKEN CARE OF WITH A PROPERLY WORKING FMS. HE FELT THE FMS SYS WAS NOT WORKING PROPERLY, THUS, A NAV DEV HAPPENED.

  65.  
  66. Accession Number: 407655
    Synopsis: A B757 FLYING FROM EUROPE TO EWR ACCIDENTALLY DEPLOYS THE RAM AIR TURBINE. SINCE THIS INCREASED DRAG INCREASES FUEL CONSUMPTION, THE FLC DECLARES AN EMER TO GET PREFERENTIAL HANDLING INTO THE EWR AREA.
    Narrative: WHILE CRUISING AT FL390 A MASTER CAUTION LIGHT CAME ON ACCOMPANIED BY 3 BEEP AURAL WARNING ON ADI: LNAV AND VNAV AND ECAMS INOP AS WELL AS SPD LIMIT WARNING. SALMON SPD BUG WENT TO 100 KIAS. EICAS MESSAGES: NO AUTOTHROTTLE AND AUTOPLT INOP WARNINGS. ALL CDU INFO TO DO WITH VNAV (FUEL REMAINING AND TIME) WAS LOST. PASSED INFO ON TO NEW YORK RADIO AND GAVE ROUGH FUEL TIME ESTIMATES. WHILE I WAS FLYING THE ACFT AND COMMUNICATING WITH NEW YORK RADIO, FO WORKING WITH QRH TRIED TO RECTIFY PROB. IN AN ATTEMPT TO REGAIN AIRSPD BUG AND AUTOTHROTTLE HE INADVERTENTLY AND UNKNOWINGLY PULLED CIRCUIT BREAKERS LABELED 'SPD CARD.' AT WHICH TIME RAM AIR TURBINE DEPLOYED. WITH INCREASED DRAG AND ONLY ROUGH FUEL ESTIMATE OF 7000 LBS OVER DEST, I DECLARED FUEL EMER AND WAS GIVEN DIRECT RTE TO EWR. WE LANDED AT EWR WITH 9000 LBS. DIRECT ROUTING SAVED US 15- 20 MINS OR 2500-3000 LBS OF FUEL. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THE TRAINING OF NEW PLTS AND RECURRENT TRAINING OF PLTS WILL NOW HAVE THE CORRECT INFO REGARDING HOW THIS DEPLOYMENT CAN HAPPEN. BECAUSE THE FLC WAS TRYING TO RESET THEIR AUTOFLT CAPABILITIES SINCE THEY WENT TO A DEFAULT MODE, CIRCUIT BREAKERS WERE PULLED. ONE OF THE CIRCUIT BREAKERS PULLED WAS THE ONE FOR THE SPD CARD. THIS CIRCUIT BREAKER BEING PULLED SIMULATES A HYD FAILURE, SO THE RAM AIR TURBINE EXTENDED. ONCE EXTENDED, IT CANNOT BE RETRACTED UNTIL ON THE GND. IT MAKES NOISE AND INCREASES FUEL CONSUMPTION WITH ITS INCREASED DRAG. FLC DECIDED THEN TO DECLARE EMER SO FLT WOULD NOT SUFFER ANY DELAYS TO DEST. ACFT HAD PROPER FUEL FOR APCH AND LNDG. SUPPLEMENTAL INFO FROM ACN 407656: IN CRUISE FLT WE RECEIVED A MASTER CAUTION LIGHT AND 3 BEEPS ACCOMPANIED BY A 'NO LNAV OR VNAV' ANNUNCIATION. IN ADDITION, EICAS WARNINGS WERE DISPLAYED, 'NO AUTOTHROTTLE, AUTOPLT INOP' WARNINGS IN ADDITION TO A 'SPD LIMIT' ANNUNCIATION. AUTOPLT REMAINED ENGAGED, AUTOTHROTTLE DISENGAGED, ALL VNAV INFO INCLUDING ALL TIME AND ETA INFO WAS LOST. REVIEWED PROCS AND COULD NOT RECTIFY SIT. IN ATTEMPT TO CLR THE 'SPD LIMIT ANNUNCIATION' ON THE ADI'S, I RESET THE 'SPD CARD' CIRCUIT BREAKERS. AT SOME POINT THE FOLLOWING MESSAGE APPEARED 'RAM AIR TURBINE UNLOCKED.' I LOOKED OVERHEAD AND NOTICED THE AMBER RAM AIR TURBINE UNLOCKED LIGHT AND THE ACCOMPANYING GREEN PRESSURIZED LIGHT. IT WAS APPARENT THE RAM AIR TURBINE HAD DEPLOYED AND THIS CANNOT BE STOWED INFLT. THIS CAUSES FUEL BURN TO INCREASE SUBSTANTIALLY AND CAUSED A POTENTIAL FUEL PROB WITH THE ACCOMPANYING DRAG. WE INFORMED ATC OF OUR PROB, DECLARED AN EMER, AND RECEIVED A DIRECT CLRNC TO DEST. THESE CIRCUIT BREAKERS (LABELED 'SPD CARD') SHOULD BE LABELED, 'WILL CAUSE IRREVERSIBLE RAM AIR TURBINE DEPLOYMENT.' WE LANDED UNEVENTFULLY. APPARENTLY THIS IS USED BY MAINT TO TEST RAM AIR TURBINE DEPLOYMENT. THIS INFO IS NOT IN OUR MANUAL. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THIS INCIDENT CAUSED AN ETOPS DEV RPT TO BE SUBMITTED SINCE IT ALTERED THEIR GND TRACK. EVEN WITH AN EMER DECLARED IT DOESN'T CHANGE THE NEED FOR AN ETOPS DEV TO BE RPTED.

  67.  
  68. Accession Number: 408901
    Synopsis: AN A320 DSNDS ON THE LAX CIVET ARR AND DSNDS BELOW AN ASSIGNED ALT BECAUSE OF MGMNT OF THE AUTOFLT SYS.
    Narrative: THE FLT WAS PART OF AN OE TRIP FOR A PLT NEW TO THE A320. WE HAD BEEN CLRED FOR THE PARADISE 2 ARR TO LAX AND WERE SWITCHED TO THE CIVET 1 ABOUT 50 MI FROM THE ARPT. DUE TO A LATE DSCNT CLRNC CAUSED BY TFC CONGESTION AND WX DEVS WE WERE ABOVE THE FMGC COMPUTED VERT PATH WHEN CLRED TO DSND VIA THE ARR. IT WAS NECESSARY TO USE OPEN DSCNT MODE AND SPD BRAKES TO RETURN TO THE VERT PATH. JUST PRIOR TO LEVELING AT 10000 FT WE WERE GIVEN AN AIRSPD RESTR TO 210 KTS AND THE OE STUDENT PULLED THE FCU ALT KNOB (I WAS UNAWARE THAT HE HAD) AND PUT THE AIRPLANE BACK TO OPEN DSCNT MODE. BECAUSE THE LOWEST ALT ON THE CIVET 1 IS 8000 FT, IT IMMEDIATELY PUT THE AIRPLANE IN IDLE/OPEN DSCNT CAUSING US TO BEGIN DSNDING PRIOR TO THE RESTR ON THE ARR. TO RETURN IMMEDIATELY TO THE ASSIGNED ALT IT WAS NECESSARY TO DISCONNECT THE AUTOPLT AND AUTOTHROTTLES SINCE THE FMGC WOULD HAVE COMMANDED A MUCH MORE GRADUAL RETURN TO ALT. THE ARRS TO LAX FROM THE E ARE BUSY ONES AND THERE ARE MANY SHORT NOTICE ALTERATIONS TO RTES, RWYS AND SPDS THAT CAN BE DIFFICULT TO KEEP UP WITH IN AN AUTOMATED AIRPLANE. THE CIVET 1 AND THE ILS TO RWY 25L HAVE TOO MANY ALT RESTRS THAT MUST BE MANUALLY COMPLIED WITH. IT WOULD BE MUCH BETTER IF THE ILS GS COULD BE USED OUT TO ARNES INTXN RATHER THAN THE COMBINATION OF THE CIVET 1 AND THE ILS RWY 25L.

  69.  
  70. Accession Number: 409737
    Synopsis: FK10. FO ALLOWED THE FLT GUIDANCE SYS TO ATTEMPT AN INTERCEPT OF A RADIAL AT TOO GREAT AN ANGLE.
    Narrative: ON DEP FROM RDU AND ENRTE TO TPA, WE WERE BEING VECTORED FOR THE FAY 2 DEP (FAY2.FAY). RDU DEP CTL GAVE US A 230 DEG HDG TO INTERCEPT THE DEP AND HANDED US OFF TO ZDC ON 133.85. AT THIS TIME WE WERE APPROX 4 MI DUE E OF THE FAY 2.FAY DEP 'DOGLEG' (RDU 210 DEG RADIAL AND FAY 360 DEG RADIAL OR N3537.6/W07855.8). A NEW FO WAS FLYING AND AFTER I CHKED IN WITH ZDC, I FELT IT COMFORTABLE TO GO OFF THE FREQ TO MAKE REQUIRED COMPANY RPTS TO OUR OPS PEOPLE. THE FO HAD SELECTED '230' ON THE AFCAS PANEL AND ARMED 'NAV' SO IT WOULD INTERCEPT THE DEP COURSE ONCE WE ARRIVED. AS THERE WERE NUMEROUS TSTMS IN THE AREA, I WAS BUSIED WITH A STRING OF UNUSUAL REQUESTS TO AND FROM OPS. AS IS MY PRACTICE, EVEN WHEN I AM 'OFF THE FREQ' I LEAVE THE ATC RADIO VOLUME UP A LITTLE SO I CAN HEAR IT TOO. MY WORKLOAD WAS INCREASED AS I WAS PROMPTING THE FO ON WX AVOIDANCE ONCE WE INTERCEPTED THE RADIAL. AS THE ACFT CAPTURED THE COURSE, IT AUTOMATICALLY TURNED FURTHER R TO 270 DEGS TO ALIGN ITSELF, SINCE WE WERE SO CLOSE TO THE DOGLEG IT PERHAPS 'THOUGHT' A MORE PERPENDICULAR INTERCEPT ANGLE NECESSARY. AT THIS SAME MOMENT, I ABANDONED THE OPS RADIO AND TURNED MY ATTN TO WHAT WAS HAPPENING WITH THE INTERCEPT. WE WERE 1.2 MI DUE E OF THE DOGLEG. I TOLD THE FO TO RESELECT A SHALLOWER HDG FOR THE INTERCEPT JUST AS ATC CALLED TO INQUIRE WHAT HDG RDU GAVE US TO INTERCEPT. THE TIME PERIOD AND DISTANCE WERE SO SHORT THAT I FEEL ATC WAS PREMATURE IN THEIR CONCERN ABOUT OUR HDG AND DOES NOT FULLY UNDERSTAND THE LIMITATIONS AND VAGARIES OF ACFT FILING FLT PLANS AS /F (FMS). THE INEXPERIENCED FO, RATTLED BY ALL THAT WAS HAPPENING, RESPONDED BY TELLING THE ATC CTLR OUR FMS TOOK OVER AND TURNED TO A 270 DEG HDG. ATC TOLD US TO TURN BACK FOR THE INTERCEPT, WHICH BY THIS TIME I HAD CLICKED THE AUTOPLT OFF AND HAD RETURNED TO A HDG THAT I SHOWED HAD US PERFECTLY ALIGNED WITH THE INBOUND COURSE (360 DEG RADIAL) TO FAY. EVEN THOUGH THE FMS DID INDEED COMMAND A MORE AGGRESSIVE INTERCEPT, WE SHOWED WE WERE STILL WELL E OF COURSE. GIVEN THE FACT THAT THE INTERCEPT PUT US R AND THE DOGLEG, I THINK ATC MAY HAVE BEEN UNDULY CONCERNED ABOUT OUR UNDESIRED, ALTHOUGH MOMENTARY CHANGE IN HDG. AFTER ALL, WE WERE STILL E OF COURSE. I ADMONISHED THE FO, HOWEVER, FOR 'LETTING THE AUTOMATION FLY HIM AND HE NOT FLY THE ACFT.' I ALSO AM MEETING WITH OUR CHIEF PLT TO URGE HIM TO TRAIN THESE NEW GUYS TO NOT GET SO COMPLACENT ABOUT AUTOMATION AND PROFILES. AVIATE, NAV, COMMUNICATE!

  71.  
  72. Accession Number: 410608
    Synopsis: FLC OF A HAWKER 700 EXPERIENCES SEVERE WAKE TURB 8 MI IN TRAIL OF A B757 ON STEPDOWN DSCNT VECTOR.
    Narrative: WHILE BEING VECTORED FOR AN APCH TO MSP WE EXPERIENCED WHAT I BELIEVE WAS SEVERE WAKE TURB. WE WERE ON AN ASSIGNED HDG AT 11000 FT AND ASSIGNED SPD OF 250 KTS. IT STARTED WITH MAYBE 5 SECONDS OF STEADY BUT VERY LIGHT TURB. I COMMENTED ON THE STRANGE FEEL TO THE PNF. AS I SAID THAT, THE AIRPLANE ROLLED INTO A 90 DEG BANK TO THE R INSTANTLY. I DISENGAGED THE AUTOPLT AND RECOVERED BY HAND FLYING THE AIRPLANE. BY THE TIME THE WINGS WERE LEVEL WE HAD LOST 700 FT OF ALT. THE PNF CALLED APCH CTL TO TELL HIM WHAT HAD HAPPENED. THE CTLR SAID THAT WE WERE 8 MI IN TRAIL OF A B757. I CALLED BOTH THE TWR AND TRACON AFTER LNDG AND TALKED FURTHER WITH THEM. GIVEN THE SPD OF THE B757 AND OUR AIRPLANE (250 KTS) THE CTLRS WERE SURPRISED THAT THE WAKE TURB WAS SO SEVERE. THEY STATED THAT USUALLY THAT SEVERE OF TURB IS ASSOCIATED WITH SLOWER SPDS AND THE ASSOCIATED DRAG FROM FLAPS, ETC. THERE WAS 1 PAX ON BOARD. THERE WERE NO INJURIES TO CREW OR PAX. OUR PAX WAS SCARED BUT OTHERWISE UNHARMED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATES THAT HIS REVIEW WITH ATC BROUGHT ADDED QUESTIONS SINCE THE B757 WAS CLEAN AND AT 250 KTS. BOTH ACFT WERE ON RADAR VECTORS AND ON THE EXACT SAME FLT PATH AND SPDS. THE IN TRAIL SEPARATION SHOULD HAVE BEEN AMPLE TO AVOID SUCH A WAKE TURB ENCOUNTER. RPTR WAS SURPRISED WHEN AUTOPLT WAS DISENGAGED THAT THERE WAS NO CTL INPUT ALREADY ACTIVE. INQUIRING OF THE MANUFACTURER THEY LEARNED THAT IN EXTREME CTL CHANGES THE AUTOPLT GOES INTO A COAST MODE UNTIL IT CAN DETERMINE IF THE EXTREME IS A FALSE INPUT OR NOT. THE AUTOPLT THEN RESPONDS WITH CORRECT INPUT. RPTR SAYS YOU LEARN SOMETHING NEW ALL THE TIME. IN HIS 23 YRS OF FLYING HE HAS NEVER EXPERIENCED ANYTHING AS SEVERE AS THIS. THE ACFT WAS A HAWKER 700.

  73.  
  74. Accession Number: 410758
    Synopsis: ACR MD82 FLC FO INADVERTENTLY DISARMS AUTOPLT IN DSCNT WHILE INPUTTING SPD DATA INTO THE DIGITAL FLT GUIDANCE PANEL. DSCNT THROUGH ASSIGNED ALT WAS OBSERVED BY THE FLC WHEN BELOW 11000 FT. ATC NOTIFICATION WAS MADE AND THE ACFT RETURNED TO ASSIGNED ALT. PIC ALLEGES THAT MANIPULATING THE DIGITAL FLT GUIDANCE SYS IN THE MD82 IS A BIG HURDLE TO OVERCOME IN THE ACFT.
    Narrative: WAS TOLD TO MAINTAIN 11000 FT, BUT DSNDED TO 10500 FT. AUTOPLT DID NOT CAPTURE ALT. DO NOT DEPEND ON AUTOPLT TO DO THE JOB. YOU MUST SCAN AT ALL TIMES. SUPPLEMENTAL INFO FROM ACN 410900: COPLT WAS FLYING WITH #2 AUTOPLT ENGAGED DSNDING TO 11000 FT WITH THAT ALT ARMED FOR CAPTURE BY AUTOPLT. IN DIAGNOSIS OF WHAT CAUSED THE ALT INCURSION, COPLT HAD MADE A DIGITAL FLT GUIDANCE PANEL SELECTION TO REDUCE AIRSPD, HOWEVER THE FLT GUIDANCE AND AUTOPLT HAD ALREADY CAPTURED THE ARMED ALT OF 11000 FT AND WAS BEGINNING TO LEVEL OFF. THE SELECTION MADE BY THE COPLT 'DISARMED' THE ALT CAPTURE AND REVERSED THE DIGITAL FLT GUIDANCE TO A VERT SPD MODE DSCNT AND ACFT CONTINUED TO DSND BELOW 11000 FT. HAD I SEEN IT, I COULD HAVE CANCELED HIS SELECTION, RE-ARMED THE ALT AND PREVENTED INCURSION. UNDERSTANDING AND MANIPULATING THE DIGITAL FLT GUIDANCE SYS IS PROBABLY THE BIGGEST HURDLE TO OVERCOME IN THIS ACFT.

  75.  
  76. Accession Number: 410940
    Synopsis: B747-400 CAPT ATTEMPTED TO DSND USING ACFT AUTOMATION. WHEN REPROGRAMMED TO COMPLY WITH A NEW CLRNC, DSCNT WAS DELAYED EXCESSIVELY.
    Narrative: MY ACFT WAS GIVEN A XING RESTR OF A POINT ABOUT 30 MI E OF ECK VOR TO BE AT OR BELOW FL290 THEN PLT DISCRETION TO FL240. A DSCNT FROM FL390 WAS STARTED. THE FMC WAS REPROGRAMMED AT ABOUT FL300 FOR A CRUISE ALT OF FL290 SO THAT A NEW TOP OF DSCNT HAD TO BE FIGURED SO AS TO START DOWN IN TIME TO CROSS THE POLAK INTXN AT 12000 FT. THE FMC LEVELED THE ACFT OFF AT ABOUT FL296 WHILE IT COMPUTED A NEW TOP OF DSCNT POINT (APPROX 30 SECONDS). THAT 30 SECOND PERIOD WAS LONG ENOUGH FOR AN ACFT TO GET WITHIN 2000 FT OF OUR ACFT (HE WAS AT FL310). ATC WARNED US TO DSND THE OTHER 600 FT IMMEDIATELY, WHICH WE DID. I DON'T BELIEVE A VIOLATION WAS FILED BUT IT TAUGHT ME A GOOD LESSON IN USING THE FMC.

  77.  
  78. Accession Number: 411850
    Synopsis: A DSNDING MD80 OVERSHOT ITS ALT WHEN THE FO DOES NOT FOLLOW THE MANDATES OF THE FLT GUIDANCE SYS'S OPERATING PROCS.
    Narrative: ALT ASSIGNED ON THE ARR WAS 11000 FT. DURING THE DSCNT FOR THE QBALL 4 STAR THE ALT WAS ARMED PROPERLY FOR 11000 FT. NEARING THE LEVELOFF, I WAS DISTRACTED RETRACTING SPOILERS AND I DIDN'T NOTICE THE ALT CAPTURE LIGHT COME ON. I WENT TO CORRECT MY SLOWING RATE OF DSCNT BY INCREASING VERT SPD TO 1500 FPM. THIS DISENGAGED THE ALT CAPTURE AND THE ACFT DSNDED TO 10650 FT. THE PROB WAS CORRECTED BUT NOT IN TIME. I BELIEVE THE FLT GUIDANCE SYS ON THE MD80 IS FAR TOO SUSCEPTIBLE TO PROBS OF THIS NATURE. THE FLT MODE ANNUNCIATOR DOES NOT GIVE YOU ENOUGH INFO QUICKLY ENOUGH TO RESPOND TO THIS PARTICULAR PROB.

  79.  
  80. 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.

  81.  
  82. Accession Number: 415100
    Synopsis: A CLBING B757 ON THE LOUPE 9 DEP FROM SJC OVERSHOT ITS ASSIGNED ALT OF 5000 FT.
    Narrative: EARLY MORNING DEP FROM SJC ON LOUPE 9 SID. INITIAL CLB ALT WAS 5000 FT. ACFT WAS A LIGHT B757 (172000 TKOF WT). BRIEFED USE OF LNAV AND VNAV FOR DEP. TKOF WAS NORMAL, AND PF CALLED FOR LNAV AFTER GEAR UP, THEN VNAV AT 800 FT AGL. INITIATED TURN AT APPROX 2 DME OFF OF SJC, SINCE LNAV DID NOT APPEAR TO BE CALLING FOR A TURN ON THE FLT DIRECTOR. TURNED R TOWARD 120 DEGS, CLBING AT 'CLEAN' MANEUVERING SPD AND APPROX 4000 FPM. PF QUESTIONED WHETHER WE NEEDED TO INTERCEPT THE SJC (339 DEG?) RADIAL NOW OR CONTINUE TO THE 120 DEG HDG. PNF (CAPT) CALLED 'LEVEL AT 5000 FT!' PF NOTED ACFT WAS CLBING RAPIDLY THROUGH APPROX 5200 FT, THEN PUSHED THE NOSE FORWARD TO RETURN TO 5000 FT. MAX ALT REACHED WAS APPROX 5300-5500 FT AND 5000 FT WAS REGAINED WITHIN 10-15 SECONDS. HUMAN PERFORMANCE CONSIDERATIONS INCLUDED: INEXPERIENCE ON ACFT TYPE (ALSO LESS THAN 50 HRS FLYING TIME IN LAST YR). FIRST FLT OUT OF SJC ARPT AND FIRST TIME FLYING THIS SID. CONFUSION ABOUT AUTOFLT COMMANDS TO THE FLT DIRECTOR WHILE HAND FLYING THE DEP. CONFUSION ABOUT THE SID. PF HAD BRIEFED A R TURN TO 120 DEGS IN LNAV, THEN INTERCEPTING THE SJC RADIAL, WHICH WAS INCORRECT. PF NOTED PNF'S VOR CDI CTRING AND ASKED IF HE SHOULD TURN L NOW TO INTERCEPT. AT THIS TIME, ACFT WAS PROBABLY WITHIN 1000 FT OF LEVELOFF AND STILL CLBING RAPIDLY WHILE APCHING 250 KIAS. LESSONS LEARNED: BRIEF SID MORE THOROUGHLY, ESPECIALLY COMPLEX SIDS. WILL USE ANOTHER AUTOFLT MODE FOR GUIDANCE WITH LOW ALT LEVELOFF (IE, FLT LEVEL CHANGE AND HDG SELECT). DON'T GET DISTR FROM AVIATING BY NAVING. SUPPLEMENTAL INFO FROM ACN 414938: IN THE FUTURE, I INTEND TO FLY THE LOUPE DEP ENTIRELY ON HDG UNTIL THE SJC VOR.
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