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Incidents related to Issue 11 incidents related to this issue.

Issue: pilots may over-rely on automation (Issue #106)
Description: Pilots may use automation in situations where it should not be used.

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  2. Accession Number: 112925
    Synopsis: DURING DESCENT FLT CREW DID NOT COMPLY WITH ASSIGNED CROSSING ALT OR SPEED RESTRICTIONS.
    Narrative: THE CAPT WAS THE PLT FLYING ON THIS LEG. WHILE FLYING THE LENDY TWO ARR INTO JFK ARPT, CENTER CLEARED US (ACR FLT XX) TO CROSS LENDY AT FL230. THE CAPT PROGRAMMED THE FMC FOR THIS CROSSING JUST S THE #1 F/A CAME INTO THE COCKPIT TO COMPLAIN ABOUT SOMETHING. NEITHER ONE OF US NOTICED THAT THE FMC REVERTED TO SPEED MODE FROM VNAV PATH MODE. ABOUT 15 MI FROM LENDY I NOTICED WE WERE MUCH TOO HIGH TO MAKE THE CROSSING AND THE CAPT CALLED CENTER FOR RELIEF. CENTER TOLD US TO STOP AT FL290, WHICH WE DID. CENTER THEN CLEARED US TO CROSS LGA AT 250 KIAS AND FL190. THE CAPT BEGAN PROGRAMMING THE FMC WHEN WE SHOULD HAVE STARTED RIGHT DOWN TO FL190. AS A RESULT WE HAD TO MAKE A HIGH SPEED DSNT TO FL190 TO MAKE THE ALT AND WE COULD NOT SLOW DOWN TO 250 KIAS WHEN WE CROSSED LGA. AFTERWARDS, THE CAPT COMMENTED THAT HE ALWAYS TELLS NEW COPLTS TO BEGIN THE DSNT BEFORE PROGRAMMING THE FMC IF THERE IS ANY DOUBT AS TO MEETING THE CROSSING, AND HE WAS UPSET THAT HE HAD TRIED TO PROGRAM THE FMC FIRST. CONTRIBUTING TO THIS INCIDENT WERE SEVERAL INTERRUPTIONS OF OUR COCKPIT ROUTINE BY THE COMPLAINING #1 F/A. ZNY GAVE US CROSSINGS WHICH REQUIRED IMMEDIATE DSNT. MOST OF ALL, HOWEVER, WE DID NOT FLY THE AIRPLANE FIRST AND PROGRAM THE FMC SECOND, WE RELIED TOO MUCH ON THE FMC'S IN A SITUATION WHERE THEY REQUIRE TOO MUCH INPUT AND MONITORING AND INCREASE THE WORKLOAD.

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  4. Accession Number: 117306
    Synopsis: AFTER RECEIVING AIR HOLDING CLRNC REPORTER ACFT INADVERTENTLY OVERFLEW HOLDING FIX WHILE TRYING TO LOCATE SAME ON NAVIGATION CHART.
    Narrative: I WAS THE F/O ON ACR FLT XX IN JULY 1989, FLYING A WDB. I WAS THE PLT AT THE CONTROLS. WE WERE IN THE APCH PORTION OF THE FLT, AMONG SCATTERED CUMULUS AND TSTMS, ON AUTOPLT, FMS 2-NAV AND V-NAV ENGAGED, AND LEVEL AT 11,000', INDICATING 250 KTS, AS ASSIGNED BY APCH CTL. WE WERE SEBND ON V-97 AIRWAY, ABOUT 30 MI NW OF KRENA INTXN. WE HAD BEEN TOLD BY A PREVIOUS CENTER CTLR TO EXPECT NO DELAYS, AND TFC SEEMED TO BE MOVING WELL. APCH CTL THEN GAVE THE ACFT AHEAD OF US HOLDING INSTRUCTIONS FOR KRENA INTXN. THAT ACFT ASKED FOR RIGHT TURNS AT KRENA VICE THE PUBLISHED LEFT TURNS BECAUSE OF A TSTM CELL. THAT REQUEST WAS GRANTED. WE VERIFIED THE TSTM CELL LOCATION ON OUR RADAR AND AT THAT MOMENT APCH CTL ISSUED US HOLDING INSTRUCTIONS FOR THE KRENA INTXN, AS PUBLISHED, 11,000'. THE CAPT REQUESTED RIGHT TURNS IN THE PATTERN DUE TO THE TSTM CELL. THE REQUEST WAS GRANTED. I BEGAN SLOWING TO HOLDING SPEED. AS THE CAPT BEGAN ENTERING THE HOLD IN THE FMS, THE ACFT AHEAD OF US REQUESTED HOLDING AT POPPS INTXN DUE TO THE CELL AT KRENA. THAT REQUEST WAS GRANTED. WE WERE BY NOW ABOUT 20 MI FROM KRENA. THE CTLR THEN ASSIGNED US HOLDING AT POPPS. WE GLANCED AT OUR CHARTS, LOCATED POPPS ON THEM, AND THE CAPT TRIED TO ENTER IT AS A WAYPOINT IN THE FMS. THE FMS REJECTED IT AS "NOT IN DATA BASE". BY THE TIME WE DETERMINED THE DISTANCE FROM THE NORTHBROOK VOR TO POPPS, AND I SWITCHED TO THE VOR MODE, WE WERE 2-3 MI PAST POPPS. I BEGAN A RIGHT TURN. AT THAT POINT, THE CTLR ASKED IF WE KNEW WE WERE "5 MILES" PAST POPPS. WE TOLD HIM WE WERE IN THE TURN. HE THEN ISSUED US A HDG OF 270 DEG. WE WERE TURNING THROUGH 180-190 DEG. WE COMPLIED, WERE SOON VECTORED BACK TOWARD ORD, AND CONTINUED ON TO LAND (WITHOUT HOLDING) WITHOUT FURTHER PROBLEMS. THE PROBLEM AROSE, I FEEL FROM 3 FACTORS: 1) LATE ISSUANCE OF HOLDING INSTRUCTIONS FOR POPPS, 2) POPPS NOT PROGRAMMED IN THE DATA BASE OF OUR FMS, AND 3) OUR DEPENDENCE ON FMS NAVIGATION AND SLOW CHANGEOVER TO THE NAV-VOR MODE. THE SOLUTIONS: 1) WE SHOULD HAVE REFUSED THE LATE HOLD AT POPPS AND REQUESTED HOLD AT KRENA OR VECTORS, 2) CTLRS SHOULD AVOID LATE/SHORT NOTICE HOLDING, 3) OUR FMS DATA BASE SHOULD INCLUDE MOST, IF NOT ALL, POTENTIAL HOLDING FIXES NEAR ARPTS.

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  6. Accession Number: 122251
    Synopsis: FO FLYING HVT AT FL390 MAKING A TURN WITH TURN KNOB ON AUTOPLT, ACFT LOST ALT AND ATTITUDE GYRO TUMBLED.
    Narrative: THE EVENT OCCURRED WHILE MAKING A TURN WITH THE AUTOPLT TURN KNOB THROUGH ABOUT 40-50 DEG USING 10-12 DEGS ANGLE OF BANK. DURING THIS TURN I WAS DISTRACTED FOR A FEW SECONDS BY "WAYPOINT PAPERWORK". THE AUTOPLT FAILED TO HOLD ALT AND WHILE REMAINING ENGAGED, BEGAN A 500-800 FPM DSNT. THE DSNT WAS NOTICED AT ABOUT 300' BELOW ASSIGNED ALT, HOWEVER, SPEED HAD ALREADY BUILT UP TO M .83 OR M .84. AT THE MOMENT THAT I REACHED FOR THE CONTROLS TO RECOVER, MY ATTITUDE GYRO TUMBLED LEAVING ME WITH NO PITCH REFERENCE. HIGH SPEED MACH BUFFET WAS EXPERIENCED AND THE CAPT RECOVERED FROM THE DSNT WITH A TOTAL ALT LOSS OF 1000'. NO TFC CONFLICT FROM THE DSNT WAS NOTED. SEVERAL FACTORS WERE CONTRIBUTING: 1) THERE HAD BEEN SEVERAL PREVIOUS WRITEUPS OF AUTOPLT PITCH MALFUNCTIONS. HOWEVER, THE AUTOPLT HAD BEEN MEL'ED WITH PITCH TRIM INOP. ON ALL PREVIOUS SEGMENTS OF THIS TRIP (16 HRS), WHEN THE PITCH TRIM FAILED, THE AUTOPLT DISCONNECTED WITH THE ASSOCIATED AURAL AND VISUAL WARNING -- MUCH LESS OF A PROBLEM THAN DIVING WITH NO WARNING. WITH THE PITCH TRIM INOP, THE AUTOPLT SHOULD NOT HAVE BEEN USED AT ALL. 2) THE F/O'S ATTITUDE GYRO HAD BEEN TUMBLING ON PREVIOUS SEGMENTS. THE MECHANIC SWAPPED GYRO'S BUT THE CAPT HAD ELECTED NOT TO WRITE THIS UP DUE TO LACK OF SPARES. 3) THE ALT ALERT HAD BEEN ACTIVATING RANDOMLY EVEN THOUGH ALT WAS CORRECT, LEADING TO A TENDENCY NOT TO BE AS ALERT TO IT (A "BOY CRIES WOLF" PROBLEM). AGAIN NOT WRITTEN UP DUE TO RANDOMNESS. AS OF THIS WRITING ALMOST A MONTH LATER, THE ACFT IS STILL FLYING WITH NO AUTOPLT PITCH AND A SICK ALT ALERTER. THIS IS IN VIOLATION OF MEL RULES AND SAFETY AND SHOULD NOT CONTINUE!

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  8. Accession Number: 125745
    Synopsis: TRACK DEVIATION.
    Narrative: PRIOR TO APCH OR DOWNWIND, DISCUSSION TOOK PLACE AS TO HOW THIS APCH MIGHT BE FLOWN ON COMPUTER DATA AND HOW TO BUILD THIS APCH. I CONCLUDED IT COULD NOT BE DONE. I CHOSE NOT TO OCCUPY MY HAND FLYING WITH DISTRACTIONS AS WE HAD BEGUN DSNT OUT OF 10,000'. WHILE MANEUVERING TO A DOWNWIND, IFR, THE CAPT WAS BUSY AT THE FMC AND WE HAD LOTS OF TIME, IN ADDITION TO AN OCCASIONAL RADIO CALL AND MONITORING MY FLYING. WE WERE GIVEN A TURN TO A RIGHT BASE AND WERE RECEIVING VECTORS TO THE FINAL APCH COURSE WITH A CLRNC TO INTERCEPT THE LOCALIZER AND FLY THE LDA APCH. THE CAPT COMMENTED THAT HE "HAD THE APCH ON THE COMPUTER". I SWITCHED TO "MAP" FOR A LOOK (RAW DATA IN VIEW IN FD DISPLAY, BOTH LOC AND GS). IT LOOKED GOOD, BUT I HAD NO TIME TO CHECK IT. I FAILED TO SEE THE ANGLE TO THE RWY WAS WRONG, HE HAD A STRAIGHT IN FINAL. I FAILED TO NOTE THE LOC DISPLAY MOVING SLOWLY FROM LEFT TO RIGHT AS WE FLEW THROUGH THE LOC. (APCH MODE OF FD WAS ARMED AND CAPTURED WITH AN APPROPRIATE LATERAL COMMAND.) WHEN I NOTICED THE FULL DEFLECTION RIGHT AND THE APCH COURSE ON THE MAP WAY TO THE LEFT, I COMMENTED THAT "SOMETHING IS WRONG". THE CTLR QUERIED US IF WE HAD THE LOC OK AND REITERATED THE FREQ WHICH WE BOTH IMMEDIATELY CHECKED. CTLR STATED HE "HAD US LEFT OF COURSE AND TO TURN RIGHT TO A NEW INTERCEPT HDG OF 170?" THE CAPT HAD INDICATED TO ATC "WE HAD A DISCREPANCY, AND TO KEEP US ADVISED OF OUR PROGRESS". I COMMENTED THAT THE RAW DATA AGREED WITH THE CTLR BUT THE HDG WOULD NEVER TAKE US ON AN INTERCEPT WITH THE MAP COURSE. THE CTLR WAS VERY HELPFUL AND SAID WE "WERE IN GOOD SHAPE AND APCHING THE LOC". THE CAPT WAS LOST IN THE PROBLEM SO I REACHED DOWN AND PUT MY DISPLAY BACK ON FULL-UP COMPASS ROSE ILS MODE. I CONCURRED WITH THE CTLR AND CONCLUDED THE CAPT'S APCH HAD LED ME ASTRAY AND THAT I WAS STAYING ON RAW DATA. THIS LEG I WAS 100% RAW DATA AND WENT TO THE "COMPUTER MAP" FOR A LOOK AT THE ABSOLUTE WRONG TIME. THE CAPT WAS CONFUSED AT THIS POINT AND I WAS NOW BACK ON THE APCH WITH RAW DATA, I COULD NOT GET HIM TO ABANDON THE COMPUTER. I CALLED OUT GLIDE SLOPE MOVING, INTERCEPT, AND GLIDE SLOPE HIGH AS I STATED I WOULD NOT DSND BELOW 3000' UNLESS HE WAS SURE OF WHERE WE WERE ALSO. HE CONCURRED. THE CAPT RECOGNIZING MY CALLS QUICKLY GOT ON RAW DATA AND COMMANDED ME TO DSND WHICH I DID AT ABOUT 1200 FPM. WE PROCEEDED AND I STATED THAT IF WE DID NOT BREAK OUT VISUALLY OR CAPTURE THE GLIDE SLOPE AT A COMFORTABLE ALT FOR MANEUVERING, I WOULD EXECUTE A GO AROUND. CAPT AGREED. WE BROKE OUT ABOUT 900' ON THE LOC AS WE CAUGHT THE GLIDE SLOPE AND WERE IN A COMFORTABLE POSITION FOR THE TURN TO FINAL WITH A SAFE UNEVENTFUL AND SMOOTH LNDG.

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  10. Accession Number: 128735
    Synopsis: ACR LGT ALT DEVIATION UNDERSHOT ALT CROSSING RESTRICTION BECAUSE FIX WAS NOT IN THE FMC.
    Narrative: TOLD TO CROSS 60 MI W OF FNT AT FL230. FNT WAS NOT ON OUR ROUTE, NOR HAD IT BEEN PROGRAMMED INTO THE FMC. BY THE TIME WE HAD PROPERLY PROGRAMMED THE FMC, WE WERE ONLY ABLE TO DSND TO 23900' AT 60 ME W OF FNT. FLT PLAN HAD US FILED TO A POINT FORMED BY V450 AND THE DXO 342 DEG R, THEN DIRECT POLAR. THE POINT FORMED BY V450 AND THE DXO 342 DEG R WAS NOT PROGRAMMED IN THE FMC DATA BASE. WHEN IN INSERTED THE ORIGINAL ROUTE, I SKIPPED THE POINT, INTENDING TO FIGURE THE PROPER PROGRAMMING WHILE ENRTE, AND THEN FORGOT ABOUT IT. TO CORRECT BOTH THESE SITUATIONS, I WOULD RECOMMEND THAT ON AUTOMATED COCKPITS, THE NECESSARY CHKPOINTS BE IN THE FMC DATA BASE, OR ATC NOT USE POINTS NOT PROGRAMMED INTO THE DATA BASE. ALSO, BOTH THESE SITUATIONS COULD HAVE BEEN PREVENTED IF WE HAD NOT DEPENDED SO MUCH ON THE AUTOMATION AND GONE BACK TO BASIC FLYING.

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  12. Accession Number: 144996
    Synopsis: ACR LGT ADVANCED COCKPIT ACFT OVERSHOOTS ALT IN DESCENT.
    Narrative: APCHING DEN OVER NW ARR GATE I PROGRAMMED THE FMC FOR A VNAV DSNT TO CROSS DRAKO AT FL200, 250 KIAS AND DEN AT 11000'. APCHING DRAKO, DEN APCH CTLR CLRED US TO CROSS THE DEN 313 DEG R AT 10 DME FIX AT 13000' DUE TO TURB I DISENGAGED THE AUTOPLT AND HAND FLEW THE DSNT, USING THE GREEN ALT ARC OVER THE 10 DME FIX WAYPOINT INSERTED BY THE F/O THIS ARC IS PREDICATED ON THE ALT SELECTED IN THE ALT WINDOW OF THE MCP. AS WE PROGRESSED I NOTICED I WAS FALLING BEHIND THE REQUIRED DSNT PROFILE. CHKING THE ALT WINDOW I SAW 11000'. I ASKED F/O IF WE HAD BEEN CLRED TO 11000', THUS CANCELLING THE 13000' RESTRICTION. HE REPLIED THAT THE CLRNC WAS TO CROSS THE FIX AT 11000'. APPARENTLY WHEN HE HAD INSERTED THE WAYPOINT, HE HAD PUT IN 11000' INSTEAD OF 13000 AND LATER SET THE MCP ALT WINDOW TO AGREE WITH IT. ANYWAY, I INCREASED OUR DSNT RATE ONLY TO HAVE APCH CTL POINT OUT OUR ERROR AS WE NEARED 11000'. RECLRED TO 11000', WE COMPLETED THE FLT. DUE TO THE TURB, THE FACT THAT WE NORMALLY ARE AT 11000' AT THAT POINT IN THE PROFILE, I FAILED TO HAVE THE F/O VERIFY OUR CLRNC BEFORE DSNDING BELOW 13000'. WE WERE IN THE TENTH HR OF A DUTY DAY THAT BEGAN EARLY A.M., AND FATIGUE MAY WELL HAVE BEEN A FACTOR. FURTHER, I HAVE RESOLVED TO DO LESS VERT NAV TECHNIQUES IN THE APCH PHASE. EFIS IS GREAT STUFF, BUT THERE IS A TENDENCY TO TRY TO DO TOO MUCH WITH IT TOO LONG. I WOULD BE INTERESTED TO KNOW IF YOU CAN DETECT A TREND OF INCREASING INCIDENTS CONCERNED WITH GLASS COCKPITS.

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  14. Accession Number: 193909
    Synopsis: ACR MLG SPD DEV. FMS PROGRAMMING CONTRIBUTED TO THE ERROR.
    Narrative: APPROX 110 NM SE OF ORD, ATC COMMENCED OUR DSCNT WITH THE KNOX 1 ARR. ANTICIPATING THE XING AND SPD RESTRICTIONS AT HALIE INTXN THE FMS WAS PROGRAMMED FOR A KNOX VOR XING OF 16000 FT AND A HALIE INTXN XING OF 11000 FT AND 250 KIAS. ULTIMATELY, THE KNOX XING WAS REMOVED AS FURTHER CLRNC REMOVED ITS APPLICABILITY. ATC ISSUED CLRNC TO MAINTAIN 300 KIAS WHICH WAS ACCOMPLISHED TO WITHIN APPROX 5 NM OF HALIE AT WHICH POINT THE ACFT WAS SLOWED TO 250 KIAS. THIS SPD WAS MAINTAINED XING HALIE AND UNTIL HDOF TO ORD APCH CTL. PASSING HALIE THE CTLR INQUIRED AS TO OUR SPD AND I REPLIED '250 KTS.' THE CTLR STATED, 'WEREN'T YOU GIVEN 300 KIAS TO MAINTAIN.' I REPLIED, 'WE SLOWED FOR THE HALIE INTXN SPD RESTRICTION.' NOTHING MORE WAS SAID UNTIL THE CTLR HANDED US OFF TO ORD APCH CTL WITH THE PARTING COMMENT OF 'THANKS FOR THE HELP.' THIS COMMENT CAUSED THIS RPT TO BE FILED, AFTER SOME INTERNAL SOUL- SEARCHING, INASMUCH AS THERE APPEARED TO BE SOME QUESTION IN THE MIND OF THE CTLR AS TO THE CIRCUMSTANCES SURROUNDING THE SPD CHANGE. ON INITIAL CONTACT WITH ORD APCH WE WERE SLOWED TO 210 KIAS AND CONTINUED TO LAND UNEVENTFULLY ON RWY 27L. IT IS UNKNOWN WHETHER, IN FACT, ATC HAD A PROBLEM WITH THE SPD REDUCTION OR NOT. THERE APPEARED TO BE SOME CONCERN, BUT NOT DYNAMICALLY STATED. HOWEVER, ON REFLECTION, IT APPEARED THAT THERE MIGHT BE SEVERAL CONCERNS ARISING OUT OF THIS INCIDENT. FIRST, THE 'GLASS COCKPIT' ENVIRONMENT IS PUSHING MORE AND MORE TOWARD AUTOMATING THE ENTIRE FLT AND THE CREWS ARE TO A GREATER OR LESSER EXTENT BEING LULLED INTO AN OPERATIONAL COMPLACENCY. HAD WE NOT PROGRAMMED THE FMS THE CHANCES OF THE SPD REDUCTION OCCURRING WOULD NO DOUBT HAVE BEEN REDUCED WITHOUT SOMEONE QUESTIONING WHAT WAS GOING ON. THIS DEPENDANCE ON AUTOMATION DOES 2 THINGS: 1) IT DEVELOPS A FALSE SENSE OF OPERATIONAL RELIANCE ON THE EQUIP TO DO THE JOB, AND 2) IT REDUCES SITUATIONAL AWARENESS OWING TO COMFORT WITH 1) ABOVE. SECOND, THOSE CREWS OPERATING A 'GLASS COCKPIT' ALMOST INVARIABLY WANT TO UTILIZE THE NEW EQUIP TO ITS FULLEST AND TO BECOME THAT MUCH MORE COMFORTABLE WITH THE NEW DEVICES AND TECHNIQUES. CONSEQUENTLY, IF THE CREW PROGRAMS THE FMS TO CARRY OUT RESTRICTIONS CONTAINED IN AN ARR PROC, AS AN EXAMPLE, THE ROTE CARRYING OUT OF THIS PROC BY THE COMPUTER MAY DRAW THE CREW INTO INADVERTENT DEVS FROM PRIOR CLRNCS. THIRDLY, IT IS POSSIBLE THAT THE PORTRAYAL ON ARR AND APCH PROCS OF 'EXPECT CLRNC TO CROSS' PROCS MAY FURTHER DRAW THE 'GLASS' CREWMEMBER INTO THE TRAP. PERHAPS, A DIFFERENT METHOD OF PROVIDING THE CREWS WITH OPERATIONAL POTENTIALS WOULD BE APPROPRIATE. THE RESTRICTIONS APPEARING ALONGSIDE THE RTE MAY BE INAPPROPRIATE AND SOME ATTN SHOULD BE GIVEN TO PLACING INFORMATIONAL DATA ELSEWHERE ON THE CHART.

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  16. Accession Number: 371637
    Synopsis: FLC OF WDB ACFT HAS PROB MAINTAINING AIR SPD AND POSSIBLE PROB WITH FUEL. THEY DECLARE AN EMER TO DSND.
    Narrative: CLBED TO FL410 TO HELP ATC, AND TO STAY ON TOP OF CLOUD LAYER. GROSS WT AT THE TIME WAS MAX FOR THAT ALT. WE WERE LATER GIVEN A CLRNC TO HOLD AT IHD. AFTER THE FIRST TURN IN HOLDING PATTERN I BEGAN TO CONSIDER FUEL REMAINING AND ALTERNATE ARPTS. DURING THIS PERIOD IAS BEGAN TO DECAY AND I FELT I WOULD BE UNABLE TO RECOVER SPD WITH ADDED THRUST ALONE. WITH ANOTHER ACFT HOLDING AT FL390 I HAD TO DECLARE AN EMER TO GET A LOWER ALT. TO SOME DEGREE THIS CAME ABOUT DUE TO MY RELYING ON THE AUTOTHROTTLE AND FMC TO HANDLE THE SIT, AND NOT TAKING TIMELY ACTION.

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

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  20. Accession Number: 398066
    Synopsis: FLC OF A CANADAIR REGIONAL JET CL65 FAILED TO TURN AND INTERCEPT THE AIRWAY AS CLRED, CAUSING A POTENTIAL CONFLICT WITH ANOTHER ACR JET AND ATC INTERVENTION TO VECTOR THEM BACK ON COURSE.
    Narrative: TAKING OFF IAD ARPT. APPROX TIME XA31. WE GOT VECTORS TO JOIN J149. THE CTLRS CHANGED OUR VECTORS 3 TIMES TO JOIN J149 -- HDG 300 DEGS TO JOIN, THEN 310 DEGS TO JOIN, AND FINALLY 330 DEGS TO JOIN. WE WERE CLBING THROUGH 6000-7000 FT WHEN WE GOT OUR LAST VECTOR. I TURNED THE HDG BUG TO 330 DEGS (WE WERE ON AUTOPLT) WITH INTENTIONS OF PRESSING THE NAV BUTTON TO CAPTURE THE RADIAL. WHEN WE ROLLED OUT ON THE 330 DEG HDG, MY ATTN GOT DIVERTED TO SOMETHING ELSE, SO I NEVER PRESSED THE NAV BUTTON. WITHIN APPROX 30-40 SECONDS, WE HAD GONE THROUGH THE RADIAL, J149, THAT WE WERE SUPPOSED TO CAPTURE. NEITHER THE CAPT NOR I SAW THIS. THEN THE DEP CTLR FOR IAD CAME ON AND ALERTED US THAT WE HAD GONE THROUGH THE AIRWAY AND TOLD US TO TURN TO A 260 DEG HDG TO REJOIN AND TO INCREASE OUR RATE OF CLB. JUST THEN, THE CTLR TOLD AN ACR Y JET TO INCREASE THEIR DSCNT. NO MENTION WAS MADE THAT THE 2 AIRPLANES WERE GETTING CLOSE. THE CTLR JUST SAID TO TAKE THESE ACTIONS. WE DID GET AN AMBER TA ALERT AND OUR TCASII DID SHOW THE ACR Y JET WITHIN 4-5-6 MI OF US. WE HAD TO GO OFF AUTOPLT TO TURN ENOUGH (INCREASE BANK), SO WE COULD BETTER AVOID ANYTHING MORE SERIOUS FROM HAPPENING. NOTHING MORE WAS SAID AND WE WERE SWITCHED TO THE NEXT CTLR. THE BIG THING THAT CONTRIBUTED TO THIS SIT WAS THE CREW'S ATTN BEING DIVERTED AWAY FROM THE FLYING AT HAND AND NOT CHKING EACH OTHER'S ACTIONS -- ESPECIALLY IN A BUSY CLASS B AREA. BTWN THE CTLR ALERTING US, TCASII, AND OUR QUICK CORRECTIVE ACTIONS HELPED MAKE THIS EVENT NOTHING MAJOR. MAYBE RELYING ON THE AUTOPLT TOO MUCH ALSO MIGHT HAVE BEEN A CONTRIBUTING FACTOR.

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  22. Accession Number: 411470
    Synopsis: FK10 CREW PENETRATED RESTR AIRSPACE (R-2601).
    Narrative: R-2601 PENETRATION. DSNDING INTO COS, FO FLYING RECEIVED HEADING TO INTERCEPT BRK 168 DEG RADIAL INBOUND. SAW FO CORRECTLY SET UP FMS AND RAW DATA AND NAV ENGAGED. I LEFT COCKPIT BRIEFLY. ON RETURN WAS BRIEFED ON ALT CHANGE. FO HAD SOME DIFFICULTY STOWING OXYGEN MASK. WHILE BRIEFING WX, TERRAIN, AND APCH RECEIVED TFC CALL FROM ZDV LOW SECTOR AND FLEW THROUGH RADIAL, WHILE SEARCHING FOR TFC, AND BRIEFING TERRAIN AHEAD. AFTER AN INQUIRY ABOUT THE RADIAL CTR ISSUED A R TURN. TURN STARTED ON AUTOPLT GAVE LESS THAN 20 DEG BANK. TURN RATE INCREASED WHEN NEXT CALL SOUNDED MORE URGENT. WAS SOME CONFUSION ABOUT IF ANOTHER HEADING HAD BEEN GIVEN AFTER INTERCEPT. WE WERE BOTH AWARE OF THE RESTR AREA BUT NOT OF ITS STATUS (HOT OR NOT). AT THE TIME THE TFC AND TERRAIN WERE THE HIGHER PRIORITIES. WE HAD ENTERED R-2601 APPROX 1.8 NM. I BELIEVE THAT THE FAILURE TO INTERCEPT WAS A COMBINATION OF UNCERTAINTY OF THE CLRNC AND AN UNDESIRED LOSS OF NAV MODE ENGAGEMENT. MOST LIKELY DURING AN ALT CHANGE, THE HEADING KNOB WAS BUMPED. WHAT TO DO DIFFERENTLY NEXT TIME: MAKE SURE OF A COMPLETE BRIEFING UPON RETURNING TO THE COCKPIT EVEN IF INTERRUPTED. RECHK FMA INDICATIONS MORE FREQUENTLY EVEN IF NO CHANGE, BE MORE ASSERTIVE AS THE PNF/CAPT AND QUICKER TO TAKE OVER CTLS WHEN MORE AGGRESSIVE MANEUVER IS NEEDED.
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