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Incidents related to Issue 5 incidents related to this issue.

Issue: workarounds may be necessary (Issue #107)
Description: Pilots may use automation in a manner not intended by designers to get desired results or to avoid undesirable consequences, possibly increasing pilot workload and opportunity for error. This may have unanticipated and undesirable side effects.

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  2. Accession Number: 155390
    Synopsis: CAPT OF ADVTECH ACR MLG ATTEMPTSTO MANIPULATE AFCS IN NEW MANNER, IS DISTRACTED, AND EXCEEDS 250KTS BELOW 10000' SPEED LIMIT.
    Narrative: OUR DEP CLRNC OUT OF ATL INCLUDED INSTRUCTIONS TO MAINTAIN 10000'. ON THIS FLT THE CAPT DECIDED TO DELETE THE 250 KT RESTRICTION FROM THE FMS CLB PAGE IN ORDER TO ELIMINATE THE THROTTLE BURST ASSOCIATED WITH THE MLG X WHEN LEVELLING OFF AT 1000'. HE PLANNED TO FOLLOW THE FLT DIRECTOR PITCH BAR UP TO 300' AGL AND THEN DECREASE PITCH TO ALLOW THEACFT TO ACCELERATE TO 250 KTS. ONCE AT 250 KTS HIS PLAN WAS TOMAINTAIN THIS SPD UP TO 10000' BY ADJUSTING PITCH AND IGNORINGTHE FLT DIRECTOR PITCH BAR. THIS TECHNIQUE HAD PROVEN TO GIVE AMUCH SMOOTHER LEVEL OFF AND ACCELERATION TO CLB SPD. THOUGH THECAPT HAD BEEN ON THE ACFT FOR SOME TIME, THIS WAS A RELATIVELYNEW TECHNIQUE FOR HIM. OUR TKOF HAD BEEN BEHIND AN ACFT ANDSHORTLY AFTER TKOF WE EXPERIENCED A LITTLE TURB WHICH WE ASSUMEDWAS FROM THE PRECEDING WDB. THE CAPT DECREASED PITCH TO STAY OUTOF HIS WAKE WHILE BOTH WERE CLRING OUTSIDE THE ACFT IN AN EFFORTTO SEE THE WDB. UNABLE TO ACQUIRE THE ACFT THE CAPT'S SCANRETURNED TO HIS ADI AND HE BEGAN TO FOLLOW THE PITCH BAR WHICHLED HIM TO ACCELERATE BEYOND 250 KTS. ACFT SPD WAS NOTED ANDREDUCTION BEGUN. SUPPLEMENTAL INFO FROM ACN 155518: THE ACFTACCELERATED TO CLB SPD AT APPROX 320 KTS.

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  4. Accession Number: 378578
    Synopsis: FO, PF, ON A B747-400 TELLS OF DIFFICULTY IN ACQUIRING THE ILS OF A PARALLEL RWY FOR A 'SIDE-STEP MANEUVER.' PRIMARY RWY HAD JUST BEEN CLOSED BY RAIN SHOWERS AT A FOREIGN ARPT. CTLR ASKED FLT TO MOVE TO THE PARALLEL RWY. THEY COULD NOT GET THE CDU TO ACCEPT THE NEW ILS FREQ FOR APCH UNTIL BOTH THE AUTOPLT AND BOTH FLT DIRECTORS WERE CYCLED OFF AND BACK ON. THIS RESULTED IN A DESTABILIZED APCH WITH A 200 FT CEILING. RPTR CALLS FOR AN ADDITIONAL OPTION ON THE ARR DEP PAGE SO AS TO AVOID THIS 'OFF AND ON' OP. AN ANONYMOUS RPT.
    Narrative: RECENTLY I WAS INVOLVED IN A HARROWING EXPERIENCE WHILE FLYING OVERSEAS IN A B747-400. ONE OF THE 'FEATURES' OF THIS PLANE IS A FAIL SAFE OR 'FAIL OPERATIONAL' DESIGN USED FOR FLYING INST APCHS. UNFORTUNATELY, THIS DESIGN CRIPPLED THE COCKPIT CREW FOR ABOUT 1 MIN WHILE WE WORKED FEVERISHLY TO RECTIFY THE PROB. I WAS FLYING A CAT I ILS APCH TO THE ACTIVE RWY. THE AUTOPLT WAS ON AND THE LOC WAS 'CAPTURED.' A RAINSTORM OVER THE FIELD CLOSED THE ACTIVE RWY AND THE CTLR ISSUED US CLRNC TO LAND ON A PARALLEL RWY. (THE RAIN WAS HVY, BUT NOT RED ON WX RADAR.) SINCE WE HAD ALREADY CAPTURED THE LOC TO THE PREVIOUS RWY, HDG SELECT MODE WAS DISABLED. SO IN ORDER TO COMPLY WITH THE CTLR'S NEW HDG TO INTERCEPT THE NEW LOC, I HAD TO TURN OFF THE AUTOPLT AND FLY TO THAT HDG MANUALLY. (FLT DIRECTORS ARE ALSO INOP AT THIS POINT.) MEANWHILE, THE CAPT IS TRYING TO RESELECT THE NEW RWY SO WE CAN PICK UP THE NEW LOC. THE FAIL OPERATIONAL DESIGN WOULD NOT ALLOW HIM TO SELECT A NEW RWY EITHER ON THE 'NAVRAD' PAGE OR THE DEP/ARR PAGE. WHILE WE 'FLAILED ALONG' ON THIS MISERABLE APCH, I THOUGHT OF GOING MISSED APCH, BUT GUESS WHAT? I HAVE NO WAY TO FLY IT BECAUSE THE LOC IS STILL TUNED TO THE WRONG RWY! MY MAP DISPLAY IS NO GOOD AND ALL I HAVE IS A $150 MILLION J-3 CUB WITH 440 PEOPLE ON BOARD! FINALLY, WE REMEMBERED FROM TRAINING THAT THE ONLY WAY TO FREE UP THE CDU IS BY PHYSICALLY TURNING OFF BOTH FLT DIRECTORS AND THE AUTOPLT. THEN AND ONLY THEN CAN YOU SELECT A NEW RWY. I CAPTURED THE LOC AND WAS HIGH ON THE GS, BROKE OUT AND LANDED. PLEASE ADVISE BOEING THAT THEY MUST ADD A NEW SELECTION ON THE DEP/ARR PAGE THAT ALLOWS SWITCHING RWYS WITHOUT TURNING OFF THE AUTOPLT AND FLT DIRECTORS.

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  6. Accession Number: 383466
    Synopsis: FLC OF AN MD88 FAILED TO MEET A DSCNT ALT XING RESTR DUE TO LACK OF MAKING THE APPROPRIATE PROGRAMMING OF THE FMS AND MONITORING THE ACFT LOCATION IN RELATION TO THE XING FIX.
    Narrative: WE WERE ON THE BUNTS ONE ARR E OF JST AT FL330. ZNY CLRED US TO CROSS 40 MI W OF HAR AT FL250. THE FMS WOULD NOT ACCEPT THE ALT RESTR AS STATED, IE, 'HAR/-40,' BECAUSE OF A CHARTED FIX (LOMON) BTWN THE RESTR FIX AND HAR. IN THE PROCESS OF ATTEMPTING TO DETERMINE WHERE THE RESTR FIX WAS RELATIVE TO LOMON SO THAT WE COULD ENTER THE XING RESTR INTO THE FMS, WE SUBSTITUTED A DISTANCE OF 20 MI FOR THE CORRECT DISTANCE OF 40 MI FROM HAR. ZNY CALLED AND ASKED IF WE WOULD BE ABLE TO MAKE THE ALT RESTR. SINCE OUR NAV DISPLAYS SHOWED WE WERE STILL SHORT OF OUR TOD (TOP OF DSCNT), I RESPONDED IN THE AFFIRMATIVE. CTR ISSUED A FREQ CHANGE TO ANOTHER CTR FREQ. WHILE CHANGING FREQS, I REALIZED OUR ERROR. WE IMMEDIATELY BEGAN A RAPID DSCNT. I CHKED IN ON THE NEXT FREQ AND RPTED WE WOULD BE UNABLE TO MAKE THE XING RESTR. (WE PASSED OVER THE RESTR FIX AT APPROX FL290.) CTR ISSUED A REVISED DSCNT CLRNC TO CROSS HAR AT 17000 FT. THERE WAS NEVER AN INDICATION OF A CONFLICT FROM EITHER ATC OR TCASII.

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  8. Accession Number: 398260
    Synopsis: AN MD82 FLC EXPERIENCES A HEADING TRACK POS DEV DURING THE DEP PROC FROM SJC.
    Narrative: WE DEPARTED SJC ARPT ON THE LOUPE 9 SID, RWY 30L. AT 1.8 DME THE FO (PF) REQUESTED 'HEADING SELECT 120 DEGS.' I SELECTED HDG 100 DEGS TO R. WITH OUR FLT DIRECTOR SYS YOU CANNOT GO FROM HDG 300 DEGS TO 120 DEGS BECAUSE THE SYS DOESN'T KNOW WHETHER TO MAKE THE 180 DEG TURN L OR R. .THEN AFTER THE TURN IS COMMENCED, WE TWEAK THE HEADING SELECT KNOB TO 120 DEGS. WITH THE CONCERN FOR THE RPTED AND PREVAILING ICING CONDITIONS, I FAILED TO TWEAK IT TO 120 DEGS. I TURNED ON THE ENG ANTI-ICE OUT OF 3500 FT MSL. AT OUR ASSIGNED ALT OF 5000 FT, THE FO (PF) TURNED ON THE AUTOPLT. AT THIS POINT THE PF TAKES OVER OPERATING AUTOPLT AND FLT DIRECTOR KNOBS. WE WERE NOW CLRED AT 6.3 DME TO 'TURN R PLT DISCRETION, CROSS SJC VOR AT 12000 FT AND RESUME THE LOUPE DEP, MAINTAIN FL230.' THE FO (PF) STARTED THE AUTOPLT CLB. OUT OF 8000 FT THE DEP CTLR ASKED OUR HEADING. I RESPONDED 'COMING R HDG 120 DEGS.' HE SAID 'TURN R HDG 180 DEGS.' I RESPONDED AND WE TURNED. WE HAD A STRONG W WIND. OUT OF 11000 FT HE HAD US 'TURN R 300 DEGS DIRECT THE VOR, RESUME THE LOUPE.' HE WAS VECTORING US AT THIS POINT BEHIND A DEPARTING DC8 HVY, WHO WAS RPTING MODERATE ICING. WE HAD ONLY A TRACE OF ICE. THE FLT WAS COMPLETED WITHOUT INCIDENT. WITH THE TURB, ICING CONDITIONS, AND DEP WORKLOAD, WE FAILED TO SET THE CORRECT HEADING.

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  10. 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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