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Incidents related to Issue 4 incidents related to this issue.

Issue: transitioning between aircraft may increase errors (Issue #130)
Description: Transitioning back and forth between advanced technology aircraft and conventional aircraft may cause problems such as erosion of aircraft-specific skills, possibly leading to pilot errors.

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  2. Accession Number: 231227
    Synopsis: FO OF ACR WDB ACFT INADVERTENTLY OVER-BOOSTED THE ENGS EXCEEDING DESIGN LIMITATIONS.
    Narrative: ON 1/FRI/93 FLT X ATL TO SJU SHIP XXX. AFTER REACHING CRUISE ALT I SET PWR TO EPR ON FLT PLAN. A FEW MINS LATER WE WERE GIVEN A RTE CHANGE AND TOLD TO CONTACT ENRTE RADIO (COMMERCIAL RADIO). THE CAPT WAS HAVING DIFFICULTY MAKING CONTACT ON HF. I WAS CHANGING THE RTE AND THE FE WAS MAKING A COMPANY POS RPT. I LOOKED UP AND NOTICED THE AIRSPD STABLE AT 208 KTS. I IMMEDIATELY INCREASED PWR TO RETURN TO REQUIRED CRUISE MACH. DURING INITIAL PWR APPLICATION #2 ENG HAD AN N1 OVERSPD (THIS WAS NOT NOTICED TILL LATER IN THE FLT). ALL ENGS RAN SMOOTHLY AND PWR WAS RESET AT A NUMBER HIGHER THAN THAT CALLED FOR ON THE FLT PLAN. WHEN WE NOTICED THAT #2 N1 HAD EXPERIENCED AN OVERSPD WE WERE MORE THAN HALF WAY TO SJU. SINCE ALL OTHER ENG INSTRUMENTS WERE NORMAL AND THE ENG WAS RUNNING SMOOTHLY WE LEFT THE ENG CONTINUE TO OPERATE AND LANDED IN SJU. CONTRIBUTING FACTORS WERE THE CONFIGN OF SHIP XXX. IT HAS NO FMS LIKE OUR OTHER WDB ACFT, SO IT HAS NO CRUISE AUTOTHROTTLE CAPABILITY. THIS WAS THE FIRST TIME THAT I FLEW THIS SHIP AND THE FIRST IN A TRIPLE INS CONFIGN. ALL PAST EXPERIENCE HAS BEEN INS/FMS CONFIGN. I LET MYSELF BECOME DISTRACTED AND UPON SEEING LOW AIRSPD ADVANCED THROTTLES RAPIDLY.

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  4. Accession Number: 366055
    Synopsis: B737-500 FAILED TO MAKE THE TURN REQUIRED BY THE WARD 4 STAR AT PXT. THEY GOT MORE THAN 4 MI OFF COURSE. THEY WERE CORRECTING WHEN ATC CALLED THEM ON THEIR MISTAKE.
    Narrative: OUR FILED FLT PLAN CALLED FOR US TO FLY DIRECTLY FROM RIC VOR TO PXT VOR THEN TO JOIN THE WARD 4 ARR INTO EWR. IT WAS THE CAPT'S LEG AND ALTHOUGH HE HAD A NUMBER OF YRS EXPERIENCE IN THE B737-100 SERIES, THIS WAS HIS SECOND MONTH ON THE B737-300/500 SERIES ACFT. WE WERE PROCEEDING IN LNAV MODE DIRECTLY TO PXT. ABOUT 10 MI W OF PXT, I WENT OFF THE RADIOS TO GET THE ATIS AND CONTACT COMPANY PER OUR PROCS IN PREPARATION FOR OUR ARR. AFTER FINISHING THIS (ABOUT 1 MIN OFF THE RADIO MONITORING) I RETURNED TO MONITORING RADIO #1 AND GAVE THE CAPT THE ATIS INFO CARD. HE MENTIONED THAT WE HAD A SIMILAR CALL SIGN SIT GOING ON WITH ZDC AND HE HAD ALREADY MESSED UP 1 CALL. I TURNED MY ATTN TO THE MCP AND NOTED WE WERE NOW IN HDG MODE AND SHOULD BE IN LNAV. I MENTIONED THIS TO THE CAPT. WE HAD JUST CROSSED OVER THE PXT VOR AND SHOULD HAVE TURNED TO INTERCEPT THE AIRWAY. THE CAPT TURNED THE HDG CURSOR BACK TO THE L TO 360 DEG HDG TO REJOIN THE AIRWAY AND THE ACFT RESPONDED CORRECTLY. THIS WOULD PROVIDE AN INTERCEPT HDG AND ALLOW US TO ENGAGE THE LNAV MODE. I SELECTED THE PROGRESS PAGE 3 ON THE CDU SCREEN FOR THE FMC AND NOTED VERBALLY WE WERE NOW 4.3 NM E OF THE AIRWAYS. JUST THEN, ZDC CALLED US AND TOLD US WE WERE OFF THE AIRWAY AND TO COME L TO 010 DEGS TO INTERCEPT THE AIRWAY AND THE WARD 4 ARR (WHICH WE HAD JUST STARTED TO DO ON OUR OWN). THERE IS AN MOA AROUND PXT, BUT NO MENTION OF ITS STATUS CAME UP.

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  6. Accession Number: 372190
    Synopsis: FO OF AN LTT OVERSHOT CLB ALT AFTER DEP DUE TO FLYING TASKS RESULTING IN RECOGNIZING THE ERROR AND CORRECTING BACK AT THE SAME TIME THE CTLR INTERVENED TO INQUIRE OF THEIR ALT.
    Narrative: ASSIGNED ALT OF 4000 FT. AUTOPLT ENGAGED AT 2500 FT MSL WITH HDG, ALT SELECT, AND INDICATED AIRSPD ON FLT DIRECTOR. CAPT LEFT DEP FREQ TO TALK TO COMPANY TO RPT TIMES. ATC CALLED WITH A TURN TO 010 DEGS AND SWITCH TO 125.8 FOR ANOTHER DEP FREQ. WHILE RESPONDING TO THE CALL, MAKING A FREQ CHANGE AND MAKING THE TURN, MY ATTN WAS DIVERTED FROM THE ALT. THE AUTOPLT FAILED TO CAPTURE THE ALT AND CONSEQUENTLY PASSED THROUGH THE ASSIGNED ALT BY 500 FT. CAPT MADE THE ALT CALL AND WE STARTED THE CORRECTION WHEN ATC CALLED FOR US TO CORRECT THE ALT. WITH LOW TIME IN TYPE, TASK PRIORITY IS EXTREMELY IMPORTANT. ALWAYS FLY THE AIRPLANE FIRST, ONE TASK AT A TIME, AND PRIORITIZE. LESSON LEARNED!

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  8. Accession Number: 392004
    Synopsis: CAPT OF A BRITISH JETSTREAM BA41 OVERSHOT ASSIGNED ALT ON CLB.
    Narrative: ON DEP CLB OUT OF STL ENRTE TO SUX, ISSUED CLB TO MAINTAIN 12000 FT. AT 1000 FT BELOW ASSIGNED ALT I ADVISED THE CAPT (PF) OF '1000 FT TO GO' AND RECEIVED CONFIRMATION REPLY FROM THE CAPT. AT 100 FT BELOW ALT I SIGNALED (SINGLE 'LITTLE FINGER') 100 FT TO GO AND THOUGHT I OBSERVED CONFIRMATION FROM THE CAPT. ANTICIPATING NORMAL AUTOPLT CAPTURE, I (PNF) BECAME BUSY WITH CHART ORGANIZATION. AT 12300 FT WE RECEIVED AN ALT ALERT HORN, OBSERVED THE DEV AND THE CAPT BEGAN THE ALT CORRECTION. AT APPROX 12200 FT ATC RPTED THE AREA ALTIMETER SETTING AND ADVISED US TO MAINTAIN 12000 FT. THE FLT THEN PROCEEDED UNEVENTFULLY. FACTORS AFFECTING THE DEV: THIS WAS THE LAST ROUND TRIP FLT OF A 4 DAY TRIP. WE WERE ALL WELL RESTED, HOWEVER, THE CAPT HAD BEEN PREPARING FOR A MAJOR AIRLINE INTERVIEW THE ENTIRE TRIP AND WAS EXPECTING THE INTERVIEW THE FOLLOWING DAY. I HAD OBSERVED SOME INCREASING PREOCCUPATION AND DISTR IN HIM ALL DAY. I FEEL THAT THIS WAS THE PRIMARY CAUSE OF THE DEV. ALSO, THIS WAS A CAPT THAT HAD TRANSITIONED TO THE ARPT RECENTLY FROM AN ACFT WITH ANALOG INSTRUMENTATION. WHETHER THERE WAS A CONFUSION ON HIS PART IN REGARD TO PROGRAMMING THE EFIS DISPLAYS OR CONFIRMING AUTOPLT ALT CAPTURE, I CANNOT POSITIVELY SAY. MY RELAXED VIGILANCE AFTER I HAD OBSERVED DISTR IN THE PF RESULTED IN THE BREAKDOWN IN 2-PLT XCHKING PROCS. HAD I NOT ASSUMED A 'NO BRAINER' ACTIVITY AND REMAINED ATTENTIVE I COULD HAVE INTERJECTED BEFORE THE HORN. PRIMARY LESSON -- PLT VIGILANCE.
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