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Incidents related to Issue 262 incidents related to this issue.

Issue: pilots may be overconfident in automation (Issue #131)
Description: Pilots may become complacent because they are overconfident in and uncritical of automation, and fail to exercise appropriate vigilance, sometimes to the extent of abdicating responsibility to it. This can lead to unsafe conditions.

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  2. Accession Number: 49344
    Synopsis:
    Narrative: WE WERE APCHING THE DFW ARPT FROM THE NW IN AN MLG ACFT. WE WERE LEVEL AT 9000' AND 210 KTS AND RECEIVED A DSNT CLRNC TO 5000'. THE PLT FLYING THE ACFT WAS USING THE AUTOPLT AND FLT GUIDANCE SYSTEM DURING THIS APCH PHASE. I DIALED IN 5000' IN THE ALT WINDOW AND ARMED THE ALT FOR THE AUTOPLT. AS WE APCH 5000', I LOOKED AND CONFIRMED THAT THE CORRECT ALT WAS SELECTED AND ARMED. FEELING CONFIDENT THAT THE ACFT WOULD CAPTURE THE ALT, I TURNED TO MY SIDE TABLE WHERE I HAD THE APCH PLATE FOR DFW OPEN. I LOOKED UP THE ILS FREQ AND FRONT COURSE, IT WAS AT THIS TIME WE DESCENDED THROUGH 5000'. AT THE SAME TIME, THE CAPT WAS LOOKING FOR TFC. HE STATED HE HAD OUR TFC IN SIGHT IN OUR 12 O'CLOCK POSITION. WE HAD HEARD ALREADY THAT THIS TFC WAS AT 4000'. I LOOKED UP FROM THE APCH PLATE AND NOTICED THAT IT DID NOT APPEAR THAT WE WERE 1000' HIGHER THAN THE TFC. I IMMEDIATELY LOOKED AND OBSERVED THAT THE ALT WAS STILL ARMED BUT WE WERE AT 4700' AND DSNDING. THE CAPT AT THE SAME TIME, OR MAYBE SLIGHTLY BEFORE, NOTED THAT THE ACFT HAD NOT CAPTURED THE ALT, HE IMMEDIATELY DISENGAGED THE AUTOPLT AND STARTED BACK UP TO 5000'. AT APPROX 4650' THE ALT ALERT SOUNDED. THE ACFT PROBABLY DESCENDED TO 4600 TO 4500' BEFORE THE DSNT WAS STOPPED AND A CLIMB BACK UP TO 5000 WAS INITIATED. AT NO TIME HAD THE CAPT TOUCHED THE PITCH WHEEL ON THE FLT GUIDANCE PANEL WHICH WOULD INHIBIT THE ALT CAPTURE PHASE. IN MY OPINION, WE HAD THE THROTTLES IN THE CLAMP MODE, THE ACFT ATTEMPTED TO LEVEL OFF, BUT THE THROTTLES FAILED TO MOVE FORWARD AS WE EXPECTED. CONSEQUENTLY ALLOWING US TO FALL THROUGH AN ALT WHICH WAS PROPERLY SELECTED AND ARMED. THERE APPEARED TO BE NO TFC CONFLICT NOR WAS THE ATC CTLR INVOLVED IN THIS ALT EXCURSION IN ANY WAY.

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  4. Accession Number: 50177
    Synopsis:
    Narrative: USING THE PMS ON THE MLG CAN BE A NICE TOOL, BUT IT DOESN'T ALWAYS WORK AS ADVERTISED. TRYING TO CORRECT IT CAN GET YOU IN A SITUATION YOU WOULDN'T NORMALLY BE EXPOSED TO IF IT WERE MORE RELIABLE IN THE COMMAND AUTOPLT FUNCTION. DESCENDING INTO ORD WITH CLRNC TO CROSS 35 DME AT 10,000' HAD NEW COPLT SO I WAS SHOWING HIM HOW TO OPERATE THE FMS TO GET IT TO DO THE DESCENT AND CROSSING AUTOMATICALLY. THE PMS KEPT SHOWING THAT IT WAS GOING TO REACH 10,000' WAY TOO EARLY. FINALLY ATC CALLED AND ASKED IF WE WERE GOING TO MAKE THE CROSSING. WE WERE AT 21,000 WITH 19 MILES TO GO SO I TOLD THE COPLT TO KNOCK OFF THE PMS AND DESCEND MANUALLY. BY THIS TIME WE HAD USED UP TOO MANY MILES AND ENDED UP DESCENDING AT MAX SPEED (BARBER POLE) WITH SPEED BRAKES OUT. WE STILL WOULD HAVE ENDED UP 4500' TOO HIGH AT THE 35 DME, HOWEVER, ATC COOPERATED AND GAVE US A VECTOR OFF AIRWAYS TO GET DOWN. THIS OCCURRENCE WAS MY FAULT BECAUSE I DIDN'T BACK UP THE PMS MENTALLY SO I COULD BE SURE IT WAS DOING WHAT IT IS SUPPOSED TO DO.

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  6. Accession Number: 51254
    Synopsis:
    Narrative: WE WERE CLEARED BY ATC TO CROSS ALKID INTERSECTION AT 11000'. DFW APCH CTL CALLED OUT TFC AT 10000', 12 O'CLOCK, AT ABOUT 5 MILES. BOTH F/O AND I WERE LOOKING OUTSIDE FOR TFC AT LEVEL OFF AT 11000. I OBSERVED ACFT TO CONTINUE DESCENT TO 10800' AS AUTO PILOT WITH ALT ARMED DID NOT LEVEL OFF. I DISCONNECTED A/P AT 10800' AND PROMPTLY CLIMBED BACK TO 11000'. ALL ALTIMETERS WERE PROPERLY SET ON 29.87 ALT SETTING. AT NO TIME DID OUR ACFT COME NEAR THE TFC NOR DID WE DESCEND BELOW 10800'. THE AUTOMATIC FEATURES OF THE ADV MLG ACTUALLY CAUSE A GREATER WORK LOAD FOR THE PLTS TO SET THE GADGETS, TRY TO OBSERVE IF THEY WORK, AND CAUSE COMPLACENCY IN RELYING ON THEM. THEN THEY FREQUENTLY DO NOT WORK JUST AT THE TIME THEY ARE CRITICALLY NEEDED.

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  8. Accession Number: 54353
    Synopsis: ACR MLG OVERSHOT CLRNC ALT DURING DESCENT TO FL210. F/O PF SELECTED WRONG PMS MODE CANCELLING AUTO CAPTURE.
    Narrative: FROM CHS TO CLT I WAS FLYING THE ACFT VIA AUTOPILOT INPUTS THROUGH THE FMA. PMS WAS NOT ENGAGED. AT APPROX 100 MILES FROM CLT, I ASKED THE CAPT TO REQUEST DESCENT CLRNC FROM ATC. ATC ADVISED US THAT HE WAS UNABLE TO DESCEND US DUE TO TRAFFIC AND TO STANDBY FOR LOWER. AT APPROX 60 MILES FROM CLT, WE WERE GIVEN A DESCENT CLRNC. I INITIATED THE DESCENT AND THE CAPT PROCEEDED TO GET THE ATIS INFO AND COMPANY CHANGEOVER INFO. SHORTLY THEREAFTER, WE WERE GIVEN ANOTHER DESCENT CLRNC TO FL210, FOLLOWED QUICKLY BY A HEADING CHANGE AND A REQUEST TO SLOW TO 250 KNOTS, AND EXPEDITE OUR DESCENT. I ACKNOWLEDGED THE TRANSMISSIONS TO ATC. THE REQUEST TO SLOW TO 250 KNOTS CAME AS WE WERE APPROACHING FL210, HOWEVER, I DID NOT NOTICE THAT WE WERE THIS CLOSE TO LEVEL OFF DUE TO MY PREOCCUPATION WITH FLYING THE ACFT, COMMUNICATING WITH ATC, AND TRYING TO CONFIGURE THE ACFT FOR AS RAPID A DESCENT AS POSSIBLE WHILE SLOWING SIMULTANEOUSLY TO 250 KTS. DUE TO THIS ERROR ON MY PART, I SELECTED IAS HOLD ON THE FLT GUIDANCE CONTROL PANEL. MY ACTION OF SELECTING IAS HOLD JUST AS FL210 WAS BEING CAPTURED DISARMED THE ALT HOLD FUNCTION. AT 20700', THE ALT WARNING SOUNDED. I DISCONNECTED THE A/P AND BEGAN A CLIMB BACK UP TO OUR ASSIGNED ALT OF 21000'. HOWEVER, THE DESCENT WAS NOT ARRESTED UNTIL THE ACFT REACHED 20300'. HAD I OBSERVED ON THE FMA DISPLAY THAT ALT CAPTURE HAD TAKEN PLACE, I WOULD NEVER HAVE SELECTED "IAS". SEVERAL THINGS CONTRIBUTED TO THE DEVIATION: THE CAPT WAS PREOCCUPIED WITH GETTING THE ARRIVAL ATIS, COMPANY CHANGEOVER, AND FAILED TO MAKE THE CALLOUT OF 1000' ABOVE ASSIGNED ALT. NUMEROUS CLRNCS BEING ISSUED BY ATC, REQUIRING SIMULTANEOUS CHANGES IN DESCENT RATE, HEADING, AND AIRSPEED. OVER-RELIANCE ON AUTOMATIC FEATURES OF FLT GUIDANCE SYSTEM WHICH CREATED A FALSE SENSE OF SECURITY. THE FLT GUIDANCE SYSTEM CONTROLS ON THE MLG ARE LOCATED BELOW THE CENTER GLARESHIELD, WHILE THE FMA ARE LOCATED ABOVE EACH PLT'S FLT INSTRUMENT GROUP. WHEN I PUSHED THE "IAS" BUTTON ON THE FLT GUIDANCE PANEL, THE FMA WOULD SHOW THE GREEN "ALT HOLD" ANNUNCIATION REPLACED WITH "IAS", THUS INDICATING THAT THE ALT HOLD FUNCTION IS NO LONGER ENGAGED. HOWEVER, BECAUSE THE FMA DISPLAY WAS OUT OF MY FIELD OF VISION WHEN I SELECTED "IAS", THIS WENT UNNOTICED. SUPPLEMENTAL INFO FROM ACN 53983: FOR REASONS UNKNOWN, IT DID NOT CAPTURE FL210.

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  10. Accession Number: 58080
    Synopsis: ACR MLG FLT CREW REQUESTED A FINAL CRUISE ALT OF FL370. ACFT WAS AT FL330 WHEN ARTCC CLEARED IT TO FL350. PIC SET 370 IN THE FMS AND THE FO DID NOT CROSSCHECK THE ALT. PIC SAYS COMPLACENCY WITH THE COMPUTER ALWAYS BEING CORRECT AND THE
    Narrative:

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  12. Accession Number: 62424
    Synopsis: ALT CROSSING RESTRICTION OVERSHOT ON DESCENT.
    Narrative: THE COPLT WAS FLYING THE ACFT. WE WERE CLEARED FOR A PROFILE DESCENT TO DENVER STAPLETON INT'L ARPT TO CROSS (1OC) AT 17000' TO MAINTAIN 11000'. CDW WAS PROGRAMMED TO CROSS IOC AT 17000'/250 KTS TO MAINTAIN 11000' APCHING IOC THE SPEED RESTRICTION AT IOC WAS DELETED, FLT CHANGE WAS SELECTED AND THE SPEED BUG WAS INCREASED TO 300 KTS. THE RATE OF DESCENT WAS INCREASED TO PICK UP THE SPEED CAUSING THE ACFT TO DESCEND THROUGH 17000' ABOUT 1/2 MILE SHORT OF IOC. THE DESCENT CARRIED THE ACFT ABOUT 400' BELOW THE 17000' CROSSING ALT BEFORE I WARNED THE COPLT OF THE EARLY DESCENT. THE AUTOPLT WAS DISENGAGED AND THE ACFT RETURNED TO 17000' CROSSING ALT. PROPER CALL OUTS WERE USED BUT THE COPLT THOUGHT THE ACFT WAS V-NAV AND WOULD LEVEL OUT ON ITS OWN. I MISS THE 17000' CROSSING AT IOC BECAUSE I WAS LOOKING UP THE DENVER ATIS FREQ.

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  14. Accession Number: 65861
    Synopsis: ACR MLG DRAGGED RIGHT WING TIP ON GND LNDG AT MCI. FLT CREW DEACTIVATED AUTO LAND AT LOW ALT WHEN ACFT DRIFTED LEFT OF CENTER LINE.
    Narrative: BRIEFED FOR PRACTICE CAT III AUTOLAND RWY 19 AT MCI. APCH CONTROL WAS ADVISED OF OUR INTENTIONS AND TURNED US IN ON THE LOC ABOUT 5 MI FROM THE MARKER. APCH WAS NORMAL AND ALL INDICATIONS CORRECT UNTIL 20' WHEN ACFT STARTED TO DRIFT LEFT OF CENTERLINE WITH RIGHT WING LOW. AUTOPILOT WAS DISCONNECTED AND SLIGHT CORRECTION MADE BACK TOWARD CENTERLINE. TOUCHDOWN WAS SMOOTH WITH RIGHT WING STILL LOW. WE WERE ADVISED BY DEPARTING ACFT AWAITING TAKEOFF TO CHECK RIGHT WING TIP ON ARRIVAL. RIGHT LANDING LIGHT AND RIGHT TAIL LIGHT ASSEMBLIES WERE DAMAGED. ALL PREVIOUS AUTOLAND I HAVE ATTEMPTED WORKED PERFECTLY. PERHAPS A LITTLE COMPLACENCY WAS PART OF THE PROBLEM ON THIS PARTICULAR ONE. IN RETROSPECT A GO AROUND AT THIS POINT WOULD APPEAR TO HAVE BEEN A BETTER SOLUTION, ALTHOUGH AT THE TIME I FELT A TOUCHDOWN WAS INEVITABLE. THE NATURE OF THE SITUATION, ACFT DRIFTING LEFT WITH AUTOPILOT PUTTING RIGHT WING DOWN TO CORRECT BACK TO CENTERLINE PLUS MY INPUT AFTER AUTOPILOT DISCONNECT, SET US UP TO DRAG THE LIGHT AND WING TIP. SUPPLEMENTAL INFORMATION FROM ACN 66438: POSSIBLE CAUSE: LOCALIZER SIGNAL ERRATIC OR INTERFERENCE BELOW 50' AGL.

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  16. Accession Number: 66661
    Synopsis: ACR WDB ALT DEVIATION OVERSHOT DURING DESCENT.
    Narrative: WE HAD BEEN CLRD TO CROSS 70 DME E OF CHICAGO HEIGHTS VOR AT FL240, AND WE WERE DESCENDING WITH THE AUTOPLT ENGAGED. I WAS TURNING THE CGT VOR AND RESETTING THE COURSE SELECTOR. THE ALT WAS NOT CAPTURED BY THE FLT GUIDANCE SYSTEM AND I FAILED TO NOTICE THAT WE HAD DESCENDED BELOW FL240 UNTIL THE ALT ALERT AURAL WARNING SOUNDED. I IMMEDIATELY STOPPED THE DESCENT AND CLIMBED BACK TO FL240 USING THE FGS TO CONTROL THE AUTOPLT. THE CAPT WAS BUSY GETTING OUT SOME CHARTS OR APCH PLATES, AND HAD NOT NOTICED THE ALT EXCURSION EITHER. THE USUAL CALLOUT AT 1000' ABOVE THE ALT WAS NOT MADE. THE S/O CALLED OUT THE PROBLEM JUST AS I WAS CORRECTING IT. I HAD COMPLETED WDB TRANSITION TRAINING AND A LINE CHECK EARLY IN THE PRECEDING MONTH, AND THEN WENT ON VACATION, AND DID NOT FLY FOR 22 DAYS. THIS WAS MY FIRST LINE TRIP AS PLT FLYING ON THE WDB. CONTRIBUTING FACTORS WERE: MY NEWNESS ON THE EQUIPMENT, MY DISTRACTION IN TUNING RADIOS, LACK OF A 1000' CALLOUT, THE CAPT'S DISTRACTION IN GETTING OUT CHARTS, AND MY LAYOFF OF 22 DAYS IMMEDIATELY AFTER CHECKOUT ON A NEW PIECE OF EQUIPMENT. RECOMMENDATIONS: A CREW MEMBER, WHEN NEW TO AN ACFT TYPE, SHOULD GET SOME IMMEDIATE EXPERIENCE PRIOR TO GOING ON VACATION. OTHER CREW MEMBERS, WHEN WORKING WITH A NEW PERSON, SHOULD EXERCISE INCREASED VIGILANCE. THE IMPORTANCE OF THE 1000' CALL SHOULD BE EMPHASIZED DURING TRAINING AND CHECKING, AND EMPHASIS SHOULD BE PUT ON THE FACT THAT ONE SHOULD EXERCISE A GOOD SCAN, AND NOT RELY HEAVILY ON THE FLT GUIDANCE SYSTEM.

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  18. Accession Number: 66967
    Synopsis: ACR WDB DEVIATION FROM CLRNC ROUTE DURING SID FROM PHX. FO LOADED THE FMC INCORRECTLY.
    Narrative: THE CAPT DID THE WALK AROUND ON OUR CONTINUING JFK PHX DFW FLT, WHILE I PREFLIGHTED THE COCKPIT. READING THE FMC ROUTE DESCRIPTION I LOADED THE STANFIELD ONE HI DEPARTURE INTO THE ROUTE. SEEING "TFD 1 COCHISE", I QUICKLY MISINTERPRETED THIS TO MEAN DIRECT COCHISE RATHER THAN THE COCHISE TRANSITION. I LOADED TFD 1 DIRECT CIE. AFTER PASSING TFD VOR ON OUR CLIMBOUT THE CENTER CTLR ASKED IF WE WERE FLYING THE 131 DEG RADIAL FROM TFD. AFTER LOOKING AT THE SID WE ADMITTED THAT WE SHOULD BE, BUT WERE NOT. WE WERE INDEED FLYING THE LOADED, TFD DIRECT CIE, ABOUT 110 DEG RATHER THAN THE 131 DEG FOR 16 DME BEFORE PROCEEDING DIRECT CIE. WE WERE THEN CLEARED TO "JUST PROCEED DIRECT COCHISE" WHICH LED ME TO BELIEVE THAT FORTUNATELY, NO TRAFFIC CONFLICT EXISTED. CONTRIBUTING FACTORS WERE MY RELATIVE NEWNESS ON THIS EQUIPMENT, ALTHOUGH IN MY FOURTH MONTH, I OFTEN DO THE WALKAROUND WHILE THE CAPT LOADS THE ROUTE. WITH A LOT OF ONE LEG DAYS, PRACTICE IS NOT AVAILABLE. ALSO I AM JUST FAMILIAR ENOUGH NOW TO WANT TO BE A LITTLE MORE SPEEDY THAN A NOVICE. HAD I PONDERED THE DEPARTURE PAGE LONGER, I WOULD HAVE PICKED UP ON THE AVAILABLE TRANSITIONS, INSTEAD OF BLUNDERING INTO THE INCORRECT CONCLUSION. IN FACT I DID LOAD THE WINK TRANSITION INTO THE ACTON 9 ARRIVAL AT DFW AFTER I SAW THE ROUTE DISCONTINUITY. BY LOADING DIRECT CIE ON THE DEPARTURE I CLOSED UP THE TELL TALE DISCONTINUITY THAT WOULD HAVE BEEN MY CLUE TO LOOK FOR AND SELECT A TRANSITION. ANOTHER FACTOR WAS FATIGUE. WITH A BABY IN THE HOUSE, AND A DOG THAT WOKE ME UP AN HOUR EARLY, BARKING AT SOMETHING IN THE YARD, MY NIGHT'S SLEEP WAS LESS THAN SATISFYING. THIS ADDED TO MY GROWING SENSE OF COMPLACENCY THAT DEVELOPS IN "WATCHING" THE AIRPLANE TRACK THE MAGENTA LINE. HAD I DUTIFULLY CROSSCHECKED OUR COURSE WITH THE PUBLISHED SID I WOULD HAVE CAUGHT THE ERROR BEFORE IT OCCURRED. I HAVE TO BREAK THE MENTAL HABIT OF ASSUMING THE VALIDITY OF THE MAGENTA LINE. BEING SOMEWHAT FATIGUED ON THE LATTER HALF OF A LONG DAY, ESPECIALLY IN NICE WEATHER, IT IS EASY TO ALLOW THE MIND TO SLIP INTO NEUTRAL WHILE THE HARDWARE TAKES OVER. THE EMBARRASSMENT OF THIS ERROR HAS BEEN SUFFICIENT TO ELEVATE, PERMANENTLY I BELIEVE, MY LEVEL OF CARE AND DILIGENCE WHEN LOADING OUR VERY OBEDIENT COMPUTER, AND SHARPEN MY CRITICAL AWARENESS OF OUR ACTIVE NAVIGATIONAL ROUTE.

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  20. Accession Number: 68784
    Synopsis: ACR WDB DEVIATED FROM PRESCRIBED SID.
    Narrative: AFTER RECEIVING CLRNC, A SFO 3 DEPARTURE WAS PROGRAMMED INTO THE FMS. AS TAXI WAS BEGUN, GND ASKED IF WE COULD ACCEPT RWY 01. WE DECLINED DUE TO MARGINAL CROSSWIND AT 17 KNOTS AND EXPRESSED OUR PREFERENCE FOR RWY 28. MEANWHILE IN A CONTINUING EFFORT TO STAY AHEAD OF THINGS AND ACCOMPLISH CHECKLISTS, CHANGED THE DEPARTURE TO A QUIET 8 AS WOULD BE USED ON RWY 01. THE CTLR THEN CAME BACK WITH A CLRNC TO RWY 28 WITH A SFO 3 DEPARTURE. I CHANGED THE RWY IN THE FMS BUT IN THE PROCESS OF PROGRAMMING, I APPARENTLY DID NOT ACTIVATE THE SFO 3 DEPARTURE. THE RESULT WAS THAT NO COURSE LINE WAS DISPLAYED FROM THE RWY TO NORMAN INTXN. CONFUSION AND LACK OF COMMUNICATION BETWEEN MYSELF AND THE CAPT LED TO OUR LACK OF A "LAST MINUTE" VERIFICATION OF SPECIFIC DEPARTURE PROCEDURES AFTER TKOF. THE NORMAL "TECHNIQUE" OF STATING THE HDG AND ALT AFTER DEPARTURE WAS OMITTED. AS A RESULT OF THIS CONFUSION, THE CAPT INITIATED WHAT HE THOUGHT WAS THE CORRECT TURN TO A 30 DEG HDG AFTER TKOF. UPON CONTACTING DEPARTURE, THE CTLR ASKED IF WE "WERE FLYING THE QUIET 8". WE REPLIED "NEGATIVE". HE GAVE US A LEFT TURN TO REJOIN THE 281R OUTBOUND WHICH WE IMMEDIATELY EXECUTED. NO PROBLEMS WERE ENCOUNTERED. THIS INCIDENT WAS A RESULT OF LAST MINUTE CHANGES CAUSING INCREASED WORKLOAD. IT CAN ONLY BE AVOIDED THROUGH GREATER VIGILANCE AND A COMMITTMENT TO USE WHATEVER CAUTION NECESSARY TO AVOID EXPOSURE TO SUCH ERRORS. ONE MUST ALSO AVOID UNDUE DEPENDANCY ON COMPUTER GENERATED FLT PATH AND ALT DISPLAYS.

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  22. Accession Number: 70453
    Synopsis: ACR WDB TRACK DEVIATION ON CLIMB.
    Narrative: THIS WAS ONE THAT TOOK ME A WEEK TO FIGURE OUT "WHY DID THE FMS DO THAT"? MY FLT WAS SLC-PDX. FLT PLANNED AND CLEARED SLC J15 IMB DIRECT PDX. WHILE PROGRAMMING THE FMS ON PREFLT, AFTER 'T.O. RWY' SELECTION (34L) I INADVERTENTLY TYPED IN 'PDX' FOR THE FIRST FIX INSTEAD OF SLC (IN OTHER WORDS, DESTINATION INSTEAD OF DEP VORTAC.) THEN ENTERED J 15 IMB, THEN DIRECT PDX. A PAX WAS IN THE COCKPIT AT THAT TIME AND WAS ASKING QUESTIONS ABOUT THE FLT. THE F/O WAS NOT PRESENT. I DID NOT RECHECK THE FMS PROGRAM AFTER ENTERING IT. AFTER TKOF ON RWY 34L, DEP CTL ASSIGNED US A 260 DEG HDG TO INTERCEPT J 15. CLIMBING THRU 11000 FT, DEP CTL SAID WE WERE 4 MI N OF THE AIRWAY, AND INSTRUCTED US TO FLY A 310 DEG HDG TO REINTERCEPT THE AIRWAYS. HE OBVIOUSLY MEANT THAT WE WERE S OF THE AIRWAYS, BUT WE TURNED TO 310 DEG NEVERTHELESS CONFUSED BECAUSE WE SAW OUR FMS SHOWING US STILL N OF THE AIRWAYS. IN ACTUALITY, THE FMS WAS NOT SHOWING US THE AIRWAYS, BUT WAS SHOWING THE TRACK DIRECT FROM RWY 34L TO PDX. THAT IS THE PART I LEARNED MUCH LATER. I DID NOT THINK THAT THE FMS WOULD ACCEPT A FLT PLAN TO THE SAME DESTINATION TWICE ON ONE LEG, BUT IT WILL. FURTHER INTO THE CLIMB, STILL ON THE 310 DEG HDG CTR SIMPLY CLEARED US 'DIRECT TO KIMBERLY (IMB), FLT PLANNED ROUTE' WHICH WE EXECUTED. HE MUST HAVE SENSED WE WERE HAVING NAV DIFFICULTIES. WE WERE VFR THROUGHOUT THE CLIMB AND OBTRUCTIONS WERE NOT A FACTOR. NO TFC WAS CALLED TO OUR ATTN BY DEP CTL, NOR WAS ANY SEEN BY THE FLT CREW. WE HAVE BEEN INSTRUCTED TO ALWAYS DOUBLE CHECK THE FMS PLANNED ROUTING ON THE 'LEGS-PLAN' PAGES OF THE FMS AFTER ENTERING IT. I DID NOT, AND SHOULD HAVE, ESPECIALLY AFTER THE DISTRACTION DURING PROGRAMMING.

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  24. Accession Number: 77914
    Synopsis: ALT OVERSHOT ON CLIMBOUT WHEN DESCENT CLRNC WITH ALT RESTRICTION GIVEN BEFORE REACHING ASSIGNED ALT AND FMC REPROGRAMMED.
    Narrative: WE HAD RECEIVED A CLRNC TO CLB TO 16000', DIR TO THE SRP VORTAC ON THE 23 MIN FLT FROM TUS TO PHX. SOMEWHERE BTWN 11000' AND 15000' (SLIGHTLY LESS THAN 1 MIN'S TIME) WE WERE CLRD TO CROSS 35 SE OF SRP AT OR BELOW 14000', 250 KTS, MAINTAIN 10000'. AS IS STANDARD PRACTICE AT OUR COMPANY, I SET THE NEW CLRNC LIMIT ALT (10000') IN THE ALT SELECTOR OF THE AUTOPLT/FLT DIRECTOR SYSTEM MODE CTL PANEL, MENTALLY ASSURING MYSELF THAT THE AUTOPLT WOULD LEVEL THE ACFT AT 16000' SINCE THAT WAS THE CRS ALT PROGRAMMED IN THE FLT MANAGEMENT COMPUTER (FMC). I REACHED INTO MY FLT BAG TO PULL OUT A BINDER TO STOW MY TUCSON PLATES, AND WAS JUST OPENING IT WHEN THE ABQ CENTER CTLR CALLED, "PHX ALTIMETER 29.84." I RESET THE ALTIMETER AND NOTED THAT THE INDICATED ALT WAS NOW 16400' AND CLBING RAPIDLY. I DISCONNECTED THE AUTOPLT AND MANUALLY LEVELED AT 16000'. THE MAX INDICATED ALT WAS 16700'. COMMON PRACTICES CAN LEAD TO CRITICAL ERRORS UNDER SITUATIONS ONLY SLIGHTLY DIFFERENT FROM THE NORM. NORMALLY, WE DON'T RECEIVE DES CLRNCS BEFORE REACHING THE ASSIGNED CRS ALT. NORMALLY, WE SET THE ALT SELECTOR OR ALERTER TO THE NEW CLRNC LIMIT ALT AS SOON AS WE RECEIVE IT. I DID THIS AUTOMATICALLY W/O CONSIDERING THAT IT MIGHT BE AN INVALID RESPONSE. WE'RE PSYCHOLOGICALLY PROGRAMMED TO EXPECT THINGS TO HAPPEN WITH A MACHINE BASED ON OUR EXPERIENCE WITH WHAT USUALLY HAPPENS. WITH THIS AIRPLANE'S EFIS DURING A CLB OR DES IN THE VNAV MODE, THE AIRPLANE WILL LEVEL OFF AT THE CRS ALT PROGRAMMED IN THE FMC EVEN IF THE ALT SELECTOR IS SET AT A HIGHER (DURING CLB) OR LOWER (DURING DES) ALT. EX: FMC CRS ALT FL330, CLRD TO FL370, ALT SELECTOR SET TO 370, AUTOPLT LEVELS THE AIRPLANE AT FL330. HAPPENS ALL THE TIME, SO I KNEW THE AUTOPLT WOULD LEVEL THE ACFT AT 16000'. WRONG! WHAT I DID, IN FACT, WAS TELL IT TO STOP AT AN ALT I WASN'T ON THE WAY TO. THE AUTOPLT THEN REVERTED TO THE CWS PITCH MODE, IN WHICH THE AIRPLANE KEEPS ON GOING IN THE LAST DIRECTION IT WAS POINTED, UNTIL THE PLT POINTS IT SOMEWHERE ELSE WITH THE YOKE. THERE IS NO AURAL WARNING WHEN THIS HAPPENS, THE AUTOPLT HASN'T DISCONNECTED, IT'S JUST HLDG A PITCH ATTITUDE. THERE'S A SMALL YELLOW CWS PITCH WARNING ON THE EADI, BUT IT HAS TO BE LOOKED AT TO BE SEEN (MUCH LIKE TFC AND ALTIMETERS). I ALSO KNEW I'D HAVE TIME TO STOW MY DEP PLATES BEFORE APCHING 16000', AS THE AUTOPLT STARTS A SMOOTH LEVEL OFF AS A FUNCTION OF RATE OF CLB AND WOULD BE REDUCING IT'S RATE OUT OF ABOUT 13000'. WRONG AGAIN! SINCE IT DEFAULTED TO CWS PITCH AND I DIDN'T NOTICE IT, WE WERE STILL CLBING AT 4 TO 6000 FPM. NO TIME FOR ANY INATTN OR DISTR. SO WHERE WAS THE NFP WHO WOULD NORMALLY BE CROSSCHECKING ALT AND MAKING APPROPRIATE CALLOUTS? THE SAME PLACE HE ALWAYS IS DURING MOST OF THE TIME SPENT ABV 10000' ON THIS RUN: DEEP IN THE MIDDLE OF COPYING ATIS AND MAKING REQUIRED FLT-FOLLOWING RADIO CALLS TO THE COMPANY. IT'S COMMON KNOWLEDGE THAT THE PF HAS LITTLE BACKUP ON A SHORT FLT LIKE THIS, BECAUSE THERE IS SO MUCH RADIO WORK TO DO. ALL THE MORE REASON FOR THE PF TO DO NOTHING BUT FLY (OR, THESE DAYS, MONITOR). SOMEWHERE IN ABQ CTR THERE WAS AN ALERT CTLR WHO TACTFULLY BROUGHT MY ATTN BACK WHERE IT SHOULD HAVE BEEN IN THE FIRST PLACE. MY HAT IS OFF TO HER! THE NEW TECHNOLOGY MACHINERY (FMC, EFIS, ETC) IS MARVELOUS, BUT IT SUCKERS US INTO COMPLACENCY. IN THE OLDER SERIES AUTOPLT, THE CWS MODE WAS THE NORM, RATHER THAT THE EXCEPTION. THIS WAS FINE, AS YOU KNEW YOU WERE IN IT. IN MY EXPERIENCE, THERE'S A MUCH HIGHER INCIDENCE OF ALT/SPD/ROUTE BUSTS IN THE FMC-EQUIPPED ACFT, LARGELY (I THINK) BECAUSE THE SYSTEM IS SO COMPLEX THAT THERE ARE MANY OPPORTUNITIES FOR FAULTY PROGRAMMING. SUGGESTIONS: ALT AWARENESS! ALT ALERTERS ARE WONDERFUL, BUT WE'VE BECOME TOO DEPENDENT ON THEM. LET'S ALL TAKE A HARD LOOK AT OUR PROCS FOR THEIR USE AND BE SURE THEY'RE VALID FOR THE INTENDED RESULT. CONTINUALLY EMPHASIZE THE IMPORTANCE OF DEVOTING YOUR FULL ATTN TO MONITORING THE FLT WHENEVER THE OTHER CREWMEMBERS ARE INVOLVED WITH OTHER DUTIES. TRY TO MINIMIZE DISTRS DURING CLBS/DES, NOT JUST BELOW 10000'. ALWAYS FOLLOW UP ANY CHANGES IN AUTOPLT/FLT DIRECTOR MODE WITH A CHK OF THE MODE ANNUNCIATOR. IN NEW TECHNOLOGY ACFT, THIS MEANS EVERY TIME YOU PUSH A BUTTON. FOR R & D: IF WE MUST HAVE AN AURAL WARNING FOR AN AUTOPLT DISCONNECT, IS IT ANY LESS DANGEROUS TO HAVE IT REVERT TO A CWS MODE W/O THE PLT BEING AWARE? THIS IS A VERY COMMON OCCURRENCE. A CANCELLABLE AURAL WARNING AFTER, SAY, 3 SECS OF CWS WOULD DO THE TRICK. PERHAPS IF THE MACHINE CAN LEAD US ASTRAY, IT SHOULD WARN US. IS IT ACCEPTED PRACTICE FOR ATC TO GIVE DES CLRNCS PRIOR TO REACHING THE ASSIGNED CRS ALT? THIS COULD LEAD TO VARIOUS ERRORS AND CONFUSION.

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  26. Accession Number: 82259
    Synopsis: FLT CREW PROGRAMMED FMC IN ERROR. INSTEAD OF PLOTTING THE AIRWAYS, THE COMPUTER THEN PLOTTED A DIRECT ROUTE FROM SFO TO KLAX, THE ARPT.
    Narrative: ENRTE FROM SFO TO LAX OUR FLT PLAN WAS FILED AS, AFTER AVE VOR, J1 LAX. THE INS ROUTE THAT WAS ENTERED AND ACCEPTED BY THE COMPUTER WAS J1 TO LAX ARPT. THE COMPUTER GAVE US A DIRECT ROUTE TO LAX ARPT FROM THE AVE VOR INSTEAD OF GOING OVER FILLMORE VOR WHICH IS ON J1. THIS RESULTED IN US BEING A FEW MILES LEFT OF THE DESIRED ARR COURSE. IN OUR COMPUTER, IF WE ENTER A JET ROUTE TO A WAYPOINT THAT IS NOT ON THAT JET ROUTE, THE COMPUTER WILL ACCEPT IT AND GIVE US A DIRECT ROUTE TO THAT WAYPOINT. I THINK THAT IN THIS CASE THE COMPUTER SHOULD SHOW AN INVALID ENTRY TO ALERT US THAT WE ARE TRYING TO ENTER A WAYPOINT ON AN ARWY THAT IS NOT PART OF THAT ARWY. SUPPLEMENTAL INFO FRAME ACN 82520: FLT PLAN WAS FILED AVE J1 LAX. FMS ROUTING ENTERED AND ACCEPTED WAS AVE J1 LAX ARPT (KLAX) COMPUTER STEERING AND TRACK WAS AVE DIRECT LAX ARPT, WHICH CUT OUT FILLMORE VOR (WHICH IS PART OF J1). CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: FLT CREW MISTAKENLY ENTERED J1 TO KLAX INSTEAD OF J1 TO LAX. THE DIFFERENCE IS THAT J1 DOES NOT GO TO KLAX AND THE COMPUTER THEREFORE AUTOMATICALLY PROGRAMS A DIRECT ROUTE. RPTR WOULD LIKE THE COMPUTER TO FLASH A WARNING, SOMETHING LIKE, "INVALID ENTRY," TO ALERT THE CREW TO THEIR MISTAKE. RPTR DID SAY THAT THEY WERE PROBABLY COMPLACENT.

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  28. Accession Number: 83690
    Synopsis: FLT CREW PROGRAMMED THE FMC USING THE ON BOARD STORED FLT PLAN. CLRNC WAS FOR A DIFFERENT PLANNED ROUTE. ARTCC CTLR ADVISED FLT OPERATING ON THE WRONG AIRWAY, WAS 60 MILES OFF COURSE AND CAUSED LESS THAN STANDARD SEPARATION WITH ANOTHER
    Narrative: ON A STOPOVER IN CANCUN, MEXICO, I PREFLTED THE FMC, ENTERED CUN ATL IN COMPANY ROUTE AND THE COMPANY ROUTE READOUT (DIRECT ROBIN, UA321 PLADE, R875, 45 MID, ETC). I ALSO SET UP THE VHF NAV FOR DIRECT ROBIN INTXN AS A BACKUP TO THE LAT NAV. DEPARTED CANCUN TO NW, TURNED ON COURSE 011 DEG R TOWARDS ROBIN INTXN. CLRNC FROM CANCUN TWR READ, "AS FILED TO MAINTAIN FL350 DEP FREQ SQUAWK 1034." AT APPROX 60 MI FROM CANCUN AND PASSING FL260 FOR FL350, MERIDA CENTER ADVISED US THAT WE WERE OFF COURSE AND APPEARED TO BE ON THE WRONG ARWY. THEY ALSO ADVISED US THAT WE CAME "VERY CLOSE" TO ANOTHER ACFT. I LOOKED AT OUR FLT PLAN ON THE PAPERWORK AND IT READ: CUN A26E PARRA UA26 SWORD A26 GNI MEI LGCG ATL. WE WERE INDEED FLYING THE WRONG ARWY. THE CAPT AND MYSELF FAILED TO VERIFY THE CLRNC WITH CANCUN TWR BEFORE OUR DEP, NOR EVEN TO CROSSCHECK OUR COMPUTER STOWED FLT PLAN WITH THE PAPERWORK FROM FILED FLT PLAN. I, NOR THE CAPT, DID NOT OBSERVE ANY CONFLICT IN TFC, NOR DID WE HEAR ANY COMPLAINTS ON FREQ ABOUT A NEAR MISS. THERE WAS NO MENTION OF HOW CLOSE WE CAME. THE CAPT WAS A CHK AIRMAN ON THE MLG WITH MANY YRS EXPERIENCE. I, AS THE F/O, HAD 4 YRS FLYING MLG, 1500 HRS AS PIC ON MLG. PERHAPS WE RELIED TOO MUCH ON EACH OTHER TO DO THE JOB PROPERLY AND THAT LITTLE OVERLOOKED ASSUMPTION THAT THE BOX WOULD NEVER LIE CAUGHT UP WITH US.

  29.  
  30. Accession Number: 85126
    Synopsis: WDB IN CRUISE SET FMS TO CLIMB FROM FL330 TO FL350. BEGAN DESCENT TO 3500' INSTEAD.
    Narrative: WE WERE IN CRUISE AT FL330 USING FMS AND AUTOPLT. MEM CENTER CLRED US TO FL350. I SELECTED FL350 ON THE FMS AND ENGAGED VNAV. THE F/O CHANGED THE ALT ALERT SELECTOR TO 35000'. I WAS DISTRACTED FOR A FEW SECS AND THE F/O SAID WE ARE DSNDING. WE WERE DSNDING AT APPROX 1000 FPM. I DISENGAGED THE AUTOPLT AND PUT THE ACFT IN A CLB TO FL350. WE LOST APPROX 1000' IN THIS MANEUVER. SINCE WE HAD UNLIMITED VIS IT WAS DONE SMOOTHLY. I ADVISED THE F/O TO TELL THE MEM CENTER WHAT WE WERE DOING, WHICH HE DID. IN CHKING TO FIND THE CAUSE I FOUND THE FMS CALLING FOR 3500' INSTEAD OF 35000'. APPARENTLY THE FMS DIDN'T TAKE A ZERO OR IT DROPPED OUT. SINCE THE ALT ALERT SELECTOR WAS SET FOR 35000', THERE WAS NO 250' WARNING OF LEAVING THE ALT. THE CENTER PROBABLY DIDN'T GET AN ALERT FOR THE SAME REASONS. I HAVE BEEN OPERATING THIS EQUIP FOR OVER 7 YRS W/O ANY OCCURRENCE OF THIS NATURE. I GUESS THE LESSON HERE IS, DON'T BE TOO COMPLACENT WITH THIS AUTOMATIC NAV EQUIP. THIS IS ONE SITUATION WHERE WE DON'T HAVE ALT ALERTING TO WARN US OF A DSNT.

  31.  
  32. Accession Number: 92431
    Synopsis: ACR MLG DEVIATES FROM COURSE AND ENTERS RESTRICTED AREA.
    Narrative: FILED FLT PLAN FROM BUR TO DEN WAS THE VNY 5 DEP, PMD TRANSITION, PMD J6 J146 HBU. CLRNC DELIVERY GAVE US THE VNY 5, PMD TRANSITION, PMD--THE PMD 046 DEG R DAG 239 DEG R DAG FLT PLAN ROUTE. LAST WK I WAS ABLE TO REPROGRAM THE FMC WITH THE NEW ROUTING. THIS TIME IT WOULDN'T ACCEPT IT. AS WE PASSED PMD ON OUR CLBOUT I WAS STILL TRYING TO REPROGRAM. WE WENT OUT J6 (PMD 067 DEG R) FOR A COUPLE OF MILES BEFORE WE WENT TO MANUAL VOR NAV. IN MAKING A LEFT TURN TO ABOUT 020 DEGS TO INTERCEPT THE PMD 046 DEG R, WE ENTERED THE EDGE OF THE EDWARDS AFB RESTRICTED AREA AS WE LEVELED AT FL370. ATC INFORMED US WE WERE IN THE AREA, GAVE US A TURN TO 080 DEGS FOR DAG AND SAID WE WERE OUT OF THE RESTRICTED AREA. (THE CAPT WAS FLYING AND I WAS ON THE RADIO.) THE PROB BEGAN WITH THE NEW ROUTING WHICH THE FMC WOULD NOT ACCEPT. ALSO, THIS ROUTING BRINGS YOU RIGHT TO THE EDGE OF THE RESTRICTED AREA--J6/J146 GIVES YOU A LOT MORE CLRNC. WE'VE BECOME SO USED TO USING THE EFIS MAP MODE AND AUTOFLT, THAT WE'VE GOTTEN AWAY FROM VOR NAV. PARTLY COMPLACENCY, PARTLY CONFUSION. UNFORTUNATELY, MY AIRLINE'S MLG B TRNING WAS ATROCIOUS AND THE FAA'S RUBBER STAMP OF THE SYLLABUS WAS CRIMINAL. (A SURVEY OF THOSE OF US FLYING THIS ACFT OVERWHELMINGLY CONDEMNED THE TRNING AND ONLY BY THREATENING TO GO PUBLIC CONVINCED THE COMPANY TO SPLIT THE MLG B FLEET FROM THE MLG A.) THIS TYPE OF INCIDENT HAS HAPPENED TO SEVERAL OF OUR CREWS AND AFTER FLYING THE MLG B FOR 18 MONTHS I FINALLY SCREWED UP, TOO! CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: WHEN ANALYST POINTED OUT THAT THE PMD 046 DEG R DID NOT INTERCEPT THE DAG 239 DEG R, RPTR SEEMED FLUSTERED AND SAID HE WAS POSITIVE THAT THE RADIALS HE RPTED WERE THE RADIALS HE WAS GIVEN BY BUR CLRNC DELIVERY, AND THAT HE HAD READ THEM BACK. HE ALSO SAID THAT HE THOUGHT THE ROUTE BTWN PMD AND DAG WAS AMENDED MORE OFTER THAN NOT AND HE WONDERED WHY THEY DIDN'T SIMPLY CHANGE THE CENTER STORED ROUTE.

  33.  
  34. Accession Number: 109778
    Synopsis: ACR MLG DEVIATED FROM CLRNC. FAILED TO HOLD ON PUBLISHED PATTERN.
    Narrative: WHILE ON DSNT AND DELAYING VECTORS INTO ORD CTLR STATED, "APCH BACKED UP, CLRED DIRECT TO PLANT INTXN, 10000', HOLD RIGHT TURNS, 10 DME LEGS, EFC SHORTLY." WHEN PLANT INSERTED INTO COMPUTER REALIZED WE WERE ON TOP OF IT (MUST HAVE BEEN 2-3 MI FROM IT WHEN CLRNC ISSUED). ENTERED HOLD WHILE LEVELING AT 10000' AND SLOWING TO HOLD SPD. AT THIS POINT I WAS STILL CONCERNED ABOUT GETTING AN EFC, LOOKING AT AND ADJUSTING RADAR, AND LISTENING TO VERY BUSY FREQ. F/O (PF) ENTERED HOLD INFO IN COMPUTER AT THIS TIME. WHILE ACFT WAS IN TURN BACK TO PLANT INTXN ATC TOLD US WE WERE 5 MI S (ON NON-HOLDING SIDE) AND QUESTIONED IF WE HAD THE PROPER RADIAL SET UP. AT THIS POINT WE BOTH REALIZED THAT THE INBND COURSE (297 DEGS OFF KNOX VOR) HAD NOT BEEN INSERTED INTO COMPUTER AND ACFT HELD AT PLANT ON ITS INBND COURSE WHEN ORIGINAL CLRNC "DIRECT PLANT" ISSUED. ENTERED PROPER INBND COURSE (297 DEGS) AND ACFT RE-ENTERED HOLD. PERHAPS IF CTLR HAD SAID, "AS PUBLISHED," IT WOULD HAVE KEYED US TO CHK THE INBND COURSE. WE DID NOT HAVE AREA CHARTS OUT AT THE TIME HOLD WAS ISSUED (ONLY APCH PLATES). SOME TIME WAS LOST (AFTER CTLR SAID WE WERE S OF PUBLISHED PATTERN) GETTING OUT PROPER CHARTS. I PUT TOO MUCH FAITH IN THE COMPUTER--IT DISPLAYED A BEAUTIFUL HOLDING PATTERN ON THE EFIS, ONLY IT WAS NOT THE HOLDING PATTERN "AS PUBLISHED," BUT ONE THAT WAS SLIGHTLY S.

  35.  
  36. Accession Number: 110142
    Synopsis: ADVANCED TECHNOLOGY ALT SELECTOR SPONTANEOUSLY CHANGED 1000' CAUSING ALT DEVIATION.
    Narrative: CLRED AFTER TKOF TO CLB ON S COURSE OF ILS (164 DEGS) TO 15000', ETC. ACFT IS MLG WITH FMC, AUTOPLT, ETC. ALT ON MCP OF AUTOPLT FLT DIRECTOR SYS (AFDS) WAS SET AT 15000' AND SHOULD GIVE NORMAL AUDIO & VIS WARNINGS APCHING AND ALSO IF AUTOPLT ENGAGED, LEVEL ACFT AT SET ALT. THE ALT IS SET BY MANUAL DRUM KNOB AND INDICATED ELECTRONICALLY. IT IS PART OF A SYS. THE COPLT WAS FLYING AND WE BOTH ASCERTAINED THE ALT SET AT 15000'. SOMETIME DURING CLB THE ALT SET (15000') IN MCP CHANGED TO 16000'. WE WERE DETRACTED OUTSIDE LOOKING FOR TFC AND COPLT NAVIGATING AND DID NOT REALIZE ALT CHANGE UNTIL APCHING 15000'. AS COPLT FLEW THROUGH 15000' AND TRYING TO SMOOTHLY CORRECT ERROR WE WERE CLRED HIGHER. WE OBVIOUSLY BOTH WERE SURPRISED TO SEE 16000' ALT SELECTED. I LATER CALLED RNO DEP CTLR (HE WAS A SUPVR) AND DISCUSSED THE SITUATION WITH HIM. HE DID AN EXCELLENT JOB AND WAS VERY PROFESSIONAL AND CAPABLE. HE SAID HE COULD SEE THE PROB COMING AND THERE WAS NO INCIDENT OR ANYTHING FURTHER. I DESIRE HE & ATC NOT BE BROUGHT INTO THIS AS WE HAD A VERY RESPECTFUL ATTITUDE OF COOPERATION AND TRUST AND I WOULDN'T WANT TO DAMAGE THAT. THE PROC OCCURRED WHEN WE WERE BUSY AND OCCUPIED WITH NUMEROUS OBLIGATIONS. TRUE, WE SHOULD NOT COMPLETELY RELY ON AN ALT WARNING AND AUTOMATIC LEVEL OFF, BUT AT TIMES, POSSIBLE DUE TO COMPLACENCY, WE DO RELY ON IT. FORTUNATELY IN THIS CASE, NOTHING SERIOUS OCCURRED, BUT IT COULD. MAINT ADVISED THIS HAS OCCURRED BEFORE W/THE SYS. A FIX SHOULD BE FOUND & IMPLEMENTED.

  37.  
  38. Accession Number: 113323
    Synopsis: FLT CREW FAILED TO COMMENCE CLIMB TO NEW CLEARED ALT IN A TIMELY MANNER. FLT CREW WORKLOAD AT CRITICAL POINT.
    Narrative: THIS SCENARIO STARTED DEVELOPING WITH NY APCH. WX WAS POOR ON THE EAST COAST, THE CTLRS WERE VERY BUSY, THE F/O WAS NEW (10-12 HRS) AND I RELIED TOO MUCH ON THE INFO IN THE FMC. WE WERE VECTORED OFF THE ARR TOWARD THE FINAL APCH FOR RWY 04 AT LGA, WX 4 OVCST, 1 MI, LIGHT RAIN, WIND 0615. THE SHORTER DISTANCE CAUGHT ME HIGH AND FAST AND I REFERRED TO THE FMC VERTICAL OFFSET. THE F/O EXTENDED THE FINAL APCH COURSE FROM THE OUTER MARKER, HOWEVER THE ALT WAS FOR AN INTXN 4.5 MI OUTSIDE THE MARKER. THIS RESULTED IN A HIGH, FAST AND UNSTABILIZED APCH. A GO AROUND WAS MADE AND ANOTHER APCH WAS UNDERTAKEN. IT WASN'T UNTIL I WAS ESTABLISHING MYSELF ON FINAL FOR THIS APCH THAT I REALIZED WHAT HAD CAUSED THE PROBLEM ON THE FIRST APCH. AT ABOUT 1000' MY GLIDE SLOPE INDICATOR WENT FULL SCALE UP AND DOWN. TWR CONFIRMED A NORMAL SIGNAL SO A SECOND GO AROUND WAS MADE. THIS APPEARED LIKE AN ACFT HAD TAXIED THROUGH THE SIGNAL PATH. A THIRD APCH WAS MADE BUT NO CONTACT AT MINIMUMS SO ANOTHER GO AROUND WAS ACCOMPLISHED. AT 3000' ON DOWNWIND NW OF THE ARPT WE WERE CLEARED TO CLIMB TO 5000' FOR HOLDING. THE F/O SET THIS IN THE ALT WINDOW THEN GOT BUSY GETTING WX FOR JFK. I MISSED THE CLRNC TO CLIMB BECAUSE I WAS PREOCCUPIED WITH FUEL AND ALTERNATE CONSIDERATIONS. THE CTLR CALLED US BACK AND TOLD US HE NEEDED US OUT OF 3000' AT THAT TIME. THE CORRECT ALT WAS SET IN BUT THE ALT HOLD MODE OF THE AUTOPLT HAD NOT BEEN CANCELLED SO WE WERE LATE IN CLIMBING TO 5000'. HOLDING WAS ESTABLISHED AT 5000' AT THAT TIME I REQUESTED AN APCH TO RWY 13 AT LGA. THEY WERE RELUCTANT TO APPROVE THAT REQUEST. AFTER 15-20 MIN THEY DID ALLOW ME TO MAKE THAT APCH. WE BROKE OUT AT ABOUT 300' AND LANDED. DURING DEPLANING, A PAX STATED THAT HE HAD SEEN AN ACFT WITHIN 500' OF US IN THE HOLDING PATTERN. SINCE WE WERE IN THE WX I THOUGHT THAT IT MIGHT HAVE BEEN ANOTHER ACFT IN THE HOLDING PATTERN 1000' ABOVE US. LATER I CONSIDERED THE TIME HE HAD SPOTTED THE ACFT AND IT COULD HAVE BEEN WHEN WE DELAYED OUR CLIMB TO 5000'. WE DID NOT SEE ANYTHING AND THE CTLR NEVER SAID ANYTHING ABOUT CONFLICTING TFC. RECOMMENDATIONS: 1) INFO STORED IN VMC'S SHOULD BE CHECKED AND CORRECTED BECAUSE PLTS DO RELY ON THIS INFO AT CRITICAL TIMES. THE COMPUTER IS THE BACKUP IN PLACE OF THE THIRD PLT ON THE NEW 2-MAN ACFT. 2) CTLRS SHOULD SLOW DOWN, ALLOWING MORE SPACE FOR ACFT TO MANEUVER, THIS MAY REDUCE THE STRESS ON CTLRS, REDUCE MISCOMMUNICATIONS PARTICULARLY WHEN THE WX IS MARGINAL. THERE ARE MANY INEXPERIENCED CTLRS AND PLTS IN THE SYSTEM TODAY. 3) REINFORCE THE REQUIREMENT FOR TAXING ACFT TO STAY AWAY FROM ILS TRANSMITTERS DURING MARGINAL WX. 4) REQUEST THAT ARPTS CHANGE APCHES AS SOON AS POSSIBLE AFTER ONE BECOMES UNUSABLE. THE CTLRS WERE VERY PROFESSIONAL DURING THIS ENTIRE TIME BUT IT WAS VERY APPARENT THAT THEY WERE UNDER A GREAT DEAL OF STRESS AND OUR FLT CREATED CONSIDERABLE ADDITIONAL WORK FOR THEM THAT MIGHT HAVE BEEN ELIMINATED IF THEY HAD TOLD ME EARLY OF THEIR INTENTION TO BRING ME IN FAST AND CLOSE.

  39.  
  40. Accession Number: 119740
    Synopsis: ALT DEVIATION UNDERSHOOT IN DESCENT. REPORTER REQUESTS NO CALLBACK.
    Narrative: ON AUG/THU/89, I WAS THE CAPT ON AN LGT ACR FLT XX, LGA-DTW. OUR ROUTING WAS THE LGA 3 SID OUT OF LGA TO NEON INTXN J95 TO KOOPER DIR AYLMER V-2 RHYME DIR DTW ARPT. WE WERE ENRTE FROM KOOPER TO AYLMER AT FL350 AND WERE CLEARED TO CROSS 15 E OF AYLMER AT FL310. WE PROGRAMMED 15 E OF AYLMER AT 310 IN THE FMC AND SET 310 IN THE MODE CTL PANEL. A "TOP OF DESCENT" CIRCLE SHOWED UP ON THE SCREEN DEPICTING WHERE THE DESCENT WOULD BEGIN. HOWEVER, AT THE TOP OF DESCENT PT, THE ACFT DID NOT DESCEND AND DUE TO DISTRACTING CONVERSATION BETWEEN US, NEITHER I NOR THE F/O NOTICED IT UNTIL WE WERE ABOUT 20 MI E OF AYLMER. I IMMEDIATELY STARTED A FAIRLY RAPID DESCENT OF ABOUT 4000 FPM WITH SPEED BRAKES AND SAW WE WERE NOT GOING TO MAKE 15 E AYLMER AT FL310. I CALLED CLE AND SAID WE STARTED DOWN TOO LATE AND WERE NOT GOING TO MAKE 15 E AYLMER AT 310. IN FACT, WE WERE CROSSING 15 E AYLMER AT 330. CLE SAID THAT'S OK AND GAVE US A FREQ CHANGE. I DON'T KNOW WHY, WITH EVERYTHING APPARENTLY SET IN PROPERLY, THE ACFT DID NOT DESCEND AT THE PROPER TIME. I FEEL THE CAUSE OF THIS MISTAKE IS TOO MUCH RELIANCE ON AUTOMATED SYSTEMS AND A LACK OF VIGILANCE ON MY PART AS TO THE ALT AND POSITION OF MY ACFT.

  41.  
  42. Accession Number: 122911
    Synopsis: ACR MLG ALT DEVIATION OVERSHOT DURING DESCENT USING 'ADVANCED FLT GUIDANCE SYSTEM.'
    Narrative: DSNDING TO CROSS 30 DME S OF BNA AT AND MAINTAIN 11000'. ACFT ON AUTOPLT WITH ALT CAPTURE ARMED. I FLEW THROUGH ALT ANYWAY. ACFT BOTTOMED OUT AT 10500' AFTER AUTOPLT DISENGAGED. THIS TYPE MLG IS NOTORIOUS FOR ALT BUSTS BECAUSE IT HAS AN "ADVANCED FLT GUIDANCE SYS," INCORPORATING AUTOMATIC ALT CAPTURE. THIS SYS WORKS JUST WELL ENOUGH TO TRAP YOU. OLDER MLGS W/O THIS SYS WERE NOT NOTED FOR THIS PROB. WHAT'S WRONG HERE? A MISGUIDED DESIRE TO RELY ON POORLY DESIGNED AUTOMATION REDUCES SAFETY MARGINS.

  43.  
  44. Accession Number: 123705
    Synopsis: ALT DEVIATION ALT UNDERSHOT. CROSSING RESTRICTION NOT COMPLIED WITH.
    Narrative: WE WERE TO IDENT TO CROSS HOLEY INTXN AT 11000'. I WAS FLYING THE ACFT COUPLED ON THE AUTOPLT. I PROGRAMMED THE CORRECT DATA INTO THE FMC, AND SELECTED 11000' ON THE MCP. THE ACFT INDICATED A TOP OF DSNT IN 17 MI. HAVING CONFIDENCE IN THE SYS, I SWITCHED ATTN TO CREATING WAYPOINTS FOR APCH AND APPROPRIATE RWY. I THOUGHT TO MYSELF, "WE SHOULD HAVE STARTED DOWN BY NOW;" WE WERE 10 MI FROM THE INTXN AND 13000' HIGH. IMMEDIATELY I STARTED A RAPID DSNT AND WE CROSSED HOLEY AT 12500'. MY POINT IS THAT I HAVE ALMOST 3000 HRS INT HIS AIRPLANE, AND I AM VERY KNOWLEDGEABLE IN ITS OPERATION, BUT PLTS CANNOT RELY ON THE COMPUTERS TO FLY THE ACFT.

  45.  
  46. Accession Number: 126918
    Synopsis: COMMUTER FLT CREW CLIMBED THROUGH ASSIGNED ALT.
    Narrative: MY COPLT WAS FLYING FROM CLEVELAND HOPKINS TO COLUMBUS, (PORT COLUMBUS) OH. SCHEDULED FLT TIME IS APPROX 25 MIN. MY COPLT HAS ONLY BEEN ON THE LINE IN THIS ACFT FOR A MONTH, AND COMES FROM A BACKGROUND OF HELICOPTER AVIATION. IN THE 20 SOME ODD MINS BETWEEN ARPTS (NOT JUST THESE 2, BUT MOST ALL OF OUR CITY PAIRS) WE GET AN OVER-ABUNDANCE OF VECTORS AND ALT CHANGES, ALT CHANGES ASSOCIATED WITH CROSSING RESTRICTIONS, AND AIRSPEED OR CONFIGURATION CHANGES. WE WERE CLEARED TO 12,000' MSL WITH AUTOPLT ENGAGED. ALT SELECT WAS PROPERLY DIALED TO 12,000' MSL. BETWEEN OUR CHECKLISTS DEP CALLS FOR THE DEP STATION, ATIS FOR THE ARR, AND OUR IN RANGE CALL TO THE ARR STATION, IT GETS PRETTY BUSY TO DO NON FLYING AND FLYING DUTIES BOTH. I DO NOT PLACE THE BLAME ON MY F/O SQUARELY AS IF HE WAS THE "BAD GUY". YES HE WAS THE FLYING PLT, YES HE IS KNOWLEDGEABLE ON THE ACFT. BUT HE IS NEW TO THE ACFT AND BLINDLY HAD PLACED HIS TRUST ON THE AUTOPLT. HE DID NOT NOTICE THE SUBTLE AND QUIET WAY THE AUTOPLT HAD NOT CAPTURED THE ALT FOR LEVEL OFF. ON MY SCAN I CAUGHT THE ERROR AT 12,300'. WITH THE ROUND OUT, WE GOT TO 12,400' MSL AT WHICH TIME THE CTLR (BEING A GOOD, SHARP CTLR) WAS CALLING FOR US TO VERIFY ASSIGNED ALT. THERE ARE MANY FACTORS THAT CONTRIBUTE TO THIS SITUATION. ONE IS SCHEDULING. TO FLY PER THE FLT AND DUTY REGS OF 121 IS ABSURD. WE WERE "LEGALLY" SCHEDULED TO FLY A 2-DAY TRIP. A FULL 7.5 HRS OF FLYING WITHOUT BREAKS (15-20 MIN TURNS). LONG DAY! ON THIS PARTICULAR RUN, NO BREAKFAST IS AVAILABLE, NO LUNCH EITHER! EITHER RESTAURANTS ARE NOT OPEN OR TOO FAR AWAY! ANOTHER CONTRIBUTING FACTOR IS THE ACFT. THERE IS SO MUCH "HIGH TECHNOLOGY" TO THIS COCKPIT, THAT A LOT OF PLTS ARE SIMPLY OVERWHELMED BY THE EFIS FOR THEIR FIRST 500 OR SO HRS IN THE COCKPIT. THERE ARE MANY OTHER FACTORS, BUT THIS LAST I'LL WRITE ABOUT IS OUR ATC SYSTEM. THE ATC SYSTEM IS TOO SATURATED. WE SMALL AIRPLANE DRIVERS (ANYTHING SMALLER THAN A DC9) HAVE BECOME THE SYSTEM DAMPERS. ONCE WE GET WITHIN 200 MI OF OUR DESTINATION, WE ARE WORKED TO THE MAX TO FILL IN FOR A FAILING ATC SYSTEM. ON OUR AVERAGE 35 MIN FLTS, WE ARE GETTING UPWARDS OF 40 ACFT CONFIGURATION CHANGES. SOMETIMES WE WILL GET EITHER A SPEED CHANGE OR ALT CHANGE BEFORE WE HAVE ACCOMPLISHED THE ORIGINAL ASSIGNMENT.

  47.  
  48. Accession Number: 130037
    Synopsis: ALT DEVIATION. DESCENT CROSSING RESTRICTION NOT MET.
    Narrative: WE WERE FLYING FROM LAS TO SNA IN AN MLG EQUIPPED WITH A SINGLE FMS CDU ON THE LEFT SIDE OF THE FORWARD ELECTRONIC PANEL (FORWARD OF THE THRUST LEVERS), AND ELECTRO-MECHANICAL FLT INSTRUMENT DISPLAYS. WE HAD BEEN CLEARED TO FLY THE KAYOH ONE ARR, AND HAD PROGRAMMED THE FMC FOR A VNAV DSNT TO CROSS DAWNA (HDF 353/29) AT 13,000, AND THEN CROSS KAYOH (SLI 075/23) AT 210 KTS AND 8000. BEFORE REACHING DAWNA WE WERE CLEARED DIRECT TO HDF. ZLA BROADCAST A SIGMET THAT FORECAST OCCASIONAL SEVERE TURBULENCE BELOW 10,000 IN THE AREA THAT WE WOULD BE MAKING OUR FINAL DSNT, FOLLOWED IMMEDIATELY BY A CLRNC FOR US TO CROSS 20 NE OF HDF AT 14,000. WE BOTH REMARKED THAT HDF WAS NOT SHOWING A DME SIGNAL, SO RAW DATA DISTANCE WAS NOT AVAILABLE. I ASKED THE F/O IF HE WOULD LIKE ME TO ENTER THE RESTRICTION INTO THE FMC (SINCE IT'S AWKWARD TO MAKE DATA ENTRIES FROM HIS SIDE OF THE COCKPIT) AND ENTERED HDF 010/20 AT 14,000. THE F/O INDICATED AGREEMENT WITH THE DATA ENTRY, AND I TOLD HIM I'D BE "OFF THE RADIO" WHILE I DISCUSSED THE ANTICIPATED TURBULENCE WITH THE CABIN CREW. DURING THAT DISCUSSION I OBSERVED THE F/O INITIATE A RAPID DSNT, CHECKED THE CDU, AND WAS SURPRISED TO SEE THAT THE WAYPOINT I HAD JUST ENTERED WAS NO LONGER DISPLAYED (SINCE WE HAD JUST PASSED IT). THE F/O TOLD ME THAT WE HAD CROSSED THE 20 MI FIX PASSING THROUGH 17,000, AND THAT CENTER'S ONLY COMMENT WAS, "YOU MISSED IT". I BELIEVE THAT THIS INCIDENT WAS NOT DUE TO ANY INATTENTION, BUT RATHER TO HUMAN FACTORS PROBLEMS INVOLVED WITH THE AUTOMATED COCKPIT AND ATC. I ALSO BELIEVE THAT IT WOULDN'T HAVE HAPPENED IN AN OLDER-TECHNOLOGY ACFT (WHICH I ALSO FLY). FOR EXAMPLE: 1) IN THE OLDER-TECHNOLOGY ACFT, I WOULDN'T'T HAVE ACCEPTED THIS CLRNC, ONCE I REALIZED THAT HDF HAD NO DME. I ASSUME THAT THE CTLR WOULDN'T HAVE ISSUED IT UNLESS HE KNEW THE ACFT WAS RNAV EQUIPPED. 2) I'M NOT USED TO RECEIVING CLRNCS TO A "DISTANCE" POINT ASSOCIATED WITH A NON-DME FAC. I ASSOCIATE THE PHRASEOLOGY, "CROSS TWENTY NE OF XYZ" WITH A DME FIX, WHERE I CAN QUICKLY LOOK AT A RAW-DATA DME DISPLAY AND MAKE AN IMMEDIATE JUDGEMENT THAT A DSNT MUST BE INITIATED. I LOOKED FOR RAW DATA. IT WASN'T AVAILABLE, SO I MENTALLY SHIFTED FROM THE OLD-TECHNOLOGY (RAW DATA) MODE TO THE AUTOMATED COCKPIT (DATA ENTRY AND COMPUTED SOLUTION) MODE. 3) MOST CLRNCS I'VE RECEIVED THAT REQUIRE RNAV INVOLVE NAMED FIXES WHICH ARE USUALLY IN THE FLT PLAN OR DATABASE. I CAN MAKE A RAPID (4 KEYSTROKES) DATA ENTRY FOR A RNAV POSITION/ALT IF IT WAS PREVIOUSLY PROGRAMMED INTO THE ROUTE, IE, DIRECT HDF. THE CLRNC IN THIS INCIDENT REQUIRED 15 KEYSTROKES, AND TOOK CONSIDERABLY MORE TIME. 4) WHEN I FLY AN AUTOMATED ACFT, I HAVE TO SPEND SOME AMOUNT OF TIME PROGRAMMING AND MONITORING THE COMPUTER. THE DECISION OF WHEN TO DO THIS AND WHEN IT ISN'T APPROPRIATE IS A SUBTLE ONE, AND LENDS ITSELF TO GENERALITIES SUCH AS, "DON'T PROGRAM IN THE TERMINAL AREA." IN THIS CASE, "DON'T PROGRAM IN SOUTHERN CALIFORNIA" WOULD HAVE BEEN APPROPRIATE. THE DATA WE NEEDED (PRESENT DISTANCE TO HDF) WAS AVAILABLE IN THE CDU, SO IF WE HAD TREATED IT AS IF WE DIDN'T HAVE RNAV AVAILABLE WE MIGHT HAVE BEEN ABLE TO MAKE THE MENTAL CALCULATION IN TIME TO MEET THE RESTRICTION. IN THE ENRTE ENVIRONMENT HOWEVER, EXPERIENCE LED ME TO THE SUBCONSCIOUS DECISION THAT THERE WAS TIME AVAILABLE TO REPROGRAM THE FMC. 5) THE CTLR ISSUED A CLRNC THAT WAS PROBABLY DELAYED DUE TO THE SIGMET BROADCAST. AS IT WAS, THE CLRNC WAS MADE SO CLOSE TO THE FIX THAT BY THE TIME IT WAS PROGRAMMED INTO THE FMC AND DSNT COMPUTATIONS MADE, IT WAS NOT POSSIBLE TO MEET THE RESTRICTION. 6) IT WASN'T UNTIL THE NEXT DAY AND A DISCUSSION EXPLORING BOTH OF OUR THOUGHT PROCESSES THAT WE FOUND ANYTHING WE (AS OPPOSED TO THE CTLR) COULD HAVE DONE DIFFERENTLY UNDER THE CIRCUMSTANCES TO PREVENT THIS INCIDENT. WHEN EITHER OF US IS THE PLT FLYING AND MAKES A DATA ENTRY, WE EACH MAKE A MENTAL VALIDITY CHECK USING SOME RULE OF THUMB, IE, "I'M 13 MI FROM THE FIX AND 6000' HIGH, SO I'VE GOT TO START DOWN NOW!" IN THIS CASE, ALTHOUGH I MADE THE DATA ENTRY I DIDN'T MAKE THE VALIDITY CHECK BECAUSE I WAS NOT FLYING, AND PREOCCUPIED WITH MY CONCERN FOR THE SAFETY OF THE PAX AND CABIN CREW IN THE CONTEXT OF THE EXPECTED SEVERE TURBULENCE. I HAD SUBCONSCIOUSLY PLACED A HIGHER PRIORITY ON COMMUNICATING WITH THE CABIN CREW THAN ON DOUBLE-CHECKING THE COMPUTER. IT HAS NOT ESCAPED ME THAT NOT DOUBLE-CHECKING THE COMPUTER OR THE PLT FLYING CAN LEAD TO A BUSTED ALT AND HENCE A MIDAIR COLLISION, WHICH SHOULD HAVE BEEN A HIGHER PRIORITY. THE F/O INDICATED THAT SINCE I HAD MADE THE DATA ENTRY HE ASSUMED THAT THE DATA WAS VALID (IT WAS, BUT TOO LATE) AND DIDN'T DOUBLE-CHECK IT.

  49.  
  50. Accession Number: 133905
    Synopsis: ACR LGT EXPERIENCES UNNOTICED AND UNEXPLAINED ALT LOSS DURING FLAP RETRACTION AND SPEED INCREASE PORTION OF INITIAL CLIMB.
    Narrative: AS ACFT CLBED THROUGH 1000' AGL, CLEAN UP STARTED AND PWR WAS REDUCED ON THE THRUST MANAGEMENT COMPUTER (TMC). DURING CLEAN UP AND PWR REDUCTION, ABNORMAL NOSE DOWN TRIM WAS FELT. IN THE PROCESS OF SORTING THINGS OUT (CLB, CLEAN UP, HDG CHANGE, ABNORMAL TRIM), THE ACFT DSNDED 300-400'. THE AUTOTHROTTLES WERE COMING BACK. THE WARNING "DON'T SINK" ON THE GPWS WENT OFF. THE F/O RESPONDED BY PUSHING THE PWR LEVERS BACK TO CLB PWR. I PULLED THE NOSE UP AND RESUMED THE CLB PROFILE. I STILL DON'T KNOW IF THE TRIM RAN AWAY, AUTOTHROTTLES MALFUNCTIONED (NOSE DOWN TRIM), OR IF I JUST PLAIN SCREWED UP. 27 YRS IN AVIATION, I'VE NEVER HAD ANY PROB. I HAVE BEEN GOING THROUGH SOME FAMILY CRISIS AND EMOTIONS HAVE CERTAINLY BEEN FRAYED. WATCH OUT FOR COMPLACENCY IN THE GLASS COCKPIT!

  51.  
  52. 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.

  53.  
  54. Accession Number: 137336
    Synopsis: ACR FLT CREW PROGRAMS FMS INCORRECTLY FLIES 43 NM OFF COURSE.
    Narrative: FLT WAS CLRED FROM YYZ TO CUG VIA AT OR ABOVE YQO 243 DEG R JOIN V5 DJB. WE PROGRAMMED OUR FLT MANAGEMENT SYS WITH THE OLD DOLFN INTXN BELIEVING IT TO BE YQO 243 DEG BUT IT WAS NOT, WE DID NOT MONITOR THE FMS AS IT TOOK THE ACFT DOWN THE YQO 213 DEG R INSTEAD. CTLR QUESTIONED OUR ROUTING AND IT WAS THEN TOO LATE WE WERE 43 NM OFF COURSE. CONTRIBUTING FACTORS COMPLACENCY AND CAPT DOING PAYROLL PAPERWORK F/O EATING CREW MEAL.

  55.  
  56. Accession Number: 137336
    Synopsis: ACR FLT CREW PROGRAMS FMS INCORRECTLY FLIES 43 NM OFF COURSE.
    Narrative: FLT WAS CLRED FROM YYZ TO CUG VIA AT OR ABOVE YQO 243 DEG R JOIN V5 DJB. WE PROGRAMMED OUR FLT MANAGEMENT SYS WITH THE OLD DOLFN INTXN BELIEVING IT TO BE YQO 243 DEG BUT IT WAS NOT, WE DID NOT MONITOR THE FMS AS IT TOOK THE ACFT DOWN THE YQO 213 DEG R INSTEAD. CTLR QUESTIONED OUR ROUTING AND IT WAS THEN TOO LATE WE WERE 43 NM OFF COURSE. CONTRIBUTING FACTORS COMPLACENCY AND CAPT DOING PAYROLL PAPERWORK F/O EATING CREW MEAL.

  57.  
  58. Accession Number: 137943
    Synopsis: HEADING AND TRACK DEVIATION ON STAR ARR.
    Narrative: SHINE ARR INTO CLT FROM OVER TYS GOES TYS DIRECT BURLS INTXN, THEN SHINE INTXN, THEN JOHNS INTXN, THEN CLT VOR. FMC DATA BASE DATED 2/XX/90 WAS MISSING BURLS INTXN, AND HAD TYS DIRECT SHINE, THEN THE ARR. WE HAD NOT NOTICED THE MISTAKE IN THE DATA BASE, AND AS WE PASSED TYS THE FMC AND AUTOPLT TOOK US S OF THE PUBLISHED ARR. ZTL CALLED THIS TO OUR ATTN JUST AS MY COPLT NOTICED THE DEVIATION ON HIS VOR NEEDLE. WE CORRECTED BACK TO THE ARR AND PROCEEDED TO CLT. MY EXPERIENCE HAS BEEN THAT THE FMC CAN FLY YOU FOR HUNDREDS OF HOURS AND NEVER MAKE A MISTAKE. THIS CAN LULL YOU INTO TRUSTING IT MORE THAN A PLT SHOULD UNTIL IT LEADS HIM ASTRAY.

  59.  
  60. Accession Number: 141158
    Synopsis: ALT DEVIATION.
    Narrative: F/O FLYING THOUGHT CLRNC WAS TO CROSS MAYO INTXN AT 22000'. CENTER SAID TO CLB BACK TO 24000', THEN 23000'. ACTUAL CLRNC WAS 24000', EXPECT 22000' AT MAY INTXN, PER ATC. SUPPLEMENTAL INFO FROM ACN 141751: WE HAD BEEN ON DUTY FOR JUST UNDER 10 HRS AND AIRBORNE FOR APPROX 8 HRS, 10 MINS WHEN THE FOLLOWING INCIDENT OCCURRED. I HAD BEEN AWAKE FOR 26+ HRS. PP/DSNT CLRNCS HAD BEEN ISSUED IN A STEP-DOWN MANNER. I ANTICIPATED THE NEXT XING RESTRICTION TO BE FL220 AT MAYOS AND PROGRAMMED IT INTO THE LEGS PAGE OF THE FMC. PP/AS WE DSNDED THROUGH 25800', ZDC ISSUED THE FOLLOWING: "YOUR DISCRETION TO FL240, EXPECT TO CROSS MAYOS AT FL220;" HOWEVER, I ANTICIPATED AND HEARD THE FOLLOWING: "YOUR DISCRETION TO 240, CROSS MAYOS AT 220." VERY ROUTINE, HOWEVER INCORRECT. FATIGUE AND ANTICIPATION HAD LED ME TO HEAR WHAT I WANTED TO HEAR. PP/THE CAPT WORKING THE RADIO READ BACK THE CLRNC AS HE HAD HEARD IT, CORRECTLY. I ONCE AGAIN HEARD WHAT I WANTED TO HEAR: "CROSS MAYOS AT FL220." HAVING INCORRECTLY HEARD "CROSS MAYOS AT 220," I SET 22000' IN THE ALT WINDOW ON THEM CP. I THEN SELECTED THE VERT SPD MODE AND REDUCED THE RATE OF DSNT TO 1000 FPM. THE VERT SPD MODE PROVIDES ALT PROTECTION FOR THE ALT YOU HAVE SELECTED IN THE ALT WINDOW ONLY AND DOES NOT INTERFACE WITH THE FMC. PP/THE CAPT DID NOT X-CHK THE ALT I HAD SET IN THE ALT WINDOW AND DID NOT NOTICE THAT I WAS OPERATING IN VERT SPD MODE. I DID NOT XCHK HIS FMC ENTRY AND THUS HAD NOTHING IN VIEW TO CAUSE ALARM. THE IRO (INTL RELIEF OFFICER) WAS READING A MAGAZINE AND GAVE US NO INPUT AT ALL. HE EITHER DIDN'T REALIZE WHAT WAS HAPPENING, OR WAS COMPLETELY OUT OF THE LOOP BY READING. WE HAD NOT SAID A WORK TO EACH OTHER SINCE THE CLRNC HAD BEEN GIVEN. PP/DSNDING THROUGH 23200' ATC ADVISED, "STOP YOUR DSNT AT FL240." WE DID NOT RESPONSE. AT THIS POINT I DISCONNECTED THE AUTOPLT AND STARTED A CLB BACK UP TO FL240. WE ASSUME EQUAL BLAME FOR THE INCIDENT, AND SURMISED THAT (OUR TRUST IN EACH OTHER AND THE COMPUTER NOT TO SCREW UP) COMPLACENCY (FOR LACK OF A BETTER WORD), ALONG WITH FATIGUE, LED TO ALL 3 OF US OPERATING IN OUR OWN PERSONAL LOOP. MORAL OF THE STORY: SAME OLD THING!! STAY IN THE LOOP!! AND KEEP THE COM FLOWING!! I'M NOT NEW TO THE FMC/MCP/CDU. I HAVE 1900+ HRS IN ACFT WITH SIMILAR SYSTEMS. FAMILIARITY WITH THE SYS WAS NOT A FACTOR.

  61.  
  62. Accession Number: 142911
    Synopsis: CAPT OF WDB DESCENDS THROUGH ASSIGNED ALT WHILE FO IS OUT OF COCKPIT DUE TO CAPT'S FAILING TO ARM THE ALT CAPTURE ON THE AUTOPLT. FO RETURNS AND SPOTS ALT DEVIATION, THEN TURNS OFF TRANSPONDER TO COVER UP THE MISTAKE WHILE THE CAPT COR
    Narrative: IF YOU ARE KEEPING RECORDS ON AUTOMATION COMPLACENCY THIS IS ANOTHER OCCURRENCE. I HAVE SPENT THE LAST THREE YRS AS AN LGT CAPT. THE LGT WILL AUTOMATICALLY CAPTURE THE ALT SELECTED ON ITS MODE CTL PANEL W/O THE NECESSITY OF ARMING. BEING A NEW WDB CAPT (APPROX 22 HRS WDB TIME) I FELL INTO AN AUTOMATION DIFFERENCE BTWN THE TWO ACFT. I WAS CLRED BY ZMP TO DSCND TO FL240. MY F/O WAS OUT OF THE COCKPIT TAKING CARE OF PERSONAL PHYSIOLOGICAL NEEDS. THE AUTOPLT WAS ENGAGED, I SELECTED FL240 ON THE ALT SELECT WINDOW AND STARTED AN IAS (INDICATED AIRSPD) DSNT. WHEN I SELECTED FL240 I SHOULD HAVE ARMED THE ALT CAPTURE MODE BUT AFTER THREE YRS OF HAVING THIS DONE AUTOMATICALLY ON THE LGT, I FORGOT TO MAKE THE SELECTION. DSNDING THROUGH APPROX FL260, I WAS DISTR BY MY F/O RETURNING TO THE COCKPIT. AS HE WAS BUCKLING INTO HIS SEAT, HE NOTICED WE WERE PASSING THROUGH THE SELECTED ALT (ABOUT 23000'). IMMEDIATELY, I STARTED A CLB BACK TO FL240 AND AT THE SAME TIME MY F/O TURNED OFF OUR TRANSPONDER. HIS INTENT IN TURNING OFF THE TRANSPONDER WAS TO PROTECT HIS CAPT FROM THE POSSIBLE CONSEQUENCES OF THIS ALT DEVIATION. TO THE BEST OF MY KNOWLEDGE ZMP DID NOT DETECT THIS DEVIATION BECAUSE NOTHING WAS SAID TO INDICATE THEIR KNOWING. AFTER MUCH THOUGHT AND AGONIZING, I CONSULTED WITH THREE OTHER COMPANY CAPTS AND WAS VERY SURPRISED TO FIND THAT TWO OF THE THREE HAD SIMILAR EXPERIENCES. THE COMMON THREAD TO ALL THREE WAS A COMBINATION OF AN ERROR IN AUTOMATION SELECTION COMBINED WITH A DISTR AT A CRITICAL TIME. IN CONCLUSION, I WOULD LIKE TO EXPRESS MY THANKS FOR THIS CONFIDENTIAL FORUM TO RELAY INFO THAT I HOPE CAN BE USED FOR THE PROMOTION OF AVIATION SAFETY. I AM NOT PROUD OF MY ACTIONS IN THIS OCCURRENCE BUT I HOPE THAT MY INDISCRETION CAN BE USED FOR A POSITIVE PURPOSE. IT IS MY SINCERE OPINION THAT AUTOMATION IS AN ASSET, BUT IT REQUIRES A SPECIAL EFFORT TO MAINTAIN VIGILANCE.

  63.  
  64. Accession Number: 143373
    Synopsis: GROSS NAVIGATION ERROR. OMEGA NAVIGATION OVER WATER.
    Narrative: I MADE A DATA ERROR ENTRY IN A LONG RANGE NAV SYS, DID NOT VERIFY THE ENTRIES, AND ALLOWED A NAV ERROR OF 180 NM. DURING A QUICK TURN AT, AN INTERMEDIATE STOP, THE NORMAL WORK FLOW WAS INTERRUPTED SEVERAL TIMES BY GND SVC PERSONNEL. I ENTERED, IN ERROR, N60.00.0 W 30.00.0 INSTEAD OF N63.00.0 W 30.00.0. THE TRIP WAS A SUBSVC CHARTER ON SHORT NOTICE AND ALREADY LATE, THEREFORE I WAS BEING ENCOURAGED TO TAKE MINIMUM GND TIME. I OPTED NOT TO VERIFY AND CHK THE FLT PLAN UNTIL WE WERE IN FLT. THIS IS NOT NORMAL AND CONSEQUENTLY I FORGOT TO DO THE CHK. AFTER LEAVING LANDFALL OUTBND WE EXPERIENCED DIFFICULTY MAKING THE REQUIRED POS RPTS IN A TIMELY MANNER. WE WERE OPERATING IN AN AREA OF EXTENDED RANGE VHF COVERAGE. ALSO, THE HF RADIOS WOULDN'T WORK. PASSING N61.00.0 A DISCREPANCY SHOWED BTWN THE #1 AND #2 NAV SYSTEMS. I DISCOUNTED THE ERROR INDICATION BECAUSE ON THE PREVIOUS LEGS THE #2 NAV SYS HAD WANDERED SLIGHTLY BUT ALWAYS CAME BACK IN SEVERAL MINS. AGAIN, I BECAME DISTRACTED, TRYING TO HELP MAKE A POS RPT. WHEN THE AUTOPLT COUPLED TO THE #1 NAV SYS MADE AN UNNATURAL TURN TOWARD THE NEXT WAYPOING FROM 60N 30 W, I DISCOVERED THE ERROR AND TOOK APPROPRIATE ACTION. I CONFESSED OUR SITUATION AND MINS LATER WAS IN RADAR CONTACT. THE INCIDENT RESULTED FROM MY OWN STUPIDITY, ALLOWING MYSELF TO BE RUSHED BY OUTSIDE FACTORS, NOT TAKING TIME TO FOLLOW A NORMAL WORK RHYTHM, AND TAKING THE COMPUTER FOR GRANTED. ALSO, IF I HAD NOT BEEN DISTRACTED BY THE RADIO PROBS I MAY, OUT OF CURIOSITY, CHKED THE MINOR DEV. SUPPLEMENTAL INFO FROM ACN 143391: ALL 3 CREW MEMBERS HAD BEEN UP ALL DAY, THE F/E HAD JUST ARRIVED IN FT WAYNE TO RELIEVE OUR PREVIOUS F/E AND HAD ARRIVED AT THE ACFT IN CIVILIAN CLOTHES. AFTER ENTERING CANADIAN AIRSPACE THE CAPT TOOK A NAP TO BE FRESH FOR THE COAST OUT POINT. OUR #2 OMEGA DRIFTS BADLY DURING INITIAL LEGS BUT I HAD UPDATED IT TWICE AND BY GOOSE OUTBND TO LEACH IT LOOKED FINE. THE CAPT TOOK OVER AT THIS POINT AND FLT CONTINUED NORMALLY WITH THE EXCEPTION OF THE OUR HF'S. AFTER OUR INITIAL HF SELCAL CHK WE HAD TO COMMUNICATE ON HF, SO POS RPTS WERE ON UHF (58N, 50 W) ARRIVING AT 61N, 40W AND WITH NO COM ON HF WE RELAYED THROUGH OTHER ACR FLT AND HE CAME BACK WITH VHF FREQ FOR ICELAND RADIO WHICH WE USED TO PASS OUR 61N, 40W RPT. APCHING 35W AND AFTER FINALLY GETTING POS RPT OUT I NOTICED OUR 2 NAV'S WERE NOT CLOSE AND THAT OUR BEARING AND DIRECT TRACK TO 63N, 30W WERE QUITE DIFFERENT. INFORMING THE CAPT OF THIS, AND AFTER CHKING BOTH SYSTEMS, HE DECIDED #1 WAS CORRECT. ONLY AFTER REACHING 60N, 30 W AND THE ACFT TURNING QUITE N DID HE REALIZE THERE WAS INDEED AN ERROR. WE TURNED N, CONTACTED ICELAND RADIO, TOLD THEM OUR REAL POS AND PROCEEDED TO PARALLEL 30W UNTIL WE WERE VECTORED DIRECT TO KEF. THE PROB HAPPENED BECAUSE WE WERE HURRIED TO DEPART WRI AND DID NOT CHK EACH NAV AGAINST THE OTHER AFTER BEING INDIVIDUALLY ENTERED. WE COULD HAVE DONE THIS AIRBORNE, BUT DID NOT. WE COULD HAVE CAUGHT IT AT 61N, 40W WITH DIFFERENCE IN DIRECT TRACK, WE DID NOT. OUR COMPANY PROCS COVER ALL OF THIS, BUT BECAUSE WE WERE ALL TIRED, OUR COM WAS POOR AT BEST AND OUR #2 NAV WAS USUALLY IN ERROR, WE WERE LED DOWN THE PATH TO THE STUPIDEST OF ERRORS.

  65.  
  66. Accession Number: 163566
    Synopsis: ADVTECH ACR MLG ALT OVERSHOT INDESCENT INTO LAX.
    Narrative: FLT FROM DAY TO LAX. WE WEREAPCHING LAX WITH A CLRNC FROM ZLA TO MAINTAIN A SPD OF 270 KTSAND DSND TO FL240. NEXT WE WERE GIVEN A LEFT TURN TO HDG 210DEGS AND CLRNC TO INTERCEPT THE LAX 25L LOC, AND A SPD OF 250KTS. AFTER WE BEGAN THE TURN, WE WERE RECLRED, "DIRECT CIVET,CLRED PROFILE DSNT," WHEREUPON I SELECTED 8000' AS THE ALT CLREDTO ON THE ALT SELECTOR. THE AUTOPLT WAS ON, AUTO THROTTLESENGAGED, CIVET ALT RESTRICTIONS 14000-18000' DISPLAYED ON LEGSPAGE OF FMC'S. THEN ATC REQUESTED AN EXPEDITED DSNT THROUGHFL200 AND I SELECTED SPD DSNT MODE ON THE DSNT PAGE OF THE FMCAND A SPD OF 250 KTS, WHICH NO LONGER AFFORDS ALT PROTECTION FORRESTRICTIONS ON THE PROFILE DSNT. WE CONTINUED DSNDING UNTILREACHING APPROX 12100' OVER NORTON AFB WHEN ATC ISSUED A CLB TO14000'. REALIZING WE HAD DSNDED TOO EARLY, WE IMMEDIATELY CLBEDTO 14000', XING CIVET AT THAT ALT, THEN I RESELECTED PATH MODEON THE DSNT PAGE OF THE FMC'S, RESTORING THE ALT RESTRICTIONS TOTHE VERT NAV MODE OF THE FMC'S. WE LANDED AT LAX W/O FURTHERINCIDENT. I FAILED TO REALIZE THAT THE ALT RESTRICTIONS ARE NOTIN EFFECT DURING A SPD MODE DSNT. THIS DEVIATION COULD HAVE BEENAVOIDED HAD I SET 14000' IN THE ALT SELECTOR WINDOW RATHER THANTHE LOWEST ALT ON THE CIVET SID, AS IS NOW RECOMMENDED BY OURCOMPANY ALT AWARENESS PROGRAM. SETTING 14000' IS THE RECOMMENDEDPROC. SUPPLEMENTAL INFO FROM ACN 163660: I MADE A QUICK VISIT TOTHE RESTROOM WHILE THE CAPT, WHO WAS ACTIVELY FLYING THE ACFT,REPROGRAMMED THE FMC FOR THE PROFILE DSNT. UPON MY RETURN TO THECOCKPIT WE WERE PASSING THROUGH FL190 AND THE CAPT INFORMED METHAT THE FMC WAS PROGRAMMED AND SET UP FOR THE PROFILE DSNT. INOTICED THAT HE SELECTED 8000' IN THE ALT SELECTOR WINDOW, WHICHIS THE BOTTOM AT ON THE STAR. AFTER ACCOMPLISHING THE APCHCHKLIST, I FOCUSED MY ATTN OUTSIDE THE COCKPIT FOR POSSIBLE VFRTFC CONFLICT. APPROX 8-10 MI E OF CIVET, WE WERE INSTRUCTED BYLAX APCH TO CLB AND MAINTAIN 14000'. FROM ABOUT 12500' WEQUICKLY CLBED BACK TO 1400' AND CROSSED CIVET AT THAT ALT. AFTERA QUICK DISCUSSION WITH THE CAPT WE REALIZED THAT IN MY ABSENCEHE HAD SELECTED THE SPD MODE INSTEAD OF THE PATH MODE ON THEFMC. IN THE SPD MODE, THE FMC FOLLOWS THE PROGRAMMED SPDS AND DISREGARDS ALL ALT RESTRICTIONS, WHICH CAUSED US TO DSND TOOEARLY. WE COULD HAVE AVOIDED THE ALT DEVIATION IF I'D RECHKED THE FMC AFTER HE PROGRAMMED IT, AND 1 OF US STAYED ON THE INS THROUGHOUT THE ENTIRE DSNT. DON'T BLINDLY TRUST COMPUTERS!

  67.  
  68. Accession Number: 168349
    Synopsis: HEADING TRACK DEVIATION.
    Narrative: AT THE TIME OF THIS SITUATION, WE HAD BEEN CLRED FOR THE APCH BY DFW APCH CTL FOR THE ILS TO 17L. THE F/O WAS FLYING THE ACFT. WE WERE AT 4000' MSL WHEN APCH CLRED US FOR THE ILS 17L. ALSO, APCH HAD GIVEN US A LATE AND WIDE CUT TO INTERCEPT THE LOC. THE FLT DIRECTOR AND AUTOPLT WERE INDICATING ARMED FOR THE APCH WHEN THE CLRNC WAS ISSUED. UNFORTUNATELY, THE INTERCEPT ANGLE AND LATE CLRNC FOR THE APCH CAUSED THE ACFT TO FLY THROUGH THE LOC, HOWEVER THE FLT DIRECTOR AND AUTOPLT MADE THE NECESSARY CAPTURE AND CORRECTIONS BACK TO THE PROPER FLT PATH. ABOUT THIS TIME THE F/O DISCONNECTED THE AUTOPLT TO FLY THE APCH BY REF TO THE FLT DIRECTOR AND RAW DATA. THE HDG BUG ON THE DFGS PANEL AND NAV DISPLAY WAS UPDATED IN THE EVENT OF A MISSED APCH. THE F/O HAD LEFT HIS NAV DISPLAY IN THE "MAP" MODE, WHICH GAVE HIM A PICTORIAL PRESENTATION OF THE APCH WAYPOINTS AND DISTANCES THAT WERE REFLECTED FROM THE FMS. I HAD THE "ARC" MODE SELECTED (PER COMPANY PROC) AND AFTER SOME CHKLIST ITEMS WERE ACCOMPLISHED, I NOTICED THAT THE LOC BAR WAS MOVING TOWARD THE SECOND DOT ON THE RIGHT, AND THAT THE FLT MODE ANNUNCIATOR (FMA) WAS SHOWING "HDG HOLD." I CALLED THIS TO THE ATTN OF THE F/O AND HE TURNED RIGHT TO REINTERCEPT THE LOC. THE LOC (AND G/S) WERE REARMED SUCCESSFULLY, BUT THE APCH CTLR THEN CALLED TO GIVE US A RIGHT TURN TO 210 DEGS TO REINTERCEPT THE LOC. I THOUGHT THIS TURN WAS EXCESSIVE SINCE WE WERE ONLY 1 1/2 DOTS TO THE LEFT OF COURSE AT THIS TIME, DSNDING THROUGH 3000' MSL. SO, I COMMENTED THAT WE WERE SHOWING ON COURSE, THOUGHT I MADE NO MENTION OF THE FACT THAT WE WERE CORRECTING BACK TO CENTERLINE (I SHOULD HAVE, BUT WE WERE WITHIN APCH CRITERIA). HE THEN ASKED OUR FLT CONDITIONS AND I REPLIED WE WERE VMC AT THE TIME. BUT IT WAS OBVIOUS THAT WE WOULD HAVE TO REENTER THE CLOUDS BTWN OUR POS AND THE ARPT. HE TOLD US TO LOOK FOR TFC LNDG ON THE W SIDE (RIGHT OF OUR POS), BUT WE DID NOT SEE THE CALLED TFC. WHEN WE CALLED THE TWR, TFC WAS STATED TO BE ON ABOUT A 1 MI FINAL, WHEN WE WERE ABOUT 4-6 MI OUT. DSNDING THROUGH ABOUT 2300-2400' MSL (NOT ON LOC CENTERLINE YET, BUT ESTIMATE WE WERE 1 DOT TO THE LEFT OF CENTERLINE), DFW TWR CLRED US TO TURN LEFT (CAN'T REMEMBER THE HDG, BUT I THINK IT WAS 120 DEGS) AND CLB TO 3000'. I ASKED FOR THE REASON FOR THE TURNOUT/GAR, AND THE TWR SAID IT WAS FOR TFC SEP. SUBSEQUENT APCH WAS NORMAL IN ALL RESPECTS. THERE WERE PLENTY OF MISTAKES ON THIS APCH. CERTAINLY, SOME OF THE AUTOMATION IS IMPLICATED HERE, BUT NOT NEARLY AS MUCH AS MY LATE MONITORING OF SOMETHING THAT NORMALLY WORKS VERY WELL. THE F/O WAS WELL-EXPERIENCES IN THE ACFT, AND YET HE BLINDLY FOLLOWED THE ERRONEOUS FLT DIRECTOR COMMANDS. I BELIEVE THAT TIREDNESS/FATIGUE WAS A FACTOR IN HIS FAILURE TO VERIFY. I WAS DISTRACTED WITH OTHER DUTIES SUCH AS FLAPS, SETTING SPD COMMAND BUGS AND CHKLISTS, BUT SHOULD HAVE BEEN AWARE OF THE PROB 30 SECS SOONER. MONITOR AND VERIFY MUST BE OUR WATCH-WORDS IN THESE ADVANCED/AUTOMATED COCKPITS. ALTHOUGH IT IS COMPANY OPERATING POLICY TO HAVE 1 PLT IN THE "ROSE" OR "ARC" MODE ON THE NAV DISPLAY (ND) FOR THE LOC CAPTURE, I TRY TO ENSURE THAT WHEN I AM FLYING THE LEG IT IS MY ND THAT IS "ARC" OR "ROSE." FROM NOW ON, I SHALL RECOMMEND THIS PROC TO MY F/O'S, BUT ABSOLUTELY REQUIRE THAT THE SPIRIT AND LETTER OF THE COMPANY PROC CONTINUES TO BE CARRIED OUT (AS A MINIMUM).

  69.  
  70. Accession Number: 168349
    Synopsis: HEADING TRACK DEVIATION.
    Narrative: AT THE TIME OF THIS SITUATION, WE HAD BEEN CLRED FOR THE APCH BY DFW APCH CTL FOR THE ILS TO 17L. THE F/O WAS FLYING THE ACFT. WE WERE AT 4000' MSL WHEN APCH CLRED US FOR THE ILS 17L. ALSO, APCH HAD GIVEN US A LATE AND WIDE CUT TO INTERCEPT THE LOC. THE FLT DIRECTOR AND AUTOPLT WERE INDICATING ARMED FOR THE APCH WHEN THE CLRNC WAS ISSUED. UNFORTUNATELY, THE INTERCEPT ANGLE AND LATE CLRNC FOR THE APCH CAUSED THE ACFT TO FLY THROUGH THE LOC, HOWEVER THE FLT DIRECTOR AND AUTOPLT MADE THE NECESSARY CAPTURE AND CORRECTIONS BACK TO THE PROPER FLT PATH. ABOUT THIS TIME THE F/O DISCONNECTED THE AUTOPLT TO FLY THE APCH BY REF TO THE FLT DIRECTOR AND RAW DATA. THE HDG BUG ON THE DFGS PANEL AND NAV DISPLAY WAS UPDATED IN THE EVENT OF A MISSED APCH. THE F/O HAD LEFT HIS NAV DISPLAY IN THE "MAP" MODE, WHICH GAVE HIM A PICTORIAL PRESENTATION OF THE APCH WAYPOINTS AND DISTANCES THAT WERE REFLECTED FROM THE FMS. I HAD THE "ARC" MODE SELECTED (PER COMPANY PROC) AND AFTER SOME CHKLIST ITEMS WERE ACCOMPLISHED, I NOTICED THAT THE LOC BAR WAS MOVING TOWARD THE SECOND DOT ON THE RIGHT, AND THAT THE FLT MODE ANNUNCIATOR (FMA) WAS SHOWING "HDG HOLD." I CALLED THIS TO THE ATTN OF THE F/O AND HE TURNED RIGHT TO REINTERCEPT THE LOC. THE LOC (AND G/S) WERE REARMED SUCCESSFULLY, BUT THE APCH CTLR THEN CALLED TO GIVE US A RIGHT TURN TO 210 DEGS TO REINTERCEPT THE LOC. I THOUGHT THIS TURN WAS EXCESSIVE SINCE WE WERE ONLY 1 1/2 DOTS TO THE LEFT OF COURSE AT THIS TIME, DSNDING THROUGH 3000' MSL. SO, I COMMENTED THAT WE WERE SHOWING ON COURSE, THOUGHT I MADE NO MENTION OF THE FACT THAT WE WERE CORRECTING BACK TO CENTERLINE (I SHOULD HAVE, BUT WE WERE WITHIN APCH CRITERIA). HE THEN ASKED OUR FLT CONDITIONS AND I REPLIED WE WERE VMC AT THE TIME. BUT IT WAS OBVIOUS THAT WE WOULD HAVE TO REENTER THE CLOUDS BTWN OUR POS AND THE ARPT. HE TOLD US TO LOOK FOR TFC LNDG ON THE W SIDE (RIGHT OF OUR POS), BUT WE DID NOT SEE THE CALLED TFC. WHEN WE CALLED THE TWR, TFC WAS STATED TO BE ON ABOUT A 1 MI FINAL, WHEN WE WERE ABOUT 4-6 MI OUT. DSNDING THROUGH ABOUT 2300-2400' MSL (NOT ON LOC CENTERLINE YET, BUT ESTIMATE WE WERE 1 DOT TO THE LEFT OF CENTERLINE), DFW TWR CLRED US TO TURN LEFT (CAN'T REMEMBER THE HDG, BUT I THINK IT WAS 120 DEGS) AND CLB TO 3000'. I ASKED FOR THE REASON FOR THE TURNOUT/GAR, AND THE TWR SAID IT WAS FOR TFC SEP. SUBSEQUENT APCH WAS NORMAL IN ALL RESPECTS. THERE WERE PLENTY OF MISTAKES ON THIS APCH. CERTAINLY, SOME OF THE AUTOMATION IS IMPLICATED HERE, BUT NOT NEARLY AS MUCH AS MY LATE MONITORING OF SOMETHING THAT NORMALLY WORKS VERY WELL. THE F/O WAS WELL-EXPERIENCES IN THE ACFT, AND YET HE BLINDLY FOLLOWED THE ERRONEOUS FLT DIRECTOR COMMANDS. I BELIEVE THAT TIREDNESS/FATIGUE WAS A FACTOR IN HIS FAILURE TO VERIFY. I WAS DISTRACTED WITH OTHER DUTIES SUCH AS FLAPS, SETTING SPD COMMAND BUGS AND CHKLISTS, BUT SHOULD HAVE BEEN AWARE OF THE PROB 30 SECS SOONER. MONITOR AND VERIFY MUST BE OUR WATCH-WORDS IN THESE ADVANCED/AUTOMATED COCKPITS. ALTHOUGH IT IS COMPANY OPERATING POLICY TO HAVE 1 PLT IN THE "ROSE" OR "ARC" MODE ON THE NAV DISPLAY (ND) FOR THE LOC CAPTURE, I TRY TO ENSURE THAT WHEN I AM FLYING THE LEG IT IS MY ND THAT IS "ARC" OR "ROSE." FROM NOW ON, I SHALL RECOMMEND THIS PROC TO MY F/O'S, BUT ABSOLUTELY REQUIRE THAT THE SPIRIT AND LETTER OF THE COMPANY PROC CONTINUES TO BE CARRIED OUT (AS A MINIMUM).

  71.  
  72. Accession Number: 168971
    Synopsis: ACR MLG TRACK HEADING DEVIATION FOLLOWING ACFT COMPUTER STORED ARR ROUTE THAT DIFFERED FROM THE FLT PLANNED ROUTE.
    Narrative: WE WERE CLRED AT TKOF THE FLT PLAN RTE WHICH INCLUDED THE ACORD 2 ARR AT VANCOUVER, BC FROM OVER THE GEG VOR. HOWEVER, AFTER PASSING THE GEG VOR, WE NOTICED THE PUBLISHED ARR RTE DID NOT CORRESPOND WITH THE ONBOARD FMC RTE AS PICTURED ON THE HSI. IMMEDIATELY A CORRECTION WAS MADE TO THE LEFT TO FLY THE PUBLISHED RTE WHICH INCLUDED A DOGLEG TO THE S. THE CORRECTIVE PROC WOULD BE TO COMPARE AND DOUBLE-CHK THE COMPUTER STORED INFO WITH THE PUBLISHED PROC WELL IN ADVANCE OF ARRIVING AT THE PUBLISHED POINTS ALONG THE COURSE, AND NOT BEING COMPLACENT IN ASSUMING THE COMPUTER HAS ALL THE CORRECT AND UP TO DATE INFO.

  73.  
  74. Accession Number: 174632
    Synopsis: ADVTECH ACR WDB EXPERIENCES MINOR FMS PROBLEM, BUT FAILS TO CATCH ERROR AND SUFFERS TRACK DEVIATION AND ALT UNDERSHOOT DUE MISSET ALTIMETER.
    Narrative: AFTER TKOF FROM LAX WBND, WE WERE CLRED LEFT TURN DIRECT LAX VOR, AS FILED. PASSING LAX, THE FMC CALLED FOR A RIGHT TURN TO SLI VOR. F/O HAND-FLYING. I NOTICED ON MAP DISPLAY AFTER SLI RTE WAS ALMOST 90 DEG LEFT TURN TO DAG. REQUESTED DIRECT DAG AND RECEIVED DIRECT. MOMENTS LATER ATC ASKED IF WE KNEW WHERE WE WERE, AND THAT WE WERE 15 MI S OF LOOP 8 DEP RTE. WE WERE TOLD TO TURN LEFT TO 330 DEG HDG AND THEN CLRED DIRECT DAG. SOMEHOW THE FMC HAD DUMPED OUT THE LOOP 8 DEP AND HAD US GOING TO SLI AND THEN DAG. WHILE WE WERE DOING THIS CLRNC AND TRYING TO FIGURE OUT WHAT MAY HAVE GONE WRONG, WE PASSED 18000' AND DIDN'T SET ALTIMETERS TO 29.92. AFTER LEVEL OFF AT 37000', ATC ASKED OUR ALT AND I REPLIED 37000'. WE WERE TOLD MODE C HAD US 300' LOW. ALTIMETER WAS 30.23". SET ALTIMETER AND REMAINDER OF FLT WAS NORMAL. ONE OF THE PROBS WAS THAT I WAS RELYING ON THE FMC TOO MUCH FOR DEP AND NOT X-CHKING WITH DEP PLATE. NEW, FIRST GLASS COCKPIT. SUPPLEMENTAL INFO FROM ACN 174704: CAPT AND I REVIEWED THE SID SEVERAL TIMES AND THE MADE CHANGES IN THE PROC WHEN WE WERE GIVEN A RWY CHANGE. WE WERE EXPECTING LAX 24L AND WE TOOK OFF ON 25R. I MADE THE CHANGES IN THE FMC AND EVERYTHING PROCEEDED NORMALLY. WE BRIEFED THE CHANGES AND INSTALLED A FIX IN THE FMC TO AID IN THE DEP. LATER FOUND OUT THERE IS A SOFTWARE GLITCH IN THE LOOP 8 SID THAT HAS NOT BEEN CORRECTED. THIS OCCURS WHEN THERE IS A RWY CHANGE, WHICH IS WHAT HAPPENED TO US. ONE CAN GET LOST OR MISDIRECTED, EVEN WITH ALL THE LATEST NAV TECH. IN THE FUTURE I WILL RELY MORE ON TRADITIONAL NAVAIDS FOR FMC BACKUP. I ALSO MADE THE MISTAKE OF USING TOO SMALL A SCALE FOR THE NAV DISPLAY. ON A LARGER SCALE I WOULD HAVE SEEN THE ERROR AND WOULD NOT HAVE FLOWN TO THE S.

  75.  
  76. Accession Number: 175779
    Synopsis: ACR MLG TRACK HEADING DEVIATION AT START OF STAR TO DEN ALSO ALT DEVIATION UNDERSHOT CROSSING RESTRICTION.
    Narrative: INCIDENT OCCURRED AT START OF DSNT ON TAG NE STARR LEADING TO KEANN ARR GATE 50 DENVER. AFTER XING SMITY INTXN WE WERE CLRED TO DSND AT PLTS DISCRETION TO CROSS KEANN INTXN AT 17000' MSL, SPD OUR CHOICE. PROGRAMMING ERROR OF FMS RESULTED IN OFF COURSE TRACK AND BEING TOO HIGH, TOO CLOSE TO INTENDED INTXN TO MEET XING RESTRICTION W/O OFF COURSE VECTOR. FACTORS INVOLVED: A VERY COMPENTENT F/O WHO WAS FLYING THE PLANE, DISTR CAUSED BY CABIN CREW MEMBER WHO WAS IN CONFLICT WITH OTHER F/A'S, LACK OF WX AND TFC (SAT AFTERNOON), A PROGRAMMING ERROR BY F/O, MY FAILURE TO X-CHK INPUT OR TRACK DURING CRITICAL PHASE OF FLT. F/A ENTREE TO DENVER ATIS. USING ATIS DATA, F/O PROGRAMMED THE APCH AND LNDG. HE APPARENTLY HIT WRONG STARR FROM KEY NEGATING FLT PLAN RTING AND SUBSTITUTING IOC INTXN FOR KEANN INTXN. I ALTERED MY NORMAL COCKPIT DISCIPLINE TO HANDLE A PRECEIVED PROB AND DELAYED OTHER NONFLT RELATED DUTIES (COMPANY CALLS, ETC) UNTIL A MORE CRITICAL PHASE, JUST PRIOR TO DSNT. ATC NOTED THE TRACK ERROR AFTER SMITY AND INQUIRED. I IMMEDIATELY SAW THE PROB AND CORRECTED BUT TOO LATE TO MEET XING RESTRICTION W/O CTR VECTOR. CONCLUSIONS: DON'T ALLOW DISTS TO INTERFERE WITH NORMAL COCKPIT PROCS AND DISCIPLINE. ALWAYS X-CHK FMS PROGRAMMING AND NAV PROGRESS NO MATTER WHO IS FLYING OR HOW TRUSTED THEY ARE. DEMAND BOTH FROM MYSELF AND MY F/O'S THAT TRACK AND DISTANCE BE MONITORED AND COMPARED WITH FLT PLAN TO HELP CATCH ERRORS. I WAS IN PROGRESS OF READING CHKLIST WHEN ASKED BY ATC WHAT OUR HDG WAS, AS THEY OFTEN DO FOR PARALLEL VECTORS OF ACFT. IF HE HAD SAID THAT WE APPEARD TO BE DIVERGING FROM FLT PLAN RTE ON HIS INITIAL CALL, MY RESPONSE WOULD HAVE BEEN MORE TIMELY AND MAY NOT HAVE REQUIRED VECTOR TO MEET XING RESTRICTION.

  77.  
  78. Accession Number: 188465
    Synopsis: FO OF ACR LGT ADVANCED COCKPIT PUT THE WRONG DEST INTO ACARS WHEN REQUESTING DEP CLRNC. ACARS GAVE BACK AN INCORRECT CLRNC AND TRANSPONDER CODE THAT WAS NOT CHKED BY THE FLC. ERROR WAS DETECTED AFTER TKOF WHEN CTLR REQUESTED A MODE C CHANGE.
    Narrative: I WAS THE FO ON FLT FROM BWI TO ORD. INADVERTENTLY, I ENTERED BWI AS THE DEP AND ARR STATION IN ACARS. THE FLT NUMBER AND THE OTHER INFO WERE ENTERED CORRECTLY. THE DEP CLRNC THAT WE RECEIVED WAS IN ERROR AS A RESULT. THE CLRNC WE RECEIVED WAS FOR A FLT FROM DFW TO BWI THAT OPERATED THE NIGHT BEFORE. I NEGLECTED TO CHK THE ENTIRE CLRNC, BUT ONLY SET THE DEP FREQ, THE INITIAL ALT, AND THE TRANSPONDER CODE. I HAD FLOWN THIS SAME SEQUENCE THE ENTIRE MONTH BEFORE WITH THE SAME CAPT AND I WAS COMPLACENT. AFTER TKOF WE TRIED TO CALL DEP AND AFTER GETTING NO REPLY, WE RETURNED TO TWR AND RECEIVED THE CORRECT FREQ. WE INFORMED DEP CTL THAT WE WERE CLBING TO 10000 FT, THE INITIAL ALT ON THE ERRONEOUS CLRNC. DEP CLRED US TO 17000 FT AND DID NOT QUESTION OUR ORIGINAL ALT. I DO NOT BELIEVE THERE WAS A CONFLICT WITH OTHER TFC. LATER, WASHINGTON CENTER HAD US CHANGE OUR TRANSPONDER CODE, WHICH LED US TO CHK OUR ORIGINAL CLRNC AND DETECT THE ERROR. AFTER ENTERING THE CORRECT DEST, WE RECEIVED A VALID CLRNC THROUGH ACARS. I HAD NEVER ENCOUNTERED A PROBLEM LIKE THIS BEFORE AND WAS VERY SURPRISED TO FIND THAT IT WAS POSSIBLE TO GET A CLRNC FOR A DIFFERENT FLT NUMBER, FROM A DIFFERENT DEP STATION THAT HAD PREVIOUSLY DEPARTED. COMPLACENCY WAS THE BIGGEST PROBLEM IN THIS INSTANCE. A CONTRIBUTING FACTOR WAS THE POSSIBILITY OF GETTING AN ERRONEOUS CLRNC WITH NO DOUBLE CHKS ON THE SYS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO. THE FLC DOES BRING A FLT PLAN TO THE ACFT FROM THE OPS OFFICE BUT THEY DID NOT COMPARE THE 2. RPTR SAYS SOME STATIONS REQUEST A READBACK OF THE TRANSPONDER CODE WHEN TKOF CLRNC IS REQUESTED BUT THAT BWI DOES NOT REQUEST A READBACK OF ANY FLT PLAN INFO. RPTR HAS TALKED WITH OTHER FLCS ABOUT THIS PROBLEM BUT NON HAVE EVER EXPERIENCED THIS AND HE NOW THINKS IT WAS PERHAPS JUST A 1 TIME COMPUTER GLITCH.

  79.  
  80. 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.

  81.  
  82. Accession Number: 196343
    Synopsis: MLG GETS OFF COURSE WHEN FMS COMPUTER IS LOADED INCORRECTLY.
    Narrative: THE FLT WAS FROM ATL TO GSO WITH A FLT PLAN ROUTING OF ATL...SPA...SPA041/GSO281...GSO. IT WAS THE CAPT'S LEG AND FOLLOWING OUR COMPANY PROCS HE LOADED THE RTE INTO THE NAV COMPUTER (FMS). THIS WAS THE CAPT'S SECOND TRIP SINCE UPGRADE AND HE HAD JUST COME OFF 2 WKS VACATION. HE OMITTED THE SPA041/GSO281 WAYPOINT AND INSTEAD ENTERED ATL...SPA...GSO-30...GSO USING THE FIX 30 MI PRIOR TO GSO AS A DSCNT REF POINT. AS THE FO I CHKED THE RTE AND SAW THAT THE THIRD POINT WAS GSO-01 WHICH I ASSUMED WAS THE SPA041/GSO281 WHEN IT WAS REALLY THE POINT 30 MI PRIOR TO GSO. ON THE DIRECT COURSE FROM SPA TO GSO. (THE FMS WE USE ASSIGNS AN ARBITRARY NUMERICAL DESIGNATION TO ANY WAYPOINT NOT ENTERED IN IT'S DATA BASE, IE, GSO-01). IT IS NECESSARY TO PULL THE POINT DOWN TO THE BOTTOM OF THE PAGE TO VERIFY THE CORRECT RADIAL/DME WAS ENTERED AND I FAILED TO DO THIS. I HAVE BEEN FLYING THIS RTE FOR SEVERAL MONTHS AND SEEING THE GSO-01 DESIGNATION EACH TIME LED ME TO COMPLACENCY. AS THE ACFT PASSED OVER SPA AND TURNED TO GSO RATHER THAN OUT THE 410 RADIAL. ATC ADVISED US TO TURN TO A 030 DEG HDG. I THEN FOUND OUR MISTAKE AND WE REPROGRAMMED THE FMS. HUMAN FACTORS CONSIDERATIONS: EARLY PICK-UP. INEXPERIENCE ON ACFT TYPE. AUTOMATION, FMS DOES NOT SHOW ACTUAL RADIAL/DME ON RTE PAGE. COMPLACENCY.

  83.  
  84. Accession Number: 204881
    Synopsis: HDG TRACK DEV ON DEP WHICH WAS CAUGHT BY ALERT DEP CTLR VIGILANCE.
    Narrative: AFTER TKOF WE ENGAGED THE RNAV TO THE AUTOPLT. ALMOST IMMEDIATELY WE GOT THE 'WHERE ARE YOU GOING?' FROM DEP CTL. ACCORDING TO OUR MAP DISPLAY, WE WERE PROCEEDING CORRECTLY, BUT DEP GAVE US VECTORS IN ALMOST THE OPPOSITE DIRECTION. IT TOOK QUITE AWHILE TO DECIPHER THE PROBLEM, WHAT WITH WORKLOAD, LOSS OF POSITIONAL AWARENESS, ETC, BUT IT APPEARED THAT I MISENTERED THE COORDS ON THE RAMP AND HAD A 2 DEG LONGITUDE ERROR. I THOUGHT THE CAPT HAD XCHKED IT BUT APPARENTLY HE NEVER DID. WE HAD OTHER IRS PROBLEMS DURING ALIGNMENT, SO WE DIDN'T CATCH THE POS ERROR AND THE IRS ACCEPTED IT. IT DIDN'T AT FIRST, BUT DUE TO THE OTHER PROBLEMS, WE MISSED THE POS PROBLEM. APPARENTLY, THE LGT IRS SYS WILL ACCEPT A GROSS ERROR AFTER A FEW TRIES. IN ANY EVENT, WE NAVIGATED THE REST OF THE TRIP THE OLD-FASHIONED WAY -- THANKFULLY, WE WERE NOT HEADED OVER THE OCEAN. ALSO, FORTUNATELY, ALTHOUGH WE STRAYED OFF COURSE, AND HAD A TFC CONFLICT, THERE WAS NO LOSS OF SEPARATION, THINKS TO A SHARP CTLR. ALL OF THIS COULD HAVE BEEN PREVENTED IF: I HAD BEEN MORE CAREFUL, THE CAPT HAD XCHKED, OR WE HAD BACKED UP THE DEP WITH VOR, ALL OF WHICH WE NORMALLY DO! GUESS IT ALL BOILS DOWN TO COMPLACENCY. ALSO, IT WOULD HELP IF THE IRS SYS WOULD TELL YOU IF YOUR POS WAS WAY OFF FROM THE LAST POS, SO THAT THE ERROR WOULD NOT BE MASKED BY OTHER ALIGNMENT PROBLEMS. LAST BUT NOT LEAST, AN UPDATE FEATURE WOULD BE VERY HELPFUL. IF WE HAD BEEN LAUNCHING ON AN OCEANIC XING, WE WOULD HAVE HAD TO LAND AND REALIGN.

  85.  
  86. Accession Number: 210639
    Synopsis: AN ACR LGT CREW, WITH ALL OF THE MOST ADVANCED FLT GUIDANCE EQUIP, FAILED TO FLY A STAR AS PUBLISHED.
    Narrative: THIS EVENT INVOLVES A FEELING OF COMPLACENCY BROUGHT ON BY THE LATEST GENERATION OF HIGHLY AUTOMATED, GLASS- COCKPIT AIRPLANES (IN THIS CASE, AN LGT). THE CAPABILITY TO FULLY PROGRAM COMPLEX PROCS (SIDS, STARS, TRANSITIONS, APCHS) CAN LEAD TO A PERCEPTION ON THE PART OF THE FLC THAT THE FLT MGMNT SYS, ONCE PROGRAMMED, WILL FOLLOW A PARTICULAR PROC FULLY AND COMPLETELY. OUR FLT INVOLVED AN ARR TO MEMPHIS INTL. WE WERE CLRED FOR A 'MIDDY 8' (ARR FROM OVER PXU). WE HAD DSNDED TO 10000 FT AT 'MIDDY' INTXN. THE ATIS INDICATED APCHS IN PROGRESS TO 36L, 36R, AND 27. AFTER SOME DISCUSSION WITH THE CTLR, WE WERE TOLD TO EXPECT AN ILS TO 36R. OUR PARTICULAR PROBLEM AROSE IN THAT AS WE APCHED 'CLARK' INTXN (8 DME FROM MEM) WE WERE NOT AWARE OF OUR NEED TO TURN TO A 175 DEG HDG FOR LNDG TO THE N. ONE REASON FOR THIS WAS THAT WE WERE IN THE MIDST OF A COCKPIT BRIEFING AND AN APCH CHKLIST FOR AN AUTOLAND TO 36R. BUT THE MAJOR REASON FOR OUR LACK OF AWARENESS WAS OUR PRESENTATION OF THE MIDDY ARR ON OUR DISPLAY UNIT'S (MCDU) FLT PLAN PAGE. THE WAYPOINTS DISPLAYED WERE: MIOLA, MIDDY, H226 MANUAL, ------ FLT PLAN DISCONTINUITY. THAT IS, AFTER 'MIDDY' INTXN, OUR FMS HAD US FLYING A HDG OF 226 DEG (INDICATED BY 'H226 MANUAL') WITH NO MENTION BEING MADE OF 'CLARK' INTXN, OR THE REQUIRED TURN TO 175 DEG. OUR SENSE OF 'AUTOMATED COMPLACENCY' LEAD US TO BELIEVE THAT A HDG OF 226 DEG WAS CORRECT AS WE BUSIED OURSELVES WITH APCH BRIEFINGS AND CHKLISTS. WE THUS FLEW PAST 'CLARK' INTXN UNTIL ROUGHLY 6 DME FROM MEM, WHEN THE CTLR REALIZED WE HAD NOT TURNED AND TOLD US WE SHOULD BE ON A HDG OF 175 DEG. WE THEN TURNED, CHKED THE CHART, AND REALIZED WE HAD, IN FACT, MISSED THE TURN POINT. WE KNOW THAT THE CHART IS THE GOSPEL AND THAT THE FMS SHOULD ALWAYS BE VERIFIED AGAINST THE CHARTS, YET WE ALLOWED OURSELVES, DURING A BUSY WORK PERIOD, TO FULLY TRUST THE AUTOMATED SYS, WHICH WE ERRONEOUSLY ASSUMED WAS COMPLETE AND CORRECT. THIS BRINGS UP 2 POINTS REGARDING HIGHLY-AUTOMATED SYSTEMS: WHY WAS 'CLARK' INTXN NOT IN THE DATA BASE PROGRAM? BECAUSE OF CAPACITY CONSTRAINTS? IF SO, WHY NOT INCREASE CAPACITY? IT SEEMS TO CREATE CONFUSION WHEN SOME, BUT NOT ALL, INTXNS ARE INCLUDED IN PROCS.

  87.  
  88. Accession Number: 210639
    Synopsis: AN ACR LGT CREW, WITH ALL OF THE MOST ADVANCED FLT GUIDANCE EQUIP, FAILED TO FLY A STAR AS PUBLISHED.
    Narrative: THIS EVENT INVOLVES A FEELING OF COMPLACENCY BROUGHT ON BY THE LATEST GENERATION OF HIGHLY AUTOMATED, GLASS- COCKPIT AIRPLANES (IN THIS CASE, AN LGT). THE CAPABILITY TO FULLY PROGRAM COMPLEX PROCS (SIDS, STARS, TRANSITIONS, APCHS) CAN LEAD TO A PERCEPTION ON THE PART OF THE FLC THAT THE FLT MGMNT SYS, ONCE PROGRAMMED, WILL FOLLOW A PARTICULAR PROC FULLY AND COMPLETELY. OUR FLT INVOLVED AN ARR TO MEMPHIS INTL. WE WERE CLRED FOR A 'MIDDY 8' (ARR FROM OVER PXU). WE HAD DSNDED TO 10000 FT AT 'MIDDY' INTXN. THE ATIS INDICATED APCHS IN PROGRESS TO 36L, 36R, AND 27. AFTER SOME DISCUSSION WITH THE CTLR, WE WERE TOLD TO EXPECT AN ILS TO 36R. OUR PARTICULAR PROBLEM AROSE IN THAT AS WE APCHED 'CLARK' INTXN (8 DME FROM MEM) WE WERE NOT AWARE OF OUR NEED TO TURN TO A 175 DEG HDG FOR LNDG TO THE N. ONE REASON FOR THIS WAS THAT WE WERE IN THE MIDST OF A COCKPIT BRIEFING AND AN APCH CHKLIST FOR AN AUTOLAND TO 36R. BUT THE MAJOR REASON FOR OUR LACK OF AWARENESS WAS OUR PRESENTATION OF THE MIDDY ARR ON OUR DISPLAY UNIT'S (MCDU) FLT PLAN PAGE. THE WAYPOINTS DISPLAYED WERE: MIOLA, MIDDY, H226 MANUAL, ------ FLT PLAN DISCONTINUITY. THAT IS, AFTER 'MIDDY' INTXN, OUR FMS HAD US FLYING A HDG OF 226 DEG (INDICATED BY 'H226 MANUAL') WITH NO MENTION BEING MADE OF 'CLARK' INTXN, OR THE REQUIRED TURN TO 175 DEG. OUR SENSE OF 'AUTOMATED COMPLACENCY' LEAD US TO BELIEVE THAT A HDG OF 226 DEG WAS CORRECT AS WE BUSIED OURSELVES WITH APCH BRIEFINGS AND CHKLISTS. WE THUS FLEW PAST 'CLARK' INTXN UNTIL ROUGHLY 6 DME FROM MEM, WHEN THE CTLR REALIZED WE HAD NOT TURNED AND TOLD US WE SHOULD BE ON A HDG OF 175 DEG. WE THEN TURNED, CHKED THE CHART, AND REALIZED WE HAD, IN FACT, MISSED THE TURN POINT. WE KNOW THAT THE CHART IS THE GOSPEL AND THAT THE FMS SHOULD ALWAYS BE VERIFIED AGAINST THE CHARTS, YET WE ALLOWED OURSELVES, DURING A BUSY WORK PERIOD, TO FULLY TRUST THE AUTOMATED SYS, WHICH WE ERRONEOUSLY ASSUMED WAS COMPLETE AND CORRECT. THIS BRINGS UP 2 POINTS REGARDING HIGHLY-AUTOMATED SYSTEMS: WHY WAS 'CLARK' INTXN NOT IN THE DATA BASE PROGRAM? BECAUSE OF CAPACITY CONSTRAINTS? IF SO, WHY NOT INCREASE CAPACITY? IT SEEMS TO CREATE CONFUSION WHEN SOME, BUT NOT ALL, INTXNS ARE INCLUDED IN PROCS.

  89.  
  90. Accession Number: 217943
    Synopsis: HDG TRACK DEV IN APCH PROC STAR.
    Narrative: FLYING FLT BNA-CLT ON SHINE 4 ARR STAR. NEW CHANGE IN STAR STIPULATES A 180 DEG HDG AT THE CLT 314/10 FOR N ARRS. WE MISSED THE TURN AS WE WERE FLYING USING AN EFIS GENERATED NAV DISPLAY THAT DID NOT DEPICT THE TURN. WE PLACED TOO MUCH RELIANCE ON THE EFIS DISPLAY AND NOT ENOUGH ON XCHK OF THE ACTUAL STAR DEPICTION IN THE APCH PLATES.

  91.  
  92. Accession Number: 223044
    Synopsis: WDB ACFT ON DSCNT MISSES XING
    Narrative: AT FL260 CTR GAVE US A RESTRICTION TO CROSS SOMTO INTXN AT 11000 FT. THE FO WAS FLYING (MYSELF) AND THE CAPT READ BACK THE RESTRICTION. I PROGRAMMED THE FMS TO CROSS SOMTO AT 11000. AT THE TIME THE CLRNC WAS RECEIVED, WE WERE APPROX 40 MI S OF SOMTO. THE FMS CAPTURED VNAV PATH AND BEGAN TO DSND. THE CAPT EXCUSED HIMSELF TO USE THE LAVATORY DSNDING. WHILE HE WAS AWAY, I BEGAN TO PROGRAM THE APCH INTO LGA. WHEN I WAS FINISHED, I WENT TO THE DSCNT PAGE ON THE FMC IN ORDER TO CHK THE PROGRESS OF OUR DSCNT. I NOTICED THAT THE FMC WAS PREDICATING THE DSCNT ON DIALS AT 2500 FT, AN ALT WHICH I HAD PROGRAMMED IN FOR THE APCH. AT THAT MOMENT, I TURNED TO THE DIRECT INTERCEPT TO SEE DISTANCE FROM SOMTO. I OBSERVED THAT WE WERE 13 MI S OF SOMTO AT FL210. I IMMEDIATELY CALLED CTR TO CONFIRM SOMTO AT 11000 FT. THE CTLR ISSUED AN IMMEDIATE TURN TO HDG 180 DEGS. DURING THIS CLRNC THE CAPT RETURNED TO THE COCKPIT. I IMMEDIATELY MADE A R AND INCREASED THE RATE OF DSCNT TO OVER 6000 FPM. AFTER ABOUT 30 DEGS OF TURN, CTR TURNED US BACK TO THE N TO INTERCEPT THE NANCI ARR N OF SOMTO. ONE OF THE MISTAKES I MADE WAS ASSUMING THAT AFTER THE ACFT CAPTURED VNAV PATH IN THE DSCNT THAT IT WOULD MAKE THE XING RESTRICTION AND REQUIRE NO SUPERVISION. WHEN I PUT THE 2500 FT ALT AT DIALS IN, SOMEHOW THE FMC ACCEPTED THAT AS ITS XING RESTRICTION. IT IS POSSIBLE THAT I MAY HAVE ERRED WITH MY INPUT, BUT I DON'T KNOW HOW. ANOTHER MISTAKE WAS CHANGING FROM THE MAP DISPLAY TO THE PLAN DISPLAY IN PROGRAMMING THE APCH. WITH 1 PLT OUT OF THE SEAT AND THE OTHER IN THE PLAN MODE, THERE IS CERTAINLY DIMINISHED POS AWARENESS. NO AMOUNT OF TECHNOLOGY RELIEVES THE PLTS OF THEIR DUTIES OF BASIC AIRMANSHIP. TECHNOLOGICAL ADVANCEMENTS HAVE IN MY OPINION GREATLY ENHANCED AND IMPROVED VIRTUALLY ALL FACETS OF AVIATION, HOWEVER, ERRORS WILL STILL BE MADE BY BOTH THE MACHINERY AND THE PLTS WHO CTL THE MACHINERY AND IN THIS PARTICULAR INCIDENT, COMPLACENCY WAS CERTAINLY A FACTOR.

  93.  
  94. Accession Number: 228661
    Synopsis: HDG TRACK DEV.
    Narrative: THE PROBLEM AROSE FROM AN INCORRECT PRESENT POS ENTERED IN THE FMS COMPUTER. APPARENTLY THE FUTURE DEST WAS ENTERED AS OUR PRESENT POS, MAKING THE MAP OF OUR RTE ON OUR NAV DISPLAY BACKWARD. AFTER TKOF, THE DEP CTLR CLRED US TO 10000 FT AND 'CLRED ON COURSE.' AS THE PNF, I SLUED THE FLT DIRECTOR HDG BUG TOWARD THE FIRST FIX ON OR RTE OF FLT AS DEPICTED ON THE NAV DISPLAY, NOT REALIZING IT WAS TAKING US IN THE OPPOSITE DIRECTION OF OUR INTENDED DEST. WHEN THE DEP CTLR ASKED US WHY WE WERE ON A S- WESTERLY COURSE VICE A N-EASTERLY COURSE, WE IMMEDIATELY REALIZED OUR MAP DISPLAY WAS BACKWARDS AND TURNED TOWARDS OUR DEST USING NORMAL NAV MEANS. THIS IS ONE OF THOSE MISTAKES MADE BY RELYING SOLELY ON COMPUTER GENERATED NAV. A COMPUTER IS ONLY AS GOOD AS THE INFO IT IS GIVEN (GIGO). SOME CONTRIBUTING FACTORS INVOLVED WERE; IT WAS THE LAST LEG OF A 5 LEG, 12 HR DAY. BOTH OF US WERE TIRED AND READY TO GET TO OUR LAYOVER. BEING A VERY QUICK TURN AROUND, THE CAPT LOADED THE FMS WHILE I DID THE WALKAROUND. GETTING BACK IN THE COCKPIT, I WAS IN A HURRY TO GET THINGS READY FOR OUR DEP AND DIDN'T BOTHER CHKING THE FMS PROGRAM. ANOTHER FACTOR WHICH CAME INTO PLAY WAS A RWY CHANGE ON TAXI OUT. I PUT THE NEW DEP RWY IN THE FMS BUT DID NOT HIT 'RWY UPDATE' UPON TAKING THE RWY, THEREBY STILL LETTING THE COMPUTER THINK IT WAS AT OUR DEST. ALTHOUGH THERE WAS NO CONFLICT, IT WAS EMBARRASSING TO TURN IN THE TOTAL OPPOSITE DIRECTION THAN WE WERE EXPECTED. IN THE FUTURE I WILL ALWAYS CHK THE FMS AND CORRELATE IT WITH THE MAP DISPLAY, NO MATTER HOW TIRED I AM OR HOW QUICK THE TURN AROUND.

  95.  
  96. Accession Number: 240452
    Synopsis: ALTDEV ALT OVERSHOT ON DEP. PROC ACCOUNT WRONG ACARS CLRNC INPUT INTO FMC.
    Narrative: COPLT PROGRAMMED ACARS AT CLE FOR CLE-ORD REQUESTED A PRE-DEP CLRNC. POSTED PRE-DEP CLRNC, SET ALTIMETER, SQUAWK, AND DEP FREQ. ON DEP UNABLE TO COMMUNICATE WITH DEP CTL. CONTINUED CLB ON 010 DEG HDG TO 7000 FT, TALKED TO TWR AGAIN (ON DEP) AND TOLD THEM UNABLE ON 132.85. THEY SENT US TO A DIFFERENT FREQ FOR DEP CTL. DEP ADVISED US THAT WE WERE GOING THROUGH OUR ASSIGNED ALT OF 5000 FT. WE WERE PASSING 5500 FT GOING TO 7000 FT AS PROGRAMMED ON FMP AND PRE-DEP CLRNC. AFTER LEVELING AT 6000 FT, CTLR ASKED US ABOUT OUR CLRNC. INFORMED HIM OF OUR PRE-DEP CLRNC ONLY TO REALIZE THAT SOMEHOW A PRE-DEP CLRNC FROM THE PREVIOUS LEG WAS BEING FLOWN FROM RDU-CLE. WE FAILED TO CATCH THE MISTAKE AND FLEW AN INCORRECT PRE- DEP CLRNC TO 7000 FT. CREW FATIGUE AND COMPLACENCY ARE CAUSAL. LACK OF ATTN TO DETAIL ALSO, RECOMMEND CLE GND VERIFY PROPER PRE-DEP CLRNC BY READBACK OF PROPER XPONDER CODE IN FUTURE. WE HAD THE RDU-CLE CODE IN XPONDER AT THE TIME. SUPPLEMENTAL INFO FROM ACN 240136: TAKING ANOTHER LOOK AT THE ACARS CLRNC SHOWED WE HAD RECEIVED A CLRNC FOR A FLT RDU-CLE!

  97.  
  98. Accession Number: 241297
    Synopsis: FLC OF ACR WDB ACFT INADVERTENTLY PROGRAMMED THE ACFT NAV COMPUTER IN ERROR RESULTING IN A 'GROSS' NAV ERROR DURING OP IN OCEANIC AIRSPACE.
    Narrative: WE WERE OPERATING A TRIP FROM LAGOS NIGERIA TO JFK WITH A TECH STOP IN SANTA MARIA AZONES. AS WE LEFT THE MINNEAPOLIS AIRSPACE AT N45/50W DIRECT BANCS INTXN. WE CONTACTED GANDER CTR. THEY CHANGED OUR ROUTING AFTER BANCS INTXN TO NORTH AMERICAN RTE 22 (BANCS DIRECT KANNI INTXN PART OF THE PLYMOUTH 3 ARR INTO JFK). WE ENTERED THE COORDINATES FOR KANNI INTO WAYPOINT POS #2. THE CAPT THEN INSERTED INTO THE INS TRACK CHANGE #7 TO #2. #7 WAS THE WAYPOINT BEHIND US #8 WAS BANCS. THE ACFT THEN TURNED TO A SOUTHERLY HDG TO INTERCEPT THE WAYPOINT BEHIND US. WE REALIZED THE HDG WAS IN ERROR AND WENT TO HDG MODE AND TURNED BACK TO BANCS INTXN. GANDER CTR CALLED RADAR CONTACT 20 MI S OF BANCS, STILL IN GANDER DOMESTIC AIRSPACE. WE SHOULD HAVE BEEN OVER BANCS AT THAT TIME. HE THEN CLRED US DIRECT KANNI. WE ALL FELT THAT FATIGUE PLAYED A MAJOR PART IN THE ERROR. THE PREVIOUS DAY WE OPERATED JFK-SMA-LOS 10:38 BLOCK HRS. 12 HR CREW REST AT A HOTEL THEN THE RETURN TRIP WHICH ENDED UP TO BE 11:37 BLOCK. I WAS CALLED IN TO OPERATE THE TRIP ON A DAY OFF, SO I WAS UP 24 HRS BEFORE REACHING THE HOTEL. I ALSO BELIEVED ONCE WE DEPARTED THE MINNEAPOLIS AIRSPACE WE BECAME MORE COMPLACENT. WE DIDN'T CHK THE WAYPOINTS AS CONSCIENTIOUSLY AS WE WERE DOING IN THE MINNEAPOLIS AIRSPACE AND THROUGH AFRICA. ANOTHER FACTOR IS THE OTHER ACFT IN THE FLEET HOME FMS'S. THE DISPLAY WHERE WE WERE AND WHERE WE WERE GOING WOULD HAVE BEEN MORE EVIDENT.

  99.  
  100. Accession Number: 248996
    Synopsis: ACR MISSES XING ALT WHILE TRYING TO REPROGRAM FMC.
    Narrative: HAD CLRNC TO CROSS 35 MI S OF ELKINS AT FL240. WE WERE LEVEL AT FL270. I ATTEMPTED TO PROGRAM FMC FOR THE DSCNT AND BECAME AWARE BELATEDLY THAT I HAD MISPROGRAMMED. THE FMC HAD INITIALLY ACCEPTED MY INPUT BUT THEN THE FO NOTICED A BYPASS SIT. WHILE WE WERE TRYING TO RECTIFY, WE FLEW OVERY 35 MI S OF ELKINS AT FL270 AND SIMULTANEOUSLY WERE ISSUED DIRECT TO ANOTHER FIX FURTHER DOWN LINE AND DSND TO FL190. I WAS LULLED INTO COMPLACENCY BECAUSE I THOUGHT THE FMC WAS PROPERLY PROGRAMMED. WHEN THE FO SAW THAT SOMETHING WAS WRONG, WE DID NOT IMMEDIATELY RECOGNIZE OUR PROX TO 35 MI S FIX BECAUSE OF SEVERAL INTERMEDIATE SHORT LEGS DISPLAYED IN FMC. I SHOULD HAVE BACKED UP MY PROGRAMMING OF FMC WITH A CHK ON THE FIX PAGE TO DETERMINE DISTANCE TO ELKINS AND DONE A MENTAL CALCULATION OF TIME AND DISTANCE TO TOP OF DSCNT.

  101.  
  102. Accession Number: 251901
    Synopsis: XING RESTR NOT MET. FMS FAILURE.
    Narrative: AT FL310 INBOUND TO ABQ VOR, CLRED TO CROSS 45 SW OF ABB AT FL240. FO PROGRAMMED FMS TO ACCOMPLISH THIS XING RESTR. FO DID NOT MANUALLY TUNE TO ABB. I WAS USING MY VOR/DME TO FIND A VOR COMBINATION FOR THE FMS TO TUNE. WE WERE DOWN TO 2 FMS DME STATIONS AND OCCASIONALLY DOWN TO 1 VOR/DME STATION. THE FMS, HOWEVER, SHOWED OUR POS AS WELL AS TOP OF DSCNT AND END OF DSCNT (AT 45 SW OF ABB). AT ABOUT 60 DME SW OF ABB (FMS MAP) IN THE DSCNT, CTR ASKED US TO STOP THE DSCNT AT FL290. ABOUT 30 SECONDS LATER THE FMS MAP FAILED (WITHOUT WARNING). CTR THEN TURNED US TO A NW HDG AND ASKED US OUR DSCNT CLRNC AND OUR DISTANCE FROM ABB. I MANUALLY TUNED ABB AND WE WERE ABOUT 46 DME SW OF ABB. I ASKED CTR IF THERE WAS A CONFLICT AND WAS TOLD THAT THE STOPPED DSCNT AT FL290 AND THE TURN OFF COURSE PREVENTED A CONFLICT. WE WERE UNABLE TO RECOVER FMS FOR REMAINDER OF FLT. FACTORS AFFECTING THIS PROB: 1) UNEXPLAINED AND UNEXPECTED FMS FAILURE. 2) ONE CREW MEMBER NOT MANUALLY TUNING OF ABB VOR AS A BACKUP. 3) ACCEPTING FMS DATA FOR NAV (HOWEVER, IS THIS NOT A SYS CERTIFIED FOR ACCURATE RNAV). 4) TOO MUCH TRUST IN THE AUTOMATION FOR 100 PERCENT RELIABILITY.

  103.  
  104. Accession Number: 357340
    Synopsis: LGT ACFT DURING CLB HAD OVERSPD WARNING RESULTING IN FLC DISTR AS ACFT FAILED TO LEVEL AT ASSIGNED ALT. RPTR CAPT DISCONNECTED AUTOPLT AND RETURNED TO ASSIGNED ALT.
    Narrative: I WAS THE CAPT ON THE FLT FROM ATL TO BHM. I WAS THE PF AND HAD THE ACFT ON AUTOPLT, VNAV AND HDG SELECTED AS WE WERE ON A RADAR VECTOR FOR BHM. WE WERE ASSIGNED 14000 FT. LEAVING ABOUT 12500 FT, THE AUTOTHROTTLES FAILED TO CTL THE AIRSPD, AND WE WENT THROUGH THE LIMIT MMO/IAS AND RECEIVED THE OVERSPD WARNING. THE AUTOPLT ALSO FAILED TO CAPTURE ALT, AND FLEW THE ASSIGNED 14000 FT. I CAUGHT THE ALT EXCURSION AT ABOUT 14700 FT, DISENGAGED THE AUTOPLT AND AUTOTHROTTLES AND PUSHED OVER TO REGAIN ALT AND SLOW THE ACFT TO A NORMAL INDICATED AIRSPD. THE OVERSPD WARNING PROBABLY CAUSED BOTH PLTS TO MISS THE ALT ALERT WE SHOULD HAVE RECEIVED ON APCHING 14000 FT, AS NEITHER OF US HEARD THE WARNING. THERE WAS NO COMMENT OR QUESTION FROM ATC ABOUT OUR ALT AND WE SAW NO OTHER ACFT VISUALLY OR ON TCASII. THERE WAS NO CONFLICT. WE WERE LATER ASSIGNED FL220 AND COMPLETED THE FLT TO BHM UNEVENTFULLY. WE WILL IN THE FUTURE BE MORE CONCERNED WITH ALT THAN AIRSPD OVERSHOOT

  105.  
  106. Accession Number: 358300
    Synopsis: MLG ACFT CLRED FOR XING RESTR, FO PROGRAMS FMC FOR VNAV DSCNT. CAPT LEAVES COCKPIT. ACFT FAILS TO DSND AND XING RESTR MISSED. FMC PROGRAMMING ERROR.
    Narrative: WE WERE GIVEN CLRNC TO CROSS COFAX AT FL250 (WE WERE AT FL310 AT THE TIME). I WAS THE PF. I PROGRAMMED COFAX AT FL250 INTO THE FMC AND VERIFIED THAT I WAS ON VNAV. A FEW MINS LATER THE CAPT STATED HE WAS GOING TO GO TO THE BATHROOM AND GOT UP. JUST AS HE STARTED OUT THE COCKPIT DOOR, I LOOKED DOWN AND REALIZED WE WERE 1 MI FROM COFAX. FOR WHATEVER REASON, THE FMC/AUTOPLT DID NOT START THE DSCNT (STILL WAS ANNUNCIATING VNAV) AND I FAILED TO BACK UP THE MACHINE WITH BASIC AIRMANSHIP. I IMMEDIATELY STARTED DOWN MANUALLY, NOTIFIED ATC THAT I WAS STARTING OUT OF FL310 AT THIS TIME AND APOLOGIZED FOR MISSING THE XING RESTR. HE SAID NO PROB, DSND AND MAINTAIN FL250, AND CONTACT NEW YORK ON 132.2. UPON CONTACT, THEY CLRED US FOR DIRECT LRP AND A FURTHER DSCNT WITH NO XING RESTRS. CONTRIBUTING FACTORS: 1) WE HAD EARLIER BEEN SLOWED DOWN BY ATC TO 250 KTS WHICH I PROGRAMMED INTO THE FMC. THEN WHEN WE WERE GIVEN NORMAL SPD, I COULDN'T GET IT OUT. CAPT SAID LOOK AT CRUISE DSCNT PAGE -- THERE IT WAS. I TOOK IT OUT, PUT BACK ECONOMY CRUISE DSCNT AND THOUGHT EVERYTHING WAS OK. I THINK, IN RETROSPECT, I TOOK IT OUT OF PLANNED DSCNT MODE BY DOING THAT. 2) MY NOT BACKING UP BEGINNING OF DSCNT POINT WITH MANUAL CALCULATIONS. NO EXCUSE EXCEPT PERHAPS FATIGUE. (THIS WAS A RED-EYE FLT FROM SFO-PHL THAT WAS DELAYED IN SFO DUE TO LATE ARR OF ACFT. DEPARTED SFO AT XX38 AM LCL TIME.) 3) FAILURE OF CAPT TO BACK ME UP. DUE ALSO, I THINK, TO BACK SIDE OF THE CLOCK FLYING. ACTION: VOW NOT TO BE LULLED INTO A SENSE OF COMPLACENCY WITH FMC. SOMETHING I NORMALLY DON'T DO. BUT FOR WHATEVER REASON, IT HAPPENED THIS TIME.

  107.  
  108. Accession Number: 358450
    Synopsis: MD80 SUPER 80 HAD DSNDED TO 11000 FT. BECAUSE FMS HAD BEEN IMPROPERLY PROGRAMMED, ACFT CLBED TO 11300 FT AND CREW WAS ALERTED BY ALT ALERT. ATC SAID NOTHING.
    Narrative: FO FLYING HAD IAS HOLD AND CLAMP ON FMA. I WAS BUSY WITH SETTING THE NEXT TURN ON RADIOS. WITH HEAD IN CHART HEARD ALT WARNING GO OFF. LOOKED UP TO SEE 11300 FT AND SLOW CLB OF 100-200 FPM. FO CORRECTED IMMEDIATELY. APCH NEVER SAID ANYTHING TO US ABOUT IT. FEEL THAT IT MIGHT HAVE BEEN CAUSED BY THE DSCNT STILL IN IAS AND REDUCING THE VERT SPD BY PWR, WHICH CAN CAUSE A CLB, ESPECIALLY IF YOU HIT SOME BUMPS AS WE DID.

  109.  
  110. Accession Number: 358642
    Synopsis: MLG CLRED TO CROSS HAYED INTXN AT FL190. DSCNT BEGUN IN VERT SPD THEN CHANGED TO VNAV. SOMEHOW, VNAV WAS NOT ENGAGED OR BECAME DISENGAGED AND ACFT APCHED HAYED AT FL240. ATC GAVE FLT A 360 DEG TURN IN ORDER TO MAKE THE ALT XING RESTR.
    Narrative: ON THE WILLIAMSPORT 1 ARR (FQM.FQM1), CLRED TO CROSS HAYED INTXN AT FL190. IT WAS SET UP IN THE FMC. DSCNT WAS INITIATED IN VERT SPD, THEN VNAV WAS SELECTED. I WAS DISTRACTED BY A CALL FROM A FLT ATTENDANT IN THE CABIN AND DID NOT CATCH THE VNAV NOT ENGAGED. ZNY CALLED ABOUT 5 NM BEFORE HAYED AND ASKED IF WE WERE GOING TO MAKE THE XING RESTR. WE THEN RECEIVED VECTORS FOR A 360 DEG TURN TO DSND. THERE APPEARED TO BE NO TFC CONFLICT. CONTRIBUTING FACTOR WAS THAT FO WAS OFF FREQ TALKING TO COMPANY AND GETTING ATIS.

  111.  
  112. Accession Number: 358670
    Synopsis: B737-400 ACFT IN CRUISE RECEIVED XING RESTR ALT CLRNC. CAPT PUT THE ALT IN THE COMPUTER, BUT FORGOT WHAT VNAV WAS INOP AND THAT THE DSCNT WOULD HAVE TO BE MANUAL. CTLR INFORMED FLC THAT THEY HAD MISSED THE XING RESTR.
    Narrative: DURING CRUISE AT FL330, ZDC ISSUED A CLRNC TO CROSS 65 MI S OF RICHMOND AT FL290. THE CAPT PROGRAMMED THE FMC WITH THE XING WAYPOINT. WHEN SELECTING THE ALT, HE PUT FL290 ON THE RICHMOND WAYPOINT AND THE 65 MI S WAYPOINT. VERT NAV (VNAV) FUNCTION OF THE AUTOPLT WAS INOP, SO THE DSCNT HAD TO BE SELECTED MANUALLY. WE BOTH DID NOT NOTICE THE 65 MI XING RESTR DROP OFF THE FMC SCREEN WHEN WE PASSED IT, BUT I KEPT LOOKING AT THE FL290 SELECTED OVER RICHMOND AND BELIEVED THAT IT WAS THE FL290 XING RESTR. AT 50 MI S OF RICHMOND ATC INFORMED US OF THE MISSED RESTR. SOLUTION: ENTER THE XING RESTR ONLY AT THE XING POINT, PAY CLOSER ATTN AND LOOK AT WHAT THE FMC SAYS NOT WHAT YOU EXPECT TO SEE.

  113.  
  114. Accession Number: 359070
    Synopsis: DC9-41 WAS CLBING TO FL240. 1000 FT TO GO CALL WAS MADE AND PNF LOOKED UP AS THEY WERE CLBING THROUGH FL242.
    Narrative: WE WERE INSTRUCTED TO LEVEL AT FL240, THE AAD WENT OFF AS WE PASSED THROUGH FL230. I THEN CALLED OUT 'OUT OF FL230 FOR FL240.' THE PF ACKNOWLEDGED 'ROGER.' I THEN CONTINUED WITH MY PAPERWORK, AND AFTER A FEW SECONDS, I GLANCED UP AND SAW THE ALTIMETER AT FL242 AND THE ACFT STILL CLBING. I CALLED THE DEV AND IMMEDIATELY PUNCHED OFF THE AUTOPLT AND PITCHED THE ACFT OVER TO CORRECT THE ALT. THE FO, PF, HAD GOTTEN DISTR WITH REPROGRAMMING THE LORAN. NO MENTION WAS MADE ABOUT ALT BY ATC.

  115.  
  116. Accession Number: 359700
    Synopsis: FLC OF AN MLG UNDERSHOT DSCNT ALT DURING A STAR ARR CAUSING ATC TO INTERVENE AND TURN THEM OFF COURSE IN ORDER TO PROVIDE THE APPROPRIATE SEPARATION OF OPPOSITE DIRECTION TFC.
    Narrative: AS FLT LEVELED OFF AT CRUISE ALT FL290, CAPT PROGRAMMED ARR ROUTING INTO FMC WHILE FO FLEW ACFT. FLT CROSSED STAR INTXN #1 AT FL240 AND WAS THEN CLRED TO FL230. ON THE ARR FLT ENCOUNTERED MODERATE CLR AIR TURB AT FL230 AND FO WENT OFF PRIMARY ATC RADIO FREQ TO MAKE PA TO PAX, WITH CAPT ASSUMING CTL OF ACFT AND CLRNC TO FL220, CROSS WHIGG INTXN AT 11000 FT. DSCNT TO FL220 WAS INITIATED AND ACFT LEVELED AT FL220, WITH ALT ALERTER SET AT 11000 FT. TURB AVOIDANCE BECAME PRIMARY FOCUS OF AIRCREW AND FMC COMPUTER WAS NOT UPDATED WITH 11000 FT ALT RESTR AT WHIGG (FMC DSCNT PROFILE WAS COMPUTED TO ARRIVE AT LAS FIELD ONLY). UPON COMPLETION OF PA, FO ASSUMED CTL OF ACFT AND CAPT LEFT PRIMARY ATC FREQ TO COORDINATE TURB ACTIONS WITH FLT ATTENDANTS AND PAX. FO FOLLOWED FMC-PROGRAMMED DSCNT PROFILE AND APPROX 5 MI FROM WHIGG INTXN CTLR ASKED IF FLT WOULD BE ABLE TO COMPLY WITH THE ASSOCIATED ALT RESTR. ACFT WAS NOT ABLE TO DSND TO MEET RESTR AND WAS VECTORED AWAY FROM ARR CORRIDOR AND INSTRUCTED TO MAINTAIN ALT FOR OPPOSITE DIRECTION TFC TO PASS BY. AIRCREW COMPLIED WITH REVISED INSTRUCTIONS AND WAS SUBSEQUENTLY RECLRED FOR ARR INTO LAS WITH NO FURTHER COMPLICATIONS. THIS SEEMS LIKE A HUMAN PERFORMANCE AND COM FAILURE BTWN THE PLTS FLYING WITH ASSUMPTION BY FO THAT BOTH ARR ROUTING AND ALT RESTRS WERE ENTERED INTO FMC WHEN THIS WAS NOT THE CASE. TURB ISSUES DISTRACTED AIRCREW FROM BACKING EACH OTHER UP.

  117.  
  118. Accession Number: 360780
    Synopsis: MD88 DSNDING TO FL180. CAPT, PF, SET LCL ALTIMETER AND DSNDED TO 17600 FT BEFORE CATCHING ERROR.
    Narrative: ON DSCNT TO FL180 CAPT SET LCL ALTIMETER (WHICH WAS VERY HIGH, APPROX 30.60) AND ACFT DSNDED TO APPROX 17600 FT (AS SEEN ON FO'S ALTIMETER SET TO 24.92). IT TOOK APPROX 3 SECONDS TO REALIZE THE ERROR AND RECOVER TO FL180. WE LEARNED THE IMPORTANCE OF XCHKING THE OTHER PLT'S ACTIONS AND MONITORING THE AUTOPLT ON LEVEL OFF. I ACTUALLY SAW THE JET DSNDING THROUGH FL180 BUT DIDN'T TAKE CORRECTIVE ACTION, (DISCONNECTING THE AUTOPLT/HITTING ALT HOLD). CAPT WAS BRIEFING THE APCH AND INADVERTENTLY SET LCL ALTIMETER.

  119.  
  120. Accession Number: 360830
    Synopsis: FLC OF A CL65, REGIONAL JET, FAILED TO FOLLOW THEIR FLT PLAN CLRNC ROUTING RESULTING IN ATC INTERVENTION AND REDIRECTION TO GET BACK ON INTENDED RTE. THE ACFT FMS WAS PROGRAMMED IN ERROR AND THE FLC USING THIS PROGRAM HAD BEEN OFF COURSE AND HAD NOT KNOWN IT.
    Narrative: OUR CLRNC FROM YYZ-BOS: (TORONTO 2 V252 J16 ALB AS FILED.) AFTER RECEIVING THE ABOVE CLRNC WE PROGRAMMED THE FLT MGMNT SYS (FMS) FOR THE FLT. THE COMPANY RTE WHICH WAS STORED IN THE FMS MEMORY WAS AS FOLLOWS.....(YYZ01 EHMAN HANKK ALB ALB01 GDM...). AS WE LOOKED OVER THE 2 PLANS WE NOTICED THE DISCREPANCY BTWN THE CLRNC OF V252 J16 AND THE FMS VERSION OF EHMAN...HANKK. ON THE CHARTS THERE IS NO INTXN WHERE V252 AND J16 MEET BUT THE 2 LISTED INTXNS ON THE FMS WERE WITHIN A FEW MI AND WE ASSUMED THAT THE FMS RTE WAS HOW THE COMPANY HAD CHOSEN US TO MAKE THE TRANSITION FROM V252 TO J16. FLYING ALONG BTWN EHMAN AND HANKK ZOB ASKED US IF WE SHOWED OURSELVES ON THE AIRWAY. WE REPLIED, 'YES,' AND ASKED IF THERE WAS A PROB. THE CTLR SAID HE SHOWED US TO BE 7 MI N OF J16 AND WE IMMEDIATELY KNEW THAT THE FMS RTE WAS NOT IN FACT IN CORRELATION WITH WHERE THE CTR HAD INTENDED US TO FLY. WE DID MATCH OUR CLRNC WITH THE FMS ON THE GND, BUT WE MADE THE WRONG ASSUMPTION WITH USING THE INTXNS INSTEAD OF PROGRAMMING EXACTLY WHERE V252 AND J16 MEET. I'VE NOTICED SEVERAL TIMES IN USING THE FMS THAT THE NUMBERS REPRESENTING THE RADIAL OF AN AIRWAY DO NOT EXACTLY COME UP THE SAME AS WHAT IS LISTED ON THE CHARTS, BUT IT HAS NEVER BEEN QUESTIONED BEFORE. I THINK THIS FACTORED IN WITH OUR ACCEPTANCE OF THE PREPROGRAMMED COMPANY RTE. IT WAS VERY CLOSE AND IN THE PAST THAT HAS ALWAYS WORKED. WE HAVE CONTACTED THE COMPANY AND HAVE BEEN INFORMED A NOTICE WILL BE PUT ON ALL TORONTO TO BOSTON FLT RELEASES NOTIFYING CREW MEMBERS OF THIS PARTICULAR CONFUSING ISSUE. IN SPEAKING WITH SEVERAL OTHER PLTS AT THE COMPANY WHO HAVE FLOWN THE SAME RTE, SOME HAD NOTICED, SOME HAD NOT. IT'S NOT THAT WE DIDN'T CHK THE ACCURACY OF THE FMS DATA, WE JUST ASSUMED IT WAS WHAT WAS INTENDED DUE TO THE CLOSE PROX OF THE TWO. SHORTLY AFTER THE CTLR ASKED US ABOUT THIS ISSUE, HE CLRED US DIRECT TO ALBANY VOR AND SEEMED TO HAVE NO FURTHER QUESTIONS. I UNDERSTAND WHAT HAPPENED AND WILL BE MORE VIGILANT IN THE FUTURE AS TO CORRELATING FMS COMPANY PLANS AND OUR CLRNCS.

  121.  
  122. Accession Number: 360920
    Synopsis: FLC OF AN LGT FAILED TO FOLLOW THEIR SID FLT PLAN RTE BY MISPROGRAMMING THEIR FMC RESULTING IN ATC INTERVENTION AND VECTORS TO GET ON COURSE.
    Narrative: CLBING OUT OF MIA TO MCO, ZMA CLRED US TO BAIRN INTXN, GOOFY ARR AT MCO. PNF TYPED BARIN INTO FMC. UNDER HIGH WORKLOAD (ALT CHANGES, BUSY ATC COM) WE ENGAGED LNAV WITHOUT VERIFYING RTE. WE CAUGHT MISTAKE IN LESS THAN 20 SECONDS ABOUT THE SAME TIME ATC NOTICED US SLIGHTLY R OF COURSE. ATC PROVIDED VECTOR TO BAIRN. WE SHOULD HAVE SELECTED BAIRN FROM DEP/ARR PAGE RATHER THAN TYPE IT IN FREE-HAND. ALWAYS VERIFY BEFORE EXECUTING.

  123.  
  124. Accession Number: 361640
    Synopsis: A MD88 MAKES A TRACK ERROR CLBING OUT FROM DFW. FO IS PF AND MAKES IMPROPER INPUTS TO NAV COMPUTER. CAPT IS NOT AVAILABLE TO XCHK INPUTS INTO THE NAV SYS.
    Narrative: DURING CLBOUT, DALLAS 1 DEP, CAPT LEFT RADIOS TO ATTEND OTHER DUTIES. I WAS FLYING, ON AUTOPLT, AND WAS CLRED FOR HDG 095 DEGS TO INTERCEPT 072 DEG RADIAL FROM DFW VOR. I CONNECTED THE INERTIAL NAV SYS (INS) AND FLT MGMNT SYS (FMS) TO COMPLETE THE COURSE TRANSITION. I FAILED TO INSURE THE NAV SYS ACCEPTED THE CHANGES. AS I REALIZED THE RADIAL OVERSHOOT, ZFW CALLED TO QUERY MY HEADING, CLRNC, AND TO REQUEST A TURN TO ON COURSE. PROPER FMS AND NAV SYS INPUTS WERE MADE AND A COURSE CORRECTION WAS MADE. I FAILED TO PROPERLY VERIFY ALL CHANGES MADE TO THE FMS AND NAV SYS, WITH THE CAPT OFF FREQ THERE WAS NO BACK UP FOR MY MISTAKE. I WILL INSURE ALL CHANGES TO THE FMS AND NAV SYS ARE PROPERLY VERIFIED AND THAT THE ACFT RESPONDS ACCORDINGLY.

  125.  
  126. Accession Number: 361890
    Synopsis: RPTR ERROR ADMITTED IN GROSS NAV ERROR, OVERWATER OP. AFTER AN AUTOPLT DISCONNECT, FLC FAILED TO RE-ENGAGE THE AUTOPLT MODE SELECTOR TO INS NAV POS FROM THE HDG POS.
    Narrative: SHORTLY AFTER REACHING CRUISE AND SELECTING INS NAV, AN ELECTRICAL SYS SPIKE TRIPPED OFF THE AUTOPLT. THE AUTOPLT WAS RE-ENGAGED USING THE NORMAL INITIAL SETUP OF 'F-H-A' FLT DIRECTOR HDG ALT. SIMULTANEOUSLY, ATC ISSUED A FREQ CHANGE, AND WE WERE PASSING THE FIRST RPTING POINT. CONTACT WAS MADE WITH NY RADIO AND THE STANDARD POS RPT MADE. THOUGH WE FAILED TO RE-ENGAGE INS/NAV THE NEXT POS RPT CAME WITHIN 1 MIN OF THE ETA AT THAT POINT. ALL APPEARED NORMAL UNTIL NY RADIO ADVISED US TO CONTACT ZNY ON VHF. WE WERE ADVISED THAT IT APPEARED THAT WE WERE APPROX 45 MI E OF THE AIRWAY. A CHK OF INS COORDINATES CONFIRMED OUR POS. THE FLT WAS CLRED DIRECT TO THE NEXT WAYPOINT AND WAS COMPLETED WITHOUT FURTHER INCIDENT. ALTHOUGH THE AUTOPLT RE-ENGAGEMENT TO 'F-H-A' WAS ANNOUNCED THE IMMEDIATE FREQ CHANGE AND POS RPT DISTR THE CREW FROM MAKING THE USUAL XCHK AND THE SUBSEQUENT RE- ENGAGEMENT OF INS NAV. SUPPLEMENTAL INFO FROM ACN 361732: WHEN RE-ENGAGED AUTOPLT WAS IN HDG MODE AND NOT NAV MODE ALLOWING ACFT TO DRIFT OFF COURSE.

  127.  
  128. Accession Number: 362093
    Synopsis: HDG TRACK POS DEV WHEN FLC FAILS TO NOTE PASSING AN ENRTE VOR AND FAILS TO ADJUST TO NEW OUTBOUND HDG.
    Narrative: CAPT WAS FLYING THE ACFT USING HDG SELECT TO TRACK THE AIRWAYS. THE NORMAL ROUTINE WOULD HAVE BEEN TO HAVE THE AUTOPLT COUPLED TO THE OMEGA AND TRACKING THE AIRWAYS. HOWEVER, THIS WAS NOT POSSIBLE SINCE THIS ACFT HAD THE OMEGAS REMOVED AND THE NEW GPS INSTALLED. I WAS DISTR BY OPERATING THE GPS AND THE CAPT DID NOT NOTICE VOR STATION PASSAGE. THIS RESULTED IN A COURSE DEV. CTR THEN PROVIDED US WITH A VECTOR TO REINTERCEPT THE AIRWAY. ALTHOUGH NO CONFLICT RESULTED, ANOTHER REMINDER NOT TO ALLOW A DISTR TO RESULT IN AN ERROR.

  129.  
  130. Accession Number: 362260
    Synopsis: AN ACR FLC ON A B737 CROSS RADDS INTXN TOO HIGH WHEN THE CAPT ENTERS THE WRONG XING POINT INTO THE FMC. NO CONFLICT.
    Narrative: FO WAS OUT OF COCKPIT TO USE BATHROOM. CAPT RECEIVED CLRNC TO CROSS RADDS INTXN AT 15000 FT. CAPT PUT 15000 FT OVER SEI VOR BY MISTAKE INTO THE FMC. AFTER XING RADDS INTXN AT FL230, CTR ASKED IF A CLRNC HAD BEEN ISSUED TO CROSS RADDS INTXN AT 15000 FT. CREW THEN REALIZED THE MISTAKE AND DSNDED. ATC ADVISED THERE WAS NO CONFLICT WITH TFC, BUT WANTED TO SEE IF PAST CTLR HAD ISSUED CLRNC.

  131.  
  132. Accession Number: 362840
    Synopsis: B737-300 IS ALLOWED TO STRAY FROM COURSE WHEN THE FMC DROPPED A WAYPOINT.
    Narrative: FLYING LKV-FRA DIRECT. AFTER PASSING FRA, ATC ADVISED WE WERE 4 MI L OF COURSE (L OF J7), AND ADVISED TO TURN R AND INTERCEPT AIRWAY (J7). EVIDENTLY THE FMC DUMPED THE NEXT WAYPOINT (DERBB). WE WERE STILL WITHIN THE BOUNDARIES OF THE AIRWAY BUT WOULD HAVE HAD A COURSE DEV IF WE HAD CONTINUED ON PRESENT HDG. (FMC DID NOT RPT THE DISCONTINUITY WHICH IT GENERATED.)

  133.  
  134. Accession Number: 363303
    Synopsis: ACR MLG CLRED TO HOLD CON VOR L TURNS FL370. CAPT WAS ON #2 VHF WITH DISPATCH REGARDING PLAN OF OP. WHEN BACK IN THE COCKPIT HE SET UP THE HOLD PER CHART WITH A R TURN. FO HAD FAILED TO ADVISE OF THE L PATTERN. CTLR QUESTIONED THE DIRECTION OF TURN AFTER 1 CIRCUIT. NO CONFLICT AND THE FLT DIVERTED TO ALTERNATE.
    Narrative: CLRED TO HOLD AT CON NW ON 300 DEG RADIAL, L TURNS, 2O MI LEGS, FL370. FO COPIED HOLDING INSTRUCTIONS AS I WAS TALKING TO DISPATCH ABOUT THE WX AT PWM (WHICH WAS NOW BELOW MINIMUMS) AND OUR POSSIBLE DIVERSION TO BGR, WHICH WE EVENTUALLY DID. UPON RETURNING TO MY PF DUTIES, WAS TOLD OF OUR INSTRUCTIONS BY ATC BUT HE NEGLECTED TO MENTION L TURNS INSTEAD OF THE PUBLISHED HOLDING PATTERN WHICH WAS R TURNS. I ENTERED THE HOLD AND AFTER 1 COMPLETE PATTERN, ATC ASKED US IF WE WERE IN THE HOLD OVER CON L TURNS. WE REPLIED THAT WE WERE HOLDING AS PUBLISHED, IE, R TURNS AND THEN THE FO TOLD ME IT WAS L TURNS AS HE HAD WRITTEN DOWN BUT FAILED TO TELL ME THAT IT WAS L TURNS. THERE WAS NO CONFLICT. WE APOLOGIZED, AND REQUESTED AND RECEIVED A CLRNC TO BGR. ATC STATED THAT THERE WASN'T A PROB AND WE LANDED AT OUR ALTERNATE. THIS WAS CAUSED BY A VERY HVY WORKLOAD AS ALL THE SURROUNDING ARPTS WERE GOING BELOW MINIMUMS OR WERE CLOSED FOR SNOW REMOVAL. IN THE FUTURE I WILL ASK MORE POINTED AND DIRECT QUESTIONS AS I RE-ENTER THE LOOP. THIS WAS ALSO THE FIRST DAY (THIRD LEG) I HAD FLOWN WITH THIS FO AND I WAS OVERCONFIDENT IN HIS ABILITIES. I NEED TO BE MORE VIGILANT! SUPPLEMENTAL INFO FROM ACN 363490: THE CAPT SAID HE WAS BACK SO I TOLD HIM THE HOLDING INSTRUCTIONS. HE PROCEEDED TO BUILD THE HOLD IN THE FMC. UPON ME REVIEWING THE ENTRY IN THE FMC I NOTICED HE HAD ENTERED THE WRONG INBOUND HDG. HOWEVER, I DID NOT NOTICE THAT THE TURNS THAT CAME UP ON THE FMC WERE R. AS WE ENTERED THE HOLD THE CAPT WAS BACK ON #2 RADIO WITH COMPANY. WE DID NOT REALIZE OUR MISTAKE UNTIL ZBW ASKED US WHAT WE WERE DOING.

  135.  
  136. Accession Number: 363420
    Synopsis: ATC INTERVENED TO ADVISE FLC OF A B737-300 THAT THEY WERE 20 MI OFF COURSE. FLC DISCOVERED THAT THE ACFT FMC ROUTING WAS DIFFERENT THAN THE ACTUAL CLRNC GIVEN BY ATC.
    Narrative: ROUTING IN FMC WAS DIFFERENT THAN FLT PLAN ROUTING. THE FMC ROUTING WAS A COMPANY PRELOADED ROUTING. CTR CTLR INFORMED US THAT WE WERE 20 MI FROM FLT PLAN RTE. WE THEN DISCOVERED DISCREPANCY. BOTH PLTS FAILED TO VERIFY FMC ROUTING WITH ROUTING ON DISPATCH RELEASE. IT WAS THE LAST LEG OF A 4 DAY TRIP WHERE WE HAD GONE FROM NIGHT FLYING (XA30 AM ARR IN BALTIMORE) ON FIRST DAY TO YA00 AM DEP FROM COLUMBUS ON LAST DAY.

  137.  
  138. Accession Number: 363684
    Synopsis: MDT ACR JET OVERSHOOTS 3000 FT ALT WHEN ALT CAPTURE FEATURE ON AUTOPLT FAILS TO LEVEL ACFT AT 3000 FT. TCASII RA CREATES A FURTHER ALTDEV IN A CLB MANEUVER. FLC ADVISES ATC OF DEV.
    Narrative: XA45 LCL (ORF). ASSIGNED 3000 FT BY DEP. ACFT ON AUTOFLT MODE (AUTOPLT) DID NOT CAPTURE. AT 3400 FT, WE STARTED PUSHOVER THEN GOT TCASII ALERT, THEN TCASII CLB RESOLUTION. WE THEN CONTINUED CLB AND NOTIFIED DEP.

  139.  
  140. Accession Number: 363811
    Synopsis: AN ACR FLC IN AN MDT CLBED ABOVE THEIR ASSIGNED ALT WHEN THEY BECAME DISTR BY OTHER TASKS AND FAILED TO NOTE THAT THE ALT SELECT MODE WAS NOT ENGAGED.
    Narrative: WE WERE CLBING TO OUR ASSIGNED ALT OF 12000 FT. THE AUTOPLT WAS ON AND ALT SELECT WAS SELECTED, BUT IT DID NOT REGISTER. BOTH PLTS FAILED TO NOTICE THAT ALT SELECT DID NOT REGISTER. JUST BEFORE REACHING 12000 FT THE CAPT (PF) BEGAN LOOKING AT THE CRUISE PWR SETTING CHART. I (THE FO) WAS LOOKING AT A LOW ALT ENRTE CHART TO DETERMINE THE OUTBOUND COURSE FROM THE PTW VOR. THE ACFT CONTINUED TO CLB TO ABOUT 12350 FT. BOTH PLTS NOTICED WHAT HAD HAPPENED. THE CAPT TURNED THE AUTOPLT OFF AND DSNDED TO 12000 FT. BOTH PLTS SHOULD HAVE MONITORED THE ACFT ALT BEFORE BEGINNING OTHER TASKS. ALSO, BOTH PLTS SHOULD HAVE NOTICED AND CONFIRMED THAT ALT SELECT DID NOT REGISTER ON THE AUTOPLT.

  141.  
  142. Accession Number: 364000
    Synopsis: FLC OF A B737-400 FAILED TO DSND IN A TIMELY MANNER TO MAKE AN ALT XING RESTR. FMC WAS NOT PROGRAMMED WITH NEW DSCNT ALT.
    Narrative: RECEIVED DSCNT CLRNC TO CROSS JAYBO INTXN AT 15000 FT. I (PNF) READ BACK THAT CLRNC. FMC HAD 15000 FT AT HEDGE INTXN, WHICH IS 9 DME PAST JAYBO INTXN. AS I WAS ABOUT TO BRING THE ERROR TO THE CAPT'S ATTN, HE BROUGHT DOWN 15000 FT TO THE SCRATCH PAD. BEING DUSK, LOOKING INTO THE SUN, AND THE GLARE MAKING VIEWING HIS FMC DIFFICULT, I FAILED TO CONFIRM THE CHANGE. PAST JAYBO, I CHKED THE DSCNT PAGE AND REALIZED THE FMC HAD NOT BEEN CHANGED AND WE HAD MISSED THE RESTR. MY INACTION TO CONFIRM THE PROPER XING RESTR HAD BEEN EXECUTED BY THE PF WAS THE RESULT OF: 1) THE PF WAS COMPETENT AND NOT PRONE TO MAKING SUCH A MAJOR MISTAKE, THEREFORE, LEADING ME IN ASSUMING THE CORRECTION WAS MADE. 2) INTENSE GLARE MAKING VIEWING THE FMC DIFFICULT. 3) SEEING THE PF BRING DOWN 15000 FT TO THE SCRATCH PAD, I WAS CONFIDENT HE WAS AWARE OF THE ERROR IN THE FMC. 4) 15000 FT IS PLAINLY NOTED ON THE ARR AS THE ALT TO EXPECT AT JAYBO, NOT HEDGE. 5) I ASSUMED MY READBACK OF THE PROPER RESTR WAS HEARD BY THE PF, IN ADDITION TO ATC'S INSTRUCTION.

  143.  
  144. Accession Number: 364225
    Synopsis: LGT FLC DEPARTS WITHOUT USING XPONDER CODE AND WITHOUT OBTAINING ENRTE CLRNC. THEY CLB THROUGH ASSIGNED ALT DUE TO POSSIBLE FAILURE OF ALT CAPTURE. CHKLIST DEFICIENCIES CITED.
    Narrative: MANY DISTRS PRIOR TO DEP (STATION MGR CONVERSATIONS REGARDING CLEANING OF ACFT, 2 OTHER MEMBER CREWS), CONTINUED INTERRUPTION OF COCKPIT SETUP. WAS DISTR WITH 1 ITEM LEFT TO ACCOMPLISH -- XPONDER. SO, FAILED TO NOTICE NO CODE IN XPONDER. PUSH BACK AND TAXI OUT NORMAL. RECEIVED TKOF CLRNC AS USUAL. TKOF ROLL WAS EXTREMELY DISTR BY LENGTHY CONVERSATION BTWN THE TWR CTLR AND A SMALL ACFT THAT APPEARED TO BE DISORIENTED. DURING CLB OUT, IT TOOK AN UNUSUAL AMOUNT OF TIME (LONG) BEFORE THE CONVERSATION STOPPED, AND WE COULD GET IN A WORD TO ASK IF WE SHOULD GO TO DEP CTL FREQ. ALSO DURING CLB OUT, OUR TCASII SHOWED US RAPIDLY APCHING AN ACFT AHEAD OF US AND SLIGHTLY TO THE L. WHEN WE FINALLY CONTACTED TWR, THEY ASKED US TO CHK OUR XPONDER, THEN GAVE US A SQUAWK (CODE). WE WERE TURNED OVER TO DEP CTL AND GIVEN A HDG OF 350 DEGS, WHICH THE FO'S MISTUNED TO 250 DEGS. I CORRECTED HIM AND ASKED HIM TO VERIFY THE HDG WITH ATC. SHORTLY THEREAFTER, I NOTICED WE WERE AT 5900 FT MSL, CLBING RAPIDLY. THE AUTOFLT SYS HAD FAILED TO OPERATE NORMALLY, AND THE ALT ALERT WAS NOT NOTICEABLE ENOUGH TO CATCH OUR ATTN -- SMALL LIGHT ON ALTIMETER, NO AURAL WARNING. I IMMEDIATELY STOPPED THE CLB, REACHING 6280 FT MSL AS WE RETURNED TO 6000 FT MSL (NO ALT ALERT INDICATING 300 FT OFF ALT). I REALIZED THAT WE HAD NOT RECEIVED OUR ENRTE CLRNC, THEREFORE, WE HAD NOT SET THE XPONDER. DURING CLBOUT, WE WERE FLYING MANUALLY, WITH AUTOTHROTTLE ENGAGED, NOT FOLLOWING PITCH BAR TO KEEP SPD LOW AND CLB RAPIDLY. CAUSES: 1) NO DEFINITIVE 'XPONDER' ON BEFORE TKOF OR STARTING ENGS CHKLIST. THIS ITEM IS COMBINED WITH 'RADIOS AND NAV EQUIP.' IT'S A NO NAVAID DEP TO AN AUTO-FLT RTE, THEREFORE, EXCEPT FOR XPONDER, THERE'S NO NAVAIDS TO SET. 2) MULTIPLE DISTRS, COMBINED WITH PAVLOVEON CONDITIONING OF AUTO-FLT SYS, AUTOMATICALLY PULLING THROTTLES TO IDLE WHEN APCHING A LEVEL OFF ALT DURING CLB. 3) 2 PLT CREW -- A THIRD PLT COULD HAVE LOOKED FOR THE TFC, TAKEN CARE OF THE OTHER MEMBER CREW, VERIFIED THE XPONDER, POSSIBLY CAUGHT THE AUTO-FLT MALFUNCTION AND THE APCHING ALT LIMIT. 4) CAPT'S AND FO'S FAILURE TO GET ATC ENRTE CLRNC. I THOUGHT THE FO HAD GOTTEN THE CLRNC -- HE HAD NOT.

  145.  
  146. Accession Number: 364385
    Synopsis: AN ACR FLC, FLYING AN MD88, RPT THAT THEY GOT AS MUCH AS 20 NM OFF COURSE ACCORDING TO ARTCC RADAR CTLR AND CONFIRMED WHEN THEY CHKED THEIR RAW DATA. THEY WERE ABLE TO UPDATE THEIR NAV SYS USING VOR INFO. NO FURTHER PROB.
    Narrative: AFTER 45 MINS OF FLT, THE FMS WAS CONTINUALLY RESORTING TO DR AND VORS WERE UPDATED. ARTCC CALLED AND ASKED OUR POS. THE RNAV SHOWED 5 MI R OF PSB AND ARTCC RADAR SHOWED 20 MI L OF PSB. XCHKING THE PSB VOR, WE SWITCHED TO VOR NAV AND AIRBORNE UPDATED THE MAP FUNCTION POS. NO FURTHER PROBS, BUT A CONSTANT XCHK WITH THE VOR WAS MADE FOR THE REMAINDER OF THE FLT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR IS AN MD88 CAPT FOR A MAJOR ACR. THE MD88'S ARE EQUIPPED WITH HONEYWELL FMS WITH HONEYWELL SOFTWARE. HE SAID THAT HIS COMPANY HAD PROBS WITH THE EQUIP GETTING OFF COURSE ABOUT A YR OR 2 AGO AND HONEYWELL REPRESENTATIVES FLEW A NUMBER OF FLTS IN THE JUMP SEAT AND WERE ABLE TO SOLVE THE PROB. THIS EVENT WAS THE FIRST THAT HE HAD HEARD OF SINCE THAT TIME. AFTER HE LANDED, THE MAINT TECHNICIANS ALLEGEDLY TOLD HIM THAT THE SOFTWARE PROGRAM WAS NOT ALLOWING THE PRIMARY NAV SYS TO AUTOMATICALLY UPDATE. THEY DID REMIND HIM THAT HE SHOULD CHK THE SYS AGAINST RAW DATA AND MANUALLY UPDATE IF NECESSARY.

  147.  
  148. Accession Number: 364750
    Synopsis: PIC OF B727-200 FAILS TO PROCEED DIRECT TO INTXN USING GPS. HE HAD FORGOTTEN TO SELECT THE MODE CTL SELECTOR TO THE 'AUX NAV' POS SO THAT THE GPS COULD DIRECT THE AUTOPLT. ARTCC RADAR CTLR NOTICES THE NON COMPLIANCE.
    Narrative: FREQ: 124.7, ALT: 15000 FT. ATC FACILITY: ZMA. LOCATION: DHP 210 DEGS 45 NM APPROX. UNDER ZMA'S DIRECTION TO PROCEED DIRECT WEVER ON DVALL 1 ARR. ENTERED DIRECT WEVER IN GPS BUT AUTOPLT WAS NOT ON AUX NAV. AFTER APPROX 2 MINS ZMA QUERIED US AS TO OUR GOING DIRECT WEVER. NOTICED MISTAKE AND TURNED TOWARDS WEVER. ASKED MIA IF THERE WAS A CONFLICT AND WAS TOLD NO. NO FURTHER ACTION WAS TAKEN BY US.

  149.  
  150. Accession Number: 364771
    Synopsis: MD80 SUPER80 OVERSHOT ASSIGNED ALT WHEN AUTOPLT FAILED TO CAPTURE.
    Narrative: APCHING LEVELOFF CLBING TO FL240, THE AUTOPLT FAILED TO CAPTURE THE LEVELOFF. DISCONNECT AND MANUAL LEVELOFF ACCOMPLISHED RESULTING IN EXCEEDING THE PLANNED LEVELOFF OF FL240 BY APPROX 300 FT.

  151.  
  152. Accession Number: 365306
    Synopsis: CAPT OF A L1011 OVERSHOT DSCNT XING RESTR ALT AND MADE SUCH AN ABRUPT CORRECTION THAT 2 FLT ATTENDANTS WERE INJURED. IN ADDITION, SINCE THE WRONG WAYPOINT HAD BEEN ENTERED INTO THE FMC, RPTR WAS NOT ON THE PRESCRIBED STAR ARR TRACK.
    Narrative: ACFT WAS CLRED TO LOGEN INTXN WHEN FO WAS ABSENT FROM COCKPIT FOR PERSONAL BIOLOGICAL REASONS. ACFT WAS LEVEL AT FL240. FO RETURNED TO COCKPIT AND WAS INFORMED OF CLRNC DIRECT TO LOGEN. UPON INSPECTION OF LATITUDE/LONGITUDE OF WAYPOINT THAT ACFT WAS PROCEEDING TO, DETERMINED WRONG WAYPOINT SELECTED. AT THAT TIME, ATC ISSUED DSCNT TO FL200. ALT SET, AND ANNUNCIATED, IN ALT SELECTOR. FO COMMENCED VERIFYING AND INPUTTING PROPER WAYPOINT LATITUDE/LONGITUDE. AT FL210, THE REQUIRED '1000 FT TO GO, OUT OF FL210 FOR FL200' WAS MADE BY THE FO AND 'ROGERED' BY THE CAPT. BEFORE THE FINALIZATION OF THE CORRECT WAYPOINT WAS COMPLETED, A RADICAL PULL-UP WAS INITIATED BY THE CAPT. WHEN QUESTIONED WHY, THE CAPT STATED THAT THE ACFT AUTOPLT FAILED TO CAPTURE THE SET ALT, FL200. THE ACFT DSNDED BELOW FL200 BY 400-450 FT BEFORE RETURNING TO THE CLRED ALT. FOR UNKNOWN REASONS, THE ACFT DID NOT LEVEL OFF. AFTER, THE ACFT WAS LEVELED OFF MANUALLY, (THE AUTOPLT WAS DISCONNECTED BY CAPT DURING HIS ATTEMPT TO RE-LEVEL THE ACFT) AND THE ALT SET KNOB WAS RESET TO FL200. 2 FLT ATTENDANTS WERE SHAKEN UP AND SUSTAINED MINOR INJURIES THAT WERE BROUGHT TO THE ATTN OF THE FLC WITHIN 10 MINS OF THE INCIDENT. NO ATC COMMENTS WERE MADE ABOUT ALT BUST.

  153.  
  154. Accession Number: 365320
    Synopsis: FLC OF AN MLG OVERSHOT DSCNT XING RESTR DUE TO MISSET AUTOPLT MODE CTL.
    Narrative: DURING DSCNT WE WERE GIVEN AN ADDITIONAL RESTR TO CROSS HITOP INTXN AT AND MAINTAIN 17000 FT. THIS WAS ENTERED IN LEGS PAGE. I DID NOT, I BELIEVE, RESET MCP ALT TO 17000 FT SINCE I WANTED TO LEVEL AT FL210 TILL WE NEEDED TO GO DOWN TO 17000 FT. WE WERE DSNDING IN VNAV ALL THE TIME WITH THE FOLLOWING ADDITIONAL WAYPOINT RESTRS IN FMC: 1) WHETO AT 12000 FT, AND 2) PSP AT 7000 FT. AS DSCNT CONTINUED, WE ADDED SPD RESTRS TO WHETO AND PSP TO GET SLOWED FOR THE FINAL DSCNT DURING THE EXPECTED VISUAL APCH. AS WE CONTINUED, I CAN'T SAY WHY, BUT I FELT SOMETHING WAS AMISS BUT DID NOT KNOW WHAT AT FIRST AND I STATED THIS TO THE CAPT. THEN I REALIZED WE WERE NEARING HITOP (DON'T RECALL HOW CLOSE WE WERE) AND WERE STILL AT FL210. IT (HITOP) WAS STILL DEFINITELY AHEAD OF US ON MAP DISPLAY. I IMMEDIATELY STATED WE MIGHT NOT MAKE HITOP AT 17000 FT TO THE CAPT, EXTENDED THE SPD BRAKES, WENT TO IDLE THRUST AND MANUALLY DSNDED THE AIRPLANE AS FAST AS POSSIBLE WITHOUT UPSETTING THE PAX. ATC THEN ASKED IF WE'D MAKE HITOP AT 17000 FT, CAPT SAID YES, I BELIEVE. I DON'T RECALL THE ALT AT HITOP BUT WE LEVELED AT 17000 FT PROBABLY 1-2 MI BEYOND. WE WERE, I PRESUME, CLOSE ENOUGH, BUT THE SIT COULD HAVE BEEN WORSE. IN THE END, I THINK OUR DOWNSTREAM WAYPOINT CHANGES CAUSED US TO DROP OUT OF VNAV AND INTO ALT HOLD AT FL210. THIS WOULD EXPLAIN THE LACK OF A 'RESET MCP ALT' MESSAGE PRIOR TO HITOP. THE MORAL OF THE STORY IS TO RECHK AND MONITOR FLT MODE ANNUNCIATIONS AND NEVER ASSUME THAT IT WON'T CHANGE MODES ON YOU WHEN YOU MAKE ALT RESTR MODIFICATIONS. IN THE END, THIS IS SOMETHING I'M QUITE MAD AT MYSELF FOR, FOR NOT MONITORING THE AUTOFLT SYS MORE CLOSELY.

  155.  
  156. Accession Number: 365344
    Synopsis: FLC OF A B757 UNDERSHOT DSCNT ALT RESULTING IN NOT MEETING A XING RESTR. THE FLC'S INATTN TO THE ACFT AUTOPLT ACTION, OF WHICH THEY THOUGHT WAS PREPROGRAMMED TO DSND THE ACFT IN TIME TO MEET THE XING RESTR, CAUSED THE ACFT TO BE 2000 FT HIGH AT XING FIX.
    Narrative: WHILE 70 NM E OF DEWITT, WE WERE GIVEN A CLRNC TO CROSS DEWITT AT FL310. THE MCA ALT WAS SET TO FL310 AND THE RESTR ENTERED INTO THE FMC. 5 NM FROM THE PROGRAMMED TOP OF DSCNT, 'DSND NOW' WAS ACTIVATED. THE THROTTLES CAME BACK AND THE DSCNT BEGAN. AFTER BEGINNING THE DSCNT, I BRIEFED THE UPCOMING APCH. I EXPECTED THE ACFT TO AUTOMATICALLY FLY THE RESTR LIKE IT IS SUPPOSED TO DO. THE CTR ASKED IF WE HAD A XING RESTR. WE LOOKED UP FROM OUR BRIEFING AND SAW THAT WE HAD CROSSED DEWITT AND WERE STILL DSNDING THROUGH FL330 AT ABOUT 1000 FPM. WE CHKED AND WE WERE STILL IN VNAV BUT THE THROTTLES WERE NOT AT IDLE. WE QUICKLY IDLED THE THROTTLES AND EXPEDITED DSCNT. CTR HAD TFC AT FL330. CONFUSED AT WHY THE ACFT DID NOT MAKE ITS RESTR, WE SET UP A SIMILAR SIT BUT THIS TIME THE ACFT MET THE RESTR. WE DON'T KNOW WHY THE ACFT DIDN'T MEET THE FIRST RESTR BUT WE CAN ONLY GUESS WE DID SOMETHING WRONG. PERHAPS THE EARLY PICKUP (XA15 HOME TIME) CONTRIBUTED. I NORMALLY GO TO SLEEP AROUND XB00 AT HOME AND DIDN'T EVEN COME CLOSE TO A FULL NIGHT'S SLEEP PRIOR TO THE INCIDENT.

  157.  
  158. Accession Number: 365550
    Synopsis: FLC OF A DO328 FAILED TO FOLLOW THEIR FPR DUE TO AN ERROR IN THEIR FMC STORED FLT PLAN RESULTING IN ATC INTERVENTION TO BRING THEM BACK ON COURSE.
    Narrative: I WAS THE CAPT OF FLT FROM GJT TO COS. OUR CLRNC WAS AS FILED WHICH WAS GJT-JNC-HBU J28 DIRECT COS 168 DEG RADIAL AT 38 DME TO COS. WE PROGRAMMED THE FMS WITH A STORED FLT PLAN WHICH WE THOUGHT WAS CORRECT, BUT THE STORED FLT PLAN WAS IN ERROR FROM THE POINT AFTER HBU VOR. THE STORED FLT PLAN WENT FROM HBU DIRECT COS AND NOT J28 TO THE COS 168 DEG RADIAL AT 38 DME. AS WE APCHED THE HBU VOR, I BEGAN TO LOOK UP SOME PERFORMANCE DATA IN THE ACFT'S POH. THE FO WAS THE PF AND HE WAS TRACKING THE FMS COURSE. I WAS BACKING HIM UP USING VOR NAV. AFTER PASSING THE HBU VOR, THE FO TRACKED A COURSE DIRECT TO COS WHICH WAS APPROX THE 050 DEG RADIAL FROM HBU AND NOT THE 080 DEG RADIAL, WHICH WOULD HAVE BEEN J28. I HAD NEGLECTED TO MONITOR THIS BECAUSE I WAS LOOKING UP SOME PERFORMANCE DATA. AFTER ABOUT 30 MI, CTR CAME ON FREQ AND SAID, FLT XX TURN R 20 DEGS -- YOU ARE NOW CLRED J28 TO THE COS 168 DEG RADIAL AT 38 DME COS, WHICH WAS HOW WE WERE CLRED BEFORE. I THEN REALIZED WHAT WAS WRONG AND REPROGRAMMED THE FMS CORRECTLY. ANOTHER CONTRIBUTING FACTOR WAS THAT THE FO WAS NOT MONITORING HIS MOVING MAP DISPLAY CORRECTLY BECAUSE HE HAD THE SCALE DOWN TO LOW SO THAT IT DID NOT SHOW HIS NEXT WAYPOINT WHICH IF HE HAD SEEN IT, HE WOULD HAVE REALIZED HE WAS PROCEEDING DIRECT TO COS AND NOT THE 168 DEG RADIAL AT 38 DME OFF COS FIX.

  159.  
  160. Accession Number: 365580
    Synopsis: FLC OF A DHC8 FAILED TO FOLLOW THE DEP TRACK DURING CLBOUT CAUSING ATC TO INTERVENE AND PROVIDE A DIRECT COURSE TO THE NEXT FLT PLAN FIX.
    Narrative: I AM AN INSTRUCTOR PLT (FLT AND SIMULATOR) FOR ACR X. THIS WAS MY FIRST LINE TRIP IN 12 MONTHS AND I WAS FLYING WITH A LINE CHK AIRMAN DUE TO THE FACT I WAS EXPIRED FOR A LINE CHK AND COULD NOT ACT AS PIC. I AM A CAPT AND WAS OCCUPYING THE L SEAT. DURING OUR PREDEP PREPARATION, IT WAS NOT NOTICED THAT ON OUR FLT PLAN (WHICH INVOLVES AT SOME POINT INTERCEPTING THE HAR 039 DEG RADIAL) WAS NOT PROGRAMMED INTO THE KNS 660 RNAV (THE HAR 039 DEG PORTION). WE DEPARTED AND WERE CLRED TO JOIN THE 039 DEG RADIAL. I WAS NAVING USING THE RMI SINCE HE HAD SELECTED THE HAR 039 DEG RADIAL ON HIS HSI. HE NOTICED THIS AND SAW IT WASN'T PROGRAMMED IN THE KNS 660. HE THEN PROGRAMMED IT IN. THE ONLY PROB WAS HE PROGRAMMED HAR 03939 (39 DME). THE AIRWAY IS INTERCEPTED (THE SEG 101 DEG RADIAL) AT 29 DME. HE HAD DIALED IN THE SEG 101 DEG RADIAL BEFORE HE STARTED PROGRAMMING THE KNS 660. WE THEN NOTICED WE HAD FLOWN THROUGH THE COURSE AND WAS TURNING TO INTERCEPT WHEN ZNY ADVISED US WE MISSED THE AIRWAY AND CLRED US TO GO DIRECT FJC VOR. NOTHING FURTHER WAS SAID BY HIM. WE WERE ABOUT THE SEG 101 DEG RADIAL AND 8 DME WHEN WE FLEW THROUGH AIRWAY ABOUT 10 DEGS, SO I DOUBT WE WERE ACTUALLY OFF THE AIRWAY.

  161.  
  162. Accession Number: 365690
    Synopsis: CL65 FLC FLY THE WRONG HDG OUT OF IIU VOR WHILE ON FMS. THE DATABASE HAD A KNOWN ERROR BUT THE FLC PASSED OVER THE FLT RELEASE WARNING OF SAME WITH A SHORT AND ERRED ASSESSMENT.
    Narrative: FMS CANNED FLT PLAN WAYPOINT GRNIN INTXN WAS INCORRECTLY SPELLED GRINN IN FMS UPDATE. FMS PLOTTED THE MISSPELLED WAYPOINT 260 DEGS FROM IIU VOR. THE CORRECT HDG AFTER IIU FOR GRNIN IS 195 DEGS. FMS COMMANDED THE TURN TO 260 DEGS. THIS WAS FLOWN FOR ABOUT 10 MI (80 SECONDS) UNKNOWN TO FLC. ATC ADVISED US OF THE DEV AND CORRECTED OUR HDG ON COURSE. WE WERE NOT ADVISED OF ANY SEPARATION PROB. THE FLT RELEASE DID INCLUDE AN ADVISORY STATING THE PROB WITH THE MISSPELLED WAYPOINT. THE WAYPOINT WAS REVIEWED BY THE CAPT PRIOR TO THE FLT. HE SAW NO PROB WITH THE WAYPOINT IN QUESTION. I WAS RUSHED IN MY PREFLT DUTIES AND WAS UNABLE TO REVIEW THE RTE MYSELF. FACTORS THAT LED TO THE DEV: 1) SMALL ERRORS IN SPELLING ARE DIFFICULT TO DETECT WHEN THE LETTER 'I' IS MOVED -- GRNIN VERSUS GRINN. 2) THE FLC'S INATTN ON THE GND AND IN THE AIR. 3) THE FLC'S COMPLACENCY WITH THE FMS'S ABILITY TO NAV. TAKES FLC OUT OF THE NAV LOOP TO A CERTAIN DEGREE.

  163.  
  164. Accession Number: 365700
    Synopsis: B757 CREW FLIES TO WRONG POS WHEN CLRED TO A FIX ON FMS. THE DATABASE HAD A KNOWN ERROR IN COORDINATES BUT FLC FAILED TO READ THE COMPANY NOTAM THAT HAD BEEN ISSUED.
    Narrative: ATC CLRED US TO THE LIN 89 FIX, SO WE USED THE FMC DATABASE LIN89. THE DATABASE LIN89 COORDINATES ARE N3846.5/W11911.3 WHICH IS WHAT WE FLEW TO. THE LIN89 (LIN062089) COORDINATES ATC WANTED US TO FLY TO WAS N3820.6/W11909.2. THESE COORDINATES WERE ON THE FLT PLAN, BUT NOT IN THE DATABASE CORRECTLY. CALLED DISPATCH AND THEY ARE AWARE AND HAVE POSTED NOTAMS, BUT DATABASE HAS NOT BEEN UPDATED.

  165.  
  166. Accession Number: 365917
    Synopsis: MLG ACFT COMMENCING APCH. RPTR CAPT COULDN'T GET AUTOPLT TO INTERCEPT ILS, THEN HAND FLEW ACFT BUT THE FLT DIRECTOR BARS WERE NOT PROVIDING ACCURATE INFO. FINALLY RPTR DISCOVERED THAT THE COURSE BAR WAS NOT SET FOR THE INBOUND COURSE. FO HAD NOTICED THE COURSE SET, BUT DIDN'T QUESTION THE CAPT THINKING HE HAD IT SET FOR A REASON. ACFT PROBABLY DEVIATED FROM COURSE ON PARALLEL APCHS.
    Narrative: PROB AROSE WHEN INTERCEPTING LOC LEVEL AT 5000 FT AND CLRED FOR APCH. AUTOPLT WAS ENGAGED AND APCH MODE SELECTED. WE CROSSED THROUGH LOC WITHOUT CAPTURING IT. I TURNED ACFT IN CTL WHEEL STEERING MODE TO RE-INTERCEPT -- IT DIDN'T. I TURNED OFF AUTOPLT TO HAND-FLY APCH AND FOLLOW FLT DIRECTOR BARS AND IT AGAIN WENT THROUGH LOC. I TURNED MY EHSI, ELECTRONIC HORIZ SIT INDICATOR, TO LOC MODE FROM MISSED APCH MODE AND DISCOVERED THE COURSE BAR WAS NOT TURNED TO THE PROPER INBOUND COURSE. SET CORRECT INBOUND HEADING IN AND IT WORKED FINE. IN SETTING UP FOR APCH THE SETTING OF THE COURSE WAS NOT ACCOMPLISHED. WHEN THE FO DID THE CHKLIST, HE SAID HE SAW IT WASN'T SET PROPERLY BUT DIDN'T SAY ANYTHING BECAUSE HE THOUGHT I WAS USING IT FOR SOMETHING ELSE. HOW FAR WE DEVIATED OFF COURSE I'M NOT SURE, BUT PARALLEL APCHS WERE IN EFFECT AND WE PROBABLY GOT CLOSE TO THE OTHER LOC. WE WERE AT DIFFERENT ALTS FROM THE OTHER ACFT. ATC DID NOT QUESTION US. FO WAS ALSO GETTING CONFUSED ON WHEN TO SWITCH TO THE TWR FREQ FROM APCH CTL. THEY DO IT EARLY AT ORD WHEN PARALLEL APCHS ARE IN USE. I LEARNED ONCE AGAIN TO DOUBLE CHK EVERYTHING.

  167.  
  168. 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.

  169.  
  170. Accession Number: 366430
    Synopsis: B737-300 CLBING TO 16000 FT. 'A' AUTOPLT INDICATED ALT ACQUIRE AT 15000 FT. GIVEN VECTOR HDG AND IN SETTING HDG NOTICED AUTOPLT DID NOT CAPTURE AND ACFT WAS NEARING 17000 FT. REGAINED 16000 FT AND CHANGED TO 'B' AUTOPLT. NO COMMENT FROM CTLR.
    Narrative: THE B737-300 HAS 2 AUTOPLT SYS -- THE 'A' SYS NORMALLY USED BY THE CAPT AND THE 'B' SYS USED BY THE FO. THE FLT ORIGINATED OUT OF SAC TO BUR WITH MY FO FLYING THE FIRST LEG. THE ACFT HAD NO WRITE-UPS AND THE FIRST FLT WAS NORMAL. THE SECOND LEG WAS FROM BUR TO PHX FLOWN BY MYSELF. ON CLBOUT, WE WERE ASSIGNED 16000 FT BY DEP. AS WE WERE CLBING THROUGH 15000 FT, THE 'A' AUTOPLT WENT INTO THE ALT ACQUIRE MODE AND APPEARED TO BE WORKING PROPERLY. WE WERE GIVEN A HDG AND RADIAL TO INTERCEPT AT ABOUT THE SAME TIME. AFTER SETTING IN THE RADIAL AND HDG, I NOTICED THAT WE WERE STILL CLBING AND APCHING 17000 FT. OBVIOUSLY THE AUTOMATIC LEVELOFF FUNCTION OF THE 'A' AUTOPLT HAD FAILED. I STARTED A QUICK DSCNT BACK TO 16000 FT. THAT WAS CORRECTLY SET INTO THE ALT WINDOW. THE AUTOPLT AGAIN WENT INTO THE ALT ACQUIRE MODE BUT DID NOT CAPTURE THE ALT OR LEVELOFF, WHICH I HAD TO DO MANUALLY. NOTHING WAS SAID BY DEP ABOUT OUR ALTDEV AND WE WERE CLRED OVER TO ZLA. WHEN WE CHKED IN WITH CTR HE QUESTIONED OUR ASSIGNED ALT, WHICH WE STATED WAS 16000 FT. WE WERE THEN CLRED TO FL180 AND I SWITCHED TO THE 'B' AUTOPLT SYS, WHICH LEVELED OFF AND FUNCTIONED NORMALLY FOR THE REMAINDER OF THE FLT. IN PHX WE HAD MAINT FIX THE 'A' AUTOPLT AND IT CHKED OUT OK TO OUR NEXT FLT TO STL. HAVING FLOWN THE 300 SERIES FOR OVER 10 YRS, THIS WAS THE FIRST TIME I'VE HAD A FAILURE OF THE AUTO LEVEL SYS. THE SYS IS SO RELIABLE AND WE DEPEND AND TRUST IT SO MUCH THAT WHEN IT FAILS IT CAN REALLY CATCH YOU OFF GUARD. I FEEL THAT IF THE AUTOPLT GOES INTO THE ALT ACQUIRE MODE BUT FAILS TO LEVEL OFF AT THE CORRECT ALT, A MORE POSITIVE WARNING THAN JUST A HORN SHOULD BE GIVEN, IE, A VERBAL 'ALT, ALT!' WOULD BE A FAR BETTER SYS.

  171.  
  172. Accession Number: 366810
    Synopsis: AN ACR B727 FLC GOT OFF COURSE BECAUSE THEY DID NOT ENGAGE THE PROPER AUTOPLT MODE WHEN PROCEEDING DIRECT TO A WAYPOINT. AN ALERT CTLR CLRED THEM BACK ON COURSE.
    Narrative: DURING DSCNT INTO SJU, CTLR ADVISED WE WERE E OF COURSE. LEAVING FLL, ZMA HAD CLRED US DIRECT TO ROBLE WHICH WAS ENTERED IN THE GFMS, BUT APPARENTLY, I DID NOT EVER SELECT AUX NAV ON THE AUTOPLT MODE SELECTOR. WE WERE RECLRED TO BEANO AND MADE THE XING. WORD TO THE WISE -- RECHK ALL SWITCH POS WHEN A DIRECT CLRNC IS ISSUED.

  173.  
  174. 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.

  175.  
  176. Accession Number: 368610
    Synopsis: ACR MLG FLC FAIL TO EXECUTE AN ALT XING RESTR. THEIR AUTOTHROTTLE SYS WAS INOP. THE FO, PF, RECEIVED DSCNT CLRNC WHILE THE PIC WAS TELLING COMPANY ABOUT IT, FAILING TO SET THE ALT IN THE ALT SYS AND FAILING TO ADVISE PIC. CTLR ASSISTED WITH VECTORS.
    Narrative: WHILE TALKING TO COMPANY ABOUT ARR AND MECHANICAL PROB WITH AUTOTHROTTLES, FO (WHO WAS FLYING) RECEIVED CLRNC TO CROSS DIGGIN AT 12000 FT. FO FAILED TO SET 12000 FT IN ALT SYS, OR INFORM ME OF CLRNC WHEN I CAME BACK FROM COMPANY RADIO. WITH AUTOTHROTTLES BROKEN, FMS PERFORMANCE WAS OFF, SO SYS DID NOT ADVISE FOR DSCNT. CTR ASKED US ABOUT OUR DSCNT AT THE SAME TIME WE HAD STARTED DOWN. ASKED FOR A TURN IN HOLDING FOR ALT LOSS, WAS GIVEN HDG VECTORS INSTEAD.

  177.  
  178. Accession Number: 368720
    Synopsis: CAPT OF AN MD88 DSNDED BELOW ASSIGNED DUE TO AUTOPLT FAILURE TO TRIM ACFT TO HOLD ALT DUE TO THE HIGH RATE OF SLOWING THE ACFT FOR A SPD REDUCTION.
    Narrative: ON ARR INTO ATL ON THE ROME ARR WE WERE LEVEL AT 11000 FT AND WE WERE SLOWING FROM 320 KTS TO 210 KIAS. AS THE ACFT WAS SLOWING DOWN AND TRIMMING UP, I WAS DOING AN APCH BRIEFING. I HAD MY COMMERCIAL CHART BOOK IN FRONT OF ME AND WAS BRIEFING THE APCH. I DID NOT NOTICE, BUT THE ACFT STARTED A GRADUAL DSCNT BECAUSE THE AUTOPLT COULD NOT TRIM FAST ENOUGH FOR THE AIRSPD CHANGE. WE LOST 300 FT BEFORE I NOTICED AND I IMMEDIATELY CORRECTED BACK TO ALT. NO OTHER ACFT WERE IN THE AREA AND ATC MADE NO COMMENT.

  179.  
  180. Accession Number: 368929
    Synopsis: A DHC-8 OVERSHOOTS ASSIGNED ALT DURING CLB AS PF ASSUMES THE AUTOPLT AND LEVELING FEATURES WILL AUTOMATICALLY LEVEL THE ACFT AT THE PROPER ALT. NO LEVELING FEATURE WAS ENGAGED, THOUGH, AND THE ACFT FLEW ABOVE ASSIGNED ALT.
    Narrative: AFTER LEVEL OFF I ENGAGED AUTOPLT ON LAST LEG OF A 13 HR DUTY DAY WITH A SHORT OVERNIGHT. I ASKED THE FO WHAT HE HAD FOR TOTAL BLOCK SO FAR TODAY. HIS NUMBERS DID NOT AGREE WITH MINE. I THEN STARTED TO CHK MY NUMBERS AND THEN LOOKED BACK AT THE ADI WHICH SHOWED A L CLBING TURN. I IMMEDIATELY RESUMED CTL OF THE ACFT AND LEVELED OFF AND THEN DSNDED BACK TO 9000 FT. CTR NEVER ASKED ABOUT THE SLIGHT CLB ABOUT 500 FT HIGH. THE AUTOPLT EITHER DIDN'T ENGAGE OR DISCONNECTED. FATIGUE WAS THE PRIMARY CAUSE OF THIS ALT BUST. CTR DIDN'T QUESTION OUR ALT AND I ASSUME IT WENT UNNOTICED. THERE WERE NO OTHER ACFT IN THE AREA. NO TCASII TARGET. SUPPLEMENTAL INFO FROM ACN 369020: HE RELEASED CTLS THINKING AUTOPLT WAS ON AND WE CLBED THROUGH OUR ASSIGNED ALT OF 9000 FT. I WAS FILLING OUT LOGBOOK AND NOT WATCHING. CAPT WAS FILLING OUT PERSONAL CREW LOG FOR TIMES OFF GATE. AS WE PASSED 9700 FT HE REALIZED AUTOPLT WAS NOT ENGAGED. WE RETURNED TO 9000 FT. CLT ATC NEVER ASKED ABOUT OUR ALT.

  181.  
  182. Accession Number: 369810
    Synopsis: COMMUTER FLT GETS OFF COURSE ON CYPRESS 3 ARR INTO MIA WHEN FO IS OPERATING AUTOPLT IN THE HDG MODE VERSUS NAV MODE. PIC WAS OFF FREQ, GIVING PA, GETTING ATIS AND GIVING COMPANY A CALL. HE NOTES FO'S DEV LATER ON.
    Narrative: ENRTE TPA-MIA LEVEL AT FL190, FO FLYING. ZMA CLRED US TO CROSS THE WORPP INTXN AT 6000 FT. FO STARTED DOWN (AUTOPLT ENGAGED IN HDG MODE RATHER THAN NAV MODE). I MADE MY PA TO THE PAX, GOT OFF FREQ TO PICK UP THE ATIS AND ALSO TO MAKE MY IN-RANGE CALL TO THE COMPANY. BY THE TIME I CAME BACK ON, WE WERE ABOUT 4 MI W OF WORPP AND DSNDING THROUGH 6600 FT. I NOTICED THIS AND ASKED MY FO WHERE HE WAS GOING AND HE SAID THAT HE THOUGHT THAT HE HAD THE AUTOPLT IN THE NAV MODE, NOT THE HDG MODE. I THINK THE PROB WAS THAT NOBODY WAS FLYING THE AIRPLANE. I FEEL THAT WE NEEDED TO BE MORE VIGILANT ABOUT WHAT IS GOING ON INSIDE THE FLT DECK AND NOT JUST OUTSIDE.

  183.  
  184. Accession Number: 369920
    Synopsis: MD80 SUPER 80 OVERSHOT ASSIGNED ALT OF FL280 WHEN AUTOPLT FAILED TO CAPTURE. CTR ALTIMETER ALSO READ 300 FT LOW, NO FACTOR.
    Narrative: CLBING TO FL280, #2 AUTOPLT FAILED TO CAPTURE ALT. FO CLICKED AUTOPLT OFF AND RETURNED TO FL280. ATC NOTIFIED AND INFORMED OF 300 FT DEV BTWN PLT'S ALTIMETER AND CTR. ATC CONFIRMED PLT'S ALTIMETER TO BE CORRECT. CTR ALTIMETER READ 300 FT LOW.

  185.  
  186. Accession Number: 370840
    Synopsis: ALT XING NOT MADE WHEN FO FAILS TO SET THE XING ALT INTO THE ALT SELECT PANEL. THE FO, PF, HAD TO 'BUILD' A XING FIX WITH AIRSPD CHANGE INTO THE FMS. THE CAPT WAS ON THE PA WITH PAX INFO. LACK OF COCKPIT COORD AND SITUATIONAL AWARENESS.
    Narrative: WE WERE INBOUND TO CLT ON THE CHESTERFIELD ARR DSNDING TO 14000 FT AND EXPECTING A CLRNC TO CROSS BOOZE INTXN AT 11000 FT. BEFORE WE LEVELED AT 14000 FT WE WERE GIVEN A CLRNC TO CROSS 13 NM S OF BOOZE AT 11000 FT AND 210 KTS. I WAS THE PF AND I SET UP THE FMS TO DISPLAY A FIX 13 NM S OF BOOZE. THEN I PROGRAMMED THE FMS TO DISPLAY THE 210 KTS, 11000 FT RESTR ON THE MOVING MAP DISPLAY. HOWEVER, I DID NOT SET 11000 FT ON THE ALT SELECT PANEL AND THIS IS NECESSARY FOR THE ACFT TO RESPOND TO THE FMS INPUTS. THEREFORE THE ACFT LEVELED AT 14000 FT AND WE MISSED THE XING RESTR. ZJX TOLD US WE MISSED THE RESTR JUST AS WE CROSSED THE 13 DME FIX. I THINK THE AUTOMATION OF THE F100 WAS A CONTRIBUTING FACTOR. IN THIS ACFT WHEN RECEIVING A XING RESTR, ESPECIALLY ONE THAT IS NOT OVER AN ESTABLISHED INTXN, THE PLTS MUST 1) BUILD THE POINT IN THE FMS, 2) PROGRAM THE ALT AND SPD IN THE FMS, 3) SET THE ALT SELECT PANEL. IN A LESS AUTOMATED ACFT, THE SAME CLRNC MEANS SIMPLY DIALING IN THE ALT ON THE ALT SELECT PANEL. OVER RELIANCE ON THE AUTOMATION WAS ANOTHER FACTOR. A BREAKDOWN OF THE ESTABLISHED ALT AWARENESS PROGRAM WAS THE THIRD AND MOST CRITICAL CONTRIBUTING FACTOR. SUPPLEMENTAL INFO FROM ACN 370841: I WAS BUSY PERFORMING THE ARR ANNOUNCEMENT ON THE PA SYS. THIS INTERRUPTED MY STANDARD FOLLOW-UP WITH OUR COMPANY ALT AWARENESS PROCS. CONSEQUENTLY I DID NOT CHK THE ALT SET AT THE FMC PANEL.

  187.  
  188. Accession Number: 371010
    Synopsis: AN ACR B737 FLC ATTEMPTS TO INTERCEPT AN ILS WITH THE WRONG COURSE SET IN THE COURSE DEV INDICATOR AND ARE TEMPORARILY CONFUSED WHEN THE ACFT MAKES AN UNEXPECTED TURN. THE ALERT APCH CTLR AND THE CAPT RECOGNIZE THAT SOMETHING IS AMISS AND START A CORRECTION PROCESS.
    Narrative: WE WERE BEING VECTORED TO THE ILS RWY 28R AT SFO. WE WERE GIVEN A HDG OF 300 DEGS TO INTERCEPT THE LOC AND TOLD TO MAINTAIN 4000 FT TO DUMBA. WE WERE CLRED FOR THE ILS TO RWY 28R AT SFO. AS THE LOC CAME ALIVE THE AUTOPLT CAPTURED IT AND BEGAN A R TURN INSTEAD OF A L TO CAPTURE THE LOC. I TOLD THE COPLT TO TURN L ONTO THE LOC. HE TRIED TO MAKE THE AUTOFLT SYS MAKE THE CORRECTION. I THEN TOLD THE FO TO 'TURN L AND GET ON THE LOC, NOW!' AS WE WERE TURNING BACK ONTO THE LOC, APCH CTL CALLED US AND TOLD US HE SHOWED US GOING N OF THE LOC, TO TURN L TO 250 DEGS TO INTERCEPT THE LOC AND TO GO OVER TO TWR FREQ. I LOOKED OVER AT THE FO'S COURSE INDICATOR ON THE MCP AND SAW IT SAID 346 DEGS INSTEAD OF 282 DEGS. I CALLED IT TO HIS ATTN AND THE REST OF THE APCH PROCEEDED NORMALLY. I HONESTLY DON'T KNOW WHEN THE COURSE INDICATOR WAS SET ON 346 DEGS. I SHOULD HAVE CHKED IT DURING THE APCH DSCNT CHKLIST. I DON'T KNOW IF I MISSED IT THERE OR IF THE FO TURNED IT INSTEAD OF THE HDG INDICATOR WHILE BEING VECTORED FOR THE APCH. WHAT I DO KNOW IS THAT IN THE FUTURE I WILL DOUBLECHK BOTH THE FREQ AND THE COURSE SELECTOR WHEN WE ARE ON A HDG TO INTERCEPT THE LOC.

  189.  
  190. Accession Number: 371460
    Synopsis: ACR LGT WAS TOO HIGH ON THE APCH DURING STAR ARR INTO LAX AFTER A RWY CHANGE WAS MADE. ACFT WENT AROUND FOR ANOTHER APCH. INITIAL CONFUSION OCCURRED OVER WHICH RWY WAS ASSIGNED AND THE FAILURE TO SET THE ALT WINDOW FOR DSCNT.
    Narrative: DSNDING INTO LAX ON THE (STAR) CIVET ONE ARR, JUST PRIOR TO 'BREMR' INTXN, APCH CTL CHANGED OUR RWY TO RWY 25R. HOWEVER, THERE WAS SOME CONFUSION IN COCKPIT AS EACH PLT 'HEARD' A DIFFERENT RWY. THE DISTR RESULTED IN OUR FAILURE TO CROSS 'ARNES' INTXN AT 10000-11000 FT PER THE STAR. FURTHER, WE GOT SO FAR BEHIND ON THE APCH THAT WE ELECTED TO DISCONTINUE THE APCH AT THE OM. WE WERE THEN VECTORED TO AN APCH AND LNDG ON RWY 24R. LAX CONTINUES TO BE A DIFFICULT ARPT TO OPERATE INTO. THERE ARE 4 RWYS WITH SIMILAR SOUNDING NAMES, SO IT IS EASY TO SAY ONE RWY AND THINK ANOTHER. ONCE AGAIN THOUGH, THE OLD ADAGE ABOUT 'SOMEONE MUST FLY THE AIRPLANE' HAS BEEN PROVEN WISE. THE COPLT, WHO WAS FLYING, GOT DISTRACTED WITH ME AND FAILED TO FLY THE AIRPLANE TO THE REQUIRED XING ALT. ALSO, THE ADDED BUSY WORK OF THE GLASS COCKPIT CONTRIBUTED TO OUR INABILITY TO COMPLETE THE APCH AND LNDG. SUPPLEMENTAL INFO FROM ACN 371434: APCHING BREMR WE WERE GIVEN A RWY CHANGE TO RWY 25R. THE PNF THOUGHT THAT THE RWY THAT WE HAD BEEN GIVEN WAS RWY 24R. THERE WAS A ZLA CTLR WHO WAS ON THE JUMP SEAT, WE ASK WHAT HE HAD HEARD. HE INDICATED HE HEARD RWY 25R. THERE IS 7 MI BTWN BREMR AND ARNES AND AT A SPD OF 210 KTS TAKES APPROX 2 MINS. THE CAPT WAS THE FIRST TO NOTICE THAT WE HAD NOT RESET OUR ALT WINDOW TO 10000 FT AFTER XING BREMR TO MEET THE BELOW 11000 FT ABOVE 10000 FT FOR ARNES. WE CONTINUED THE APCH BUT WERE HIGH AND MADE A GAR AND LANDED RWY 24R. I PERSONALLY BLAME MYSELF FOR BECOMING DISTRACTED AND NOT MONITORING THE FLT PATH OF THE ACFT. ALTHOUGH A RWY CHANGE APPEARS TO BE A SIMPLE PROC, THIS PHASE OF THE APCH IS BUSY ENOUGH WITHOUT ADDING A NEW SET OF PROBS. SET PRIORITIES AND HAVE THE SELF DISCIPLINE TO MAINTAIN THOSE PRIORITIES. POSSIBLY USING SCENARIOS SIMILAR TO THE ONE WE EXPERIENCE, IN TRAINING WOULD HELP TEACH SOME OF THESE POINTS.

  191.  
  192. Accession Number: 372128
    Synopsis: THE FLC OF AN ACR B757 EXPERIENCED A MAP SHIFT DURING AN APCH TO LGA. THE ATCT LCL CTLR DIRECTED THE FLC TO GAR AND THEY SUCCESSFULLY COMPLETED A RAW DATA APCH LATER. THE EFIS MAP DISPLAY WAS 2 PT 5 NM OFF TO THE W AFTER THE FLT WAS IN THE GATE. THE RPTR ADMITTED THAT THEY WERE NOT MONITORING THE RAW DATA DURING THEIR INITIAL APCH.
    Narrative: CLRED THE LGA VOR/DME-G RWY 22 TURNED ON 4 MI OUTSIDE FAF. NOTICED A SLIGHT MOVEMENT ON HSI MAP, WHICH WE HAD ENTERED THE VOR APCH IN EARLIER. FLYING THE LNAV COURSE ON THE HSI, NO ASSOCIATED MESSAGES FROM EICAS OR FMS, NO FLAGS ON ANY INSTS. WHEN WE FINALLY SAW RWY 22 WE WERE 2 MI N AND APCH CTL DIRECTED A MISSED APCH TO 3000 FT AND VECTORED FOR ANOTHER APCH VOR DME-G TO RWY 22, WHICH WAS UNEVENTFUL. AFTER LNDG, THE HSI MAP HAD DRIFTED 2.5 MI AWAY FROM THE ACTUAL RWY. THIS WAS A VERY INSIDIOUS EVENT DURING THE BUSY TIME OF APCH AT THE FAF. SOME NOTIFICATION OF OUR PRIMARY NAV BEING BOLDLY DISPLAYED WHEN IT IS OUT OF TOLERANCE, WOULD BE HELPFUL IN PREVENTING THIS PROB IN THE FUTURE. SUPPLEMENTAL INFO FROM ACN 372125: IN THE BASE TURN FROM NORMAL DSCNT, AND SUDDEN 2 1/2 MI MAP SHIFT OCCURRED IN FMS, WITH NO ASSOCIATED MESSAGES/FLAGS. COMPUTER/AUTOPLT FLEW APPROX 2 MI L OF RWY, AND LGA TWR DIRECTED MISSED APCH, HDOF TO TRACON. WE RE-FLEW SAME APCH ON RAW DATA. AFTER LNDG, MAP WAS SHIFTED 2 1/2 MI W. THIS IS INSIDIOUS, PARTICULARLY WHEN IT OCCURS DURING A BUSY PERIOD, AS TRANSITIONING TO FINAL. CALLBACK CONVERSATION WITH RPTR ACN #372128 REVEALED THE FOLLOWING INFO: THE RPTR SAID THAT HE WAS FLYING A B757-200 EQUIPPED WITH HONEYWELL FMCS WHEN THE MAP SHIFT OCCURRED. HE SAID THAT THIS WAS THE FIRST MAP SHIFT THAT HE HAS EXPERIENCED IN THE SEVERAL YRS THAT HE HAS FLOWN THE ACFT. HE DID HAVE THE RAW DATA TUNED, BUT NOT DISPLAYED AND HE ADMITTED THAT THE FO AS THE PNF SHOULD HAVE HAD THE ILS DISPLAYED ON HIS HSI IN ACCORDANCE WITH COMPANY PROC. AFTER LNDG THE EFIS MAP WAS IN ERROR BY 2 1/2 NM TO THE W. HE ENTERED THE PROB IN THE LOGBOOK AND FURTHER DISCUSSED IT WITH MAINT TECHNICIANS. THEY COULD NOT PINPOINT THE CAUSE OF THE ERROR SO MAINT PERSONNEL CHANGED THE FMCS AND SOME RELATED EQUIP. THE RPTR TALKED TO HIS CHIEF PLT ABOUT THE PROB ALSO. HE HAS NOT BEEN TOLD OF THE CAUSE AS YET. HE HAS DECIDED TO CAREFULLY BACK UP HIS APCH DISPLAYS WITH RAW DATA IN THE FUTURE, HE SAID. HE SAID THAT THIS EPISODE WAS DEEPLY DISTURBING TO HIM AND HIS FO.

  193.  
  194. Accession Number: 373211
    Synopsis: B737-500 FLC FAILS TO MAKE AN ALT XING. ADVISED ZSE CTLR AND RECEIVED SOME VERBAL ADMONITION. FLT SWITCHED TO SEA APCH, CTLR GAVE A NEW ALT ASSIGNMENT. RPTRS CITE A LATE START OF DSCNT BY THE FMS.
    Narrative: THE AUTOPLT DID NOT START THE DSCNT TO CROSS TAWBN INTXN AT 16000 FT ON TIME OR AS PROGRAMMED. ATC INSTRUCTED US TO CROSS JAWBN AT 16000 FT. I DID NOT XCHK THE DSCNT COMPUTER IN MY HEAD TO INSURE ITS CALCULATIONS WERE CORRECT. ABOUT 15 MI FROM JAWBN, WE REALIZED THAT WE WERE NOT GOING TO MAKE JAWBN AT 16000 FT, AND TOLD ATC OF THIS SO SHE COULD VECTOR US OR HOLD US AS NECESSARY. SHE JUST SAID SOMETHING TO THE EFFECT OF 'DON'T TELL US YOU CAN MAKE THE ALT THEN FIND OUT YOU CAN'T -- CONTACT SEA APCH ON XXX.XX.' APCH THEN GAVE US A NEW ALT TO DSND TO. NOTHING MORE WAS SAID. AS I SEE IT, THE MAIN PROB WAS I RELIED TOO MUCH ON THE ONBOARD COMPUTER WITHOUT WORKING THROUGH THE CALCULATIONS IN MY HEAD. ALSO THE COMMENT AND TONE OF THE AIR TFC CTLR WAS NOT NECESSARY SINCE WE GAVE HER 15 MI NOTICE TO OUR SIT. SUPPLEMENTAL INFO FROM ACN 373210: AUTOPLT, THROUGH PMS, WAS SET FOR THIS ALT. DURING BRIEFING WE NOTICED THAT THE ACFT HAD STARTED DSCNT LATE AND WE WOULD NOT MAKE THE XING RESTR. ONCE AGAIN THIS SHOWS THAT PLT VIGILANCE OVER ALL ASPECTS OF ACFT SHOULD BE MAINTAINED AND THAT RELIANCE ON AUTOMATION CAN GET YOU IN TROUBLE IF YOU'RE NOT BACKING IT UP USING YOUR OWN EXPERIENCE.

  195.  
  196. Accession Number: 373260
    Synopsis: AN ACR MLG FLC CROSSED A DSCNT FIX 3000 FT HIGH. THEY IMPROPERLY ENTERED THE XING FIX IN THE FMC AND DID NOT MONITOR THE ACFT'S PROGRESS.
    Narrative: MISSED ASSIGNED XING RESTR BY APPROX 3000 FT, 'CROSS BLD 16000 FT 25 MI AT 12000 FT.' REASON: ENTERED THE 12000 FT RESTR ON THE FMC AT BLD VERSUS THE BLD 160 DEG/25 MI FIX. FAILED TO XCHK DSCNT/RESTR PROGRESS WITH VOR!

  197.  
  198. Accession Number: 373340
    Synopsis: B737 FLC ENTERS WRONG FIX IN FMC. ATC CAUGHT THE ERROR AND GAVE VECTORS TO CORRECT. THEY LEVELED OFF AT CORRECT ALT.
    Narrative: AIRLINE FLT SLC TO LAS, THE CTR GAVE US A FIX OF LAS 240 DEG RADIAL AT 40 DME, 12000 FT. THE CAPT'S LEG, HE MISTAKENLY PUT LAS 240 DEGS/50 DME IN FMC-FIX PAGE. AS WE APCHED THE IMPROPER FIX THE CTLR QUESTIONED OUR POS AND GAVE US A HEADING TO CORRECT OUR POS. WE DID SO AND LEVELED AT 12000 FT. END OF EVENT. PRIMARY CAUSE FOR ERROR WAS NOT DOUBLE-CHKING INPUTS AND BACKING UP WITH CONFIRMATION FROM OTHER PLT. ALSO FATIGUE A MAJOR FACTOR 3RD LEG OF TRIP 10+ HRS OF DUTY GOING INTO DAY 3 OF 4 DAY TRIP. I THINK THE INDUSTRY, FAA, ACR, SHOULD CONSIDER LOWER DUTY DAY PERIOD REQUIREMENTS AS WE FLY NIGHT PAIRINGS WHEN THE BODY IS ADJUSTING TO IMPROPER REST.

  199.  
  200. Accession Number: 373360
    Synopsis: AN ACR B737 FLC CROSSED AN ASSIGNED XING POINT 1000 FT TOO HIGH. ERROR ADMITTED. NO CONFLICT.
    Narrative: GIVEN 20 MI SE BYI AT FL270 WHILE ON BEARR.BEARR2 ARR. STARTED DSCNT EARLY TO EASILY MAKE RESTR. WHILE DSNDING I WENT OFF TO RETRIEVE ATIS. AFTER RETURN FROM ATIS NOTED WE CROSSED RESTR AT FL280 DSNDING. NO QUERY BY CTR. MY COMMENTARY: THIS RESTR SHOULD BE NOTED ON THE STAR, ESPECIALLY SINCE THIS IS GIVEN EVERY TIME OR SO IT APPEARS. MY FO MENTIONED THAT ALTHOUGH HE ACKNOWLEDGED THE CLRNC HE FIXATED ON THE FMS AND ACTUALLY SHALLOWED THE DSCNT TO MAKE FL270 AT THE NEXT POINT ON THE FMS.

  201.  
  202. Accession Number: 373570
    Synopsis: MLG ACFT ON STAR ARR FAILED TO COMMENCE DSCNT TO MAKE XING RESTR DUE TO INADVERTENT DISENGAGE OF VNAV.
    Narrative: ON A FLT FROM SFO TO LAS, APPROX 50 NM W OF BTY, HEADED DIRECT BTY FOR THE FUZZY 4 ARR. I STEPPED BACK TO THE CABIN FOR PERSONAL NEEDS AND UPON RETURNING I NOTICED THE FO HAD SET FL180 IN THE ALT ALERTER AND HAD TAKEN A COURSE OF DIRECT FUZZY. I WAS TOLD BY THE FO THAT ATC HAD ASSIGNED US DIRECT FUZZY, CROSS FUZZY AT FL180. IN THE MEANTIME, I WAS BUSY WITH PAPERWORK WHEN ASKED US ABOUT OUR ALT. I LOOKED AT THE ELECTRONIC ATTITUDE DIRECTOR INDICATOR AND OBSERVED THAT WE WERE ABOUT 15 NM W OF FUZZY AND STILL LEVEL AT FL270. ATC THEN ASSIGNED A 360 DEG TURN SO THAT WE COULD DSND TO CROSS FUZZY AT FL180. WE COMPLIED WITHOUT ANY FURTHER INCIDENT. DURING MY ABSENCE FROM THE FLT DECK THE VNAV HAD DISENGAGED WHILE THE FO WAS MANEUVERING THE AIRPLANE AND UPON MY RETURN I NEVER NOTICED I WAS RELYING ON THE VNAV TO INITIATE THE DSCNT, WHICH NEVER HAPPENED. THE LESSON HERE, DON'T DEPEND ON THE AUTOFLT SYS TO FLY THE AIRPLANE, BECAUSE, AS IN THIS CASE, IT MAY HAVE DISENGAGED WITHOUT YOU KNOWING.

  203.  
  204. Accession Number: 373610
    Synopsis: WDB ACFT IN DSCNT, ANNUNCIATORS INDICATED NORMAL OPS FOR ALT CAPTURE, BUT DSCNT RATE INCREASED AND BEFORE RPTR CAPT COULD CATCH IT, THE ACFT DSNDED 500 FT BELOW ASSIGNED.
    Narrative: FLT INBOUND TO CVG. WE WERE INBOUND TO CAP VOR AT FL330 WHEN ATC ISSUED A SE HDG FOR TFC. WE WERE THEN CLRED TO A NE HDG TO INTERCEPT THE 087 DEG RADIAL, CAP VOR, CLRED FOR THE MICAN 3 ARR, TO CROSS LEWEY INTXN AT FL240. I PROGRAMMED THE DSCNT ON THE FMS AND INITIATED THE DSCNT. THE DSCNT APPEARED NORMAL. AS THE ACFT APCHED THE ASSIGNED ALT OF FL240, ALL ANNUNCIATIONS INDICATED A NORMAL ALT CAPTURE. DURING THE FINAL SEVERAL HUNDRED FT, THE RATE OF DSCNT INCREASED TO 3000-3500 FPM WITH STILL A NORMAL ALT CAPTURE ANNUNCIATED. AS WE PASSED FL240 IT THEN BECAME OBVIOUS THE ACFT WAS NOT GOING TO LEVEL OFF. I DISCONNECTED THE AUTOPLT APPROX 100 FT BELOW FL240 AND BEGAN TO INITIATE A RECOVERY. WITH THE EXCESSIVE NOSE DOWN TRIM AND RATE OF DSCNT, IT TOOK 500 FT TO REVERSE THE DSCNT. WE RETURNED TO FL240.

  205.  
  206. Accession Number: 373730
    Synopsis: AN ACR A320 FLC EXCEEDS 250 KIAS BELOW 10000 FT WHEN THE FO, ON HIS IOE, SELECTS 'OPEN DSCNT' MODE ON THE AUTOFLT SYS. THE CAPT NOTES THE HIGH SPD AT 9700 FT AND INSTRUCTS THE FO TO SLOW.
    Narrative: WE WERE ON THE PULLMAN FOUR ARR TO ORD BTWN PIVOT AND STOREY, LEVEL AT 12000 FT, 300 KTS (BEST FORWARD SPD). WE WERE SWITCHED TO CHICAGO APCH. APCH CLRED US TO 10000 FT. FO BEGAN DSCNT WITH AUTOPLT ENGAGED. AT APPROX 10500 FT, APCH CTL CLRED US TO 8000 FT, PNF (ME) SET ALT ALERTER TO 8000 FT. FO POINTED TO NEW ALT AND REPEATED '8000' FT. AS ACFT APCHED 10000 FT, FO PUSHED VERT SPD KNOB (PUSH TO LEVEL OFF) ACFT BEGAN TO SLOW, BUT CONTINUED TO DSND BELOW 10000 FT TO APPROX 9700 FT AS SPD SLOWED TO 280- 270-265-260-250 KTS. I DIRECTED FO TO AGGRESSIVELY SLOW AND CLB BACK 10000 FT. HE SLOWED THE ACFT, BUT ONLY GOT BACK UP TO TO 9800 FT BEFORE SPD REACHED 250 KTS. CONTINUED DSCNT FOR ROUTINE APCH AND LNDG. PROB AROSE DUE TO INEXPERIENCED COPLT AND HIS OVER-RELIANCE ON AUTOFLT SYS. WITH INEXPERIENCED COPLT, I SHOULD HAVE BEEN WATCHING/MONITORING MORE CLOSELY. SHOULD HAVE PHYSICALLY TAKEN OVER CTL OF ACFT -- DID NOT, DUE TO IOE. SUPPLEMENTAL INFO FROM ACN 373922: THE CAPT CHANGED THE RWYS, BUT FOR SOME REASON THE MAP STILL SHOWED SOME FIXES ON THE WRONG SIDE OF THE ARPT. AS I WAS TRYING TO DECIPHER WHAT THEY WERE AND WHY THEY WERE THERE, WE WERE TOLD TO DSND TO 7000 FT MSL. STILL MOSTLY PREOCCUPIED WITH THE ND MAP, I PULLED OPENED DSCNT, AND THEN ASKED THE CAPT ABOUT THE ERRONEOUS MAP INDICATIONS WHICH HE WAS ALREADY BEGINNING TO CLR OUT OF FMC. IT WAS THEN THAT WE REALIZED THAT WE HAD DSNDED BELOW 10000 FT MSL ABOVE 300 KIAS. I DISCONNECTED THE AUTOPLT AND LEVELED AT 9800 FT AND SLOWED TO 250 KIAS. I FEEL THAT THE DISTR OF MY PRE- OCCUPATION WITH THE ND MAP COUPLED WITH MY BEING USED TO THE ACFT SLOWING ON ITS OWN IN MANAGED SPD MODE, CAUSED ME TO FORGET THAT WE WERE IN SELECTED SPD MODE AND SUBSEQUENTLY NOT SLOWING THE ACFT BELOW 10000 FT MSL. ALSO A BIG FACTOR WAS FATIGUE. ALTHOUGH IT WAS THE FIRST FLT OF THE DAY, I HAD AWAKEN AT XD45 AM EASTERN WHICH IS REALLY XA45 AM PACIFIC TO MY BODY. IT WAS ALSO DIFFICULT TO FALL ASLEEP THE NIGHT BEFORE AS I AM ACCUSTOMED TO SLEEP AROUND XV30 OR XW00 PM PACIFIC, WHICH WOULD BE XA30 OR XB00 LCL EASTERN TIME, RESULTING IN ONLY A COUPLE OF HRS OF SLEEP.

  207.  
  208. Accession Number: 373750
    Synopsis: AN ACR MLG FLC FAILED TO XCHK THE STORED FLT PLAN IN THE FMC AGAINST THE RTE THAT THEY WERE CLRED TO FLY. AN ALERT ARTCC RADAR CTLR CORRECTED THEIR DEV.
    Narrative: SHORTLY AFTER PASSING LAKEVIEW VORTAC, WE WERE ADVISED BY ZSE TO TURN R 20 DEGS TO INTERCEPT J-189 TO LINDEN VORTAC. WE WERE PROCEEDING LKV DIRECT TO FILMORE VORTAC. WE ESTIMATE BEING 6-7 NM L OF COURSE. THE COMPANY STORED FLT PLAN DID NOT MATCH THE #1 RTE STORED IN FMC, AND WE FAILED TO CHK IT IN TIME. AFTER INITIATING NAV SYS, FO SELECTED THE #1 FMC RTE AND WAITED UNTIL CAPT OBTAINED RELEASE TO 'EXECUTE' RTE. RTE WAS SOMEHOW EXECUTED WITHOUT BEING CHKED. PERHAPS AN ITEM SHOULD BE ADDED TO CHKLIST TO ENSURE RTE IS CHKED.

  209.  
  210. Accession Number: 374080
    Synopsis: A COMMERCIAL FIXED WING LGT ON CLBOUT WAS DIRECTED BY ATC TO THE CORRECT DEP OUTBOUND HDG DUE TO THE FMS BEING LOADED INCORRECTLY.
    Narrative: ATC RADIOED AN INQUIRY ON OUR INTERCEPTING THE DEP OUTBOUND. THE FMS HAD BEEN LOADED WITH THE INCORRECT OUTBOUND COURSE AND THE PF WAS FOLLOWING THAT INFO. ATC VECTORED US BACK TO COURSE AND RAW DATA WAS USED INSTEAD OF FMS DATA.

  211.  
  212. Accession Number: 374570
    Synopsis: FLC OF AN MLG UNDERSHOT XING ALT RESTR DURING DSCNT ON A STAR ARR DUE TO IMPROPER PROGRAMMING OF FMC FOR THE RATE OF DSCNT NEEDED FOR XING ALT RESTR.
    Narrative: WE WERE CLRED TO CROSS ARGAL AT 10000 FT BY ZDC. FMS WAS IN PROFILE AND WAS PROGRAMMED TO CROSS ARGAL AT 250 KTS AND 10000 FT. 10000 FT WAS SELECTED AND ARMED IN ALT WINDOW. IMMEDIATE DSCNT SELECTED IN FMS. WE EVENTUALLY LEVELED AT 10000 FT APPROX 5 NM PAST ARGAL.

  213.  
  214. Accession Number: 374700
    Synopsis: FLC OF MDT NEGLECTS TO UPDATE FMS FLT PLAN RESULTING IN HDG DEV TO WRONG VOR. RADAR CTLR CAUGHT THE ERROR.
    Narrative: DURING PREPARATIONS FOR A FLT FROM CVG TO SYR, THE FMS WAS INITIALIZED AND THE COMPANY-STORED FLT PLAN WAS PULLED UP AND WAS CHKED AGAINST OUR FLT RELEASE ROUTING AND ATC CLRNC. WE BOTH LOOKED AT THE RTES, BELIEVED THEY MATCHED AND ACTIVATED/EXECUTED THE FMS FLT PLAN. I WAS THE PNF. DURING CRUISE CLB, PASSING APPROX FL230 AND APPROX 10 NM N OF THE FFO VOR, THE ZID CTLR ASKED IF WE 'WERE NAVING TO ROD.' I RESPONDED 'AFFIRMATIVE.' THE CTLR REPLIED, 'NEGATIVE, NEGATIVE, TURN R TO 060 DEGS.' WE COMPLIED AND CONTINUED CLBING WHILE RECHKING OUR ROUTING. ROD WAS NOT ON IT. THE RTE READ IN PART: FFO DIRECT DJB. THE FMS WAS PROGRAMMED TO FLY FFO DIRECT ROD DIRECT DJB. IN RETROSPECT, WE DID REMEMBER NOTING THE DIFFERENCE ON THE GND BUT, PROBABLY DUE TO TYPICAL INTERRUPTIONS, NEITHER OF US DELETED THE UNWANTED FIX. WE DID NOT OBSERVE ANY CONFLICTING TFC NOR DID ATC ISSUE ANY. OUR TCASII DISPLAY DID NOT SHOW POTENTIAL CONFLICTING TFC WITHIN 40 NM (THE LONGEST RANGE THAT CAN BE DISPLAYED). OUR CLB WAS NOT STOPPED. AFTER A SHORT WHILE THE CTLR ASKED FOR OUR ATC RTE CLRNC. I COMPLIED AND READ IT TO HIM. HE THEN GAVE US A SHORT LECTURE ON BEING SURE TO CHK ISSUED CLRNCS MORE CAREFULLY AND THAT THE CTR HAD HAD SEVERAL PREVIOUS INSTANCES OF COMPANY ACFT DEVIATING FROM ATC ROUTING IN THE SAME AREA. HE STATED HE KNEW WE HAD BEEN BRIEFED BY OUR COMPANY ON THIS PROB BECAUSE OF CONTACTS WITH OUR CHIEF PLT. I REPLIED THAT WE HAD INDEED BEEN BRIEFED BUT THAT SOMEHOW THE ERROR SLIPPED THROUGH. HE THEN CLRED US DIRECT TO DJB AND ON COURSE AND HANDED US OFF. ALL COMS WERE CALM AND CORDIAL. I BELIEVE SEVERAL INTERRUPTIONS WITH GND SVCING TASKS DURING THE FMS SETUP CONTRIBUTED TO THE PROGRAMMING OVERSIGHT. THIS IS THE FIRST TIME IN MY 2 YRS OF FMS OP THAT I HAVE HAD A PROB WITH A NAV EXCURSION OF THIS KIND. OTHER THAN MORE VIGILANCE BY CREWS, THE ONLY WAY THIS PROB MIGHT BE AVOIDED IN THE FUTURE IS TO HAVE COMPANY MORE VIGOROUSLY UPDATE 'PROB' FMS FLT PLANS, ESPECIALLY WHEN THE DATABASE DOES NOT MATCH SCHEDULED BUT DIFFERENT ROUTINGS OVER EXTENDED PERIODS OF TIME.

  215.  
  216. Accession Number: 375010
    Synopsis: AN ACR FLC IN AN MLG ENTERED THE NEXT WAYPOINT INTO THE FMC INCORRECTLY AND DID NOT VERIFY THE ENTRY. LATER, A CTLR QUESTIONED THEIR RTE OF FLT AND THEY THEN NOTED THE ERROR.
    Narrative: COPLT WAS FLYING. WE WERE CLRED DIRECT LFK. I READ BACK THEN ENTERED IN FMC. 1 OF 2 THINGS THEN HAPPENED, 1) I SELECTED WRONG FIX, OR 2) FMC UPDATED JUST PRIOR TO MY SELECTING LFK CAUSING MOTLY INTXN TO JUMP TO THE LINE I SELECTED. FAILURE BY EITHER MYSELF OR THE COPLT TO VERIFY WHERE WE WERE GOING RESULTED IN ANOTHER CALL FROM A DIFFERENT CTLR THAT WE WERE CLRED DIRECT LUFKIN. COPLT AND I THEN SAW WE WERE HEADED DIRECT TO MOTLY INTXN. WE ENTERED DIRECT LUFKIN INTO FMC AND PROCEEDED ON COURSE. THERE WAS NEVER ANY TFC CONFLICT. COMPLACENCY, HOW OFTEN DO WE HAVE TO HEAR ABOUT IT? THIS KIND OF FAILURE TO VERIFY NAV POS IN MOUNTAINOUS TERRAIN COULD BE FATAL. I'VE LEARNED MY LESSON. SET IT, VERIFY IT AND VERIFY IT AGAIN AND QUESTION IT IF IT DOESN'T MAKE SENSE.

  217.  
  218. Accession Number: 375098
    Synopsis: B757 FLC WAS DISTRACTED AFTER TKOF BY AUTOTHROTTLE PROB AND WHEN ENGAGING LNAV THE ACFT TURNED, NOT IN ACCORDANCE WITH THE DEP PROC. DEP CTLR QUESTIONED THEIR TURN.
    Narrative: ON TKOF ROLL CAPT COULD NOT GET AUTOTHROTTLES ENGAGED (RWY 24L LAX). DECISION TO GO AND SOLVE PROB IN THE AIR. ONCE AIRBORNE AND GEAR UP FLAP RETRACTION ON SCHEDULE, CAPT TRIED MANY DIFFERENT THINGS TO SOLVE PROB, IE: RECYCLING FMC, DIRECT VNAV/LNAV, AND FLT DIRECTORS. I WAS FLYING THE AIRPLANE. THE CAPT AND I THOUGHT IT WAS A TMC PROB (THRUST MODE CTL). I COMMUNICATED TO HIM I HAD A LIST OF CIRCUIT BREAKERS FOR THAT HIGHLIGHTED IN MY BOOK. I THEN NOTICED THAT DURING HIS TRYING DIFFERENT THINGS HE LEFT THE FLT DIRECTORS OFF. I ASKED HIM TO TURN THE FLT DIRECTORS ON AND ENGAGE VNAV/LNAV. AS I WATCHED HIM DO THIS, I NOTICED THE AUTOTHROTTLES SWITCH WAS OFF. AS THE LNAV ENGAGED AND COMMENCED A L TURN I FOLLOWED THE FLT DIRECTOR AND POINTED OUT THE SWITCH TO THE CAPT. HE TURNED ON THE SWITCH AND SOLVED OUR PROB. AT WHICH TIME ATC CALLED AND ASKED WHY WE WERE TURNING OFF. THE SID (LAXX2) RWY 24L CALLS FOR A 250 DEG HDG FOR VECTORS. BY ENGAGING LNAV THE FLT DIRECTORS COMMANDED US TO FLY THE SID. FORTUNATELY THERE WERE NO OTHER ACFT IN THE AREA. THE CAPT MISSED PART OF HIS PREFLT FLOW, THERE WAS NO CHKLIST ITEM TO BACK IT UP. I ALLOWED MYSELF TO BE DISTR FROM MY DUTY OF FLYING THE AIRPLANE AND GET INVOLVED IN THE PROB SOLVING. ANOTHER KEY LESSON HERE IS TO NOT LET THE TECHNOLOGY RUN YOU AS A PLT. THE PLT HAS TO RUN/MANAGE THE TECHNOLOGY.

  219.  
  220. Accession Number: 375110
    Synopsis: A B757 FLYING IN ZJX AIRSPACE, LOSES THE NAV GND TRACK FROM THE FMC AND BEGINS TO WANDER OFF THE FLT PLAN COURSE.
    Narrative: FMC LOADED AND VERIFIED RTE BY BOTH CAPT AND FO. AFTER PASSING CHS, FMC APPARENTLY DELETED J79, UNCOMMANDED, AND ACFT PROCEEDED DIRECT TOWARD OMN, WHICH WOULD PENETRATE A WARNING AREA. AFTER PASSING CHS (WITHIN 10 MI), CTR CTLR NOTICED ACFT RTE DEV AND VECTORED FLT BACK ONTO J79. CAPT AND FO AT A LOSS TO EXPLAIN WHY FMC DROPPED J79 (FROM CHS TO OMN) FROM DATABASE.

  221.  
  222. Accession Number: 375574
    Synopsis: MLG ACFT ON STAR WITH XING RESTR WAS RECLRED DIRECT TO ANOTHER FIX. NEXT CTLR CLRNC REVERTED BACK TO THE ORIGINAL CLRNC, BUT FLC HAD ALREADY SET IN THE NEW FIX ON THE FMC, SO CTLR CLRED THEM TO A POINT CLOSE TO THE ORIGINAL XING FIX. FLC ERRONEOUSLY SET IN WRONG ALT.
    Narrative: ON THE SINCA 3 ARR INTO ATL WE HAD PROGRAMMED THE FMC TO CROSS CANUK AT 250 KTS AND 12000 FT. WE WERE SUBSEQUENTLY CLRED DIRECT TO HUSKY INTXN WITH NO ALT OR AIRSPD RESTR. THE NEXT CTLR TOLD US TO CROSS CANUK AT 250 KTS AND 12000 FT. WE TOLD HER WE WERE DIRECT TO HUSKY, SO SHE THEN RECLRED US TO CROSS 40 MI SE OF ATL AT 12000 FT AND 250 KTS. WE PROGRAMMED THE FMC TO CROSS 11 MI SE OF HUSKY (45 MI SE OF ATL) AT 250 KTS AND 11000 FT. WE SET OUR MCP TO 11000 FT. I BELIEVE WE READ BACK 11000 FT BUT I AM NOT SURE. THE CTLR CAUGHT OUR DSCNT THROUGH 12000 FT AND WE CLBED IMMEDIATELY BACK TO 12000 FT. END OF EVENT. I FEEL IT WAS NOT NECESSARY TO AMEND THE ORIGINAL SINCA ARR IN THE FIRST PLACE (ATC COM GAP BTWN CTLRS). HOWEVER, OUR INATTN TO THE ALT WAS CAUSED BY: 1) FAILURE TO MONITOR THE ACFT BY FOCUSING ENTIRELY ON THE FMC, 2) NOT DOUBLECHKING THE PUBLISHED ARR PLATE FOR CONTINUITY, AND 3) AUTOMATIC AIRPLANE COMPLACENCY.

  223.  
  224. Accession Number: 376660
    Synopsis: S80 FLC FAILS TO NOTE THAT THEIR FMC IS NOT GOING TO MAKE THE ALT XING RESTR PAST RMG DURING A NIGHT OP. FLC WAS BUSY, CAPT ON PA AND FO WORKING ON THE MEL FOR A LNDG LIGHT THAT HAD NOT RETRACTED AND HAS A CONCERN REGARDING ADDITIONAL FUEL BURN. CTLR CALLS FLT.
    Narrative: FREQ 132.05, FL330. ATC FACILITY: ATL. LOCATION: RMG. ZTL GAVE US A DSCNT TO CROSS ERLIN AT 13000 FT, 250 KTS. WE STARTED DOWN FROM FL290, ALT SET IN WINDOW AND IN FMC. XING ALT AND SPD SET IN FMC. CAPT FLYING. I, FO, WAS PNF AND WAS WORKING ON THE FMR CODES FOR A LNDG LIGHT THAT WOULD NOT RETRACT. I ASKED THE CAPT FOR MEL TO SEE ABOUT RESTRS AND EXTRA FUEL BECAUSE WE HAD USED 800 LBS MORE. JUST AFTER LOOKING AT MEL, ATC ASKED IF WE WERE GOING TO MAKE THE RESTR. WE HAD 9 MI TO GO AND 9000 FT. WE TOLD THEM WE COULD NOT MAKE THE XING AND REQUESTED A TURN. A SERIES OF 120 DEG TURNS LATER WE WERE BACK ON THE ARR AT THE PROPER SPD. I HAVE NO IDEA WHY THE FMC DID NOT MEET THE ALT RESTR. WE SHOULD HAVE MADE THE ALT RESTR BY A NUMBER OF MI. SUPPLEMENTAL INFO FROM ACN 376659: IN PROFILE MODE AND INSERTED RESTR IN FMS AND BEGAN AN IMMEDIATE DSCNT. CHANGED RATE OF DSCNT TO 1500 FPM AND LEVEL BUG SHOWED LEVELOFF SHORT OF ROME. ADJUSTED RATE TO 1200 FPM AND LEVELOFF BUG MOVED BTWN ROME AND ERLIN. PF TURNED ATTN TO ARR PA AND 9 MI SHORT OF ERLIN, CTR ASKED IF WE WOULD MAKE THE XING. COMPLETED A 360 DEG TURN AND REJOINED THE ARR. I FAILED TO MANUALLY COMPUTE ALT VERSUS DISTANCE AND RELIED ON THE FMS TO CORRECTLY PLACE THE LEVELOFF BUG AND IN PROFILE TO TAKE OVER THE DSCNT IF PARAMETERS WERE EXCEEDED.

  225.  
  226. Accession Number: 376720
    Synopsis: EMB120 FLC OVERSHOT THEIR ALT DURING DSCNT. CREW WAS BUSY AND FAILED TO PAY ATTN TO THEIR DSCNT PROFILE. ACFT WAS BEING OPERATED WITHOUT THEIR TCASII SYS. OTHER ACFT NOTED THEIR PRESENCE, APPARENTLY WITH THEIR TCASII.
    Narrative: THE WX AT TLH REGIONAL ARPT WAS IFR WITH A 500 FT OVCST AND THE TOPS WERE ABOUT 2000 FT. THE WX ON TOP WAS VMC WITH GOOD VISIBILITY. AT APPROX AX25 WE WERE LEVEL AT 9000 FT AND CLRED DOWN TO 7000 FT AND WERE ALSO ASSIGNED A HDG. THE CAPT, WHO WAS THE PF, STARTED THE DSCNT AND ASKED FOR THE IN-RANGE CHKLIST AND THE INST APCH CHKLIST. I, THE FO AND PNF, PERFORMED THE IN-RANGE CHKLIST. I THEN BEGAN THE INST APCH CHKLIST BY FIRST BRIEFING THE ILS TO RWY 27 AND THEN I BEGAN PERFORMING THE OTHER CHKS INCLUDED, WHEN I HAD A QUESTION CONCERNING THE CHKING OF THE RADAR ALTIMETERS. THE CAPT EXPLAINED TO ME THE ANSWER TO MY QUESTION AND AT THE SAME TIME WE BOTH LOOKED UP AND REALIZED WE WERE AT 6500 FT AND DSNDING. THE CAPT IMMEDIATELY ARRESTED THE SINK RATE AND BEGAN A CLB AT 6450 FT. AT ABOUT THE SAME TIME THE ACFT OFF OUR R WING AND SLIGHTLY AHEAD QUERIED THE CTLR ABOUT OUR ALT. THE CTLR THEN GAVE US OUR ORIGINAL ALT OF 7000 FT AGAIN AND GAVE US A HDG OF 10 DEGS TO THE L. THE REST OF THE FLT AND APCH WAS UNEVENTFUL. AT THE TIME THE CTLR GAVE US 10 DEG TURN TO THE L WE WERE AT 6700 FT AND CLBING. SOME OF WHAT I BELIEVE TO BE THE CONTRIBUTING FACTORS ARE: 1) FOR SOME REASON THE ALT ALARM DID NOT GO OFF. 2) I AS THE FO HAD A QUESTION ABOUT AN ITEM ON THE CHKLIST THAT I SHOULD HAVE KNOWN. 3) THE CAPT (PF) AND MYSELF (PNF) WERE PREOCCUPIED AND NOT FLYING AND MONITORING THE AIRPLANE PROPERLY. 4) THE TCASII WAS INOP. 5) I BELIEVE THAT ALSO, ON A SMALL SCALE, WE WERE A LITTLE TIRED, WE WERE IN THE LAST 20 MINS OF A 12 HR DUTY DAY, ON THE LAST DAY OF A 4- DAY SCHEDULE.

  227.  
  228. Accession Number: 376921
    Synopsis: MD80S ACFT BEING VECTORED FOR RWY 1 AND CLRNC FOR DSCNT TO 3000 FT. APCH CTLR TELLS FLC TO LEVEL AT 5000 FT BECAUSE THEY WERE CHANGING RWYS. AUTOPLT FAILED TO CAPTURE ALT AND ACFT DSNDED 200 FT BELOW BEFORE CAPT RPTR DISCONNECTED AUTOPLT AND REGAINED THE ALT.
    Narrative: DSNDING INTO MSY WE WERE BEING VECTORED FOR RWY 1 AND GIVEN DSCNT TO 3000 FT. APCH SAID THEY WERE CHANGING RWYS AND NOW TO STOP AT 5000 FT AND WE WERE GOING TO RWY 10. APCH GAVE THIS CLRNC. PASSING ABOUT 5500 FT THE AUTOPLT DID NOT CAPTURE AT 5000 FT AND AUTOPLT WAS DISCONNECTED. DURING THE DISCONNECT, WE BOTTOMED OUT AT 4800 FT BEFORE WE COULD RETURN TO 5000 FT. APCH AND LNDG WERE NORMAL.

  229.  
  230. Accession Number: 377247
    Synopsis: THE ACR FLC OF A B737 INCREASES THEIR AIRSPD AND CHANGES THE ASSIGNED ALT TO A LOWER ONE IN COMPLIANCE WITH A CTLR'S CLRNC. THE ACFT STARTED A SLOW CLB AS IT ACCELERATED, EVEN THOUGH THE 'ALT HOLD' MODE WAS, APPARENTLY, STILL ENGAGED.
    Narrative: LEVEL CRUISE FLT, ASKED BY ATC TO ACCELERATE TO 300 KTS AND GIVEN PLT'S DISCRETION TO FL280. ACFT WAS ENGAGED IN VNAV AND LNAV MODE WITH FL280 SET IN THE ALT SELECTOR AND 300 KTS IN THE SPD SELECTOR. AS THE ACFT WAS ACCELERATING FROM .74 MACH TO 300 KTS IT STARTED A 600 FPM CLB, BUT WAS NOT NOTICED, SINCE THE ALT ALERT DID NOT SOUND UNTIL FL359 HAD BEEN REACHED. ACFT WAS RETURNED IMMEDIATELY TO FL350 AND SOON THEREAFTER DSNDED TO FL280. WHEN ANY CHANGE IS MADE IN SPD OR ALT BE ESPECIALLY ALERT THAT VNAV DOES NOT DISENGAGE. ALTHOUGH IN THIS OCCURRENCE MAINT WAS NOTIFIED BECAUSE IT DID REMAIN ENGAGED. SUPPLEMENTAL INFO FROM ACN 377680: IN CRUISE AT FL350 AUTOFLT, BOTH VNAV AND LNAV, ENGAGED, GIVEN PLT'S DISCRETION TO FL240. 24000 FT SET IN MODE SELECTOR PANEL ALT WINDOW, MANY MI PRIOR TO TOP OF DSCNT. ACFT WAS IN STEADY STATE CRUISE AT FL350 WITH 'ALT HOLD' DISPLAYED.

  231.  
  232. Accession Number: 377570
    Synopsis: FLC OF A B737-300 FAILED TO MAKE A XING ALT DURING DSCNT DUE TO NOT NOTICING THAT THE MODE CTL EXECUTE FUNCTION HAD NOT ACTIVATED AND THE CAPT, FLYING, HAD NOT RECHKED TO ASSURE THAT IT WAS PERFORMING AS DIRECTED.
    Narrative: ATC HAD US KEEP SPD AT 310 KTS OR GREATER. AT 17000 FT THEY GAVE US 'CROSS LRP AT 11000 FT.' I SET 11000 FT IN MODE CTL PANEL AND FMC UNIT. I PUSHED EXECUTE BUTTON BUT NEVER NOTICED IT DIDN'T EXECUTE PROPERLY. ABOUT 5 MI FROM LRP I NOTICED WE WERE STILL DSNDING THROUGH 15000 FT. I WENT MANUAL AND MAX DSCNT AND WAS AT 12500 FT AS WE CROSSED LRP AND DSNDING AT ABOUT 4000 FPM DUE TO THE HIGH SPD. SOLUTION WOULD HAVE BEEN TO DOUBLE-CHK THE FMC TO BE SURE IT EXECUTED. WE WERE IN VISUAL CONDITIONS SO OUR HEADS WERE OUTSIDE THE COCKPIT INSTEAD OF INSIDE. FROM NOW ON I'LL DOUBLE-CHK.

  233.  
  234. Accession Number: 378000
    Synopsis: ACR LGT PERFORMS AN AUTO ALT EXCURSION WHILE ON AUTOPLT AND PERFORMANCE MGMNT SYS ENGAGED. FLC RECOVERS IN SHORT ORDER AND SYMPTOM FAILS TO APPEAR FOR REST OF FLT.
    Narrative: THE FO LEVELED OFF THE ACFT AT 17000 FT MSL WITH AUTOPLT AND PMS ENGAGED. SHORTLY AFTER, THE ACFT BEGAN AN UNCOMMANDED DSCNT. THE FO DISCONNECTED THE AUTOPLT AND ARRESTED THE ALT AT 16600 FT MSL, THEN RETURNED TO OUR ASSIGNED 17000 FT MSL. I FEEL A RECURRENCE WILL BE PREVENTED BY MAINTAINING A MORE VIGILANT WATCH ON THE GAUGES AND BY INVESTING LESS TRUST IN THE AUTOMATION. SUPPLEMENTAL INFO FROM ACN 377918: NO EXPLANATION COULD BE FOUND FOR THE UNCOMMANDED DSCNT, THE SYS PERFORMED NORMALLY FOR REMAINDER OF FLT.

  235.  
  236. Accession Number: 378019
    Synopsis: FO OF AN AIRBUS A320, OVERSHOT THE SID DEP XING ALT DUE TO SETTING THE FMC MODE SELECTOR IN ERROR.
    Narrative: COPLT WAS PF ON LOUPE 9 DEP SID TO CROSS SJC VOR AT 12000 FT WITH ALT CLRNC TO FL230. COPLT WAS USING AUTOPLT AND MANAGED CLB ON FMS MODE WITH THE PRE-PROGRAMMED RESTR OF 12000 FT AT SJC VOR. THE ACFT HOWEVER CONTINUED TO CLB HIGHER THAN 12000 FT JUST PRIOR TO SJC VOR AND COPLT STOPPED CLB BY TURNING OFF AUTOPLT AND HAND-FLYING THE ACFT BACK TO 12000 FT. MAX ALT REACHED ON CAPT ALTIMETER WAS 12400 FT. SAME ON FO ALTIMETER. ATC CTLR NOTICED THE ALTDEV AND CLRED US TO 14000 FT. WE INITIATED CLB TO 14000 FT BUT HAD ALREADY RETURNED TO 12000 FT WHEN CLB WAS INITIATED. CAPT (MYSELF) WAS DISTRACTED SLIGHTLY FROM MONITORING INSTS BY CLB CHKLIST AND FREQ CHANGE. ON ANALYSIS AND DISCUSSION WITH COPLT AS TO WHY ACFT AUTOPLT DID NOT LEVELOFF AT 12000 FT WE CONCLUDED THAT WHEN COPLT SET IN AN ALT CHANGE ON FMP FROM 12000 FT TO FL230 HE INADVERTENTLY SELECTED OPEN CLB BY PULLING THE ALT CHANGE BUTTON INSTEAD OF JUST SELECTING THE NEW ALT IN THE WINDOW. THIS WOULD HAVE DEACTIVATED THE ALT CONSTRAINT. UNFORTUNATELY NEITHER PLT CAUGHT THE MISTAKE DUE TO THE MANY TASKS THAT WE WERE ACCOMPLISHING IN A SHORT TIME FRAME.

  237.  
  238. Accession Number: 378070
    Synopsis: AN ACR FLC ON AN L1011 STARTS THEIR DSCNT EARLY AT CIVET WHEN THEY REF THEIR FMS ONLY, WITHOUT USING AVAILABLE VOR AND DME RAW DATA. FLC STATES THAT THEY FOLLOWED COMPANY PROC AND THEY THEN COMPLAIN ABOUT AGING ACFT.
    Narrative: AFTER REACHING CIVET ON THE FMS AND FRM (FROM) CIVET WAS DISPLAYED, WE BEGAN OUR DSCNT TO CROSS THE NEXT FIX, BREMR, AT 12000 FT. AFTER CIVET WE ALSO SWITCHED FROM FMS NAV TO VOR/DME NAV UTILIZING THE LAX ILS/DME TO RWY 25L, PER PLT'S APCH CHKLIST WHICH DICTATES THAT RADIO/NAV SWITCHES BE PLACED IN THE RADIO POS. AS THE LAX ILS/DME FREQ WAS BEING TUNED AND IDENTED, ATC INFORMED US THAT THEIR RADAR SHOWED THAT WE WERE NOT YET AT CIVET AND HAD BEGUN OUR DSCNT PRIOR TO CIVET. AFTER CONFIRMING OUR POS WITH ATC, WE DETERMINED THAT THE FMS WAS IN ERROR AT CIVET BY APPROX 4 MI. WE CONFIRMED THAT THE LATITUDE AND LONGITUDE IN THE DATABASE WERE CORRECT FOR CIVET AND WE MADE A MAINT LOGBOOK ENTRY TO THIS EFFECT AFTER ARRIVING LAX FOR MAINT TROUBLESHOOTING OF THIS FMS PROB. ALSO, ALL 3 CREW MEMBERS VERIFIED THAT WE HAD INDEED PASSED CIVET ON THE FMS DISPLAY AND WERE NOW ENRTE TO BREMR. WE RECEIVED NO TCASII ALERTS AND WERE IN VMC. THE BAL OF THE ARR, APCH, AND LNDG ON RWY 25L WERE NORMAL. THE PROB: AS THE L1011 AGES, MORE PROBS LIKE THIS WILL APPEAR AND SPECIAL ATTN MUST BE GIVEN TO NOT ONLY THE NAV SYS BUT TO ALL THE MAINT CONCERNS OF AN OLDER ACFT.

  239.  
  240. Accession Number: 378188
    Synopsis: AN ACR B767 FLC SELECTED A DIRECT RTE TO SLT, BUT DID NOT SELECT 'LNAV' MODE IN THE AUTOFLT SYS. THE ALERT ARTCC CTLR QUESTIONED THEIR FLT PATH.
    Narrative: AFTER BEING ON A VECTOR FOR TFC FROM ZME FOR APPROX 10 MINS, WE WERE CLRED DIRECT TO SLT VOR APPROX 350 MI AWAY. WE ENTERED SLT IN THE DIRECT LEGS PAGE AND EXECUTED. AFTER 1 MIN ATC ASKED IF WE WERE PROCEEDING DIRECT TO SLT AND WE CHKED AND NOTICED WE HAD FAILED TO SELECT LNAV AND WERE STILL ON OUR OLD HEADING. WE LEARNED TO PAY MORE ATTN.

  241.  
  242. Accession Number: 378580
    Synopsis: MD88 FLC FAILS TO MAKE A XING RESTR EVEN THOUGH THEY WERE MONITORING THEIR DSCNT PROFILE AS SET UP BY THE FMS. TOO LATE THEY REALIZED THAT THEY WERE TOO HIGH TO MAKE IT. CTLR THEN ASKED FOR AN EXPEDITED DSCNT.
    Narrative: ENRTE FROM ATL TO DAY, ATC CLRNC WAS TO DSND OUT OF CRUISE (FL350) TO FL330 WITH PLT'S DISCRETION TO CROSS 20 NM S OF FLM VORTAC AT FL180. THE FMS COMPUTER WAS PROGRAMMED AND VNAV SELECTED. INITIALLY, FMS SHOWED US WELL BELOW GLIDE PATH AND FO MANUALLY VERIFIED THAT WE WERE. FO CONTINUED THROUGH FL330 AND WE WERE WELL BELOW GLIDE PATH AND MANUALLY DERIVED GLIDE PATH. FURTHER INTO DSCNT, THE FO AND I GOT DISTR WITH ATIS AND IN-RANGE RPT TO COMPANY. FO KEPT EYE ON VNAV GLIDE PATH WHICH STILL INDICATED WE WERE LOW FOR XING RESTR. ONCE AGAIN, FO MANUALLY CHKED DSCNT PROGRESS AND HE/WE REALIZED WE WERE ACTUALLY WAY HIGHER -- ALMOST 6000 FT ABOVE FL180 WITH ONLY 10.5 NM TO GET DOWN! FO DID HIS BEST TO SMOOTHLY GET ACFT DOWN BUT WE ACTUALLY CROSSED THE FIX ABOUT 1000 FT HIGH. NO TFC CONFLICTS WERE NOTED (ATC DID ASK US TO EXPEDITE OUR DSCNT JUST AFTER ERROR WAS NOTED). SUBSEQUENT EXAMINATION REVEALED THE FMS HAD BEEN PROGRAMMED CORRECTLY, BUT HAD MALFUNCTIONED ON GLIDE PATH COMPUTATIONS. MORAL TO STORY: PLTS MUST NEVER TOTALLY RELY ON AUTOMATION.

  243.  
  244. Accession Number: 378600
    Synopsis: NEW RTE CLRNC RECEIVED FROM ZJX. AS BOTH PLTS ARE DISTR WITH OMEGA INPUT THE AUTOPLT DISCONNECTS. FLC MADE AWARE OF ALTDEV WHEN ALT ALERT GOES OFF. NOTHING SAID BY ATC AS CREW GETS BACK TO ASSIGNED ALT.
    Narrative: FO FLYING. WE WERE GIVEN NEW CLRNC. BOTH OF US WERE WORKING ON THE OMEGA TO PUT IN NEW FIX. ALL OF A SUDDEN, ALT ALERT GOES OFF. WE HAD DSNDED TO FL235 BEFORE WE CORRECTED BACK TO FL240. ATC NEVER MENTIONED OUR DEV. SUPPLEMENTAL INFO FROM ACN 378509: AUTOPLT DISENGAGED FOR UNKNOWN REASON.

  245.  
  246. Accession Number: 378826
    Synopsis: B757-200 ENTERS THE HOLDING PATTERN AT ARNES INTXN WITH A R TURN AS PER THE FMC DATABASE AS SELECTED BY THE FLC. THE 'PUBLISHED' PATTERN CALLS FOR A L TURN ENTRY. APCH CTLR CATCHES THEIR ERROR AND GIVES THEM A NEW HDG FOR THE L PATTERN. RPTRS CITE COMPANY POLICY OF ENTERING STANDARD R-HAND TURNS FOR ARR WAYPOINTS IN THE DATABASE, EVEN IF NOT CORRECT.
    Narrative: CLRED FOR CIVET 1 ARR AND IN CONTACT WITH SOCAL/LAX APCH FLT WAS 2 MI E OF ARNES AT 12000 FT ASSIGNED BY ATC. CTLR TOLD FLT TO HOLD AT ARNES AS PUBLISHED AS EMER WAS IN PROGRESS AT LAX AND MAINTAIN 12000 FT UNTIL EAC OF AM48Z. FO PROGRAMMED FMC'S FOR ARNES HOLDING BY LINE SELECTING THE ARNES WAYPOINT TO THE SCRATCHPAD AND LNDG IT IN THE HOLD PAGE. THE HOLDING PATTERN DEPICTED ON THE CRT SHOWED A STANDARD HOLDING PATTERN AND BECAUSE OF THE SHORT DISTANCE TO THE FIX, THE ACFT ENTERED THE HOLDING PATTERN WHILE BEING SLOWED TO HOLDING SPD OF 210 KTS. AS THE R- HAND TURN WAS COMMENCED, BOTH PLTS NOTICED AND COMMENTED ON THE FACT THAT THE PUBLISHED HOLDING PATTERN SHOWED L- HAND TURNS AND AS COMS WITH APCH CTL WERE ABOUT TO ADDRESS THE WRONG TURN, THE CTLR TOLD THE FLT THAT THE HOLDING PATTERN WAS L TURNS AND GAVE US AN IMMEDIATE TURN FOR A VECTOR BACK TO THE HOLDING FIX (ARNES) TO RE-ENTER THE PATTERN WITHOUT COMMENT. SINCE ALL MISSED APCH HOLDING PATTERNS IN THE FMC DATABASE SHOW THE CORRECT PATTERN TURN WHEN THE ARNES WAYPOINT WAS SELECTED ON THE HOLD PAGE, AND DUE TO THE CLOSENESS OF THE FIX WHEN THE CLRNC WAS RECEIVED, THE CREW PRESUPPOSED THAT THE DEPICTED PATTERN TURNS WERE CORRECT AND THE FMS EXECUTED SAME UNTIL THE HOLDING PATTERN WAS XCHKED WITH THE PUBLISHED ARR PAGE. APPARENTLY, THE HOLDING PATTERNS FOR ARR WAYPOINTS ARE NOT STORED IN THE DATABASE AS PUBLISHED BUT AS STANDARD PATTERNS, THUS MAKING CONFIRMATION WITH THE COMMERCIAL CHART'S PUBLISHED ARR MANDATORY. THIS IS CONTRARY TO THE PUBLISHED MISSED APCH HOLDING PATTERNS DEPICTED IN THE DATABASE WHICH SHOW THE PROPER TURN FOR THE DEPICTED PATTERN. ONE CANNOT ASSUME THAT ALL WAYPOINTS IN THE FMC DATABASE WITH AN ASSOCIATED HOLDING PATTERN WILL SHOW THE CORRECT PATTERN TURNS AND THEREFORE MUST BE VERIFIED. SUPPLEMENTAL INFO FROM ACN 378491: I WENT TO THE HOLD PAGE AND PROCEEDED TO PAGE 2. I ENTERED OUR HOLD INSTRUCTIONS AND EXECUTED. BECAUSE WE WERE ALREADY AT ARNES, I DID NOT HAVE TIME TO LOOK AT THE APCH SHEET IN THE CLIP ON THE WINDOW. BECAUSE SO MANY OF OUR HOLDING PROCS ARE DEPICTED CORRECTLY, I ASSUMED THE STANDARD PROC OF R TURNS WAS CORRECT.

  247.  
  248. Accession Number: 378860
    Synopsis: FLC ON AN ACR MLG FAIL TO MAKE A REQUIRED ALT XING RESTR. PIC WAS DISTR WITH EQUIP PROB AND THE FO FAILED TO OPERATE THE FMS IN A SATISFACTORY MANNER. RPTR CITES HIS OWN COMPLACENCY.
    Narrative: SCHEDULED FLT FROM RDU TO BDL. WHILE ON J191 AT FL290 WE WERE CLRED TO CROSS 30 MI S OF RBV AT A LOWER FLT LEVEL. (XING POINT AND ALT ARE ESTIMATES.) EXPERIENCED FO WAS FLYING. HE APPEARED TO PROGRAM THE RESTR INTO THE FMS. I WAS ATTENDING TO A POSSIBLE CABIN AUTO TEMP CTL PROB WHILE THE FO FLEW THE ACFT. ATC THEN ASKED IF WE WOULD MAKE THE RESTR. I THEN REALIZED THE FO AND FMS HAD NOT INITIATED THE DSCNT AND MAKING THE RESTR WOULD BE DIFFICULT BUT NOT IMPOSSIBLE AND REPLIED THAT WE COULD MAKE THE RESTR. FO DID NOT EXPEDITE THE DSCNT AND CONSEQUENTLY MAKING THE RESTR WAS NO LONGER POSSIBLE AND I SO ADVISED ATC, ADDING THAT WE WOULD BE CLOSE. ATC DID NOT INDICATE THIS WOULD BE A PROB AND WE MISSED THE RESTR BY A FEW MI. I SHOULD HAVE CONFIRMED THE FMS PROGRAMMING FOR THE RESTR AND MONITORED THE PROGRESS OF THE FLT MORE CLOSELY. I WAS TOO COMPLACENT BECAUSE THE FO WAS EXPERIENCED AND WE INITIALLY RECEIVED THE XING RESTR WITH PLENTY OF TIME TO MAKE IT.

  249.  
  250. Accession Number: 378980
    Synopsis: A B737-300 APCHING LAX, DSNDS LATE TO CROSS CIVET AT ASSIGNED ALT IN ZLA, CA, AIRSPACE.
    Narrative: FMC VNAV SYS WAS PROGRAMMED TO CROSS CIVET AT FL180. WE HAD BEEN CLRED DIRECT TO CIVET FROM SOMEWHERE IN ARIZONA. ABOUT 15 MI FROM CIVET AND PRIOR TO DSCNT WITH VNAV I NOTICED THE ACFT WAS TRACKING SEVERAL MI S OF COURSE. I SELECTED HEADING MODE ON THE MODE CTL PANEL AND TURNED THE ACFT MORE TO THE N TO INTERCEPT THE LAX RWY 25L LOC. WHEN I PUSHED THE HEADING MODE BUTTON I DIDN'T NOTICE THAT THE FMC DROPPED OUT OF VNAV MODE. WHEN I DID NOTICE, WE WERE ONLY 3 MI FROM CIVET AND STILL AT FL240. I IMMEDIATELY STARTED A MANUAL DSCNT TO FL180. ABOUT 2 MI FROM CIVET ZLA ASKED WHAT ALT WE WERE LEAVING. I RESPONDED FL240. ZLA THEN GAVE US A HDG OF 200 DEGS AND CLRED US TO 14000 FT. ADDING TO THE CONFUSION IN THE COCKPIT WAS THE FO BEING DISTRACTED BY A FLT ATTENDANT IN THE COCKPIT SHOWING HIM PICTURES IN AN ALBUM. NEXT TIME, I WILL INSURE THAT ALL EYES ARE ON THE JOB AT HAND.

  251.  
  252. Accession Number: 379070
    Synopsis: A B737-300 DSNDING IN ZNY AIRSPACE, RECEIVES CLRNC TO CROSS HAYED AT FL180. THE FO DOESN'T PROGRAM THE FMS PROPERLY AND CANCELS THE DSCNT. ACFT CROSSED HAYED AT FL250.
    Narrative: WE WERE GIVEN A CLRNC TO DSND FROM FL370 TO FL280 AND CROSS HAYED INTXN AT FL180. I HAD THE FMC PROGRAMMED TO CROSS HAYED AT FL180 AND I STARTED THE DSCNT. I RESET FL180 IN THE CRUISE PAGE, WHICH WAS MY MISTAKE BECAUSE THIS DELETES ANY RESTRS. ALSO, AS I WAS DSNDING, I WAS THINKING MY ALT WAS FL280 AND NOT FL180 -- MY MISTAKE AGAIN. BY THE TIME I REALIZED THE MISTAKE, IT WAS TOO LATE FOR THE XING RESTR. CONSEQUENTLY, WE WERE HIGH ON OUR HAYED XING OF FL180. ATC ASKED IF WE WERE GIVEN A XING RESTR. WX WAS VFR.

  253.  
  254. Accession Number: 379210
    Synopsis: MLG ACFT IN CRUISE DEVIATED FROM ASSIGNED ALT WHEN VERT SPD MODE SHIFTED DUE TO INADVERTENT ACTUATION OF TRIM WHEEL.
    Narrative: OUR FLT HAD DSNDED TO FL280 WITH PLT'S DISCRETION TO FL240. THE CAPT WAS FLYING THE LEG. BOTH OF US WERE TIRED, HAVING FLOWN 2 LONG LEGS WITH 3 TO GO. CAPT CHOSE TO DSND IN VERT SPD MODE TO FL280. REACHING FL280 THE ALT ALERTER WAS RESET TO FL240. ALT HOLD WAS CONFIRMED AS THE ACTIVE MODE BEFORE RESETTING THE ALERTER. AFTER SETTING FL240 IN THE WINDOW ALT HOLD REMAINS THE ACTIVE VERT MODE, HOWEVER VERT SPD IS NOW THE ARMED MODE AND ANY MOVEMENT OF THE VERT TRIM WHEEL WILL ACTIVATE VERT SPD MODE. ADDITIONALLY, WITH THE ALT ALERTER SET TO FL240, NO DEV WARNINGS ARE GENERATED IF ACFT DEPARTS FROM FL280. MY GUESS AS TO WHAT CAUSED THE ACFT TO DEVIATE FROM FL280 WAS AN INADVERTENT BUMP OF THE VERT TRIM WHEEL OR SOME OTHER UNKNOWN CAUSE BECAUSE THE ACFT CLBED, UNBEKNOWNST TO EITHER CREW MEMBER, TO FL298 BEFORE WE BOTH BECAME AWARE OF IT AS THE ACFT BEGAN A SLIGHT PITCHING MOMENT IN RESPONSE TO WHAT FELT LIKE MOUNTAIN WAVE ACTIVITY. THE CAPT CHANGED MODES QUICKLY AND I NEVER SAW WHAT VERT MODES WERE ACTIVE DURING THE DEV. DURING THE DEV I HAD BEEN PREOCCUPIED WITH FILING AWAY APCH PLATES AND SETTING UP FOR THE ARR TO LAX. THE CAPT WAS LIKEWISE PREOCCUPIED WITH SIMILAR TASKS. A BETTER WAY TO MAKE A CRUISE DSCNT (WHERE TOD IS NOT A CONCERN) WOULD HAVE BEEN TO SET FL240 IN THE ALERTER FIRST, FL280 ON THE CRZ PAGE OF THE FMC AND MADE A CRUISE DSCNT TO FL280. LAPSES IN ATTN ARE NOT UNCOMMON WHEN FATIGUE BECOMES A FACTOR, HOWEVER, THIS INCIDENT REINFORCES THE EXTRA VIGILANCE REQUIRED WHENEVER ANY MODES, VERT OR LATERAL, ARE ARMED.

  255.  
  256. Accession Number: 379290
    Synopsis: FLC OF A FOKKER 100, FK10, FAILED TO MAKE STAR XING ALT DUE MISPROGRAMMING THE FMC AND NOT SUFFICIENTLY MONITORING RATE OF DSCNT AND ALT IN ORDER TO TAKE OVER ACFT MANUALLY IN TIME TO ASSURE MEETING CLRNC.
    Narrative: ENRTE TO SLC ON THE SPANE 2 ARR, WE WERE CLRED TO DSND AND CROSS THE SPANE INTXN AT FL190. THE PNF DIALED IN FL190 AND A PROPERLY PROGRAMMED PROFILE DSCNT WAS INITIATED WITH THE AUTOPLT ENGAGED. APPROX 8 MI FROM SPANE, IT WAS CONCLUDED THAT THE FMC COMPUTED DSCNT RATE WAS NOT GOING TO BE SUFFICIENT TO REACH SPANE BY FL190. THE PF RESPONDED BY DROPPING DOWN A LEVEL IN AUTOMATION. WHILE LEAVING THE AUTOPLT ON, LEVEL CHANGE WAS SELECTED ON THE FMP AND THE SPD BRAKE WAS EXTENDED. WHEN THE ACFT CROSSED SPANE, THE ACFT WAS IN ALT CAPTURE MODE APPROX 200-300 FT ABOVE ASSIGNED ALT.

  257.  
  258. Accession Number: 379620
    Synopsis: FLC OF MD80 RESETS THE FMS TO CHANGE FROM 20 MI TO 10 MI LEGS IN HOLDING PATTERN. THOUGH THEY FOLLOW CORRECT PROCS THE FMS DOES NOT CHANGE TO 10 MI LEGS.
    Narrative: A CLASSIC AUTOMATION BITES YOU STORY. HOLDING AT MIGET INTXN ON J146, CLRED FOR 20 MI LEGS. CTLR TOLD US TO CHANGE LEG LENGTH TO 10 MI. I WENT TO HOLD PAGE ON FMS AND ENTERED 10 MI LEG LENGTH. IT ACCEPTED THE ENTRY AND THE EXECUTE KEY ILLUMINATED. I PUSHED THE EXECUTE KEY. I THEN CHANGED TO A LONGER RANGE DISPLAY ON THE NAV DISPLAY TO ENTER AN EXPECTED RTE FOLLOWING HOLDING. WE WERE VERY BUSY DECIDING HOW LONG WE COULD HOLD AND TALKING TO THE DISPATCHER TO SELECT AN ALTERNATE FOR POSSIBLE REFUELING. WHAT HAPPENED WAS THAT ALTHOUGH THE FMS ACCEPTED THE 10 MI LEG INPUT, IT DID NOT ACTUALLY FLY 10 MI LEGS BUT CONTINUED TO FLY 20 MI LEGS. I HAD ETG VOR TUNED TO DOUBLECHK THE FMS. MIGET INTXN IS 33 MI W ON J146. BY THE TIME WE FINISHED TALKING TO THE DISPATCHER AND I NOTICED THE DME, IT SAID 55, NOT 43, WHICH WOULD REPRESENT THE END OF THE OUTBOUND LEG OF A 10 MI LEG HOLDING PATTERN. I TURNED INBOUND IMMEDIATELY. NO OTHER ACFT WERE ON TCASII AND THE CTLR NEVER SAID ANYTHING TO US. HOWEVER, THE MISTAKE WAS MINE FOR NOT MONITORING THE FMS.

  259.  
  260. Accession Number: 379860
    Synopsis: AN ACR LTT FLC OVERSHOT THEIR ASSIGNED ALT WHILE LOOKING FOR TFC. THE FLC RETURNED TO THEIR PROPER ALT WITH NO CONFLICT.
    Narrative: WE HAD BEEN CLRED DIRECT TO ROBINSVILLE VOR AFTER DEPARTING JFK UP TO 14000 FT. PASSING 13000 FT, WE WERE GIVEN A TA FROM N90. I ENGAGED THE AUTOPLT AND SELECTED 14000 FT IN THE ALT SELECT WINDOW AND BEGAN SEARCHING FOR THE TFC WHICH MY FO WAS ALREADY LOOKING FOR AT THE TIME. WHEN I LOOKED BACK DOWN THE ACFT WAS PASSING THROUGH 14250 FT. INSTEAD OF DOING A HARD NOSE OVER I SMOOTHLY, BUT FIRMLY, STOPPED THE CLB AT 14330 FT AND IMMEDIATELY RETURNED TO 14000 FT. THERE WAS NO COMMENT FROM DEP CONCERNING OUR DEV AND WERE SOON HANDED OFF TO ZNY WITHOUT FURTHER INCIDENT. SIMPLY PUT, I MADE A MISTAKE. BOTH HEADS WERE OUT THE WINDOW DURING OTHER THAN LEVEL FLT. I HAVE SINCE ADOPTED A POLICY THAT THE PNF WILL LOOK FOR TFC WHILE THE PF DOES JUST THAT -- FLY! I LEARNED A LESSON -- HOPEFULLY WITHOUT LOSS.

  261.  
  262. Accession Number: 379870
    Synopsis: AN ACR FLC IN AN MLG GOT OFF COURSE WHEN THEY FOLLOWED AN FMC COURSE THAT WAS IMPROPERLY DEPICTED ON THEIR SCREEN. THE CAPT ATTEMPTED TO REPROGRAM THE FMC INSTEAD OF USING THE AVAILABLE VOR INFO.
    Narrative: SHORTLY AFTER TKOF FROM BUR, WE WERE TOLD TO INTERCEPT A RADIAL THAT WAS ON THE SID (218 DEG RADIAL PMD). I, AS THE PF, SAW ON THE SID THAT THE RADIAL WAS SHOWN ON OUR RTE, SO I TURNED TOWARD THE LINE SHOWN ON THE EFIS SCREEN. IT TURNS OUT THAT THE FMC FOR SOME REASON LOADED THE SID INCORRECTLY, EVEN THOUGH IT WAS ENTERED CORRECTLY SO THE LINE SHOWN WAS THE WRONG RADIAL. DURING THIS TIME, THE CAPT WAS TRYING TO FIX THE BOX INSTEAD OF TUNING THE VOR. IN ANY CASE, THE CTLR NOTED OUR HDG WAS 40 DEGS FROM OUR INTERCEPT HDG GIVEN TO US BY HIM. WE TURNED APPROX 5- 8 MI BEFORE THE ASSIGNED RADIAL. HE TOLD US TO TURN BACK AND WE DID. TO PREVENT THIS FROM HAPPENING AGAIN, I WILL VERIFY THE RTE ON THE LEGS PAGE IN ADDITION TO THE RTE PAGE IN THE FMC. ALSO, I THINK TYPING IN THE BOX BELOW 10000 FT IS NEVER A GOOD IDEA.

  263.  
  264. Accession Number: 380282
    Synopsis: EMB120 FLC PERFORMS AN EVASIVE ACTION TO MISS 2 C140'S FLYING OPPOSITE DIRECTION. FLC MISJUDGED THEIR ACFT'S PERFORMANCE CAPABILITIES AND THE RATE OF CLOSURE.
    Narrative: CLBING OUT OF CRW ON VECTORS TO OUR FIRST FIX WE WERE ADVISED BY ATC ABOUT A FLT OF SEVERAL C140'S. A PAIR OF THEM IN FORMATION, APPEARED ON OUR TCASI AT A RANGE OF 5- 6 MI. AT FIRST, IT LOOKED LIKE WE WOULD BE ABLE TO CLB AND PASS THROUGH THEIR ALT WITH NO CONFLICT. SOON, WE REALIZED THAT THIS WAS INCORRECT. AT 1200 FT HORIZ AND 200 FT VERT WE LEVELED THE ACFT AND TURNED L TO AVOID A POSSIBLE COLLISION. THE CTLR ASKED IF WE HAD TURNED L. THE CAPT RESPONDED AFFIRMATIVE TO THE QUESTION. THE CTLR REPLIED 'THAT'S FINE, BUT I'D LIKE TO KNOW ABOUT IT.' THE CAPT SAID THE MANEUVER WAS UNEXPECTED AND HE DIDN'T HAVE TIME TO RPT THE TURN, BUT HE APOLOGIZED FOR BEING UNABLE TO ADVISE THE CTLR. I BELIEVE THE CONFLICT RESULTED FROM OVERESTIMATING OUR CLB PERFORMANCE AND UNDERESTIMATING OUR CLOSURE RATE. I SHOULD HAVE SLOWED OUR RATE OF CLB DOWN OR LEVELED OFF. ALSO, LOOKING TO THE R AT 2 SMALL ACFT, I COULDN'T SEE THE TCASI. I COULDN'T SEE THEIR DIRECTION OF FLT UNTIL THE LAST FEW SECONDS BEFORE OUR TURN TO THE L. SUPPLEMENTAL INFO FROM ACN 380281: IN RETROSPECT, I BELIEVE THE CONFLICT RESULTED FROM MY UNDERESTIMATING OUR RATE OF CLOSURE. IF I HAD IT TO DO OVER, I WOULD HAVE LEVELED OFF EARLIER AND NOT NEEDED THE TURN OFF COURSE. I MIGHT ALSO HAVE OVERESTIMATED OUR CLB PERFORMANCE. A CONTRIBUTING FACTOR TO THIS INCIDENT MAY HAVE BEEN A FALSE SENSE OF SECURITY PROVIDED BY THE TCASI. WITHOUT IT, I DOUBT THAT I WOULD HAVE EVEN ATTEMPTED TO OUT CLB THE TFC.

  265.  
  266. Accession Number: 380502
    Synopsis: AN ACR B767 FLC USED IMPROPER PROC TO ENTER THE RTE INTO THE FMC AND THEN THIS DATA WAS XCHKED IMPROPERLY. THE ACFT GOT OFF COURSE UNTIL THE ARTCC CTLR GAVE A NEW CLRNC DIRECT TO A WAYPOINT.
    Narrative: EZEIZA CTR ASKED OUR HDG, THEN VECTORED US DIRECT PAGON. ORIGINAL CLRNC READ: UA300 GUA, UA301 PAGON, DIRECT VANAR, PAGON 1 SAEZ. WE THEN REALIZED THAT WE HAD BEEN TRACKING DIRECT EZE AFTER GUA INSTEAD OF UA301 PAGON. POS APPROX 10 NM NE PAGON, 4 NM E OF UA301 TRACK CTRLINE. 10 HRS OF ALL NIGHT FLYING HAD ELAPSED, ALL 3 PLTS WERE AT STATIONS IN COCKPIT. FMC HAD BEEN PROGRAMMED FOR UA301 PAGON, ARRS PAGE: PAGON 1A, ILS 11 ARSOT TRANSITION. ATIS ADVISED ILS RWY 35 IN USE. WHEN ILS RWY 35, EZE TRANSITION WAS SELECTED, THE STAR WAS OMITTED. WHEN IT WAS ACTIVATED NOT ONLY WAS PAGON 1A STAR ERASED, BUT ALSO UA301 PAGON, LEAVING EZE AS THE NEXT WAYPOINT AFTER GUA. WE IMMEDIATELY HEADED DIRECT PAGON AND WHEN IN CONTACT WITH EZEIZA APCH WERE VECTORED AND CLRED DIRECT EZE. IMPROPER PROCS WERE FOLLOWED IN THAT VERIFICATION OF THE NEW APCH SELECTION, ILS RWY 35, EZE TRANSITION, WAS NOT COMPLETED UNTIL AFTER ACTIVATION INSTEAD OF BEFORE EXECUTION. ALSO, THE DISCONTINUITY WHICH RESULTED WAS CLOSED WITHOUT VERIFICATION PRIOR TO EXECUTION. THUS, NONE OF US CAUGHT THE FACT THAT WE WERE TRACKING DIRECT EZE VERSUS DIRECT PAGON AND THAT THE FMC HAD DROPPED UA301 PAGON AND PAGON 1A STAR. OTHER CONTRIBUTING FACTORS: FATIGUE. WE WERE LULLED INTO ACCEPTING EZE AS THE NEXT WAYPOINT. IT MADE SENSE WHEN WE LOOKED AT THE HSI. THE APCH WAS NOT ILS RWY 35, EZE TRANSITION (VERSUS ILS RWY 11). BUT WE HAD NOT YET BEEN CLRED DIRECT EZE.

  267.  
  268. Accession Number: 380530
    Synopsis: WDB ACFT IN CRUISE ON OCEANIC RTE WAS OFF COURSE DUE TO EITHER A FAULTY IRS OR DATABASE ERRORS. WAYPOINTS WERE IN ERROR AND RPTR CAPT CLAIMS THAT CORRECT ENTRIES HAD BEEN MADE BEFORE FLT.
    Narrative: ENRTE FROM LONDON HEATHROW (LHR) TO NEW YORK (JFK) WE WERE CLRED DIRECT TO MERLY INTXN. ABOUT 50 MI NE OF MERLY WE WERE CLRED TO N52W15 DIRECT. WE ENTERED THIS WAYPOINT FROM THE DIRECT INTERCEPT PAGE OF THE FMC, BOTH PLTS VERIFIED AND THEN EXECUTED THE PAGE. WE PROCEEDED TO 15W AND ABOUT 3/4 OF THE WAY THERE THE ACTIVE WAYPOINT BEGAN TO APPEAR AS N52W104 ON THE FMC AND THE HSI. SHORTLY THEREAFTER, ATC (SHANNON) CONTACTED US ON VHF AND TOLD US TO FLY A HDG OF 180 DEGS. ORIGINALLY, WE THOUGHT THE TURN WAS FOR TFC (WE WERE STILL IN RADAR CONTACT). I QUESTIONED THE CTLR AND ASKED HIM HOW LONG WE WOULD BE ON THAT HDG. HE TOLD US THAT HE SHOWED US 16 MI N OF COURSE. WE LOOKED AT THE FMC AND SAW THE ACTIVE WAYPOINT AS N52W104. IT SHOULD HAVE BEEN N52W15. NEITHER MYSELF NOR THE FO HAD ENTERED THAT WAYPOINT AT ANY TIME. THE FMC RTE WAS LOADED BY ACARS DATA LINK IN LHR. ALL COMPANY SOP'S WERE FOLLOWED AND THE RTE VERIFIED BY BOTH PLTS. THE ONLY THING THAT WAS NOT ACCOMPLISHED WAS A LINE SELECT AND COORDINATE VERIFICATION OF THE ABBREVIATED OCEANIC WAYPOINTS WHICH IS NOT REQUIRED UNDER OUR SOP'S. ONCE WE CORRECTED BACK TO COURSE WE REVERIFIED THE WAYPOINTS IN THE FMC'S. WE DISCOVERED THAT THE NEXT CHKPOINT LOADED (N52W020) WAS ALSO WRONG. WHEN WE LINE SELECTED IT DOWN THE COORDINATES WERE WRONG SHOWING AS N5217.8W020. ADDITIONALLY ANOTHER WAYPOINT WAS ON THE LEGS PAGE THAT WE DID NOT ENTER. WE DELETED THIS PHANTOM WAYPOINT AND RE-ENTERED THE COORDINATES OF THE SUBSEQUENT OCEANIC WAYPOINTS SPECIFIED IN NAT TRACK E, OUR CLRED RTE. AFTER THE EVENT WE SUSPECTED BAD DATA ON THE FMC DOWNLINK OF THE RTE. DISPATCH WAS NOTIFIED. AT NO TIME WAS THERE A LOSS OF TFC SEPARATION, AND BECAUSE WE WERE STILL IN RADAR CONTACT WHEN WE WENT OFF COURSE, NO OCEANIC GROSS NAV ERROR OCCURRED. LATER IN THE FLT WE GOT A R IRS FAULT ERROR. THE IRS WAS OPERATED IN ATTITUDE ONLY AND NAV WAS NORMAL. THE R IRS WAS ALSO SUSPECTED AS A CONTRIBUTING FACTOR.

  269.  
  270. Accession Number: 380820
    Synopsis: AN ACR B737 FLC CLB ABOVE THEIR ASSIGNED ALT WHILE ENTERING DATA INTO THE FMS FOR A DSCNT AND AN INCREASED AIRSPD.
    Narrative: UPON RECEIVING DSCNT CLRNC WITH PLT DISCRETION WE ALSO RECEIVED A RESTR TO MAINTAIN 320 KTS OR MORE INTO LAX. I WAS REPROGRAMMING THE FMS TO COMPLY WITH THIS CLRNC WHILE IN VNAV. THE ACFT ACCELERATED TO 320 KTS AND BEGAN A SHALLOW CLB. I WAS HEAD DOWN SO I AM NOT SURE EXACTLY WHAT THE CAPT WAS DOING WITH THE MCP, BUT WHEN I LOOKED UP WE WERE 200 FT OFF ALT. CAPT DISENGAGED AUTOPLT AND MAX DEV WAS APPROX 300 FT.

  271.  
  272. Accession Number: 380850
    Synopsis: B737 FLC FAILS TO MAKE AN ALT XING RESTR. THE CAPT WAS FLYING VIA THE FMS AND THE FO WAS PUTTING HIS CHART REVISIONS IN HIS HANDBOOK. BOTH WERE IN CONVERSATION. NEITHER WAS MONITORING THE PROGRESS OF THE FLT IN THE DSCNT PROC.
    Narrative: WE WERE FLYING FROM LAX TO SMF AT 35000 FT ON THE WRAPS 5 ARR TO SMF. WE HAD BEEN GIVEN A XING RESTR AT TURLO INTXN OF FL240. THE CAPT WAS FLYING THE LEG. WE WERE CONVERSING WHILE I WAS REVISING MY MANUALS. CTR ASKED US IF WE WERE GOING TO MAKE THE TURLO RESTR. WE HAD ABOUT 2 MINS TO DSND 11000 FT AT THAT POINT. I ASKED CTR FOR RELIEF ON THE RESTR DUE TO STARTING DOWN TOO LATE. OAKLAND SAID TO 'DO THE BEST WE COULD' ON THE DSCNT. WE REACHED FL240 ABOUT 7 MI PAST TURLO INTXN. WE WERE THEN GIVEN THE TELEPHONE NUMBER TO ZOA. THE CAPT CALLED WHEN WE REACHED SMF. CTR SAID THAT NO CONFLICTS OCCURRED BECAUSE OF THE LATE DSCNT. THE CAPT WAS VERY SENIOR AND I WASN'T PAYING ENOUGH ATTN TO HIS DSCNT PLANNING. WE HAD THE XING RESTR IN THE FMC WITH THE DSCNT PAGE SELECTED BUT WE WERE NOT LOOKING AT IT.

  273.  
  274. Accession Number: 380906
    Synopsis: ACR MLG FLC FAILS TO MAKE AN ALT XING RESTR. FO, PF, IMPROPERLY PROGRAMMED THE FMC IN THE DSCNT PAGE, USING THE WRONG INTXN. PIC, PNF, WAS USING THE WRONG VOR DME FOR DISTANCE INFO.
    Narrative: (STRUK ARR HOU, HOBBY.) CLRED TO CROSS MARIT AT 10000 FT. 10000 FT RESTR PLACED IN WRONG LINE (WRONG INTXN) -- STRUK. INITIAL DSCNT WAS BEGUN AT AN APPROPRIATE DISTANCE, BUT PNF SWITCHED VOR TO NEXT NAV AID, LOST BACK-UP CHK FOR ALT XING. PF GOT BEHIND ACFT. CTR AND APCH NOTIFIED ASAP AS TO DEV AND VOLUNTEERED TO TURN IF NEEDED. NO COMMENTS MADE BY EITHER CTR OR APCH. ACFT CROSSED MARIT INTXN ABOUT 2500 FT HIGH. HI-TECH EQUIP -- SYS OVERLOAD ON LOW-TECH USER. MUCH OF OUR NEW TECHNOLOGY ACTUALLY GETS IN THE WAY OF GOOD SOLID AVIATING. SUPPLEMENTAL INFO FROM ACN 380988: CTR CTLR ASKED IF WE WOULD MAKE 'MARIT AT TEN.' PNF INITIALLY RESPONDED AFFIRMATIVE AS WE DOUBLE CHKED OUR PROGRESS. I DISCOVERED I HAD ENTERED XING RESTR (10000 FT/250 KTS) IN FMC AT STRUK INTXN VERSUS MARIT. PF (ME) WAS USING LNAV/DSCNT PAGE. PNF HAD SWITCHED VOR TO HOBBY VERSUS TNV AND LOST AWARENESS OF XING PROGRESS. 13TH HR OF LONG DAY CONTRIBUTED. INADEQUATE XCHK BY CREW.

  275.  
  276. Accession Number: 380970
    Synopsis: FLC OF WDB ACFT CHKS FLT PLAN AS LOADED INTO COMPUTER AND QUESTIONS ONE LEG. DUE TO INTERRUPTIONS THEY FAIL TO CHK THAT LEG AND END UP OFF COURSE ONCE AIRBORNE.
    Narrative: AS A RESERVE PLT, GOT CALL FOR FLT WHICH WAS TO DEPART DTW AT XY00. I ARRIVED AT ACFT APPROX XX25-XX30, WHICH DID NOT ALLOW A LOT OF TIME. AFTER CAPT LOADED FLT PLAN INTO COMPUTER, MY JOB IS TO CHK RTE AND LEGS OF FLT PLAN. ON THE DEP, WE WERE TO FLY RWY HEADING, RADAR VECTORS TO DUNKS INTXN, AS FILED, J-70, ETC. DUNKS WAS IN THE COMPUTER, THEN BAE, NOT J-70. I ASKED CAPT IF DUNKS TO BAE IS J-70, AND HE SAID HE WOULD LOOK IT UP ON MAP. I SAID I WOULD LOOK IT UP TOO. HOWEVER, I THEN CONTINUED CHKING THE REMAINDER OF THE RTE AND LEGS, ASSUMING HE WAS LOOKING IT UP. AT THIS POINT AN AGENT CAME INTO THE COCKPIT, ALONG WITH OTHERS, AND WE WERE DISTRACTED AND WE BOTH FORGOT TO GO BACK AND CHK THE CHART. I DID FINISH CHKING RTE AND LEGS, BUT DID NOT DOUBLE-CHK MY QUESTION. ON DEP WE WERE CLRED DIRECT DUNKS, AS FILED. WE SHOULD HAVE FLOWN DUNKS, J-70 PMM, BAE, ETC. AFTER DUNKS, WE STARTED HEADING FOR BAE (ON LNAV). ATC QUESTIONED OUR NAV SOON AFTER PASSING DUNKS, SAID WE WERE 10 MI N OF COURSE. WE REQUESTED DIRECT BAE AND IMMEDIATELY WERE GRANTED OUR REQUEST. NO FURTHER COMMENTS FROM ATC. I LET MYSELF GET TOO HURRIED WHICH LED TO MY MISTAKE. IT IS A VERY BUSY TIME BEFORE DEP WITH A LOT TO DO. WHEN TIME IS SHORT AND WITH SUBSEQUENT DISTRACTIONS IT IS EVEN MORE CRITICAL TO CHK OUT QUESTIONS AT THE TIME THEY ARISE AND NOT PUT THEM OFF, SO THEY CAN BE FORGOTTEN.

  277.  
  278. Accession Number: 381280
    Synopsis: F100 CREW FAILS TO MAKE AN ALT XING RESTR. A CASUAL CHK OF THE PROGRESS PAGE SATISFIED THE FO THAT ALL WAS WELL. RPTR FO SAYS HE SHOULD HAVE CHKED THE RAW DATA MORE CLOSELY PLUS A FEW MORE TIPS.
    Narrative: ON DSCNT INTO SLC, ATC CLRED US FROM FL280 TO CROSS 16000 FT AT SPANE ON THE SPANE ARR. THE CAPT WAS FLYING AND HE STARTED DOWN USING THE IMMEDIATE DSCNT MODE OF THE PROFILE MODE OF THE FMS. APPROX 10 MI FROM SPANE, ATC QUERIED US IF WE WOULD MAKE THE ALT. I LOOKED AT THE NAV DISPLAY AND IT LOOKED CLOSE (I DON'T REMEMBER THE EXACT NUMBERS). I WAS RUNNING THE DSCNT CHK AND GETTING THE CHANGEOVER RPT. INSTEAD OF DOING THE MATH, I SIMPLY WENT TO THE PROGRESS PAGE OF THE FMS AND CHKED THE DSCNT PROGRESS. IT HAD US BELOW THE PROFILE BY MORE THAN 1500 FT SO I DID NOT PURSUE IT FURTHER AND STATED WE WOULD MAKE IT. THE CAPT CONCURRED. WE ENDED UP XING AT FL205. WE NOTIFIED ATC AND THEY TOLD US TO CONTINUE. PASSING FL180, WHEN I WENT TO RESET QNH, I NOTICED I HAD INADVERTENTLY PRE-SET THE FIELD QFE OF 29.93 IN THE QNH WINDOW. THIS SHOULD NOT HAVE AFFECTED THE FMS PROFILE, HOWEVER, SINCE AUTOPLT #1 WAS IN USE. LESSONS LEARNED: 1) ATC CLRNCS ARE MORE IMPORTANT THAN CHKLISTS. 2) TAKE ATC HINTS ABOUT ALT QUERIES MORE SERIOUSLY. 3) STAY IN THE LOOP ON ACFT POS WHEN NOT FLYING. 4) DON'T RELY ON FMS DATA ALONE, AND 5) ALWAYS MONITOR RAW DATA.

  279.  
  280. Accession Number: 381600
    Synopsis: PIC OF AN A320 FAILS TO PROGRAM HIS FMS PROPERLY AND THE ACFT BYPASSES THE 'CLRED DIRECT TO' WAYPOINT. ZLA CTLR QUESTIONS ROUTING.
    Narrative: ON THE OFFSHORE 3 DEP OUT OF SFO AROUND CYPRS INTXN, ATC CLRED US DIRECT LAX. THE AUTOFLT SYS WAS ENGAGED AND I SELECTED DIRECT ON THE MCDU AND LINE SELECTED 'LAX.' THE ACFT TURNED TO AN APPROPRIATE HDG AND WE CONFIRMED. ABEAM LAX, CTR ASKED IF WE WERE DIRECT JLI, AND I LOOKED AT THE MCDU AND THE NAV DISPLAY AND SAW THAT WE WERE INDEED GOING DIRECT TO JLI. WE WERE SHOWING 12 DME FROM LAX. (JLI WAS OUR NEXT WAYPOINT AFTER LAX.) I DO NOT KNOW HOW JLI GOT TO BE THE 'TO' WAYPOINT BUT I HAVE 3 POSSIBILITIES: 1) I SELECTED JLI RATHER THAN LAX, 2) WE PASSED OVER A WAYPOINT WHEN I PUSHED THE LINE SELECT FOR LAX, THE WAYPOINT SCROLLED, AND JLI WAS SELECTED, OR 3) WE CROSSED OUR LAX WAYPOINT AS ATC ASKED, SO JLI WOULD BE THE NEXT WAYPOINT. I THINK SCENARIO #2 TO BE THE MOST LIKELY. TO PREVENT THIS, I RECOMMEND THE PROC TO BE: 1) PRESS DIRECT, 2) TYPE THE IDENT IN THE SCRATCH PAD, AND 3)LS 1L, THE (DIRECT TO) PROMPT. OBVIOUSLY I SHOULD HAVE XCHKED THE MCDU ALSO TO CONFIRM THE CORRECT WAYPOINT WAS ACTIVE.

  281.  
  282. Accession Number: 381871
    Synopsis: WDB ACFT ON OCEANIC ROUTING WAS OFF COURSE DUE TO WAYPOINT ERROR ENTERED IN THE FMC. RPTR CAPT ELECTED TO GO DIRECT NEXT WAYPOINT, BUT 500 FT OFF ALT. APPARENTLY THEY WERE NOT IN COM WITH OCEANIC.
    Narrative: IN CRUISE ON THE OCEANIC PORTION OF THE FLT, I RETURNED FROM MY REST BREAK AND WAS ADVISED THAT THE RELIEF FO PLOTTED A FIX AND CONFIRMED THAT WE WERE OFF COURSE. I RECHKED HIS WORK AND THE PLOT MADE BY THE OPERATING FO. WE WERE OFF COURSE. BY FLYING TO THE WAYPOINT, WHICH WAS PRESENTLY ACTIVE, WE WOULD BE ON COURSE AND ARRIVE AT THE NEXT WAYPOINT, WHICH WAS AS CLRED AT THE TIME GIVEN IN THE LAST POS RPT. I BELIEVED THE SAFEST COURSE OF ACTION TO BE CONTINUING TO THE WAYPOINT AT AN ALT 500 FT LOWER THAN THE CLRNC ALT AND TO CONTINUE TO MAKE FULL USE OF THE TCASII. AT ALL TIMES WE WERE MONITORING 121.5 AND 131.8 PER OCEANIC PROCS. NO ACFT WERE SIGHTED AND NONE WERE ON THE 2 FREQS. THE WAYPOINT ERROR MUST HAVE BEEN INTRODUCED DURING THE WAYPOINT LOADING. THE ERROR WAS NOT DETECTED BY EITHER MYSELF OR THE OPERATING FO. I LATER FOUND THAT HIS PLOT OF POS, WHICH WOULD HAVE SHOWN THE ERROR EARLIER, WAS IN ERROR SHOWING US TO BE ON COURSE. MY ONLY EXPLANATION FOR THE ERROR GOING UNDETECTED IS OUR EXPECTING TO SEE THE 'NORMAL' NUMBERS. I CHKED THE WAYPOINTS AT LEAST TWICE AND OBSERVED THE FO DOING THE SAME. I HAVE NO OTHER EXPLANATION. THE SHOCK OF THIS TYPE OF ERROR IS DEVASTATING.

  283.  
  284. Accession Number: 382000
    Synopsis: FLC OF A B737 FAILED TO FOLLOW THE ASSIGNED SID TRANSITION DURING CLB DUE TO THE FMC PROGRAMMED WITH THE WRONG TRANSITION.
    Narrative: CLRNC GAVE US THE OASYS 2 DEP DAGGETT TRANSITION. OUR FMC HAD THE GFS TRANSITION. WE DIDN'T NOTICE UNTIL WE HAD ALREADY MADE THE TURN INBOUND TO GFS.

  285.  
  286. Accession Number: 382690
    Synopsis: FLC OF CPR LR25 HAS FAILURE OF ALT ALERTER AND CLBS ABOVE ASSIGNED ALT. THIS RESULTS IN LTSS. CTLR VECTORS BOTH ACFT FOR SEPARATION.
    Narrative: THE PF, FILED AS PIC, CALLED ZLA AS REQUESTED. BETTER CRM ON OUR PART WOULD HAVE PREVENTED THE DEV. I TOOK CTL OF ACFT, CLICKED OFF AUTOPLT AFTER WARNING HIM OF HIS ALT. I SHOULD HAVE TAKEN CTL AT FL283 INSTEAD OF FL285. WE DID SEE ABC ACR AT FIRST ATC RPT. AS CAPTS, WE SOMETIMES TRY NOT TO HURT A COPLT'S FEELINGS. A LESSON LEARNED. GOOD/BETTER CRM COULD HAVE PREVENTED THE DEV. I CERTAINLY OWE AN APOLOGY TO ZLA AND ABC ACR AND THANK THEM FOR THEIR PROFESSIONALISM. NOTE: THE COPLT ALSO TOOK YOKE AND INITIATED CORRECTIVE ACTION ABOUT SAME TIME I DID. WE TALKED LATER AND DISCUSSED HOW WE COULD HAVE DONE BETTER. SUPPLEMENTAL INFO FROM ACN 382279: THE ALT ALERTER WAS NEVER HEARD OR SEEN THROUGHOUT THIS DEV. AFTER ROTATING BOTH THE ALTIMETER AND ALERTER KNOBS, BOTH ALTIMETER AND THE ALT ALERTER BEGAN TO FUNCTION AGAIN NORMALLY. WE WERE ASKED TO CALL ZLA UPON OUR ARR AT SFO TO EXPLAIN THE SIT AND WE COMPLIED IMMEDIATELY UPON LNDG. THE FAILED EQUIP WAS TRACED TO AN ALTIMETER, REQUIRING ADJUSTMENTS TO ALLOW FOR CORRECT ALT AND ALT WARNING SYS FUNCTIONS.

  287.  
  288. Accession Number: 382820
    Synopsis: FLC OF B757 RESETS FMC WHEN GIVEN XING RESTR BUT FAILS TO ENGAGE IT. CTLR RECLRS TO MAINTAIN ALT.
    Narrative: OUR ORIGINAL DSCNT ALT IN THE FMC WAS SET TO CROSS CLAWZ AT THE EXPECT ALT OF FL270. ATC CLRED US FROM FL370 TO FL350 PRIOR TO OTK FOR TFC. ATC SUBSEQUENTLY CLRED US TO CROSS CLAWZ AT FL310, RATHER THAN FL270. WITH THE CHANGE OF XING ALTS AND OTHER DSCNT DUTIES THE NEW ALT (FL310) WAS ENTERED INTO THE FMC, BUT NOT ENGAGED. WE REALIZED THE ACFT HAD NOT STARTED THE DSCNT, BUT WE WERE TOO CLOSE TO CLAWZ. CTR CALLED US AND RECLRED US TO MAINTAIN FL350. FACTOR: NEW FO PERCEPTION -- THOUGHT PNF ENGAGED FMC. CORRECTIVE: ALWAYS CONFIRM AUTOMATION.

  289.  
  290. 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.

  291.  
  292. Accession Number: 383500
    Synopsis: AN ACR FK10 FLC GOT OFF COURSE WHEN THEY ENTERED THE PLANNED RTE IN THE FMC RATHER THAN THE CLRED RTE. AN ALERT ARTCC CTLR CALLED THE ERROR TO THEIR ATTN.
    Narrative: FMC ROUTING DISCUSSED PRIOR TO DEP AT MCI, BUT ATTN WAS DIVERTED TO ANOTHER EVENT. ATC QUERIED US AT CAP AS TO REMAINDER OF FLT PLAN. WE TOOK IMMEDIATE ACTION TO CORRECT THE STORED DATABASE FLT PLAN. NO PROBS WERE OTHERWISE ENCOUNTERED.

  293.  
  294. Accession Number: 384678
    Synopsis: AN ACR DC10 FLC DSNDED BELOW THEIR ASSIGNED ALT WHEN THE ALT CAPTURE MODE OF THE AUTOPLT MALFUNCTIONED.
    Narrative: ACFT CLRED TO DSND TO 11000 FT. AUTOPLT #1 WAS ENGAGED. ALT DID NOT CAPTURE. PF BEGAN CORRECTIVE MEASURE AT 10800 FT, BUT DSCNT CONTINUED TO 10500 FT BEFORE CLBING BACK TO ASSIGNED 11000 FT. FLT PROCEEDED TO MSP ARPT UNEVENTFULLY. THIS SIT COULD HAVE BEEN AVOIDED BY CLOSER MONITORING OF THE FLT INSTS.

  295.  
  296. Accession Number: 385047
    Synopsis: FLC OF AN MLG FAILED TO FOLLOW STAR TRANSITION RESULTING IN ATC INTERVENTION AND SUBSEQUENT CLRING OF RPTRS DIRECT TO THE VORTAC THEY WERE ALREADY HEADING.
    Narrative: INADVERTENTLY FLEW DIRECT FROM OAL TO HYP INSTEAD OF THE OAL TRANSITION ON THE HYP 3 ARR INTO SJC. WHEN MISTAKE WAS IDENTED, WE RECEIVED CLRNC DIRECT TO HYP. FACTORS: NEW ARPT FOR NEW CAPT, ARR CHANGED IN FMS WHICH AFFECTED TRANSITION. WHEN CHANGES ARE MADE BE MORE CAREFUL TO CHK EXACTLY WHAT YOU HAVE IS WHAT YOU WANT.

  297.  
  298. Accession Number: 385079
    Synopsis: A B757-200 CROSSES POM, CA, 1000 FT ABOVE PUBLISHED ALT BECAUSE THE AUTOMATIC FLT CTLS WERE IN VNAV.
    Narrative: ON DEP ON POMONA 6 SID WITH AN 8000 FT AT OR BELOW RESTR AT POMONA WE WERE USING LNAV AND VNAV. THE CTLR QUESTIONED OUR ALT WHICH WAS 9000 FT AND SAID WE HAD A RESTR OF 8000 FT. OUR LNAV WAS AT THAT TIME DIRECTING A TURN TOWARD DAG 227 DEG RADIAL HAVING DROPPED THE LAST WAYPOINT POMONA AND ALLOWING US TO CLB TO OUR NEXT ALT. THAT WAS A NORMAL LNAV, VNAV SIT. IF THIS DEP DOES TAKE INTO ACCOUNT THE NORMAL LNAV, VNAV OP IT NEEDS TO BE CHANGED TO ALLOW FOR HOW THESE FUNCTIONS OPERATE. IN OTHER WORDS OUR NAV SYS SHOWED US PAST THE RESTRICTIVE FIX AND ALLOWED US TO CLB TO OUR NEXT ALT. SUPPLEMENTAL INFO FROM ACN 385080: ATC CTLR ADVISED US OF ALTDEV DURING POMONA SIX DEP FROM ONTARIO ARPT. THERE IS AN ALT XING RESTR AT POMONA VOR AT OR BELOW 8000 FT. OUR NAV SYS SHOWED US AT VOR AND TURNING TO NEXT WAYPOINT. WE CONTINUED CLB TO 14000 FT ASSIGNED. ATC CTLR ADVISED US THAT WE WERE HIGHER THAN 8000 FT AT POMONA. OUR CLB RATE WAS 3000 FPM. OUR FMC WAS IN VERT NAV MODE AND LATERAL NAV MODE. WHEN WE ARRIVE AT WAYPOINT, THE WAYPOINT CHANGES DISTANCE AND TIME IN ZULU OF NEXT WAYPOINT. THIS HAD HAPPENED WHEN CTLR ADVISED US OF OVER POMONA VOR.

  299.  
  300. Accession Number: 385280
    Synopsis: MLG ACFT IN DSCNT, PF, FO DIDN'T SEE AUTOPLT FAILING TO CAPTURE LEVEL AT ASSIGNED ALT. CAPT RPTR PROMPTED FO OF ALTDEV AND ACFT WAS FLOWN BACK TO ASSIGNED.
    Narrative: ON DSCNT TO 11000 FT, ENRTE TO HUNTSVILLE, AL, THE AUTOPLT DID NOT CAPTURE THE ALT. PASSING 12000 FT, WE CALLED OUT 12000 FT FOR 11000 FT. APCHING 11000 FT, I NOTICED THE ACFT WAS NOT REDUCING DSCNT TO CAPTURE THE ALT. AT 11000 FT, I TOLD THE FO, WHO WAS FLYING, THAT THE ALT WAS NOT CAPTURING. HE DISCONNECTED THE AUTOPLT AND LEVELED THE AIRPLANE MANUALLY TO 11000 FT. THE ALT BOTTOMED OUT AT 10750 FT FOR A FEW SECONDS AND WAS BROUGHT BACK TO 11000 FT VERY QUICKLY. PRIOR TO AND AFTER THIS, THE AUTOPLT CAPTURED THE ALTS NORMALLY. ATC DID NOT SAY ANYTHING, SO I GUESS THEY DID NOT NOTICE.

  301.  
  302. Accession Number: 385330
    Synopsis: FLC OF AN ACR MDT FAILED TO FOLLOW FLT PLAN ROUTING DUE TO A MISPROGRAMMED FMS RESULTING IN ATC INTERVENTION AND A VECTOR HEADING TO ASSIGNED COURSE.
    Narrative: ON A SCHEDULED FLT FROM HPN TO CVG FO AND I BOTH CHKED FLT PLAN ON RELEASE (FLT RELEASE) AND COMPARED IT TO FLT PLAN IN THE FMS (CANNED WITH ONCE A MONTH CHANGE). THE FLT PLAN IN THE BOX (FMS) WAS WRONG (J6). WE MODIFIED THE FLT PLAN TO PUT THE ARR FOR CVG IN. HOWEVER, I DID NOT CLR THE OLD FLT PLAN BUT CHOSE TO MODIFY IT. BTWN ETX AND AIR ON J80 ARE 5 INTXNS WITH A TURN AT KIPPI INTXN (SUZIE AND HOUTN INTXNS ARE NEXT EACH OTHER ON J80 AND J6). WE DID NOT TAKE OUT (OR CLR) HOUTN FROM FLT PLAN AND WE CHKED THE COMMERCIAL CHARTS AND MISTAKENLY THOUGHT HOUTN INTXN WAS ON J80 WHEN IT WAS ON J6. ZNY GAVE US A 270 DEG HDG BACK TO J80 ABOUT HALF WAY BTWN ETX AND HOUTN INTXN. NO CONFLICTS NOTED, FMS CORRECTED.

  303.  
  304. Accession Number: 385590
    Synopsis: MDT ACFT IN CRUISE HAD WRONG ROUTING SET IN FMS AND OVER FIX TURNED TO WRONG TRACK. ATC INTERVENED AND ASSIGNED CORRECT RTE.
    Narrative: FLT PLAN RTE CALLED FOR CENCE TWO ARR BUT IT WAS NOT PROGRAMMED INTO THE FMS. INSTEAD FREDDY INTXN WAS THE NEXT FIX PROGRAMMED AFTER FDY VOR. WE DEPARTED FDY ON A SW HEADING TO FREDDY WHEN ATC POINTED OUT OUR ERROR AND GAVE US A L TURN TO INTERCEPT THE CENCE TWO ARR.

  305.  
  306. Accession Number: 385890
    Synopsis: FLC OF MDT FAILS TO VERIFY ROUTING IN THE FMS AND THEY FLY THE WRONG STAR.
    Narrative: FAILED TO VERIFY ROUTING IN FMS. FLEW WRONG STAR TO DEST.

  307.  
  308. Accession Number: 386030
    Synopsis: B737-400 ACFT CLRED FOR ARR ROUTING, FLC FAILED TO INSERT AN ARR FIX IN FMC AND ACFT WAS 35 MI OFF COURSE WHEN CTLR INTERVENED WITH HDG VECTOR.
    Narrative: WE WERE CLRED DIRECT TO CRG THEN LLAKE 2 ARR INTO WEST PALM BEACH, FL. UPON SELECTING THE ARR IN THE FMC, WE FAILED TO NOTICE THAT INPIN INTXN WAS NOT LOADED. WHEN CTLR QUERIED US AFTER PASSING CRG (GOING DIRECT TO LLAKE INSTEAD OF INPIN) WE WERE ABOUT 35 MI E OF COURSE. HE GAVE US A VECTOR TO REJOIN THE ARR. WHEN WE ASKED, THE CTLR STATED THERE WAS NO CONFLICT.

  309.  
  310. Accession Number: 386340
    Synopsis: AN ACR DC9 FLC DSND BELOW THE GS INTERCEPT ALT WHILE STILL OUTSIDE OF THE OM. THE AUTOPLT SYS HAD DEFAULTED TO THE VERT SPD MODE WHEN IT WAS ACTIVATED AND ARMED FOR INTERCEPT WHILE BELOW THE GS AND THE CAPT DID NOT RECOGNIZE THIS.
    Narrative: WE HAD JUST RECEIVED APCH CLRNC AND HAD JOINED THE LOC OUTSIDE THE OM. WE HAD NOT YET INTERCEPTED THE GS AND WERE ABOVE THE MINIMUM GS INTERCEPT ALT. THE CAPT (PF) BEGAN A DSCNT TO MINIMUM GS INTERCEPT ALT (AT LEAST I THOUGHT). AS WE APCHED THE ALT, THE CAPT DID NOT APPEAR TO BE LEVELING OFF. I ANNOUNCED THAT I WAS NOT RECEIVING GS INDICATIONS ON MY HSI AND ADI. HE IMMEDIATELY COMMANDED A GAR. WE WERE REVECTORED FOR THE APCH AND LANDED WITHOUT FURTHER INCIDENT. I BELIEVE PART OF THE CONFUSION ON THE CAPT'S PART WAS THAT HE WAS HAND FLYING WHEN WE INITIATED OUR DSCNT TOWARD GS INTERCEPT ALT. DURING THIS, HE ASKED ME TO ENGAGE THE AUTOPLT AND ARM THE ILS CAPTURE. BECAUSE HE WAS BENEATH THE GS AT THE TIME, THE AUTOPLT WOULD REMAIN IN VERT SPD MODE UNTIL GS CAPTURE. APPARENTLY HE MUST HAVE THOUGHT THE AUTOPLT CAPTURED. BETTER COMS AND CHOICE OF WORDS ON MY PART MAY HAVE PREVENTED THE GAR.

  311.  
  312. Accession Number: 386954
    Synopsis: AN MLG DSNDING IN ZNY AIRSPACE MISSES THE XING RESTR AT 20 MI W OF LHY, PA.
    Narrative: IN CRUISE BTWN CVG-SWF, ZNY CLRED ACFT FOR DSCNT. ACTUAL CLRNC 'CLRED DIRECT LHY CROSS 20 NM W AT FL190.' I STARTED DSCNT USING IAS FUNCTION OF AUTOPLT. I THEN PROGRAMMED THE FMS FOR THE RTE CHANGE AND ENTERED THE XING RESTR. HOWEVER, I NEVER SELECTED 'VNAV.' WHEN I NOTICED ACFT APCHING WAYPOINT (20 MI W LHY) FO CALLED TO MY ATTN WE WOULD HAVE TROUBLE MAKING THE ALT RESTR. WE LEVELED AT FL190 APPROX 5 MI LATE (15 NM SW LHY). CAUSE OF INCIDENT WAS MY LACK OF ATTN TO AUTOPLT/ACFT PERFORMANCE. A SIGNIFICANT FACTOR WAS THE VERY RECENT DEATH OF A VERY CLOSE RELATIVE (1 WK AGO) AND MY INABILITY TO CONCENTRATE AS WELL AS I USUALLY CAN. SUPPLEMENTAL INFO FROM ACN 387140: HE THEN PROGRAMMED THE FMS FOR THE RTE CHANGE AND ENTERED THE XING RESTR. 'NAV' WAS SELECTED. APCHING THE XING RESTR, I NOTICED THAT WE WERE GOING TO HAVE TROUBLE MAKING THE RESTR AND REALIZED THE CAPT NEVER ENGAGED 'VNAV.' THE CAPT INCREASED TO THE MAX RATE OF DSCNT AND LEVELED THE ACFT AT FL190 APPROX 5 NM LATE. THE CAUSE OF THE INCIDENT WAS LACK OF ATTN TO THE AUTOPLT/ACFT PERFORMANCE. COMPLACENCY AND OVERRELIANCE ON AUTOMATION WAS ALSO A CONTRIBUTING FACTOR.

  313.  
  314. Accession Number: 387250
    Synopsis: FLC OF AN EMBRAER BRASILIA EMB120 (E120), OVERSHOT CLB ALT DUE TO THE AUTOPLT CAPTURE WAS NOT TURNED ON RESULTING IN ATC INTERVENTION TO BRING THEM BACK TO ASSIGNED ALT.
    Narrative: SET ALT ALERTER AT 20000 FT AS PER OUR CLRNC. ALT CAPTURE WAS DISENGAGED FOR UNKNOWN REASON. AUTOPLT DID NOT CAPTURE AND ATC ADVISED US AS WE CLBED THROUGH 20700 FT. NO FURTHER MENTION FROM CTR OF THE DEV.

  315.  
  316. Accession Number: 388280
    Synopsis: RPTED ALTDEV WHEN ACFT DSNDED BELOW ASSIGNED ALT APPARENTLY DUE TO AUTOPLT PROB.
    Narrative: IN CRUISE AT FL310, FO FLYING, AUTOPLT ON, LNAV ON, VNAV ON, FO IS BRIEFING ILS DME RWY 34L APCH TO SLC. WHEN FO NOTICES ACFT DSNDING VERY SLOWLY PASSING THROUGH FL306, FO IMMEDIATELY KICKED OFF AUTOPLT, HAND FLEW ACFT BACK TO FL310. TRIED 'A' AND 'B' AUTOPLTS, NO HELP. ACFT WAS TOO ERRATIC TO FLY IN PITCH SO HE HAND FLEW IT. LATER, DISCOVERED A FLT CTL 'SPD TRIM FAIL.' NO COMMENT WAS MADE TO US ABOUT ALTDEV. REST OF FLT UNEVENTFUL.

  317.  
  318. Accession Number: 388490
    Synopsis: INBOUND TO EWR ARPT, ACR FLC WAS UNABLE TO MAKE A TIMELY FMS INPUT FOR AN INTXN ALT XING RESTR ON A STAR, CAUSING THE FLC TO TAKE BACK MANUAL CTL OF ACFT. FLC ADVISED ATC THAT THEY WERE UNABLE TO MEET RESTR. THOUGH ATC EXPRESSED DISPLEASURE, FLT PROCEEDED ON COURSE TO DEST.
    Narrative: ENRTE FROM BUF TO EWR, ZBW CLRED US DIRECT TO CRANK INTXN TO INTERCEPT SHAFF 3 ARR, TO CROSS CRANK INTXN AT 7000 FT MSL. FMC WAS PROGRAMMED AND DSCNT BEGUN. AT 10500 FT MSL, THE ACFT HAD NOT BEGUN TO SLOW DOWN TO 250 KTS. WE TOOK OVER MANUALLY AND REALIZED THAT WE WOULD NOT MAKE CRANK INTXN AT 7000 FT MSL. I NOTIFIED ZBW, HE WAS VERY MAD. I ASKED FOR A VECTOR FOR DSCNT. NOTHING ELSE SAID.

  319.  
  320. Accession Number: 388890
    Synopsis: AN ACR B737 FLC GOT OFF COURSE WHEN THEY LEFT THE CANNED FLT PLAN IN THE FMS INSTEAD OF THE 'AS CLRED' FLT PLAN.
    Narrative: UPON INITIAL PROGRAMMING OF THE FMS, THE 'COMPANY RTE' STORED IN THE FMS WAS VERIFIED WITH THE 'CANNED RTE' INSTEAD OF THE FILED RTE ON THE FLT RELEASE. THE COMPANY RECENTLY CHANGED FROM USING 'CANNED' FLT PLANS TO FILING INDIVIDUAL FLT PLANS. THE RTES WERE THE SAME UNTIL MEM WHERE THE 'CANNED' RTE WAS MEM J29 PXV AND THE FILED RTE WAS MEM J35 FAM. PASSING MEM AND JOINING J29 THE CTR CTLR ADVISED THAT WE APPEARED E OF COURSE. WE REALIZED THE ERROR, CORRECTED THE FMS ROUTING TO THE FILED ROUTING AND CORRECTED COURSE. FATIGUE CONTRIBUTED. THE PREVIOUS DAY WAS A 13.5 HR DUTY DAY WITH 7.5 BLOCK FLT TIME FOLLOWED BY 10 HRS REST WITH AN XB50 (BODY CLOCK TIME ZONE) RPT. XA00 BODY TIME GET UP.

  321.  
  322. Accession Number: 390900
    Synopsis: WDB ACFT IN CRUISE AND ON LNAV. ACFT WENT OFF TRACK WHEN LNAV REVERTED TO HEADING HOLD MODE. ATC INTERVENED ALERTING FLC TO COURSE DEV.
    Narrative: ACFT HAD BEEN TRACKING THE FMS FLT PLAN RTE IN LNAV FOR THE PAST HR. CTR CALLED AND ASKED OUR NEXT FIX ON RTE OF FLT. WE REPLIED DOPHN. CTR SAID WE WERE SLIGHTLY N OF TRACK. WE THEN NOTICED LNAV HAD DISENGAGED AND WE WERE APPARENTLY IN HEADING HOLD MODE. (HEADING MODE WAS NOT ANNUNCIATED.) WE IMMEDIATELY CORRECTED BACK TO TRACK. WE APPARENTLY WERE ONLY A FEW MI OFF TRACK. LNAV WAS RE- ENGAGED AND TRACKED NORMALLY THE REST OF FLT. WE HAVE NO IDEA WHAT CAUSED THE MOMENTARY LNAV DISENGAGEMENT.

  323.  
  324. Accession Number: 390916
    Synopsis: AN A320 FLC TURNS THE WRONG WAY IN THE HOLDING PATTERN AT PHX AND HAS A POTENTIAL CONFLICT WITH ANOTHER ACR MLG. PIC WAS USING THE STANDARD FORMAT AS CONTAINED WITHIN THE FMC'S DATABASE FOR A R TURN.
    Narrative: WE WERE ON THE MISSED APCH PROC FOR RWY 26R. WE WERE THE SECOND ACFT TO MISS THE APCH FOR GND FOG THAT WOULD LAST FOR OVER 1 HR. THE APCH FREQ WAS VERY CONGESTED AS WELL AS THE COMPANY FREQ. SHORTLY AFTER WE MISSED THE APCH, THE CAPT TOLD ME TO GO TO COMPANY. I WAS OFF THE APCH FREQ DURING MOST OF THE VECTORING. WHEN I CAME BACK TO THE APCH CTL, I WAS TOLD THAT WE WERE TO EXPECT A HOLD AT A FIX ON ANOTHER RWY EXTENSION. THE CTLR THEN CHANGED THE FIX TO 'PRUNN' AND CLEARLY SAID HOLD 'E OF PRUNN ON THE LOC AT 5000 FT WITH L HAND TURNS.' AT THIS POINT WE WERE INTERCEPTING THE LOC. I READ BACK THE HOLDING INSTRUCTIONS AND SAW THE CAPT BUILDING THE HOLD IN THE FMCS. I LOOKED AT THE SCREEN TO SEE WHERE WE WERE AND I SAW PRUNN DIRECTLY IN FRONT OF US, BUT I FAILED TO NOTICE THE R HAND TURN. MOMENTS LATER, I MADE A POS RPT AS WE CROSSED OVER THE FIX, 'FLT X, OVER PRUNN AT 30 MINS PAST THE HR AT 5000 FT.' THE PLANE BEGAN ITS TURN AND THE CTLR IMMEDIATELY CAME BACK, 'FLT X, ARE YOU TURNING L?' CAPT TOOK THE ACFT OFF AUTOPLT AND SAID 'TELL HIM WE ARE TURNING BACK L NOW.' I SAID 'YES, WE ARE TURNING BACK TO THE L.' THEN ATC SAID 'YOU HAVE TFC AHEAD,' AND TOLD US 'TO DSND TO 4000 FT AND TURN L TO 210 DEGS.' CAPT AND I BOTH IMMEDIATELY SAW THE ACR Y JET AND HEARD A TFC ALERT ON TCASII BUT GOT NO RA. WE CONTINUED WITH VECTORS UNTIL WE WERE RE-ESTABLISHED IN THE HOLD AGAIN. FACTORS CONTRIBUTING WERE FATIGUE. WE STARTED THE TRIP ON NIGHTS FLYING FROM XA00 PM TO XM00 AM PHX TIME, AND REVERSED TO DAYS FLYING FROM XM00 AM TO XA00 PM ON THE 3RD AND 4TH DAYS OF THE TRIP. WE HAD BOTH COMPLAINED ABOUT FATIGUE. IN THE AIRBUS FMCS, THERE WAS A STANDARD HOLD AT PRUNN IN THE DATA BANK. THE CAPT DID NOT HEAR THE CTLR SAY 'L HAND TURNS' SO HE ENTERED THE PUBLISHED HOLD AT PRUNN. I WAS SO OVERLOADED BY CHANGING BACK AND FORTH BTWN DISPATCH AND APCH, THAT I DID NOT CATCH HIS MISTAKE.

  325.  
  326. Accession Number: 391160
    Synopsis: B737-300 AUTOPLT FAILS TO CAPTURE FL190. IT OVERSHOT ALT TO FL185. CAPT HAD TO HAND FLY IT UP TO FL190.
    Narrative: CLRED TO FL190. NOTICED AUTOPLT DID NOT CAPTURE ALT. TURNED OFF AUTOPLT AND MANUALLY CLBED BACK TO FL190. ACFT BOTTOMED OUT AT ABOUT FL185.

  327.  
  328. Accession Number: 391328
    Synopsis: CAPT OF A SUPER MD80 DSNDED BELOW ASSIGNED ALT DURING DSCNT DUE TO AN AUTOPLT ALT CAPTURE PROB. HE RETURNED ACFT TO ASSIGNED ALT AND THEN CAUGHT ERROR BEFORE THE ACFT PASSED LEVELOFF ALT DURING SUBSEQUENT DSCNTS.
    Narrative: FLYING ON #2 AUTOPLT, WAS GIVEN CLRNC TO DSND TO FL200 DURING APCH TO RSW. ALT WAS SET AND ARMED. APCHING LEVELOFF, AMBER ALT LIGHT ON FMA WENT OUT BUT AUTOPLT FAILED TO CAPTURE ALT. ACFT NOTED PASSING THROUGH FL200 VERT SPD WHEEL WAS ROLLED UP AND ALT HOLD SELECTED. ACFT STOPPED DSCNT 400 FT BELOW FL200. VERT SPD CLB AND FL200 RESELECTED. BEFORE REACHING FL200 CTR ISSUED CLRNC TO 13000 FT. SAME OCCURRENCE WITH AUTOPLT LEVELOFF AT 13000 FT AND SUBSEQUENT 11000 FT CLRNC. HOWEVER, CLOSER MONITORING PREVENTED ALTDEV. TWO OTHER AUTOPLT MALFUNCTIONS DURING FLT, RELATED TO TURNS. AUTOFLT WRITE- UP MADE AT FLT TERMINATION.

  329.  
  330. Accession Number: 391630
    Synopsis: B737-300 FLC MISPROGRAMS FMS ON RECEIVING DSCNT CLRNC CHANGE AND HAS AN ALTDEV.
    Narrative: WE WERE FLT PLANNED TO ARRIVE DFW VIA THE BOWIE (UKW) ARR. FMS WAS PROGRAMMED TO CROSS KAJAY INTXN AT THE EXPECTED ALT OF FL240, AND ALSO PROGRAMMED TO CROSS BAMBE INTXN AT 11000 FT. PRIOR TO REACHING THE UKW 287 DEG RADIAL, IN THE VICINITY OF TXO, WE WERE RECLRED DIRECT UKW, WHICH ELIMINATED THE FMS PROGRAMMED DSCNT TO FL240 AT KAJAY. FMS DSCNT PROFILE IS NOW COMPUTED TO CROSS BAMBE AT 11000 FT. WHILE PROCEEDING DIRECT UKW, WE WERE CLRED TO CROSS 40 DME W OF UKW AT FL240, PLT DISCRETION. WE REPROGRAMMED THE FMS WITH A NAV POINT 40 DME W OF UKW, BUT APPARENTLY FAILED TO INCLUDE THE ALT CONSTRAINT OF FL240, SO THE FMS DSCNT PROFILE WAS PREDICATED ON REACHING BAMBE INTXN AT 11000 FT. THE REASON FOR THIS OVERSIGHT IS UNKNOWN, BUT PROBABLE CAUSES ARE CREW INVOLVEMENT WITH ARR PROCS (APCH BRIEFING, CONTACTING COMPANY FOR GATE ASSIGNMENT, ETC) AND DISTR DUE TO A CALL FROM THE LEAD FLT ATTENDANT TO RPT CABIN MAINT DISCREPANCIES OR PAX SPECIAL ASSISTANCE REQUESTS UPON ARR. IN ANY CASE, THE FMS VNAV FUNCTION INITIATED ITS DSCNT ACCORDING TO THE PROFILE FOR MEETING THE BAMBE AT 11000 FT RESTR. WHILE IN THE DSCNT, CTR SUBSEQUENTLY CLRED US TO CROSS BAMBE AT 11000 FT, WHICH LEGALLY CANCELED THE 40 DME AT FL240 RESTR. APCHING THE 40 DME FIX, WE REALIZED WE WERE TOO HIGH TO REALISTICALLY MEET THE PREVIOUS RESTR, AND QUESTIONED OURSELVES AS TO WHY WE WERE IN THAT POS, AND THE MOST LOGICAL REASON WAS THAT WE PROBABLY FAILED TO ENTER THE ALT CONSTRAINT INTO THE FMS AND FAILED TO BACK IT UP WITH RAW DATA NAV DUE TO CREW PREOCCUPATION WITH ANCILLARY DUTIES. LESSON LEARNED IS NOTHING NEW: THE PRIORITIES ARE 1) AVIATE, 2) NAV, 3) COMMUNICATE, AND 4) CHKS.

  331.  
  332. Accession Number: 391856
    Synopsis: WDB OVERSHOT ASSIGNED ALT ON DSCNT DUE TO NOT MONITORING AUTOPLT LEVELOFF AT THE PRESELECTED ALT.
    Narrative: LAST LEG ON 3 DAY TRIP. ON EXTENDED FLAP FOR RWY 19R DUE TO WX. AFTER NUMEROUS VECTORS OFF APCH AND BACK ON, WE WERE GIVEN DSCNT FROM 6000 FT TO 5000 FT. PNF (CAPT) SET 5000 FT IN WINDOW, AND BOTH PLTS POINTED AND CONFIRMED. ALT ARM LIGHT WAS ON. I NOTICED WE WERE A COUPLE HUNDRED FT TO LEVEL OFF AND TURNED TO RECHK MY ENGINEER PANEL. WHEN I TURNED BACK I NOTICED WE HAD DSNDED BELOW (PASSING 4900 FT) 5000 FT. AS I STARTED TO SAY SOMETHING THE CAPT CALLED OUT THE DEV. THE FO MADE A SMOOTH RECOVERY TO 5000 FT, BUT THE ACFT WENT DOWN TO APPROX 4600 FT. ATC DID NOT SAY ANYTHING DURING OR AFTER THE DEV. IN RETROSPECT I SHOULD HAVE MONITORED THE PLTS THROUGHOUT THE DSCNT AND LEVELOFF, INSTEAD OF TRUSTING THE AUTOPLT.

  333.  
  334. 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.

  335.  
  336. Accession Number: 392166
    Synopsis: AN L1011 DSNDING IN ZLC AIRSPACE FAILS TO PROGRAM THE COMPUTER ROUTING PROPERLY AND CROSSES THE ASSIGNED WAYPOINT 2000 FT HIGH.
    Narrative: DURING INITIAL FMS LOADING/VERIFICATION OF RTE SPANE-FFU- SLC DID NOT INCLUDE OTHER POINTS ON SID. ENRTE ENTRY OF ADDITIONAL POINTS FOR LNDG TO S AT SLC. BOAGY WAS INSERTED ERRONEOUSLY PRIOR TO SPANE INSTEAD OF AFTER SPANE. WE NOTED DSCNT CLRNC SEEMED SOMEWHAT EARLY FOR XING SPANE AT FL190, BUT DIDN'T PICK UP ON THE FACT THAT RTE WAS BOAGY DIRECT SPANE INSTEAD OF SPANE DIRECT BOAGY. DSCNT OF ABOUT 1000 FPM INITIATED FOR ARR AT FL190 AND 280 KTS PRIOR TO SPANE. CTR CALLED TO QUESTION OUR NAV. NOTED WE WERE N OF COURSE. WENT TO MANUAL NAV, XCHKED DIRECT ON FMS AND REALIZED THE ERROR. CTR ASSIGNED US A HDG FOR VECTORS FOR APCH AND I INITIATED AND EXPEDITED DSCNT WITH SPD BRAKES TO ATTEMPT TO REGAIN ALT COMPLIANCE. FURTHER DSCNT CLRNC TO 17000 FT ALSO ISSUED WITH VECTOR. ALTHOUGH NO MENTION WAS MADE OF ALT OR XING PROB BY CTR, I ASSUME WE WOULD NOT HAVE BEEN IN COMPLIANCE BY SPANE AS WE WERE NEARLY THERE WHEN CORRECTIVE ACTION INITIATED AND VECTOR ISSUED. HDOF TO APCH WAS GIVEN BY CTR, SO NO FOLLOW-UP WAS AVAILABLE FROM ATC AND APCH CONTINUED NORMALLY. TO THE BEST OF MY KNOWLEDGE, THERE WAS NO CONFLICT WITH ANY OTHER TFC. A CLOSER REVIEW OF THE SID OR A FOLLOW-UP ON THE QUESTION OF THE EARLY DSCNT RAISED WOULD HAVE CAUGHT THE PROGRAMMING ERROR. SUPPLEMENTAL INFO FROM ACN 392023: APCHING SLC WE WERE GIVEN CLRNC TO CROSS SPANE AT FL190. WE THOUGHT CLRNC SEEMED 'EARLY' DUE TO DISTANCE TO SPANE. WE BEGAN DSCNT TO REACH SPANE AT FL190 BASED ON BAD DATA. AT ABOUT 5 MI FROM SPANE ATC SAID THEY SHOWED US ABOUT 5 MI N OF ARR TRACK. THIS IS WHEN WE NOTICED PROGRAM ERROR. WE WERE AT FL230. WE IMMEDIATELY WENT TO MANUAL NAV (VOR) AND EXPEDITED DSCNT. WE MISSED OUR SPANE RESTR BY ABOUT 2000 FT. ALTHOUGH BOAGY WAS VERIFIED AS A CORRECT FIX ON THE SPANE 3 ARR WE MISSED THE FACT THAT IT WAS INSERTED IN THE WRONG LOCATION. HAD WE BEEN MORE DILIGENT IN THE RTE CHANGE OR QUESTIONED 'EARLY' DSCNT CLRNC FOR SPANE, THIS ERROR WOULD NOT HAVE OCCURRED.

  337.  
  338. Accession Number: 392910
    Synopsis: A B737-300 FLYING IN ZME AIRSPACE FOLLOWS THE WRONG AIRWAY. FLT PLAN WAS NEVER CHKED AGAINST CLRNC RECEIVED.
    Narrative: ACR FLT ABC DEPARTED JACKSON, MS, ENRTE TO MDW. LEVEL CRUISE FLT. HAD THE AUTOPLT FLYING LNAV ROUTING THAT SHOWED MEM J29 PXV, WHEN OUR ACTUAL ROUTING FROM OUR DISPATCH (AND THE RTE GIVEN TO US BY CLRNC DELIVERY IN JAN) WAS MEM J35 FAM. AUTOPLT JOINED J29 AND SHORTLY THEREAFTER THE ZME CTLR ADVISED US WE WERE SUPPOSED TO BE ON J35. WE TURNED L TO JOIN THE AIRWAY, REPROGRAMMED THE CDU FOR PROPER ROUTING AND CONTINUED TO DEST. NO TFC CONFLICTS WERE ADVISED BY ZME, AND NONE ON TCASII. I SHOULD HAVE STUDIED THE COMPLETE RTE IN THE CDU AND COMPARED WITH THE FILED ROUTING. SUPPLEMENTAL INFO FROM ACN 392524: FLT FROM JACKSON, MS, TO MDW, IL. FLT PLAN FILED BY COMPANY DISPATCH (JAN DIRECT SQS J35 CAPITAL.MOTIF ARR) DIFFERED FROM STANDARD COMPANY RTE STORED IN ACFT FMS (JAN DIRECT SQS J35 MEM J29 PXV DIRECT TTH DIRECT BVT.BVT2 ARR). CAPT WAS FLYING, AUTOPLT ENGAGED, LNAV MODE SELECTED. I (FO) WAS 'BACKING UP' NAV ON VOR (J35 COURSE INBOUND TO MEM). JUST PRIOR TO MEM, FLT ATTENDANT CAME IN COCKPIT TO TAKE COFFEE ORDERS. SHE RETURNED WITH COFFEE, STARTED ASKING ABOUT COMPANY'S HIRING REQUIREMENTS, AS HER BROTHER IS WANTING TO APPLY. ACFT MAKES SLIGHT R TURN TO INTERCEPT J29 OVER MEM (INSTEAD OF STAYING ON J35, AS FILED). APPROX 10 DME N OF MEM, CTR CTLR ASKS IF WE'RE TURNING TO INTERCEPT J35, SHOWS US E OF COURSE. CAPT REALIZES WRONG TURN BY FMS/LNAV. HE SELECTS HDG MODE, TURNS FOR J35 INTERCEPT. SOON AFTER, CTLR GIVES US FREQ CHANGE. NEW CTLR GIVES US DIRECT CAP. REST OF FLT UNEVENTFUL. CONTRIBUTING FACTORS: DISTR BY FLT ATTENDANT'S SVC, QUESTIONS DURING APCH TO AND OVERFLT OF MEM VOR. HAD ARRIVED EARLY AT JAN ON PREVIOUS LEG. HAD NOT RECEIVED RELEASE WITH DISPATCH FILED FLT PLAN INFO YET WHEN FMS LOADED WITH CANNED COMPANY RTE. DIDN'T HAVE IT TO COMPARE THE TWO. SHOULD HAVE COMPARED PRIOR TO PUSHBACK ONCE RELEASE PAPERWORK WAS BROUGHT TO COCKPIT.

  339.  
  340. Accession Number: 393524
    Synopsis: L1011 ACFT CLBED TO FIND SMOOTH AIR AND AFTER LEVELOFF AUTOTHROTTLES MALFUNCTIONED. #2 THROTTLE WAS FORWARD AND #1 AND #3 WERE PULLED BACK RESULTING IN DETERIORATING AIRSPD. SPD WAS LOW ENOUGH THAT RPTR HAD TO DSND TO GET SPD BACK.
    Narrative: WE WERE REROUTED BY ATC DUE TO RPTS OF MODERATE TO SEVERE TURB ON OUR ORIGINAL RTE. FLT CTL HAD ADVISED US THIS MIGHT HAPPEN. WE ENCOUNTERED LIGHT TO MODERATE DURING OUR CLB TO FL370. FL390 WAS RPTED SMOOTH SO WE ASKED FOR AND RECEIVED CLRNC TO FL390. AT LEVELOFF THE AUTOPLT AND AUTOTHROTTLES CAPTURED NORMAL CRUISE. IT WAS SMOOTH. I TURNED OFF THE SEAT BELT LIGHT AND WENT TO USE THE RESTROOM. THE COPLT WAS ON OXYGEN AND EVERYTHING WAS NORMAL. AS I RETURNED TO THE COCKPIT A SHORT TIME LATER, I BEGAN TO FEEL SOME TURB. I QUICKLY GOT INTO MY SEAT AND AS I DID SO, I NOTICED THE AIRSPD WAS DOWN TO APPROX 205 KTS AND ENG #2 THROTTLE WAS FORWARD WHILE #1 AND #3 PULLED BACK. I DISCONNECTED THE AUTOPLT AND AUTOTHROTTLES, PUSHED FORWARD ON THE CTL COLUMN AND PUSHED THROTTLES #1 AND #3 UP WHILE CALLING FOR MAX CLB. THE AIRPLANE WOULD NOT ACCELERATE AND HAD DIFFICULTY MAINTAINING ALT. I TOLD THE COPLT TO ASK FOR A LOWER ALT. HE WAS STILL WEARING HIS OXYGEN MASK SO I COULDNÃūT TELL WHETHER OR NOT HE WAS REQUESTING LOWER. HE PULLED THE MASK OFF AND SAID WE ARE CLRED A BLOCK ALT OF FL390 TO FL370. WE WERE FL388 AT THE TIME. I DUMPED THE NOSE SLIGHTLY AND LEVELED OFF AT FL370 AT NORMAL CRUISE SPD. ALTHOUGH WE NEVER GOT BELOW STALL SPD DURING THE INCIDENT, WE NEVERTHELESS DID ENCOUNTER SOME SLIGHT BUFFETING DUE TO THE HIGH ALT AND TURBULENT ENVIRONMENT. WE MADE A TURB RPT TO CTR AND WROTE UP THE AUTOTHROTTLES. THE WHOLE INCIDENT COULD HAVE BEEN AVOIDED IF THE CAPT HAD BRIEFED AND WARNED THE CREW ABOUT THE 'NOTORIOUS' AUTOTHROTTLES ON THE L1011.

  341.  
  342. Accession Number: 393990
    Synopsis: FLC OF MD82 NEGLECTS TO ARM THE ALT ALERT DURING CLB. THERE IS CONFUSION IN THE COCKPIT AS TO ASSIGNED ALT SO THEY QUERY ATC WHO ASSIGNS ALT CLOSE TO THEIR PRESENT ALT.
    Narrative: ALT ALERT SYS WAS NOT ARMED (ERRONEOUSLY) PRECLUDING AUTOMATIC CAPTURE OF ALT. BOTH FO AND MYSELF RECALLED LAST ALT CLRNC AS 17000 FT. PASSING THROUGH FL190, AUTOPLT WAS DISCONNECTED. ZNY WAS QUERIED WITH REGARD TO ALT CLRNC AND ADVISED ACFT WAS AT FL195. CTR RESPONDED THAT WE SHOULD LEVEL OFF AT FL200 AND XFERRED US TO ANOTHER SECTOR. THE FO ON 2 PREVIOUS OCCASIONS HAD FAILED TO PROPERLY ARM THE ALT SYS. WE MAY HAVE BEEN CLRED TO FL200, BUT THE FACT THAT THE ALT ALERT SYS HAD NOT BEEN ARMED RAISED QUESTIONS IN BOTH OF OUR MINDS. FL200 WAS SET IN THE ALT ALERT WINDOW.

  343.  
  344. Accession Number: 394740
    Synopsis: A B757 OVERSHOT ITS ASSIGNED ALT OF FL190 BY 400 FT. ACFT HAD BEEN ON AUTOPLT AND AT A HIGH RATE OF CLB.
    Narrative: CAPT WAS HAND FLYING. AFTER CONTACTING DEP WE WERE CLRED TO 10000 FT ON A N HDG. PASSING THROUGH 8300 FT MSL, ATC TOLD US TO LEVEL AT 8000 FT. CLB WAS STOPPED AND STARTING DSCNT TO 8000 FT WE WERE RECLRED TO 10000 FT WITH A 120 DEG TURN TOWARDS THE E, AWAY FROM ANOTHER ACFT AT 10000 FT. ZDC LATER CLRED US UP TO FL190. THE ALTIMETER SETTING WAS 29.52. DUE TO TFC, AUTOPLT WAS ENGAGED. THE ACFT WAS LIGHT AND 'ALT CAPTURE' OCCURRED AT 17000 FT. AT 17300 FT ALTIMETER WAS RESET TO 29.92. REACHING FL190 ACFT LEVELED OFF. HOWEVER, IT CONTINUED UP TO FL193, AT WHICH TIME THE ALT ALERT SIGNALED US THAT A DEV HAD OCCURRED. ATC ALSO QUESTIONED US BECAUSE THEY SHOWED US AT FL194. IN FACT, BY THIS TIME, WE TOUCHED FL194. ACFT WAS MANUALLY FLOWN BACK TO FL190 WHICH WAS THE ALT SET ALL ALONG IN THE MODE SELECTOR PANEL. BECAUSE THE AIRPLANE HAD BEEN ON AUTOPLT AND WE WERE LOOKING OUTSIDE FOR TFC AND THE SUN WAS RISING IN OUR EYES, I FAILED TO NOTICE THE ALTDEV. WE CALLED OUR MAINT BASE, SUSPECTING THAT THE LARGE ALTIMETER DIFFERENCE WAS TOO LARGE FOR THE AIRPLANE SYS TO ACCOMMODATE IN JUST A FEW HUNDRED FT (GOING THROUGH 17000 FT TO FL190), PARTICULARLY AFTER ENGAGING IN THE ALT CAPTURE MODE. THEY THOUGHT SO, TOO. THIS IS SOMETHING TO REALLY PAY ATTN TO WHEN TRANSITION LEVELS AND LEVELOFFS NEAR THEM INVOLVE LARGE DIFFERENCES IN ALTIMETER CHANGES, ESPECIALLY WHEN NOT HAND FLYING, BUT RELYING ON AUTOMATED SYS. I DON'T THINK THERE WAS A CONFLICT WITH ANY OTHER ACFT.

  345.  
  346. Accession Number: 395103
    Synopsis: B737-400 ACFT ON COUPLED APCH, PF, FO DSNDS BELOW THE APCH PROFILE, BUT CORRECTS BACK WHEN RECOGNIZING THE 'PICTURE' DOESN'T LOOK RIGHT. COCKPIT CONFLICT CONTRIBUTES.
    Narrative: THE EVENT BEGAN WITH THE EXECUTION OF AN RNP APCH. WE SET UP THE APCH AS TRAINED AND FOLLOWED THE APPROPRIATE CHKLIST. 99% OF THE TIME I HAND FLY APCHS, SO AT 10000 FT ON THIS APCH, I UNCOUPLED THE AUTOPLT. AS SOON AS I DID THE CAPT GOT UPSET AND SAID, 'WHAT ARE YOU DOING? WE HAVE TO LEAVE IT COUPLED!' WHICH IS NOT TRUE. NOT WANTING TO CREATE ANY CONFLICT, I RE-ENGAGED THE AUTOPLT. THEN HE MADE A COMMENT LIKE, 'OH, GO AHEAD AND HAND FLY IT.' I CHOSE NOT TO. WE ENTERED VMC CONDITIONS PRIOR TO THE FAF, AT WHICH POINT I QUIT REFING MY APCH PLATE. INSTEAD I WAS LOOKING OUT AT THE ARPT THINKING ABOUT LNDG ON RWY 8. I SOON REALIZED THAT 'THE PICTURE' DIDN'T LOOK RIGHT AND THAT WE WERE MUCH LOWER THAN WE SHOULD HAVE BEEN. WE WERE APCHING 800 FT MSL INSTEAD OF BEING AT 1270 FT WHERE WE SHOULD HAVE BEEN. WITHOUT HESITATION, I DISCONNECTED THE AUTOPLT AND AUTOTHROTTLES AND CLBED BACK UP TO 1000 FT MSL. AT THIS POINT WE WERE NEAR CGL NDB. ONCE PAST CGL I MADE THE TURN THROUGH 'THE CUT' TO LINE UP AND LAND ON RWY 8. I BELIEVE THAT THE PROB STEMMED FROM: 1) MY NEWNESS TO THE AIRPLANE. 2) BEING ON REVERSE AND VERY SELDOM FLYING (COMMON COMPLAINT WITH NEW B737-400 FO'S HERE AT ACR X). 3) SECOND TIME I'VE FLOWN THE APCH (FIRST TIME AS THE PF). 4) CAPT WAS VERY CTLING, NONSTANDARD (I'D BEEN INFORMED OF THIS THE DAY BEFORE BY A CHK AIRMAN AND ALSO TOLD BY THIS PERSON THAT 'A LOT OF FO'S DON'T LIKE TO FLY WITH THIS GUY') AND HE WAS ABRASIVE WHICH CAUSED ME TO MENTALLY DISTANCE MYSELF FROM THE COCKPIT. 5) CAPT 'PLAYED' BY HIS OWN RULES, WHICH MADE MATTERS VERY CONFUSING SINCE I WAS NEVER SURE WHAT HE WANTED AND HE COULDN'T RELATE WHAT HE WANTED. SINCE THE CAPT HAD BEEN AT ACR X FOR 14 YRS AND ACTED LIKE HE WAS VERY KNOWLEDGEABLE ABOUT FLYING IN SOUTHEAST ALASKA, I TENDED TO LET MYSELF BE LED LIKE A STUPID SHEEP OUT TO SLAUGHTER. I NEED TO NOT ALLOW MYSELF TO BE INTIMIDATED BY CAPTS LIKE THIS. ALTHOUGH I'M NEW AND RELATIVELY INEXPERIENCED IN THE AIRPLANE, I KNOW BETTER THAN TO STOP MONITORING THE COUPLED APCH, EVEN IN VMC.

  347.  
  348. Accession Number: 396392
    Synopsis: A G3 OVERSHOT THEIR ASSIGNED ALT WHEN THE AIR DATA COMPUTER FAILS TO RECOGNIZE THE ALT CAPTURE ALT AND DOES NOT LEVEL THE ACFT AT THE ALT ALERTER SETTING OF FL350. AN OPPOSITE DIRECTION MD80 GETS A TCASII TA.
    Narrative: GULFSTREAM ACFT WAS PROCEEDING WBOUND DIRECT TO FLYBY INTXN JUST W OF LVS VOR AT FL430 WHEN ZAB CLRED THEM TO DSND TO FL350. THE FO RESET THE ALT ALERT TO 35000 FT AND THE CAPT STARTED THE DSCNT ON AUTOPLT USING VERT SPD MODE AND APPROX 1500-1800 FPM RATE OF DSCNT SET ON THE SPZ-800 FLT DIRECTOR/AUTOPLT CTL. AS THE ACFT PASSED THROUGH FL360 THE FO CALLED OUT 1000 FT TO GO AND THE CAPT SLOWED THE RATE OF DSCNT SLIGHTLY. THE DSCNT PROCEEDED NORMALLY UNTIL APCHING FL350. AT 35100 FT THE FO CALLED OUT THAT THE AUTOPLT WAS NOT CAPTURING THE SELECTED ALT. THE CAPT IMMEDIATELY SELECTED ALT SELECT ON THE FLT GUIDANCE CTL PANEL BUT THE ACFT CONTINUED THROUGH THE ALT. THE AUTOPLT WAS THEN DISCONNECTED BY THE CAPT AND A PULL-UP MANEUVER EXECUTED. THE ACFT STARTED TO LEVEL AND REVERSE DIRECTION AS THE ALTIMETER INDICATED ABOUT 34700 FT AND WAS LEVEL AT 35000 FT APPROX 10 SECONDS LATER. I BELIEVE THE CONTRIBUTING FACTORS TO THIS INCIDENT TO BE THE POSSIBLE MALFUNCTION OF THE FLT DIRECTOR/AUTOPLT ALT HOLD FUNCTION AND THE CREW'S FAILURE TO REALIZE THAT THE AUTOPLT WAS NOT DOING ITS JOB UNTIL TOO LATE. ANOTHER FACTOR WAS THE CAPT HAD JUST COMPLETED 21 DAY INITIAL TRAINING ON AN ACFT WITH A VERY DIFFERENT FLT GUIDANCE CTLR (FMZ-8400). SUBSEQUENT CORRECTIVE ACTIONS: 1) A VISIT TO ZAB WAS MADE THE NEXT DAY BY THE PLT. 2) ALL ACFT SYS INCLUDING THE ADC'S, ALTIMETERS, FLT DIRECTOR COMPUTERS AND AUTOPLT WERE CHKED BY THE AVIONICS SHOP IN ALBUQUERQUE THE NEXT DAY. TWO DISCREPANCIES WERE FOUND: A) THE #1 XPONDER COULD NOT BE SUPPLIED DATA FROM THE #2 ADC, AND B) ON ONE ATTEMPT TO CAPTURE ALT, THE #2 FLT DIRECTOR FAILED. 3) CREW PROCS ARE BEING CHANGED SO THAT IN ADDITION TO THE NORMAL CALLOUT AT 1000 FT ABOVE OR BELOW THE ASSIGNED ALT OR RESTR THE COPLT WILL ALSO STATE 'RATE OF DSCNT 1000 FPM OR LESS AND FLT DIRECTOR ARMED.' 4) THE NEW PROC WILL BE SENT TO FLT SAFETY TO BE INCORPORATED INTO OUR FLC SEMI-ANNUAL TRAINING PROGRAM. 5) A CREW MEETING HAS BEEN SCHEDULED TO INFORM ALL PLTS OF THE NEW PROC AND TO EXPLAIN FURTHER THE LIMITATIONS OF THE AUTOPLT SYS. SUPPLEMENTAL INFO FROM ACN 396174: IMMEDIATELY FOLLOWING THIS AN MD80 AIRLINER AT FL330 RPTED TO ATC THEY WERE RECEIVING A TA ALERT ON TCASII. AT THAT TIME WE WERE QUESTIONED BY ATC AND TOLD TO CALL CTR ON THE GND. FROM THAT POINT ON A NORMAL DSCNT AND LNDG WERE MADE. WE HAVE TWO TYPES OF ACFT WITH TWO DIFFERENT FLT GUIDANCE COMPUTERS. ONE DOES NOT REQUIRE ACTIVATION OF ALT SELECT TO CAPTURE THE PRESELECTED ALT. AFTER FLYING THIS ONE TYPE FOR A NUMBER OF TRIPS AND THEN SWITCHING ACFT, IT DOES TAKE A CONTINUOUS EFFORT TO MAKE SURE ALT SELECT IS SELECTED. RECOMMENDATIONS: THE PNF SHOULD CALL '1000 FT TO GO, ALT SELECT.'

  349.  
  350. Accession Number: 396430
    Synopsis: A B737-500 IS 2000 FT HIGH XING THE ASSIGNED INTXN DURING DSCNT INTO ZHU, TX, AIRSPACE.
    Narrative: WAS TOLD BY ZHU TO CROSS SMITH INTXN AT 10000 FT AND 250 KTS. HAD NOT PROGRAMMED COMPUTER FOR 10000 FT BUT HAD PROGRAMMED ILS RWY 27 AT IAH. COMPUTER STARTED ACFT DOWN BASED ON FINAL APCH FIX ALT WHICH PUT US 2000 FT HIGH AT 300 KTS AT SMITH. DIDN'T REALIZE I WAS HIGH UNTIL 8 MI OUTSIDE OF SMITH WHEN ZHU ASKED IF WE WOULD MAKE XING RESTR. PROB WAS CAUSED BY TWO OF MOST COMMON CAUSES. AUTOMATION COMPLACENCY ON MY PART, AND DISTR CAUSED BY FLT ATTENDANT BEING IN COCKPIT AT CRITICAL TIME.

  351.  
  352. Accession Number: 396950
    Synopsis: FO OF A B767 MISSET FMS DURING AN ARR STAR RESULTING IN EXCEEDING A SPD XING RESTR.
    Narrative: DSNDING ON THE CHINS 2 ARR IN SEA, VERY FAMILIAR WITH THIS PROC. I CONSIDER MYSELF ADEPT AT ALL LEVELS OF AUTOMATION ON B767 AND MOVE COMFORTABLY BTWN THE VARIOUS LEVELS. HAD PREVIOUSLY PROGRAMMED THE VNAV WITH 250 KT SPD AT AUBURN INTXN BUT WAS USING FLT LEVEL CHANGE. WHEN THE ACFT REACHED SELECTED ALT, IT REVERTED TO THE HIGH SPD SET IN THE MCP, AS IT IS PROGRAMMED TO DO. BOTH THE CAPT AND I WERE BUSY DURING THE ARR. AFTER PASSING AUBURN AND TURNING TO 340 DEG HDG, I REALIZED I HAD FAILED TO SLOW TO 250 KTS. THE TURN WAS FURTHER WIDENED BY THE FACT I HAD NEGLECTED TO DESELECT THE 2.5 DEG BANK ANGLE I USE ABOVE FL180 (AND NORMALLY RESET ON DSCNT THROUGH FL180). I BELIEVE APCH CAUGHT MY ERRORS WHEN THEY ASKED 'WERE YOU GIVEN THE CHINS ARR?' MINOR CONTRIBUTING FACTOR WAS AN INTERMITTENT AUTOTHROTTLE PROB THAT HAD SEEMED TO FIX ITSELF. PAYING CLOSE ATTN TO XING RESTRS AND WHERE THE AUTOMATION IS SET TO TAKE YOU IS THE ACTION NECESSARY TO PREVENT THIS TYPE OF OCCURRENCE.

  353.  
  354. Accession Number: 397100
    Synopsis: MLG ACFT WITH XING ALT RESTR IN DSCNT WAS HIGH ON PROFILE AND WAS NOT CAPTURED BY FMC. FLC REQUESTED AND RECEIVED A 360 DEG TURN TO LOSE ALT IN ORDER TO MAKE RESTR.
    Narrative: WE WERE CLRED TO CROSS PLSNT INTXN (PXR 321 DEG RADIAL 35 DME) AT 12000 FT AND 280 KTS. THE ACFT WAS IN VNAV AND APPEARED TO BE GRADUALLY DSNDING TO 12000 FT WHILE INTERCEPTING THE DSCNT PROFILE. APPARENTLY IT MISSED THE PROFILE AND WE WERE WAY HIGH AND FAST. WE WERE ABLE TO GET A 360 DEG AND DSCNT TO THE FIX FROM ZAB PRIOR TO HDOF. HAD WE BEEN ABLE TO GET UNDER THE PROFILE AND NOT TRY TO INTERCEPT IT FROM ABOVE, THE FLT PATH WOULD HAVE BEEN CAPTURED MORE EASILY. CONTRIBUTING FACTORS INCLUDE MY GETTING THE ATIS AND TROUBLESHOOTING SOME MINOR UNRELATED ELECTRICAL MALFUNCTIONS. I COULD HAVE QUERIED THE CAPT AS TO WHAT EXACTLY HE WANTED THE AIRPLANE TO DO. AS IT WAS, IT INITIALLY APPEARED THAT WE WERE GOING TO MAKE THE RESTR WITHOUT A PROB.

  355.  
  356. Accession Number: 397152
    Synopsis: B737-300 ACFT IN DSCNT WITH XING RESTR ALT, PF, CAPT USING VERT SPD ON FMS WITH A SHALLOW DSCNT RATE, MISSED XING RESTR BY 2000 FT. RPTR FO WAS NOT IN THE LOOP OBTAINING ATIS AND COM WITH COMPANY.
    Narrative: WE WERE ESTABLISHED ON THE MINKS ONE ARR FOR LGA, AT A CRUISE ALT OF FL290. CLRNC WAS RECEIVED TO CROSS KERNO AT FL260, STANDARD FOR THIS ARR. JUST SW OF KERNO I TOLD THE CAPT THAT I WOULD BE OFF FREQ FOR A FEW MINS TO GET ATIS AND TALK TO COMPANY OPS. (WE HAD BEGUN A SLOW DSCNT JUST ABOUT THIS TIME -- CAPT SELECTED VERT SPD MODE AT A VERY LOW RATE.) IT TOOK ME SEVERAL MINS TO COMPLETE MY COMS BUSINESS. WHEN I LOOKED UP, I WAS STARTLED TO SEE THAT WE WERE ONLY 2 MI OR SO FROM KERNO, 2000 FT OR SO HIGH, AND DSNDING AT 300 FPM IN VERT SPD MODE. THE CAPT WAS ABSORBED IN FILLING OUT HIS LOGBOOK FOR THE TRIP. I TOLD ATC WE WOULD NOT MAKE OUR XING RESTR, AND WE WERE RECLRED TO A LOWER ALT, AND THE REST OF THE FLT WAS UNEVENTFUL. I THINK THIS SIT CLRLY RESULTED FROM THE DISTR OF BOTH CREW MEMBERS AT THE SAME TIME. THE PF NEEDS TO BE EXTRA VIGILANT WHEN THE PNF IS TEMPORARILY OUT OF THE LOOP. IN RETROSPECT, THIS WAS A VERY POOR TIME TO START WORKING ON A TRIP LOG. AS A CONTRIBUTING FACTOR, THE DSCNT WAS MADE IN VERT SPD MODE. THIS TOOK AWAY THE PROTECTION OF XING RESTRS WHICH WAS ALREADY PROGRAMMED INTO THE FMC IF VNAV WERE USED. I AM NOT SURE WHY PF SELECTED VERT SPD FOR THIS DSCNT (THOUGH NONE OF US USE VNAV EXCLUSIVELY). IN LATER DISCUSSION WE AGREED IT WAS NOT THE BEST CHOICE IN THIS CASE. I REALLY TRY HARD TO STAY UP WITH THE SIT, EVEN WHEN COPYING ATIS, ETC. IT IS NOT ALWAYS EASY, BUT I WILL BE RE-DOUBLING MY EFFORTS.

  357.  
  358. Accession Number: 397243
    Synopsis: CAPT OF AN ACR LGT FAILS TO INSURE THAT HIS FMS STARTS THE DSCNT FOR AN ALT XING RESTR.
    Narrative: WE HAD BEEN CLRED FROM FL370 TO FL290 AND THE AUTOPLT/FMS WAS ENGAGED AND MAKING THE DSCNT. UPON LEVELOFF THE FLT ATTENDANTS CAME INTO THE COCKPIT TO OFFER BEVERAGES. DURING THE LEVELOFF THE FMS MODE CHANGED FROM VNAV TO ALT HOLD. AS EVIDENCED BY LATER EVENTS, I DID NOT NOTICE THE FMS MODE CHANGE. SHORTLY AFTER LEVELING AT FL290 WE WERE CLRED TO CROSS OTT VOR AT FL250. I PROGRAMMED THE FMS AND SET THE ALT ALERT WINDOW FOR THE XING RESTR. LATER, WHEN I SHOULD'VE BEEN STARTING THE DSCNT I WAS ENJOYING THE VIEW OUT THE WINDOW AND LOST SITUATIONAL AWARENESS. I DID NOT START THE DSCNT. VNAV, WHICH I NORMALLY ONLY RELY UPON AS A BACKUP FOR DSCNTS COULD NOT START US DOWN BECAUSE THE FMS HAD PREVIOUSLY CHANGED TO ALT HOLD. AS A RESULT OF THE DISTRACTIONS AND LOSS OF SITUATIONAL AWARENESS I DID NOT START THE DSCNT UNTIL ALMOST OVER OTT VOR. THE FO ASKED IF WE WERE SUPPOSED TO CROSS AT FL250, WHEREUPON I BEGAN AN IMMEDIATE DSCNT. WE CROSSED OTT AT LEAST SEVERAL THOUSAND FT HIGH. APPARENTLY THERE WAS NO CONFLICTING TFC IN THE AREA (AT LEAST AS FAR AS WE COULD TELL FROM TCASII) AND THE CTLR SAID NOTHING ABOUT THE XING ALT. IT HAS BEEN SEVERAL YRS, AT LEAST, SINCE I'VE HAD AN ALT 'BUST.' FORTUNATELY, I WILL BE ABLE TO LEARN FROM THIS EVENT AND PAY BETTER ATTN IN THE FUTURE.

  359.  
  360. Accession Number: 398020
    Synopsis: AN EMB-145 FLC OVERSHOT THEIR ALT WHEN THEY WERE UNAWARE THAT THE AUTOPLT HAD DISCONNECTED AND FAILED TO LEVEL THE ACFT AT 14000 FT. THE AUTOPLT DESIGN WAS CRITICIZED FOR NOT HAVING A WARNING SYS ALERT WHEN DISCONNECT OCCURS OVER 2500 FT AGL. BOTH PLTS WERE FILLING OUT CUSTOMS FORMS IN DSCNT.
    Narrative: WE WERE FLYING FROM HALIFAX, NOVA SCOTIA (YHZ), TO NEWARK (EWR) ON A STAR AND GIVEN A DSCNT CLRNC TO 14000 FT. I'M NOT SURE TODAY IF THIS WAS THE ALT ATC GAVE US, BUT IT WAS AN EVEN MIDDLE-TEEN ALT AND I WAS SURE OF THE ALT ON THE DAY OF THIS INCIDENT -- THAT WAS NOT THE ISSUE. WHILE DSNDING ROUTINELY, IT WAS THE FO'S LEG AND I WAS FILLING OUT OUR CREW DECLARATION CUSTOMS FORM. I NOTICED THAT MY FO WAS ALSO FILLING OUT HER CUSTOMS FORM, SO I WOULD OCCASIONALLY LOOK UP TO MONITOR OUR FLT SIT. THE AUTOPLT WAS ON AND DSNDING INITIALLY, BUT HAD SOMEHOW DISENGAGED WITHOUT US KNOWING WHY. THE AUTOPLT AURAL WARNING ANNOUNCING DISENGAGEMENT ONLY OCCURS BELOW 2500 FT AGL AND NOT AT ANY OTHER ALTS ABOVE THAT. I HAVE ALREADY EXPERIENCED SEVERAL UNANNOUNCED AND UNKNOWN DISENGAGEMENTS OF THE AUTOPLT DURING CLBS, CRUISE, AND DSCNTS AND CAUGHT THEM DURING NORMAL MONITORING OF THE AUTOPLT WHILE IT WAS FLYING. BECAUSE OUR DSCNT WAS SHALLOW AND BECAUSE WE WERE BOTH FILLING OUT OUR CUSTOMS FORMS, NO ONE NOTICED WE HAD DSNDED THROUGH OUR ASSIGNED ALT UNTIL WE WERE 500 FT BELOW IT. MY FO CORRECTED PROMPTLY AND NO TFC WAS ON TCASII. BEING A SATURDAY, IT WAS A LIGHT TFC DAY ON THE ATC FREQ. ZBW DIDN'T MENTION THE ALTDEV. I STILL DON'T KNOW WHY THE AUTOPLT DISENGAGED. I'M CONCERNED THAT THIS PRIMUS 1000 DOES NOT ANNOUNCE DISENGAGEMENT ABOVE 2500 FT. I HAVE TALKED TO SEVERAL CREW MEMBERS WHO HAVE EXPERIENCED SIMILAR UNEXPLAINED DISENGAGEMENTS. IN THE FUTURE, I WILL PAY CLOSER ATTN TO MONITORING THE AUTOPLT SO THAT A DEV DOES NOT OCCUR IN THE FUTURE AS A RESULT OF AN UNEXPLAINED AND UNANNOUNCED DISENGAGEMENT AND SUPERVISE MY FO'S MORE CLOSELY DURING AUTOFLT. A SIMPLE CHANGE IN THE PRIMUS 1000 SOFTWARE WOULD PROBABLY SOLVE THIS ANNOUNCEMENT PROB. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR INDICATED THAT HE HAS HAD ANOTHER DISCONNECT INCIDENT SINCE HIS INITIAL RPT ON THE EMB145 AUTOPLT PROB. THE COMPANY HAS BEEN INFORMED OF THE INADEQUATE WARNING SYS AND HE IS INTENDING TO INFORM HIS AIRLINE UNION SAFETY COMMITTEE. THE ONLY WARNING THAT THE CREW RECEIVES FROM AN AUTOPLT DISCONNECT INFLT ABOVE 2500 FT IS WHEN THE LITTLE LIGHT GOES OUT IN THE CORNER QUADRANT OF THE AUTOPLT 'PUSH TO ENGAGE' BUTTON. ONE MUST BE VERY ALERT TO THIS LIGHT BEING LIT AND IT IS DIFFICULT AT BEST TO NOTE ANY CHANGE IN THE STATUS OF THE AUTOPLT.

  361.  
  362. 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.

  363.  
  364. Accession Number: 398228
    Synopsis: CL6013A ACFT IN CLB TO 10000 FT ENCOUNTERED CLR AIR TURB JUST PRIOR TO LEVELOFF. AUTOPLT KICKED OFF AND ACFT WENT ABOVE ASSIGNED ALT INTERFERING WITH ANOTHER ACFT CREATING A LOSS OF SEPARATION.
    Narrative: I WAS A PNF IN THE L SEAT OF A CANADAIR CHALLENGER 601/3A THAT HAD AN ALT OVERSHOOT AT 10000 FT MSL ON DEP OUT OF DTW. THE FOLLOWING SERIES OF EVENTS OCCURRED: 1) WE WERE LEVEL AT 7000 FT MSL IN MOSTLY LIGHT TURB FROM THE START OF THE FLT. 2) DTW DEP CLRED US TO 10000 FT MSL. ON THE READBACK I SAID 12000 FT MSL AND WAS CORRECTED BY ATC. I ACKNOWLEDGED THE 10000 FT MSL AND SET 10000 FT MSL IN THE ALT PRESELECT. 3) THE PF IN THE R SEAT HAD THE ACFT ON AUTOPLT AND INITIATED A CLB ON THE AUTOPLT TO 10000 FT MSL. 4) WE WERE JUST PRIOR TO OUR LEVELOUT AT 10000 FT MSL WHEN WE EXPERIENCED A MODERATE JOLT ON THE CTL YOKE FROM CLR AIR TURB. THE AUTOPLT DISENGAGED AS WE WERE IN A PITCH UP CLB. 5) THE PF TOOK OVER FLYING MANUALLY AND MADE A SMOOTH RECOVERY. AT THE SAME TIME, A BRIEF SLOW RESOLUTION DSCNT CALLOUT OCCURRED LASTING NO MORE THAN A FEW SECONDS. WE OBSERVED THE ALTIMETER PASSING THROUGH 10300 FT MSL ON THE RECOVERY AND FEEL WE COULD HAVE GOTTEN AS HIGH AS 10500 FT, BUT WE ARE NOT POSITIVE OF THIS. THE RA WE OBSERVED ON THE TCASII FROM WHAT WE COULD DETERMINE WAS FROM AN ACFT OUTSIDE OF OUR 3 MI CIRCLE, AT OUR 2-3 O'CLOCK POS, AT 11000 FT MSL. THE TFC WAS EITHER FLYING PARALLEL TO US OR AWAY FROM US. THERE WAS NO TIME DURING THIS PERIOD THAT WE OBSERVED ANY TFC WITHIN OUR TCASII 3 MI CIRCLE. WE WERE VMC AT THIS TIME AND DIDN'T OBSERVE ANY TFC OUTSIDE VISUALLY. 6) I ACKNOWLEDGED TO ATC THAT WE WERE GETTING OUR PLANE UNDER CTL AND LEVELING AT 10000 FT MSL. THE CTLR ACKNOWLEDGED US LEVELING AT 10000 FT MSL. HE IMMEDIATELY GAVE US A CLB TO A HIGHER ALT WITH A FREQ CHANGE AND SAID GOOD DAY. 7) DTW MEANWHILE HAD GOTTEN A TCASII RA FEEDBACK FROM A SAAB COMMUTER ACFT THAT WAS ON ANOTHER FREQ. I BELIEVE THEY CORRELATED THIS TO BE THE ACFT THAT WE OBSERVED AT OUR 2- 3 O'CLOCK POS AT GREATER THAN 3 MI TO US, AT 11000 FT MSL. DTW FORWARDED A MESSAGE TO US THROUGH ZOB TO CALL. 8) DTW DEP ADVISED ME OF THE SAAB COMMUTER RESOLUTION ALERT RPT. I TOLD THE DTW SUPVR OF OUR INTENTION TO LEVEL AT 10000 FT MSL, UNTIL THE ACFT WAS DISTURBED FROM ITS FLT BY TURB. HE DIDN'T INDICATE THAT ANYTHING SERIOUS HAD HAPPENED, OTHER THAN HE INTENDED TO FILE A RPT WITH THE ENFORCEMENT AUTHS. I ADVISED HIM THAT I WOULD FILE A NASA RPT. 9) THE HUMAN FACTORS INVOLVED AT THE TIME WERE NORMAL COCKPIT DUTIES. WE CAN'T PINPOINT IF IT WAS TURB OR THE YOKE MOVEMENT THAT CAUSED AUTOPLT DISCONNECT. 10) I AM PERSONALLY GLAD THAT THERE WAS NO MORE DEV FROM OUR FLT PATH THAN OCCURRED. I THANK YOU FOR YOUR TIME IN HANDLING THIS RPT.

  365.  
  366. Accession Number: 398257
    Synopsis: FLC OF AN EMBRAER BRASILIA EMB120 OVERSHOT ALT ON DSCNT TO A CRUISE ALT 1000 FT LOWER DUE TO NOT NOTICING THAT THE AUTOPLT WAS NOT LEVELING OFF THE ACFT AND THE ALT ALERTER DID NOT GIVE NORMAL WARNING.
    Narrative: WE WERE IN CRUISE FLT AT FL210 AND GIVEN A CLRNC TO DSND TO FL200. WE BEGAN OUR DSCNT AT ABOUT 700 FPM WITH THE AUTOPLT ENGAGED. THE ALT ALERTER WAS SET FOR FL200, HOWEVER, THE AUTOPLT DID NOT LEVEL OFF AT FL200. ALSO, THE ALT ALERTER NEVER ALERTED US THAT THE AUTOPLT DID NOT CAPTURE ALT. RECOGNIZING THE PROB, WE DISENGAGED THE AUTOPLT TO LEVEL AT FL190. THE CTLR QUESTIONED US ABOUT OUR ALT. WE ACKNOWLEDGED THAT WE WERE ASSIGNED FL200. THE CTLR ADVISED US TO CONTINUE TO MAINTAIN FL190, AND HE IMPLIED THAT IT WAS 'NO PROB.'

  367.  
  368. 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.

  369.  
  370. Accession Number: 398287
    Synopsis: AN ACR B757 FLC FORGOT TO RESET ALL OF THEIR ALTIMETERS AND THE AUTOPLT, REFING THE MISSET ALTIMETER, CLBED ABOVE THEIR ASSIGNED ALT.
    Narrative: ON LEVELOFF FL210 (AUTOPLT ENGAGED IN PROX OF TSTM AND MODERATE TURB) AUTOPLT OVERSHOT ALT BY +/-100 FT. AUTOPLT WAS DISENGAGED AND ACFT FLOWN BY HAND TO FL210. AUTOPLT WAS RE-ENGAGED AND ACFT BEGAN CLB AGAIN. ATC QUERIED US ABOUT OUR ALT AND CALLED TFC AT FL220. WE NOTED CTR ALTIMETER WAS NOT RESET TO 29.92 (STILL READING DFW LCL ALTIMETER SETTING). WE RESET CTR ALTIMETER, DISCONNECTED AUTOPLT AGAIN, AND HAND FLEW BACK TO FL210. NO EVASIVE ACTION WAS TAKEN BY EITHER ACFT AND THE OTHER ACR ADVISED ATC THEY HAD VISUAL CONTACT WITH OUR ACFT. PROBABLE CAUSE: FAILURE TO ACCOMPLISH CLB CHKLIST AS PER SOP. BOTH CAPT AND FO ALTIMETERS WERE PROPERLY RESET TO 29.92, BUT CTR WAS NOT. CONTRIBUTING FACTORS: TSTM AVOIDANCE AND MODERATE TURB DISTRACTING FACTORS. 3 HR GND DELAY AWAITING DEP RELEASE FOR WX (TSTMS). I THOUGHT ALT OVERSHOOT WAS DUE TO MODERATE TURB INITIALLY.

  371.  
  372. Accession Number: 398580
    Synopsis: A B757 FLC FORGETS TO START DSCNT INTO PHL AFTER RECEIVING THEIR CLRNC FROM ZNY. CTLR HAS TO GIVE THE CREW A 'WAKE UP' CALL TO START THEIR DSCNT.
    Narrative: WE WERE GIVEN DSCNT TO 15000 FT BUT DID NOT BEGIN DSCNT UNTIL 1 MIN LATER (MAYBE LONGER). ATC (ZNY) PROMPTED US AND DSCNT WAS THEN MADE TO 15000 FT AT A GOOD RATE OF DSCNT. THE MODE CTL PANEL CHANGE AND ALTIMETER SETTING TOOK PLACE BUT NEITHER VNAV NOR FLT LEVEL CHANGE WAS SELECTED UNTIL PROMPTED. CONVERSATION DURING CLRNC CONTRIBUTED TO THE TASK OF DSNDING FROM NOT HAVING TAKEN PLACE. FATIGUE ALSO A FACTOR, BUT MOSTLY LACK OF ADHERENCE TO PROC. READBACK TO ZNY WITH ALTIMETER SETTING GIVEN. SELECTION OF FLT LEVEL CHANGE TO INITIATE THE DSCNT, HOWEVER, WAS NOT MADE AS THE CONVERSATION WE HAD BEEN IN PRIOR TO THE CLRNC CONTINUED. I THINK THE CAUSE OF THIS WAS THAT THE TASK AT HAND, IE, ALT CHANGE AND ALTIMETER SETTING ADJUSTMENT, WAS MADE AND THE TASK 'SEEMED' TO HAVE BEEN COMPLETED. BETTER ADHERENCE TO FULL TASK RESOLUTION NEEDED.

  373.  
  374. 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.

  375.  
  376. Accession Number: 399607
    Synopsis: AUTOFLT SYSTEM ALT SET CHANGED FROM FL330 TO FL340 BY ITSELF. FO NOTICED DEVIATION AT FL334. EXCURSION CORRECTED BY FL337 USING MANUAL CTL.
    Narrative: CAPT JUST FINISHED AN ENGINE HEALTH CHECK (AUTOPLT IN BASIC ALT HOLD MODE) AND HAD REENGAGED THE AUTOMATED PMS ALT HOLD MODE AT FL330. SOON THEREAFTER, I NOTICED ACFT WAS CLBING THROUGH FL334 AND ALERTED THE CAPT. USING BASIC AUTOPLT, HE STOPPED THE CLB BY FL337 AND DSNDED PROMPTLY AFTER TOTALLY DISCONNECTING THE AUTOPLT. I ALSO NOTICED THAT THE DIGITAL ALT WINDOW READOUT READ FL340. AS THE PMS WAS IN THE CRUISE MODE, AN INADVERTENT CHANGING OF THE DIGITAL ALT LEVEL WOULD NOT NORMALLY CAUSE ANY CHANGE IN ALT, A CLB OR DSCNT MODE MUST FIRST BE ENGAGED. LIKEWISE, AN INADVERTENT ACTIVATION OF THE VERTICAL SPEED WHEEL (BASIC AUTOPLT) WOULD NOT CAUSE THE DIGITAL ALT WINDOW TO READ FL340. THEREFORE TWO SEPARATE INADVERTENT ACTS WOULD HAVE BEEN NECESSARY TO ACHIEVE THIS EFFECT WITHOUT A MALFUNCTION OF THE PMS. THEREFORE IT IS MY BELIEF THAT A MOMENTARY PMS MALFUNCTION CAUSED THE DIGITAL DISCREPANCY AND RESULTED IN THE SHORT DURATION ALT DEV DESCRIBED.

  377.  
  378. Accession Number: 399700
    Synopsis: ON LOC APCH DSNDS BELOW PUBLISHED ALT PRIOR TO REACHING AN INTXN. THEY ARE 1300 FT LOW.
    Narrative: ON MSY LOC RWY 19 APCH, DSNDED TO 700 FT MSL BEFORE JASPO INBOUND. WAS NOT USING VNAV. DID NOT HAVE 2000 FT IN ALT WINDOW. HAD 700 FT IN WINDOW BEFORE 2000 FT LEVELOFF AND ACFT DSNDED TO 700 FT. SOLUTION: DO NOT CHANGE ALT WINDOW UNTIL ACFT HAS CAPTURED THE CORRECT ALT. WE WERE TOO FAR AHEAD OF THE ACFT.

  379.  
  380. Accession Number: 400250
    Synopsis: AN EMB145 ON DSCNT WITH AUTOPLT CTL OVERSHOT THE ASSIGNED ALT DUE TO THE WRONG ALT SELECTED ON THE AUTOPLT CTL PANEL.
    Narrative: OUR CARRIER IS CURRENTLY INTRODUCING THE EMB145 REGIONAL JET INTO SVC AND DURING ONE PARTICULAR PRACTICE PROVING RUN, WE WERE GIVEN A DSCNT CLRNC TO 17000 FT. I, AS THE PNF, NOTICED THE AUTOPLT WAS NOT CAPTURING 17000 FT AND IN FACT CONTINUED TO DSND TO ABOUT 16000 FT BEFORE THE PF DISENGAGED THE AUTOPLT AND MANUALLY FLEW THE ACFT BACK TO 17000 FT. DURING THIS TIME I IMMEDIATELY CHKED THE ALT PRESELECT AND SAW MOMENTARILY 17400 FT SELECTED. I BELIEVE THAT UNFAMILIARITY LED TO CHANGING THE ALT PRESELECT INADVERTENTLY. THE ALT PRESELECT, COURSE KNOB AND LEADING KNOBS ARE ALL LOCATED ON THE GLARE SHIELD PANEL AND I CAN SEE THAT CONSTANT VIGILANCE WILL BE REQUIRED TO INSURE THE CORRECT KNOB IS BEING ADJUSTED UNTIL WE ALL BECOME MORE FAMILIAR WITH THIS NEW ACFT.

  381.  
  382. Accession Number: 400360
    Synopsis: FO OF AN AIRBUS A320, EA32, EXCEEDED SPD LIMITATION BELOW 10000 FT DURING DSCNT ARR DUE TO MISPROGRAMMING THE FMS MODE CTLING THE DECELERATION OF THE AIRSPD. THE MISTAKE WAS NOTICED JUST PRIOR TO LEVELING OFF AT THE ASSIGNED 9000 FT.
    Narrative: WHILE SERVING AS PF/SIC I FAILED TO DECELERATE TO 250 KIAS BELOW 10000 FT MSL. IT IS CUSTOMARY TO UTILIZE THE A320'S MANAGED VERT NAV FUNCTION WHILE IN THE APCH ENVIRONMENT. IN THIS CIRCUMSTANCE I LEFT VERT NAV AND SELECTED THE IAS/OPEN DSCNT MODE IN ORDER TO COMPLY WITH AN ATC REQUEST TO 'KEEP YOUR SPD UP.' NOT ONLY IS VERT GUIDANCE SACRIFICED IN SELECTED SPD/OPEN DSCNT MODE, SO IS AUTOMATIC DECELERATION TO 250 KIAS. WE WERE INFORMED BY ATC TO EXPECT A RWY OTHER THAN THE ONE WE HAD PLANNED AND PROGRAMMED IN THE FMS. AS THE ACFT APCHED 10000 FT WITH CLRNC TO 9000 FT THE PNF/PIC MADE APPROPRIATE FMS CHANGES FOR THE NEW RWY AND I TOOK OUT THE CHARTED IAP IN ANTICIPATION OF A 'REBRIEF.' DESPITE MAKING THE STANDARD 'ONE TO GO' AND 'TWO TO GO' ALT AWARENESS CALLOUTS, I WAS DISTRACTED AND DID NOT NOTICE THE ACFT WAS STILL OPERATING AT 335 KIAS AS WE PASSED 10000 FT. I RECOGNIZED THE EXCESSIVE SPD PRIOR TO REACHING 9000 FT AND INITIATED A DECELERATION TO 250 KIAS. APPROX 1 1/2 MINS ELAPSED WHILE THE ACFT WAS BELOW 10000 FT AND ABOVE 250 KIAS. THIS IS A TEXTBOOK EXAMPLE HOW IMPORTANT IT IS TO CLOSELY MONITOR ADVANCED TECHNOLOGY ACFT, AND NOT TO BECOME TOO RELIANT ON THE FUNCTIONS THAT NORMALLY EASE PLT WORKLOAD. IT IS ALSO A LESSON IN DIVISION OF COCKPIT DUTIES -- BASIC CRM DICTATES 1 PLT REMAIN FOCUSED AT ALL TIMES ON FLYING THE AIRPLANE. WHILE I BELIEVE I WAS ALWAYS COGNIZANT OF ACFT POS AND ALT, I LOST TRACK OF AN IMPORTANT SITUATIONAL AWARENESS ELEMENT.

  383.  
  384. Accession Number: 400590
    Synopsis: FLC OF A B757 MISPROGRAMMED THE FMC CAUSING A SLOWER DSCNT ON A STAR ARR THAN REQUIRED BY ATC. ARTCC WAS NOTIFIED OF THE PROB PRIOR TO THE FIX RESULTING IN ATC VECTORING OFF COURSE UNTIL ACFT HAD APPROPRIATELY DSNDED BEFORE THE XING FIX.
    Narrative: RECEIVED CLRNC TO CROSS HAYED INTXN AT FL190. FMS (CDU) ORIGINALLY HAD HAYED AT FL180 PROGRAMMED. PF PUT IN NEW CLRNC IN CDU BUT LINE SELECTED PENNS INTXN INSTEAD OF HAYED. PENNS IS FURTHER AWAY THAN HAYED INTXN. BECAUSE IT WAS A HIGHER ALT AT A FIX FURTHER AWAY FROM ORIGINAL PROGRAMMING, THE BOX (FMC) DELETED THE HAYED AT FL180 RESTR AND NOW COMPUTED PENNS AT FL190 FOR TOP OF DSCNT POINT. ABOUT 10 MI FROM HAYED INTXN, CAPT NOTICED THE ERROR WHILE IN A DSCNT (ACFT PROGRAMMED TO CROSS PENNS AT FL190). IMMEDIATELY CALLED ATC AND ADVISED. WAS GIVEN A TURN OFF AIRWAY TO FACILITATE DSCNT, THEN TURNED BACK TO ORIGINAL COURSE AND RESUMED NORMAL NAV. ERROR WAS MADE BY NOT DOUBLECHKING LINE ENTRY AND NEW XING RESTR AND SECOND ERROR WAS MADE BY NOT CHKING LINE 1R OF CDU ON 'DSCNT PAGE' TO SEE WHAT THE TOP OF DSCNT POINT WAS BEING COMPUTED ON.

  385.  
  386. Accession Number: 400760
    Synopsis: A DC10 FLC WAS TOO BUSY TO NOTE THE AUTOPLT DISCONNECT AND THEIR DEV FROM ALT. BRIGHT DAY ON TOP AND NO AURAL WARNING. CREW WAS BUSY COPYING AN ACARS RE-RELEASE.
    Narrative: FLT DURING IFR -- VISUAL ON TOP. AUTOPLT DISCONNECTED WHILE CREW WAS READING AND COPYING THE RE-RELEASE. ALTDEV WAS 600 FT. CONTRIBUTING FACTORS -- VERY BRIGHT GLARE IN COCKPIT AND NO AURAL DISCONNECT WARNING.

  387.  
  388. 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.

  389.  
  390. Accession Number: 401193
    Synopsis: FO OF A B737-400 ALLOWED THE ACFT TO ASCEND ABOVE ASSIGNED ALT WHEN SLOWING THE ACFT FOR DSCNT DUE MISPROGRAMMING THE FMC AUTO HOLD BEFORE IT WAS TIME FOR THEIR DSCNT.
    Narrative: ZSE WAS SLOWING US DOWN AND GIVING US VECTORS FOR SPACING INTO SEATTLE. APPROX 40 MI FROM TOP OF DSCNT, WE WERE CLRED, PLT'S DISCRETION, TO FL240, WHICH WE SET IN THE ALT ALERTER. THE FO WAS PF AND RESPONDED TO ATC AS I WAS OFF FREQ TO GET ATIS. A FLT ATTENDANT CAME UP AT THAT TIME TO TAKE AWAY OUR MEAL TRAYS AND REMIND US THAT A MEDICAL OXYGEN BOTTLE WAS NEEDED IN SEATTLE ON LNDG. WHEN I TURNED FORWARD, I NOTICED THAT WE WERE TURNING BACK TO BTG PER ATC INSTRUCTIONS, BUT THE AUTOPLT WAS IN CTL WHEEL STEERING PITCH MODE. A QUICK GLANCE AT THE ALT SHOWED THAT WE WERE CLBING AND PASSING FL316. (ASSIGNED ALT WAS FL310.) I GRABBED THE CTLS AND GENTLY PUSHED THE ELEVATOR OVER TO GET US BACK TO FL310. OUR ALTIMETER SHOWED WE GOT TO FL318 BEFORE WE STARTED BACK DOWN. NO ALT ALERTER WENT OFF BECAUSE WE HAD FL240 IN THE MCP. I AM NOT SURE HOW THE ACFT GOT INTO CTL WHEEL STEERING PITCH MODE, BUT THE LACK OF ANY BELLS, MY ATTN DIVERTED TO THE FLT ATTENDANT, BUSY ATC INSTRUCTIONS, AND THE FO NOT NOTICING WHAT MODE THE AIRPLANE HAD DOWNGRADED TO, CAUSED US TO BUST OUR ALT.

  391.  
  392. 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.

  393.  
  394. Accession Number: 401960
    Synopsis: AN ACR E120 FLC CLBED ABOVE THEIR ASSIGNED ALT BECAUSE ALTHOUGH THE PLT FLYING HAD SET THE PROPER INFO INTO THE AUTOPLT HE NEGLECTED TO SWITCH THE AUTOPLT CTL TO HIS POSITION.
    Narrative: DURING FLT FROM FSD TO HON ON OUR CLBOUT WE OVERSHOT OUR ALT BY 500-600 FT. THE AUTOPLT WAS ON AND IT WAS MY LEG (COPLT). I AM A CAPT WITH THE COMPANY, BUT AM R SEAT QUALIFIED AND WAS ACTING IN THAT CAPACITY. I DISCOVERED THE DISCREPANCY DURING MY CHKS, AND XCHKS. THE PROBLEM OCCURRED BECAUSE OF NOT PROPERLY MONITORING THE INSTRUMENTS WHILE THE AUTOPLT WAS FLYING THE ACFT. UPON FURTHER INVESTIGATION, WE DETERMINED THAT THE REASON THE AUTOPLT OVERSHOT THE ALT WAS BECAUSE THE COMPUTER WAS NOT SWITCHED TO MY SIDE. IT IS PART OF THE BEFORE TKOF CHKLIST TO SWITCH THE COMPUTER TO THE FLYING PLT'S SIDE, BEFORE THE TKOF. I REMEMBER GOING THROUGH THE ITEM ON THE CHKLIST, BUT THE BUTTON MUST NOT HAVE BEEN DEPRESSED FULLY. WE CAN LEARN MUCH FROM THIS, ESPECIALLY THAT WHILE AUTOPLT IS FLYING THE ACFT WE MUST NOT BECOME COMPLACENT, AND MUST MONITOR THE ACFT'S SPEED, ALT, AND GENERAL ATTITUDE.

  395.  
  396. Accession Number: 402411
    Synopsis: CAPT OF DC10 FAILED TO FOLLOW THE FLT PLAN RTE DUE TO INADVERTENTLY MISPROGRAMMED FMC NAV DATABASE. AFTER THE FLC NOTED THEIR ERROR THEY WERE GIVEN A VECTOR TO BACK ON COURSE.
    Narrative: ENRTE WBOUND ON J80 WE WERE FILED J80 GLD DIRECT TO JNC THEN VIA J80 OAL . ALTHOUGH THE RTE WAS ENTERED INTO THE GPS PROPERLY ON THE RTE PAGE OF THE GPS, I CLOSED UP A DISCONTINUITY ON THE LEGS PAGE AND THE DIRECT ROUTING WAS INADVERTENTLY REMOVED AND WE FLEW THE INITIAL PORTION OF J80. DURING OUR NAV CHK WITH THE VORS BTWN GLD AND JNC WE DISCOVERED THE PROB. I THEN ASKED FOR DIRECT JNC AND ATC APPROVED MY REQUEST. THIS CAN BE AN INSIDIOUS TRAP BECAUSE WE CHKED THE LEG PAGE WITH THE FLT PLAN AS WELL AS THE PROGRESS PAGE DISTANCE AND THE 2 POINTS WERE BOTH CHKED ON THE GND AS OK.

  397.  
  398. Accession Number: 402440
    Synopsis: FLC OF A B737-400 FAILED TO CROSS ALT FIX AT ASSIGNED ALT RESULTING IN ATC INTERVENTION TO REMIND RPTR THAT THE FIX HAD BEEN OVERSHOT. ATC AMENDED CLRNC FOR OTHER ALT XING FIXES.
    Narrative: CRUISING AT FL240, ATC ISSUED 'CROSS 15 MI S OF DNY AT FL190.' I READ BACK CLRNC. FO (PF) ENTERED XING RESTR IN FMC. A FEW MINS AFTER THAT, FO MADE PA TO PAX. AS HE STARTED PA I WENT TO DSCNT PAGE ON FMC. I NOTICED WE STILL HAD 24 MI UNTIL TOP OF DSCNT. ALL I LOOKED AT WAS JUST THAT, AND NOT TOP OF DSCNT FOR 15 MI S OF DNY. TURNS OUT 24000 FT UNTIL TOP OF DSCNT WAS FOR NEXT WAYPOINT DOWN THE ROAD. JUST ABOUT THE TIME WE REALIZED THE PROB, ATC INQUIRED WHEN WE WOULD BEGIN OUR DSCNT. I REPLIED 'NOT FOR A LITTLE WHILE YET.' I WAS STILL THINKING WE HAD A FEW MORE MI YET. HOWEVER, AN INQUIRY FROM ATC ABOUT YOUR ALT USUALLY SENDS A JOLT OF ADRENALINE AND WE BOTH CHKED OUR DISTANCE FROM DNY. TO OUR SHOCK, WE WERE ABOUT 20 MI S, ALREADY PAST THE XING RESTR, AND STILL AT FL240. ATC THEN ISSUED THE FOLLOWING, 'JUST CROSS LHY AT 12000 FT.' NOTHING FURTHER WAS SAID ABOUT IT BTWN ATC AND US. AFTER REFLECTING ON THE INCIDENT, THE FO AND I THOUGHT THE ONLY POSSIBLE SCENARIO WAS THE FMC DUMPED THE DATA BECAUSE IT WAS ENTERED PROPERLY, VNAV WAS ENGAGED, AND IT IS POSSIBLE THAT THE DATA WAS LOST BECAUSE IT COULDN'T 'MAKE' THE DSCNT. THIS IS THE FIRST TIME THIS HAS EVER HAPPENED TO ME AND OTHER THAN THE FACT I SHOULD HAVE MONITORED BETTER, I HAVE NEVER SEEN AN FMS DO THAT. NOW I MONITOR BETTER AND CHK IT AGAIN BEFORE ALLOWING AND TRUSTING A COMPUTER TO DO IT.

  399.  
  400. 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.

  401.  
  402. Accession Number: 402884
    Synopsis: A DC9-40 FLC TURNS TOO EARLY FOR VECTORING TO DTW. FO HAD USED THEIR GPS FOR THE POS WITHOUT REF TO THE VOR DME.
    Narrative: WE WERE ESTABLISHED ON THE CETUS 2 ARR INTO DTW. TRACKING THE 147 DEG RADIAL INBOUND TO DXO VOR, APCH CTL INSTRUCTED US TO TURN TO A HDG OF 030 DEGS. UPON REACHING GLOZE INTXN (DXO 8 DME), THE FO WAS THE PF. AS I WAS HEADS DOWN REVIEWING THE ILS RWY 21L APCH PLATE, THE FO STARTED A R TURN TO A HDG OF 030 DEGS AS ASSIGNED BY ATC. AS HE TURNED, HE STATED 'PASSING GLOZE.' SINCE HE WAS ON THE ASSIGNED HDG, I DIALED IN THE LOC FREQ FOR RWY 21L. ABOUT THE SAME TIME APCH CALLED AND SAID, 'HEY, YOU MISSED THE TURN FOR GLOZE, TURN BACK TO A HDG OF 300 DEGS.' WE ACKNOWLEDGED HIM AND TURNED BACK IMMEDIATELY, AND ALSO APOLOGIZED FOR THE EARLY TURN. CONTRIBUTING FACTORS INCLUDED THE GPS AND THE CREW. THE FO MISINTERPED THE GPS. HE SAW THE GPS READING 8 MI FROM GLOZE, AND THOUGHT IT WAS READING 8 MI FROM DXO VOR. THINKING WE WERE AT GLOZE, HE TURNED TO THE 030 DEG ASSIGNED HDG. ACTUALLY HE TURNED 16 MI FROM DXO INSTEAD OF 8 MI. I DIDN'T NOTICE BECAUSE I WAS REVIEWING THE APCH PLATE AND HAD MY HEAD DOWN WHEN HE TURNED. BEFORE I PICKED UP ON WHAT HAPPENED, APCH CALLED AND GAVE US THE HDG BACK TO GLOZE. IN MY OPINION, THIS OCCURRED BECAUSE THE GPS ACTUALLY LOWERED OUR LEVEL OF SITUATIONAL AWARENESS. RELYING TOO MUCH ON THE GPS DURING THE ARR, WE FAILED TO CONFIRM OUR POS WITH THE VOR. HAD WE DONE THIS, I WOULDN'T BE WRITING THIS RPT.

  403.  
  404. Accession Number: 403612
    Synopsis: FLC OF A CL65 WITH HIGH MINIMUMS CAPT EXECUTED A MISSED APCH. CAPT CONCENTRATED ON COM WITH NO ASSIST TO FO FLYING. THEY HAD DIFFICULTY SETTING UP FOR ENTRY TO THE HOLD, CONFIGURING THE ACFT, AND THEY OVERSPEED THE ACFT FOR FLAP SETTING. ON SECOND TRY A RWY CHANGE CREATED MORE COCKPIT CONFUSION BUT APCH AND LNDG ACCOMPLISHED.
    Narrative: THE CAPT HAD JUST MOVED FROM THE L SEAT OF THE EMB120 TO THE L SEAT OF THE CL65 AND HAD ACCUMULATED APPROX 12 HRS SINCE FINISHING IOE. HE WAS A HIGH MINIMUMS CAPT AND LATER TOLD ME THAT IN 9 YRS OF FLYING THE LINE HE HAD ONLY ONCE BEFORE HAD TO PERFORM AN ACTUAL MISSED APCH PROC. THE WX AT OUR DEST WAS RIGHT AT THE CAPT'S HIGH MINIMUMS. SO WE MADE SURE TO DISCUSS NOT ONLY THE PUBLISHED MISSED APCH PROC, BUT ALSO THE STANDARD CALLS TO BE USED THROUGHOUT THE APCH AND SUBSEQUENT MISSED APCH, IF REQUIRED. AT THE BOTTOM OF THE APCH, THE CAPT CALLED 'MINIMUMS' AND I SAW ONLY CLOUDS/FOG. SO I CALLED 'GO MISSED, SET THRUST, FLAPS 8 DEGS.' HE COMPLIED AND THEN IMMEDIATELY TRIED TO CALL TWR TO NOTIFY THEM OF OUR MISSED APCH. TWR DID NOT ANSWER THE FIRST CALL, NOR THE SUBSEQUENT 3. UNFORTUNATELY, WHILE THE CAPT WAS MAKING REPEATED CALLS TO THE TWR, THE SUBSEQUENT STANDARD CALLS OF 'POSITIVE RATE' AND '1000 FT' WERE OMITTED. NONETHELESS, I CALLED FOR 'GEAR UP' WHEN I SAW THE POSITIVE RATE. AND ABOUT THAT TIME, I NEEDED TO SET UP THE MISSED APCH NAVAIDS IN ORDER TO INTERCEPT THE PROPER OUTBOUND CLB RADIAL. AS I REACHED DOWN TO SET THE RADIO, THE OVERSPD CLACKER SOUNDED BRIEFLY BECAUSE I HAD REACHED THE FLAPS 8 DEG LIMIT SPD OF 230 KTS. IN A WAY, THIS MAY HAVE BEEN A BLESSING BECAUSE WHEN THE CAPT OMITTED THE '1000 FT' CALL, I DID NOT ORDER THE FLAPS TO 0 DEGS. AS A RESULT, THE CLACKER AT 230 KTS PROMPTED MY ATTN BACK FROM THE NAV RADIOS TO THE AIRSPD WHICH I REDUCED TO 200 KTS TO COMPLY WITH THE 200 KT SPD LIMIT NEAR THE CLASS C PRIMARY ARPT. AT THIS POINT, I TOLD THE CAPT (WHO WAS STILL ON THE RADIO TRYING TO CALL THE TWR) 'I NEED SOME HELP HERE.' SIMULTANEOUSLY, I LEVELED OFF AND SLOWED WHILE BANKING AGGRESSIVELY TO INTERCEPT THE OUTBOUND RADIAL TOWARD THE HOLD. FINALLY, TWR RETURNED OUR CALL AND AFTER SOME DISCUSSION ISSUED US A HOLD ON THE SAME LOC (RWY 18L) AS THE APCH WE HAD JUST ATTEMPTED TO SO WE COULD WAIT FOR THE WX TO IMPROVE. WE PROGRAMMED THE HOLD AT THE RWY 18L FAF (FRAZE) INTO THE FMS AND ENGAGED THE AUTOPLT, BUT BECAUSE OF OUR NAV SETUP, THE FMS/AUTOPLT FLEW DUTIFULLY INBOUND ON THE LOC TO FRAZE BUT DID NOT ENTER THE HOLD AT FRAZE. I WAS MONITORING CLOSELY, SO I SIMPLY USED HDG MODE TO STEER US INTO THE HOLD. HOWEVER, DURING THIS DISTR, WE DID NOT CALL ENTERING THE HOLD. FURTHERMORE, NO EFC TIME HAD BEEN ISSUED. SHORTLY THEREAFTER, ATC ISSUED VECTORS TAKING US OUT OF THE HOLD AND WBOUND TO 'GET US OUT OF THE WAY.' THEN ATC ASKED IF WE WANTED TO TRY 'THE APCH' AGAIN. THE CAPT SAID YES AND ATC BEGAN TO ISSUE VECTORS AROUND TO A NE HDG. AT THIS POINT, I ASKED THE CAPT TO PROCEED THROUGH THE CHKLISTS FROM CLB ALL THE WAY THROUGH THE APCH CHKLIST JUST TO MAKE SURE WE HADN'T MISSED ANYTHING. WHEN WE REACHED THE 'APCH BRIEFING' ITEM, I REBRIEFED THE ILS TO RWY 18L INCLUDING THE STANDARD CALLOUTS AND THE PUBLISHED MISSED APCH PROC. I THEN ASKED THE CAPT IF HE WOULD TRY TO ASK TWR FOR ALTERNATE MISSED APCH INSTRUCTIONS JUST IN CASE THE CONDITIONS HAD NOT IMPROVED. HE DENIED MY REQUEST. THEN ATC ISSUED A VECTOR TO JOIN THE ILS RWY 18R LOC. THE CAPT DID NOT CATCH THIS CHANGE OF ASSIGNED APCHS, BUT I WAS PRETTY SURE ATC SAID 'RIGHT.' SO I QUICKLY ASKED THE CAPT TO VERIFY THE APCH ASSIGNED. WE TRIED BUT THE FREQ WAS SATURATED AND I HONESTLY DID NOT KNOW WHAT TO DO. THIS WAS THE FIRST TIME ATC SAID ANYTHING ABOUT THE ILS TO THE R SIDE. AS WE PASSED THROUGH THE ILS RWY 18R LOC, ATC VERY GRUFFLY TOLD US TO FLY 'HDG TO REINTERCEPT ILS RWY 18R LOC.' ONCE ESTABLISHED, WE COMPLETED THE APCH TO MINIMUMS (HIGH MINIMUMS). LIFE WOULD HAVE BEEN A BIT EASIER IF THE CAPT, AFTER AN INITIAL TRY OR 2, HAD CHOSEN TO CONCENTRATE MORE ON AVIATE AND NAV RATHER THAN FIXATING ON COMMUNICATE. AND I WISH ATC HAD GIVEN US A HEADS UP ON THE CHANGE IN OUR APCH ASSIGNMENT. IN RETROSPECT, GIVEN OUR POS ON THE W SIDE OF THE ARPT, I PROBABLY SHOULD HAVE SUSPECTED A CHANGE TO RWY 18R.

  405.  
  406. Accession Number: 403819
    Synopsis: A CLBING L1011-500 EXPERIENCES AN ALT UNDERSHOOT WHEN THE FMC DOES NOT CAPTURE THE CLB TO ALT. ACFT SLOWLY DSNDED UNTIL ATC CTLR CORRECTED SIT.
    Narrative: I WAS OUT OF THE COCKPIT (IN THE LAVATORY) WHEN I FELT A SHARP PULL UP. UPON RETURNING, SAW CAPT ADDING FULL PWR TO CLB BACK TO CRUISE ALT. HE SAID ACFT WAS IN LAST 400 FT OF CLB, AUTOPLT ON IN LNAV MODE WHEN VERT SPD COMMAND DROPPED OUT (AS NORMALLY DOES DURING LAST 300 FT OF ALT CAPTURE). CTR HAD CLRED HIM DIRECT TO FIX, WHICH HE ENTERED INTO FMS. HOWEVER, PRIOR EXPERIENCE HAS TAUGHT ME, THIS OVERLOADS THIS OLD TYPE OF FMS WHILE IT COMPUTES NEW COURSE. THE BLACK MAGIC WAS IN THE PROCESS OF RETARDING THE AUTOTHROTTLES PRIOR TO CAPTURE AND THE PITCH MODE WAS IN NEUTRAL. THE ACFT STARTED A SLOW DSCNT WHEN CTR ASKED FOR OUR ALT. THERE IS NO WARNING OTHER THAN THE 'C' CHIME ON THE ALT ALERTER, HOWEVER THOSE PARAMETERS WERE SHORT-CUT BECAUSE WE HADN'T BEEN WITHIN 250 FT OF LEVELOFF. THE NEXT CHIME IS AT 750 FT OFF SELECTED ALT.

  407.  
  408. Accession Number: 403852
    Synopsis: A B737-700 CREW OVERSHOT THEIR ASSIGNED ALT, BELIEVING THAT THEIR AUTOPLT IS COUPLED. IT WASN'T, MAINT HAD DISENGAGED BOTH AUTOPLTS PRIOR TO THE FLT.
    Narrative: FIRST FLT IN A NEW MODEL B737 ACFT. THE NEW MODEL B737- 700 HAS A GLASS COCKPIT WITH MANY SYS DIFFERENCES COMPARED TO THE B737-200, B737-300, OR B737-500 ACFT WE USUALLY FLY. THIS WAS MY FIRST FLT AND THE CAPT'S SECOND FLT IN THE B737-700. WE HAD RECEIVED THE ACFT FROM MAINT AND DID NOT REALIZE THEY HAD USED THE 'GANG BAR' TO DISENGAGE BOTH AUTOPLT SYS. AS WE WERE CLBING OUT, THE CAPT (PF) SELECTED THE 'A' AUTOPLT. THE ACFT WAS TRIMMED AND STABLE. AS WE APCHED OUR ASSIGNED ALT I NOTICED THE ACFT RATE OF CLB WAS NOT DECREASING. I ASKED THE CAPT IF THE ACFT WAS GOING TO LEVEL OFF. HE IMMEDIATELY TOOK CTL OF THE ACFT AND LEVELED AS BEST HE COULD, BUT DUE TO OUR HIGH RATE OF CLB, WE LEVELED APPROX 300 FT HIGH. WE CORRECTED TO ALT ASAP.

  409.  
  410. Accession Number: 403917
    Synopsis: ALT EXCURSION DURING HIGH ALT CRUISE BY FLC OF AN MD11.
    Narrative: I WAS ACTING AS PNF WHILE RECEIVING MY IOE ON THE MD11. THE CHK CAPT WAS FLYING IN THE R SEAT AND WAS THE PF. AFTER DEPARTING CVG FOR EUROPE, WE WERE AT CRUISE ALT OF 33000 FT MSL NEAR SYRACUSE, NY. THE WX WAS DETERIORATING RAPIDLY WITH MULTIPLE TSTMS, EXTREME TURB, STRONG WINDS, AND ACCORDING TO THE CTR, TORNADIC ACTIVITY. IT WAS NECESSARY TO MAKE MANY LATERAL DEVS TO AVOID THE WX, AND WE WERE BOTH CONCENTRATING ON THE WX RADAR WHILE BEING GIVEN SEVERAL CHANGES TO OUR CLRNC BY ZNY. I WAS VERY BUSY TALKING ON THE RADIO AND ATTEMPTING TO CHK OUR RTE ON THE CHARTS AND MAPS. CTR CALLED AND ASKED OUR ALT, AT WHICH POINT WE BOTH REALIZED THAT THE AIRPLANE (WHICH WAS ON AUTOPLT AT ALL TIMES) WAS LEVEL AT 32000 FT. THE PF IMMEDIATELY CLBED BACK TO 33000 FT. THERE WAS NEVER AN ALT WARNING FROM THE AUTOPLT OR ALTIMETER SYS, AND NEITHER OF US CAN EXPLAIN HOW THE ALT CHANGED. IT IS POSSIBLE THAT IN ALL THE CONFUSION TAKING PLACE, THAT THE PF TURNED THE ALT CTL KNOB INSTEAD OF THE HEADING KNOB TO ATTEMPT A WX DEV. THE 2 KNOBS ARE NEXT TO EACH OTHER AND ARE ALMOST IDENTICAL ON THIS AIRPLANE. THE CTLR SAID THAT THERE WAS NO CONFLICT AND 'NO PROB.'

  411.  
  412. Accession Number: 405187
    Synopsis: A B777 FLC FAILS TO FOLLOW THE SID AS PORTRAYED ON THE DEP CHART. THEY EXPERIENCE A HDG TRACK POS DEV JUST W OF CDG. FO COMPLAINS OF CHART DESIGN AND PRESENTATION.
    Narrative: DEPARTING CHARLES DE GAULLE RWY 27, BNE 8D DEP. AFTER TKOF FROM CDG, RWY 27, WE BEGAN A SLOW R TURN TO INTERCEPT THE BT 331 DEG RADIAL AS PER THE WRITTEN INSTRUCTIONS ON THE SID. PASSING APPROX 2000 FT, ATC ADVISED US TO TURN TO A HDG OF 270 DEGS BECAUSE 'WE HAD TURNED EARLY.' AFTER REACHING CRUISE ALT, WE EXAMINED THE PROC AND THE ARROWS/LINES ON THE SID DIAGRAM SHOWED A TURN AT 1.5 DME. TO OUR KNOWLEDGE THERE WAS NO TFC CONFLICT. FACTORS THAT CONTRIBUTED TO THIS INCLUDE RELIANCE ON THE DIRECTION OF THE 'MAGENTA LINE' ON THE FMC/EFIS WHICH SHOWED DIRECT TO THE 8.5 MI FIX OF THE BT 331 DEG RADIAL. ANOTHER MAJOR CONTRIBUTING FACTOR WAS THE LACK OF WRITTEN INSTRUCTION NOT TO TURN PRIOR TO 1.5 DME, AND THE FACT THAT THE SYMBOL USED TO SHOW THIS POINT ON THE SID DIAGRAM IS EASILY MISTAKEN AS THE SYMBOL FOR A NOISE MONITORING POINT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE FO HAD OFFERED A COPY OF THE CHART WHICH IS NOT AVAILABLE TO ANALYST. FO ADMITTED THAT HE WAS FAIRLY NEW TO THE INTL OP. HE WOULD LIKE THE CHART PRODUCER TO REVIEW THIS SID TO BETTER DEFINE THE DEP PROC AND WHEN TO MAKE THE TURN WITHIN THE WRITTEN TEXT. SUPPLEMENTAL INFO FROM ACN 403830: THERE WAS NO DANGER, BUT WE MAY HAVE CAUSED A NOISE PROB ON THE GND. DURING PREFLT WE HAD LINE SELECTED THE BNE 8A DEP, BUT THE FO, IN AN EFFORT TO VERIFY THE IDENT OF THE 08.5 BT WAYPOINT, MAY HAVE THEN DELETED THE CGN AND OR CGN 1.5 WAYPOINTS. ON THE END OF THE RWY, SEEING THE MAGENTA LINE TURN RIGHT NEAR THE DEP END OF THE RWY, I ASKED IF THERE WAS ANY REASON TO FLY STRAIGHT AHEAD FOR A WAYS BEFORE TURNING, BUT HE CHECKED, AND NOT SEEING A RWY HDG INSTRUCTION, WE MADE THE MISTAKE OF FOLLOWING AN LNAV TRACK WITHOUT A RAW DATA BACKUP. ALSO, AFTER TRYING TO IDENT THE DEP WAYPOINTS, WE SHOULD HAVE RESELECTED THE SID TO PROTECT AGAINST AN INADVERTENT CHANGE LIKE HE MUST HAVE MADE. NAV ERROR.

  413.  
  414. Accession Number: 405990
    Synopsis: A DSNDING FK100 FLC DOES NOT CROSS THEIR ASSIGNED POINT AT THE REQUESTED ALT. THEIR FMS WAS OFF ON ITS PROFILE. CREW REALIZED THIS TOO LATE.
    Narrative: WE RECEIVED CLRNC TO CROSS HOLEY INTXN AT 11000 FT. THIS WAS ENTERED INTO THE FMC AND XCHKED WITH THE EFIS DISPLAY WHICH SHOWED BOTH ALT AND DSCNT POINT. ABOUT 9 MI FROM HOLEY WITH THE ACFT ON AUTOPLT AND IN A DSCNT WE REALIZED THE ACFT, ALTHOUGH DSNDING, WAS NOT FOLLOWING ITS COMPUTED PROFILE. THE ACFT WAS THEN HAND FLOWN DOWN TO THE ALT RESTR, USING LEVEL CHANGE, MANUAL IDLE THRUST AND SPD BRAKES. ATC WAS ADVISED THAT WE WOULD BE LATE ON THE XING RESTR AND WE REACHED 11000 FT ABOUT 5 MI TO THE N OF HOLEY. WE COULD HAVE AVOIDED THIS BY MORE CLOSELY MONITORING THE ACFT DURING ITS DSCNT IN ORDER TO PICK UP ITS PROFILE DEV SOONER, ALLOWING US TO STEP IN SOONER. THERE WERE NO KNOWN CONFLICTS.

  415.  
  416. Accession Number: 406470
    Synopsis: SF340 CREW OVERSHOT ASSIGNED ALT CLBING IN DTW AIRSPACE.
    Narrative: THE FO WAS THE PF. THE WX WAS SEVERE TSTMS. WE WERE TRYING TO FIND A WAY AROUND THEM DIFFERENT THAN PREVIOUSLY CHOSEN. THE AUTOPLT WAS ON AND 5000 FT WAS SELECTED. AT 5600 FT WE BOTH NOTICED THE ALT DID NOT CAPTURE. THE FO IMMEDIATELY STARTED BACK TO 5000 FT. THE ATC CTLR ADVISED WE WERE ASSIGNED 5000 FT. WE INFORMED HIM WE WERE CORRECTING. HE SAID, 'NO PROB' AND GAVE US THE ALTIMETER SETTING. NO OTHER ACFT WERE INVOLVED.

  417.  
  418. 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.

  419.  
  420. Accession Number: 407497
    Synopsis: AN EMB145 FLC OVERSHOT ITS ALT IN DSCNT WHEN THE FLT DIRECTOR FAILS TO INDICATE AN ALT CAPTURE. FO INDICATED A DISTR WITH WX IN LCL AREA.
    Narrative: OUR FLT WAS DSNDING INTO CINCINNATI TERMINAL AREA CLRED TO DSND TO 7000 FT. AUTOPLT WAS DISENGAGED AT APPROX 8000 FT. I CONTINUED TO FOLLOW FLT COMMANDS FROM FLT DIRECTOR. ADDITIONALLY, CAPT REQUESTED A DEV AROUND WX. I VISUALLY SCANNED FOR THE WX AND SHORTLY THEREAFTER HEARD ALT ALERTER SOUND. ALTIMETER INDICATED 6500 FT BEFORE A CLB WAS INITIATED. ATC WAS CONTACTED IMMEDIATELY TO CONFIRM ASSIGNED ALT. ATC NOTICED OUR DEV AND RECLRED FLT TO 6500 FT AND ASSIGNED A HEADING TO KEEP US CLR OF TFC. NO TCASII ADVISORIES WERE OBSERVED. DURING DSCNT FLT DIRECTOR DID NOT COMMAND A CLB EVEN AFTER DSNDING THROUGH SELECTED ALT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR SAID THAT HE DID NOT KNOW OF ANY OTHER PLTS HAVING THIS PROB BUT THE SLOWNESS OF THE FLT DIRECTOR IN CAPTURING AN ALT SELECTED WAS KNOWN WITHIN THE COMPANY. DURING TRAINING THIS ANOMALY OF THE SLOW FLT DIRECTOR RESPONSE WAS BROUGHT OUT TO THE STUDENTS, THE INSTRUCTOR SAYING THAT IT WAS A 'PAX COMFORT FACTOR' IE, WOULD NOT PULL TOO MANY POSITIVE G'S DURING LEVELOFF. THE RPTR CLAIMS THAT THIS PRIMUS 1000 FLT DIRECTOR SYS CAN BE PROGRAMMED FOR A FASTER CAPTURE. RPTR SAID THAT HE WOULD BRING THIS DESIGN PROB UP TO HIS FLEET MGR FOR THE EMB145 AND SEE IF SOMETHING COULD BE DONE. HE ALSO SAID THAT IF HE HEARS OF FUTURE EVENTS SIMILAR TO THIS HE WILL FORWARD THE INFO TO ASRS. SUPPLEMENTAL INFO FROM ACN 407510: ALT BOX WAS SET AT 7000 FT.

  421.  
  422. 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.

  423.  
  424. Accession Number: 407580
    Synopsis: ARTCC CTLR ASSIGNS NEW CLRNC WHEN OBSERVING A B757 FLC CROSS ASSIGNED COURSE. FLC WAS IN LNAV EQUIP MODE. FLC DID NOT OBSERVE DEV FROM ASSIGNED RTE.
    Narrative: I WAS THE PLT FLYING THE ACFT. THE ACFT WAS ON AUTOPLT WITH THE LNAV ENGAGED WHEN WE WERE CLRED TO BRIGS INTXN. I WATCHED THE ACFT MAKE THE TURN TO MAYZE INTXN TO JOIN J6O. AFTER PASSING ASHEN INTXN, ZOB CALLED TO ASK IF WE WERE ON A HEADING. NEITHER THE CAPT OR I COULD REMEMBER IF WE HAD BEEN GIVEN A HEADING, BUT THE ACFT WAS IN HDG MODE AND 6.5 MI R OF COURSE. WE SHOULD HAVE MADE A 20 DEG L TURN TO JOIN THE AIRWAY AT MAYZE INTXN. I SHOULD HAVE BEEN MONITORING THE ACFT CLOSELY, BUT RELAXED ONCE WE HAD REACHED CRUISE ALT AND ESTABLISHED ON COURSE. I STILL DO NOT KNOW HOW WE ENDED UP IN HEADING MODE. SUPPLEMENTAL INFO FROM ACN 406785: UNKNOWN HOW AUTOPLT GOT OFF OF LNAV TRACKING. CORRECTED BACK ON COURSE.

  425.  
  426. Accession Number: 407760
    Synopsis: MISUSE OF AN ALT ALERTER CONTRIBUTES TO AN ALTDEV ON DEP CLB IN AN ATR42 NEAR SJU, PR.
    Narrative: WE WERE CLBING TO OUR FINAL ALT OF 8000 FT. I WAS FLYING BY HAND (AUTOPLT OFF) BUT FOLLOWING THE FLT DIRECTOR BARS. USING THE FLT DIRECTOR BARS HELPS MAINTAIN TIGHTER AIRWORK TOLERANCES, BUT HAND FLYING INCREASES RELIANCE ON YOUR COPLT TO MANAGE THE FLT DIRECTOR. PASSING 6500 FT IN THE CLB, WE WERE GIVEN 'PLT'S DISCRETION TO 6000 FT.' I ASKED THE CAPT IF WE WERE STILL CLRED TO 8000 FT. HE SAID YES AND DIRECTED ME TO CONTINUE THE CLB. HE SET 6000 FT IN THE FLT DIRECTOR AND I CONFIRMED IT AS OUR NEXT ALT. UNFORTUNATELY, NEITHER OF US IMMEDIATELY REALIZED THAT WE HAD A CLB WITHOUT A TARGET ALT. THE FLT DIRECTOR WOULD NOT CAPTURE ALT (8000 FT) SINCE WE RESET IT TO AN ALT WE HAD ALREADY PASSED. THE CAPT, AS PNF, DIRECTED HIS ATTN TO SOME ADMINISTRATIVE COMPANY COMS, WHILE I CONCENTRATED ON THE FLT DIRECTOR BARS. AT 8500 FT, WE BOTH REALIZED THE ERROR AND I BEGAN A DSCNT BACK TO 8000 FT (WHICH I OVERSHOT TO 7900 FT). RECOMMENDATION: 1) FOR PNF, FOCUS ON MONITORING TASKS DURING TRANSITIONS. COMPANY CALLS CAN WAIT. 2) FOR PF, DON'T BE A SLAVE TO THE FLT DIRECTOR. ONE MUST DRIVE THE BARS JUST AS WHEN USING THE AUTOPLT TO ENSURE THEY ARE COMMANDING WHAT YOU WANT. MATCHING THE 'PIPPER' TO THE BARS IS SECONDARY. SMALL DEVS FROM PERFECT AIRWORK ARE PREFERABLE TO FLYING THE WRONG ALT, HDG OR AIRSPD PERFECTLY.

  427.  
  428. Accession Number: 407880
    Synopsis: A CL65RJ ON APCH TO CVG FLIES THROUGH THE LOC COURSE WHEN THE AUTO-CAPTURE MODE OF THE AUTOPLT DEFAULTS TO THE HEADING MODE.
    Narrative: AFTER BEING CLR FOR ILS RWY 18R AT CVG AND ARMING THE APCH MODE ON AUTOPLT, APPARENTLY THE MODE CTL DEACTIVATED AND DEFAULTED TO HEADING MODE. DID NOT NOTICE UNTIL FLYING THROUGH THE LOC. AUTOPLT WAS DISCONNECTED AND WE TURNED BACK TO THE RWY 18R LOC. NO CONFLICT WITH TFC WAS NOTED.

  429.  
  430. Accession Number: 408150
    Synopsis: FLC OF A B737-300 CLBED ABOVE ASSIGNED ALT DUE TO THE AUTOPLT ALT HOLD MODE DISCONNECTING DUE TO HIGHER THAN CRUISE PWR SETTING.
    Narrative: WE WERE AT FL280 WITH DISCRETION TO FL240 AND AT AN ASSIGNED SPD OF 280 KTS. ZHU CHANGED OUR SPD TO 300 KTS. I INCREASED OUR AIRSPD TO 300 KTS BY MEANS OF THE MODE CTL PANEL. DURING ALL OF THE SPD CHANGES, THE CAPT AND MYSELF WERE HAVING A DISCUSSION ON CONVERTING CENTIGRADE TEMP TO FAHRENHEIT TEMP. AFTER A WHILE THE CTLR ASKED ABOUT OUR ALT. THE ACFT HAD BEGUN A SLOW CLB FROM FL280 TO FL290. THE CAPT AND MYSELF HAD A LONG DISCUSSION ON THIS INCIDENT. WE THINK THAT WHEN I INCREASED THE AIRSPD THE ENGS ACCELERATED THE ACFT TO THE POINT THAT THE AUTOPLT COULD NOT KEEP UP WITH THE ACCELERATION. THE PITCH MODE OF THE AUTOPLT DISCONNECTED AND IT BEGAN A SLOW CLB. SINCE WE WERE IN A CRUISE PORTION OF FLT WE MISSED THE ACFT WAS IN A CLB. IN ADDITION TO CLB AND DSCNT LEVELOFFS, I WILL WATCH SPD CHANGES TO MAKE SURE WE DON'T GO THROUGH ON ALT.

  431.  
  432. Accession Number: 408440
    Synopsis: B737 CREW HAD FLT GUIDANCE CHANGE FROM ALT HOLD TO CTL WHEEL STEERING PITCH. THIS RESULTED IN A 1000 FT ALT EXCURSION.
    Narrative: WE WERE AT FL280. ATC HAD GIVEN US 'PLT'S DISCRETION TO FL240.' IT WAS THE FO'S LEG TO FLY. ATC DIRECTED US TO MAINTAIN 300 KIAS. AT THAT MOMENT WE WERE CRUISING AT 280 KIAS. I VISUALLY CONFIRMED THAT THE FO HAD DIALED 300 KIAS INTO THE MCP AIRSPD WINDOW. APPROX 1 MIN LATER, ATC SAID TO US, 'CALL SIGN, SAY YOUR ALT.' SINCE WE HAD BEEN GIVEN A FREQ CHANGE BTWN THE TIME WE WERE GIVEN PLT'S DISCRETION TO FL240 AND NOW, I THOUGHT MAYBE THERE HAD BEEN A FAILURE TO COM BTWN THE LAST SECTOR CTLR AND THIS ONE. I GLANCED AT THE FMC TO CONFIRM WE WERE NOT YET AT OUR TOP OF DSCNT POINT AND REPLIED, 'CALL SIGN WAS GIVEN PLT'S DISCRETION TO FL240.' THEN ATC REPLIED, 'CALL SIGN, SAY YOUR ALT.' WELL, I WAS SURE WE WERE STILL AT FL280 (BECAUSE THAT HAD BEEN OUR CRUISING ALT, AND WE HAD NOT YET STARTED OUR DSCNT), BUT A QUICK GLANCE AT MY INSTS TOLD ME I WAS DEAD WRONG, AND WE HAD A PROB. WITH NO WARNING WHATSOEVER, AND FOR NO APPARENT REASON, THE ACFT HAD BEGUN A VERY SLOW CLB, AND WAS NOW NEARING FL290. AT THE SAME INSTANT I SAW OUR ALTDEV, I ALSO SAW THAT THE PITCH MODE OF THE AUTOPLT HAD REVERTED FROM 'ALT HOLD' TO 'CTL WHEEL STEERING PITCH.' FOR THOSE NOT COMPLETELY FAMILIAR WITH THE B737-500 AUTOPLT, CTL WHEEL STEERING PITCH IS AN AUTOPLT MODE DESIGNED TO MAINTAIN A CONSTANT PITCH ATTITUDE. THE ACFT WAS AT THE MOMENT OF REVERSION TO CTL WHEEL STEERING PITCH. WELL, THAT PART OF THE SYS WORKED AS ADVERTISED. BUT REMEMBER, WE HAD ACCELERATED FROM 280 KIAS TO 300 KIAS. AND (LESSON FROM BASIC AIRMANSHIP 101) A CONSTANT PITCH AT AN INCREASING AIRSPD RESULTS IN -- THAT'S RIGHT -- A CLB. I IMMEDIATELY TOOK CTL OF THE ACFT AND BEGAN A DSCNT, NOT JUST BACK DOWN TO FL280, BUT CONTINUING DOWN TO FL240. SIMULTANEOUSLY I KEYED THE MIKE AND TOLD CTR, 'CALL SIGN IS AT FL290, DSNDING NOW TO FL240. OUR AUTOPLT APPEARS TO HAVE MALFUNCTIONED.' CTR REPLIED, 'ROGER, COPY YOU DSNDING TO FL240.' WE HAD NO TCASII ALERT OF ANY KIND, AND WHEN I ASKED THE CTLR IF I NEEDED TO CALL HIM WHEN WE GOT ON THE GND, HE REPLIED 'NO, DON'T WORRY ABOUT IT.' IN MY 12 1/2 YRS AND 11000 HRS ON B737-300/500 ACFT, I HAVE NEVER SEEN THIS HAPPEN. I HAVE SEEN THE AUTOPLT ON THE B737-300/500 REVERT TO CTL WHEEL STEERING PITCH FOR ONLY 3 REASONS: 1) MANUALLY DESELECTING ALL OTHER PITCH MODES. (THIS DID NOT HAPPEN.) 2) TURB SO BAD THE AUTOPLT CANNOT MAINTAIN ALT. (WE WERE IN PERFECTLY SMOOTH RIDE CONDITIONS.) 3) A FORCE BEING APPLIED TO THE FLT CTLS SIGNIFICANT ENOUGH TO CAUSE THE SELECTED AUTOPLT PITCH MODE TO DISENGAGE. THIS IS THE ONLY POSSIBILITY I CAN THINK OF. WHAT MAY HAVE HAPPENED IS THAT THE NOSE-UP PITCH FORCES RESULTING FROM THE PWR ADVANCING TO ACCELERATE FROM 280 KIAS TO 300 KIAS WERE SIGNIFICANT ENOUGH TO CAUSE THE AUTOPLT TO REVERT FROM 'ALT HOLD' TO 'CTL WHEEL STEERING PITCH.' NORMALLY WE WOULD GET A WARNING HORN IF THE ACFT DEVIATED FROM THE SELECTED CRUISE ALT BY MORE THAN 150 FT. BUT IN THIS CASE, BECAUSE WE HAD DIALED FL240 INTO THE ALT WINDOW ON THE MCP TO COMPLY WITH OUR CLRNC, WHEN THE ACFT DEPARTED FL280, EVEN THOUGH IT WAS CLBING INSTEAD OF DSNDING, WE GOT NO WARNING HORN AND NO ALT ALERT LIGHT. ALSO, BECAUSE THE AUTOPLT HAD NOT COMPLETELY DISENGAGED, WE GOT NO 'AUTOPLT DISENGAGED' WARNING TONE OR LIGHT. WHAT APPARENTLY HAPPENED WAS THE CTL WHEEL STEERING PITCH APPEARED ON THE EFIS DISPLAY. I HAD MY HEAD DOWN AT THE MOMENT THIS OCCURRED AND WAS NOT LOOKING AT THE INST PANEL. THE FO, WITH NO REASON TO EXPECT ANY ANOMALY, DID NOT NOTICE THE CTL WHEEL STEERING PITCH DISPLAY APPEAR. AND THE CLB WAS SO SLOW THAT NEITHER THE FO NOR I HAD ANY 'SEAT-OF-THE-PANTS' INDICATION WE HAD DEPARTED ALT. RECOMMENDATIONS: HUMAN FACTORS: 1) INCREASED VIGILANCE. 2) GET THE WORD OUT HOW THIS CAN HAPPEN. MECHANICAL: CONDUCT INSPECTIONS TO DETERMINE IF THE 'PENDULUM EFFECT' RESULTING FROM LARGE PWR CHANGES IN B737'S IS SIGNIFICANT ENOUGH TO CAUSE AUTOPLT REVERSION TO CTL WHEEL STEERING PITCH IN A STATISTICALLY SIGNIFICANT NUMBER OF ACFT.

  433.  
  434. Accession Number: 409085
    Synopsis: A CANADAIR CL65 ON DSCNT AT 11000 FT HAD THE DME JUMP FROM 20 MI TO 10 MI RESULTING IN MISSING AN INTXN 2 MI LATE. CREW SUSPECTS CABIN PAX ELECTRONICS AND NOT THE AUTOPLT AS RPTED.
    Narrative: FMS DME JUMPED FROM 20 MI TO 10 MI IN A MATTER OF SECONDS. WE RESPONDED BY INCREASING OUR DSCNT RATE TO APPROX 4000 FPM. CROSSED SARGO 2 MI LATE. CLRNC WAS TO CROSS SARGO AT 11000 FT, WE CROSSED AT 12000 FT. ADDITIONALLY, THE FMS LED THE AUTOPLT 2 MI S OF COURSE (APCHING SARGO) BEFORE THE CREW RETURNED TO THE PROPER COURSE. NO ATC QUERIES WERE RECEIVED. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE ACFT WAS A CANADAIR CL65 AND THE DME PERFORMED NORMALLY AFTER THE 20 MI TO 10 MI JUMP AND NO WRITE-UP WAS NECESSARY. THE RPTR SUSPECTS THE ANOMALY IN THE DME WAS CAUSED BY PAX PERSONAL ELECTRONIC UNITS.

  435.  
  436. Accession Number: 409112
    Synopsis: A B737-300 FLC CRUISING THROUGH ZMP AIRSPACE TESTS THE FUEL GAUGES AND TAKES THE AUTOFLT SYS OUT OF VNAV. THE ACFT HAS AN ALT EXCURSION OF 400 FT.
    Narrative: B737-300 IN CRUISE AT FL350, AUTOPLT ENGAGED IN VNAV. I TESTED THE FUEL GAUGES, AND FOR SOME REASON THE VNAV DISCONNECTED AND THE AUTOPLT DID NOT DEFAULT TO ALT HOLD, BUT RATHER STARTED A SLOW DSCNT. WE DID NOT PICK UP THE DSCNT UNTIL THE ALT ALERT HORN SOUNDED AT 300 FT BELOW FL350. I TOOK CORRECTIVE ACTION BY DISENGAGING THE AUTOPLT AND RETURNING TO FL350. THE ACFT DSNDED TO ABOUT 400 FT BELOW OUR ASSIGNED ALT OF FL350. TESTING THE FUEL GAUGES RESULTED IN VNAV DISENGAGEMENT. HOWEVER ON EACH SUBSEQUENT TEST THE AUTOPLT DEFAULTED TO ALT HOLD AND DID NOT CHANGE ALT.

  437.  
  438. Accession Number: 409279
    Synopsis: B767 CRUISING AT FL350. CAPT FAILED TO INITIATE DSCNT WHEN CLRED TO LOWER ALT DUE TO UNMONITORED VNAV MALFUNCTION.
    Narrative: 30 NM W OF MOL, WHILE AT FL350, ZDC CLRED US TO DSND TO FL330. WE RESET THE ALT WINDOW TO FL330 AND SELECTED FL330 AS CRUISE ALT IN CDU. WE HAD BEEN OPERATING IN VNAV BUT FOR SOME UNKNOWN REASON THE ACFT THEN REVERTED TO ALT HOLD. I, AS THE PF, FAILED TO CHK THE ADI FOR THE APPROPRIATE DSCNT INDICATIONS AND WENT ABOUT REVIEWING THE ARR PROCS FOR JFK. A MIN OR 2 LATER, CTR CALLED AND ASKED IF WE HAD RECEIVED THE DSCNT TO FL330. I THEN INITIATED THE DSCNT USING FLT LEVEL CHANGE. THE FLT CONTINUED WITHOUT FURTHER INCIDENT. LESSON LEARNED: CHK WHAT IS ACTUALLY ON YOUR PLATE. SUPPLEMENTAL INFO FROM ACN 409280: WE RESET THE ALT WINDOW BUT FAILED TO NOTICE THAT WE HAD NOT ENGAGED THE AUTOPLT TO START THE DSCNT.

  439.  
  440. Accession Number: 409350
    Synopsis: FK10 CREW EXCEEDED 250 KTS BELOW 10000 FT.
    Narrative: I SET 250 KTS ON FMC BUT NOTICED 290 KTS AT 9500 FT. I LEVELED OFF AND SLOWED TO 250 KTS AND CONTINUED. I MUST WATCH FMC MORE CLOSELY.

  441.  
  442. Accession Number: 409386
    Synopsis: ACR FLC DOES NOT RE-ENTER NEW COMPANY DISPATCH FLT PLAN AND FLC FLY OLD FILED RTE. ATC CHALLENGES PIC AND INCORRECT FLOWN RTE IS RECOGNIZED.
    Narrative: THE RTE WAS ENTERED INTO THE FMS (NORMAL COMPANY ROUTING). HOWEVER, DUE TO A LINE OF TSTMS ALONG OUR RTE, A DIFFERENT RTE WAS FILED BY OUR DISPATCH. BECAUSE OF UNUSUAL CIRCUMSTANCES SURROUNDING OUR PREFLT PREPARATION, THE ROUTING WAS NOT VERIFIED BY THE CREW MEMBERS INVOLVED. ONCE AIRBORNE, ATC INQUIRED TO VERIFY OUR RTE. WE READ BACK THE COMPANY ROUTING FROM THE DISPATCH RELEASE. THE MISTAKE WAS MADE BECAUSE THE ORIGINAL RTE WAS TYPED INTO THE FMS.

  443.  
  444. Accession Number: 409722
    Synopsis: THE CREW ON A B757 LNDG RWY 12 AT MIA IS INSTRUCTED TO LAND AND HOLD SHORT OF RWY 9R. APPROX 2-3 MI OUT, THE B757 CREW ADVISES THE TWR THAT THEY ARE UNABLE TO LAND AND HOLD SHORT.
    Narrative: WE WERE CLRED FOR THE ILS RWY 12 AT MIA ARPT. APCH CTLR REQUESTED WE KEEP OUR SPD UP AS LONG AS POSSIBLE. WHEN WE WERE AT THE FINAL APCH FIX, WE WERE SWITCHED TO TWR FREQ. THE TWR CTLR CLRED US TO LAND ON RWY 12, HOLD SHORT OF RWY 9R. WE WERE AT A FASTER SPD THAN NORMAL, TO FACILITATE APCH'S REQUEST. BY THIS TIME WE WERE INSIDE THE FAF, TRYING TO SLOW AND CONFIGURE THE AIRPLANE FOR LNDG. THE CAPT ASKED TWR HOW MUCH RWY WOULD BE AVAILABLE WITH LAHSO AND GOT NO REPLY. HE STARTED TO LOOK AT THE COMPANY SPECIAL PAGES TO FIND A LAHSO RWY AVAILABLE DISTANCE, BUT HAD A HARD TIME SINCE IT WAS DARK AND HE WEARS GLASSES. I FELT UNCOMFORTABLE GETTING A LAHSO CLRNC SO LATE, WHILE WE WERE VERY BUSY. ALSO, OUR UNION HAS ISSUED MANY SAFETY BULLETINS RECOMMENDING PLTS NOT ACCEPT LAHSO CLRNCS UNTIL MANY ISSUES ARE RESOLVED. I TOLD THE CAPT I DIDN'T WANT TO LAND AND HOLD SHORT OF RWY 9R. HE TOLD TWR 'UNABLE TO LAND AND HOLD SHORT.' TWR REPLIED, CANCEL LNDG CLRNC RWY 12, CLRED TO LAND RWY 9L. WE WERE ABOUT 2-3 MI OUT, AND I COULDN'T SEE RWY 9L. WE DIDN'T HAVE ANY NAVAIDS OR FMS DISPLAY SET FOR RWY 9L, AND I WASN'T SURE WHERE RWY 9L WAS IN RELATION TO RWY 12. I ASKED THE CAPT TO DIAL IN THE RWY 9L LOC FREQ, BUT HE WAS BUSY AND DIDN'T HEAR. DURING ALL THIS CONFUSION, SOMEHOW THE AUTOTHROTTLES WERE DISCONNECTED AND I DIDN'T REALIZE IT, GETTING 10 KIAS SLOW. WE WERE BOTH LOOKING OUTSIDE FOR THE 9L RWY AND PICKED UP THE VASI FOR A NORMAL LNDG. TWR PUT US IN A DANGEROUS SIT. LAHSO IS A BAD IDEA. NEXT TIME I'LL GO AROUND.

  445.  
  446. Accession Number: 409880
    Synopsis: FLC INBOUND TO JFK CLRED BY ZFW TO CROSS 20 MI E OF PARCH AT FL240. FO WAS PF. CAPT SET CLRNC DATA INTO CDU FMC BUT DID NOT SET ALT IN FMC OR VERIFY ALT WITH THE FO FLYING.
    Narrative: ARR INTO NEW YORK JFK ON THE PLYMM ARR. TALKING TO ZBW. CLRED TO CROSS TRAKE AT FL240. I WAS FLYING. CAPT SET UP XING RESTR IN CDU FMC. ACFT WAS OPERATING IN VNAV. CTR CHANGED XING RESTR AND CLRED US DIRECT PARCH TO CROSS 20 MI E OF PARCH AT FL240. CAPT RESET DIRECT PARCH AND 20 MI E OF PARCH IN CDU/FMC. DID NOT SET FL240 IN FMC. ACFT WAS STILL IN VNAV FOR AN AUTOMATIC DSCNT. WE ASSUMED THAT WE HAD FL240 SET IN BECAUSE WE HAD SET UP FL240 FOR TRAKE. APCHING 20 MI E OF PARCH WE WERE ASKED BY CTR IF WE WERE GOING TO MAKE THE RESTR. WE SAID THAT IT WILL BE CLOSE. CTR THEN GAVE US A DIRECT TO ROBER INTXN TO CROSS AT 9000 FT WHICH WE PUT IN THE FMC AND BOTH VERIFIED AND MADE. WE BOTH LEARNED THAT WHEN ANY ENTRY IS MADE IN THE CDU/FMC IT SHOULD ALWAYS BE VERIFIED BY THE PNF.

  447.  
  448. Accession Number: 410097
    Synopsis: FO OF AN MD88 OVERSHOT ASSIGNED DSCNT ALT DUE TO MISSETTING THE FMC MODE CTL PANEL FOR AN ATC REQUESTED SPD REDUCTION CAUSING THE AUTOPLT TO NOT CAPTURE PRESET ASSIGNED ALT. FO RECOGNIZED HIS MISTAKE AND MANUALLY RETURNED THE ACFT TO ASSIGNED ALT. HOWEVER, TCASII ALERT SHOWED LOSS OF STANDARD SEPARATION WITH ANOTHER ACFT.
    Narrative: WHEN DSNDING TO 12000 FT MSL I WAS GIVEN A SPD REDUCTION TO 250 KTS AND A HEADING CHANGE AT APPROX 12300 FT. I NOTICED THAT THE ALTIMETER WAS STILL AT 29.92 AND RESET IT TO 30.16. THAT CAUSED THE ALT CAPTURE MODE OF THE AUTOPLT TO CANCEL. I DID NOT IMMEDIATELY CATCH THE LOSS OF ALT CAPTURE. I INCORRECTLY PUSHED 'IAS' ON THE AUTOPLT IN AN EFFORT TO CHANGE FROM THE FMS SPD TO ENABLE ME TO REDUCE TO 250 KTS AS INSTRUCTED. I THEN CAUGHT SIGHT OF THE ACFT ALT GOING THROUGH 11900 FT. TO QUICKLY GAIN ACFT CTL I CLICKED OFF THE AUTOPLT AND PROCEEDED TO BRING THE ACFT BACK TO 12000 FT MSL AFTER DROPPING TO APPROX 11750 FT. THERE WAS AN RA ON TCASII FOR LOWER TFC WHILE OFF ALT. I FEEL THE EVENTS HAPPENED FOR SEVERAL REASONS. NOT ALREADY HAVING THE ALTIMETER SET TO 30.16. THIS, WITH BEING INSTRUCTED TO TURN AND CHANGE AIRSPD DIVERTED MY ATTN FROM THE ALT. I PUSHED 'IAS' ON THE AUTOPLT IN ERROR DUE TO BEING NEW TO THE ACFT AND ITS AUTOMATION AND BEING IN A RUSHED SIT. SOLUTION: I SHOULD HAVE CALLED FOR DSCNT CHKLIST DSNDING THROUGH 18000 FT. THAT WOULD HAVE RESET MY ALTIMETER. MORE INITIAL FMS TRAINING WOULD HAVE HELPED WITH NOT PUSHING 'IAS' ON THE AUTOPLT. THIS CAUSED A DISTR. HAVING MORE FLT EXPERIENCE IN THE ACFT WOULD HAVE INCREASED FAMILIARITY.

  449.  
  450. Accession Number: 410170
    Synopsis: FLC OF A B737 UNDERSHOT XING FIX ON DSCNT STAR DUE TO COMPLACENCY IN STARTING THE DSCNT AND DISTR OF ENTERING FMC DATA FOR LNDG. NO CONFLICT NOTED.
    Narrative: I DID NOT DSND TO FL270 FROM FL330 (AT MY DISCRETION) UNTIL TOO LATE. I HAD PREVIOUSLY ENTERED 24000 FT IN THE FMC AT TURLO BUT WAS BUSY PROGRAMMING THE ARR RWY AND WHEN I SWITCHED BACK TO THE DSCNT PAGE, I FOUND THAT I WAS LATE TO START THE DSCNT. I BEGAN A MAX RATE DSCNT +6000 FPM AND ESTIMATE THAT TURLO WAS CROSSED AT ABOUT FL270. I LEVELED AT FL240 APPROX 3 MI PAST THE TURLO FIX. THE CAUSAL FACTOR WAS DISTR/INATTENTION. I SHOULD HAVE WAITED UNTIL AFTER I DSNDED TO FL240 BEFORE I ENTERED MORE FMC DATA. NO ACFT SEPARATION COMPROMISED. NO OTHER ACFT WERE NOTED WITHIN 15 MI ON TCASII.

  451.  
  452. Accession Number: 410460
    Synopsis: A B777 FLC DOES NOT CATCH THE ERRONEOUS FMC ENTRY RELATIVE TO THEIR RERTE OVER CANADA AND EXPERIENCE A HDG TRACK POS DEV. CTLR CATCHES MISTAKE AND DSNDS ACFT FOR OPPOSING TFC.
    Narrative: ON FLT FROM LHR TO SFO, APCHING N64 W60, RECEIVED RERTE FROM MONTREAL, AS FOLLOWS: N6330 W67, N60 W80, N5530 W90, YWE, AS FILED. I INCORRECTLY ENTERED N5330 W90 VICE N5530 W90 IN THE FMC. FO CHKED RTE BUT DID NOT CATCH ERROR, NOR DID I. SHORTLY THEREAFTER, I WENT ON REST BREAK. THE RERTE WAS PASSED TO DISPATCH (CORRECTLY) BUT NEW FLT PLAN NOT RECEIVED IN COCKPIT UNTIL AFTER 80W SO CREW WAS UNABLE TO CHK ROUTING AGAINST PAPER PLAN. PLOTTING CHART IS NOT REQUIRED OVER CANADA, SO THAT XCHK WAS GONE. 2 POS RPTS WERE MADE (67W AND 80W), BUT ATC DID NOT CATCH ERROR. AT 83W WINNIPEG CALLED TO VERIFY NEXT WAYPOINT. ERROR WAS CAUGHT AT THAT TIME AND FLT WAS CLRED TO DSND TO FL330 FROM FL350 AND CLRED DIRECT WINNIPEG. AFTER SEVERAL MINS FLT WAS CLRED BACK TO FL350. DEV FROM COURSE WAS APPROX 30 NM. PERHAPS RESUMPTION OF POS PLOTTING OVER CANADA WOULD HELP PREVENT ANOTHER OCCURRENCE OF THIS KIND. SUPPLEMENTAL INFO FROM ACN 410444: 2 POS RPTS WERE MADE PRIOR WITH INCORRECT WAYPOINT GIVEN, AND NONE CAUGHT ERROR. FLYING FO HAD COME BACK FROM BREAK PRIOR TO 080W AND CAPT WENT BACK FOR HIS BREAK AT THAT TIME. THE FLYING FO DID NOT CATCH ERROR EITHER. THIS KEYBOARD ENTRY ERROR WHICH CAUSED THE NAV DEV WAS NOT RECOGNIZED BY 3 PLTS AND 3 CTLRS (THROUGH POS RPTS). WE FOLLOWED ALL PROCS CORRECTLY BUT DIDN'T HAVE A NEW FLT PLAN FROM DISPATCH FOR THE FINAL AND MOST ESSENTIAL VERIFICATION. SUPPLEMENTAL INFO FROM ACN 410452: THE CAPT TOOK HIS REST BREAK PRIOR TO W80, I TOOK HIS SEAT AND THE FLYING FO TOOK R SEAT. WE BRIEFED THE RERTE BUT DIDN'T HAVE THE HARD COPY FROM DISPATCH YET FOR HER TO CHK IT. I TOLD THEM THE INCORRECTLY ENTERED WAYPOINT OF N5330 W090. THEY TOLD US TO DSND FROM FL350 TO FL330 (WE SAW TFC AHEAD APPROX 40 NM AT FL350). (ORIGINAL FLT PLAN RTE: N64 W060 DIRECT KAGLY DIRECT TEFFO N544B YWG.) WE DID QUERY DISPATCH AS TO WHY IT WAS TAKING SO LONG TO GET NEW FLT PLAN. THEY ANSWERED OVER ACARS SAYING THEY HAD TO ENTER IT IN THE COMPUTER AND IT WOULD BE A WHILE.

  453.  
  454. 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.

  455.  
  456. Accession Number: 411330
    Synopsis: B737 CREW DID NOT MAKE A CTLR ISSUED XING RESTR.
    Narrative: ON DSCNT ON THE VCN STAR, CTR GAVE US A XING RESTR. AT THE SAME TIME, THE FLT ATTENDANT RANG US. FO WAS FLYING. I ANSWERED THE RADIO, THEN ANSWERED FLT ATTENDANT. FO PROGRAMMED THE FMC. SOMEHOW SIE VOR DROPPED FROM FMC. FO SAID HE DIDN'T DO IT. I WAS TALKING ON INTERPHONE TO A FLT ATTENDANT AND THUS DISTR BY OTHER DUTIES. CTR SAID THERE WASN'T A CONFLICT, BUT WE DID GO OFF THE STAR.

  457.  
  458. 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.

  459.  
  460. Accession Number: 411610
    Synopsis: CAPT OF AN ACR ATTEMPTED TO INTERCEPT THE WRONG LOC COURSE. DUE TO NOT REPROGRAMMING THE FMS TO THE NEWLY ASSIGNED LOC THE ACFT TRIED TO INTERCEPT LOC FOR RWY 26R VERSUS RWY 27L. APCH CTLR INTERVENED AND GAVE ANOTHER HEADING TO INTERCEPT THE NEW RWY LOC ASSIGNMENT.
    Narrative: TALKING TO FINAL CTLR, HE TOLD US TO EXPECT RWY 26R, I WAS AT 250 KTS DSNDING FROM 10000 FT TO 6000 FT, TOLD TO TURN TO HDG 220 DEGS AND SLOW TO 210 KTS. WE WERE 2-3 MI FROM FINAL APCH COURSE. WHEN WE WERE TOLD WE WERE GOING TO RWY 27L, DSND TO 2800 FT, THE FO STARTED TO SET UP FMS FOR ME TO VERIFY AND PUT THE LOC ON HIS SIDE. I PUT THE LOC COURSE ON MY SIDE BUT DID NOT BRING THE FREQ OVER ON MY PANEL AND PROGRAM THE FLT DIRECTOR TO CAPTURE THE LOC. THE AUTOPLT TRIED TO CAPTURE RWY 26R LOC. AT THE SPD WE WERE GOING THE ACFT WENT THROUGH THE LOC SO THAT IT WAS R OF COURSE. THE CTLR SAW THIS AND MADE IT PLAIN THAT WE WERE TRYING TO CAPTURE THE WRONG LOC AND TO TURN MORE L FOR RWY 27L. IF WE DID NOT SEE THE ACFT FOR RWY 26R WE WOULD HAVE TO STOP DSCNT. WE SAW THE ACFT. NO CONFLICT. INTERCEPTED LOC RWY 27L, LNDG WITH NO PROBS. THIS WAS THE LAST DAY OF A 5 DAY LINE. 1ST DAY 14 HRS, WITH AN 8 HR OVERNIGHT. 8 HRS NEXT DAY. DAY 3, XA30 SHOW FOR AN 11 HR DAY WITH A LOT OF WX, TURNED INTO A 13 HR DAY. 4TH DAY, 9 HRS WITH A 9 HR 30 MIN OVERNIGHT. THIS WAS 5TH DAY, 2 HRS 20 MIN FLT -- 770 MI. WE WERE GIVEN DIFFERENT RWY, WHEN CLOSE IN, WHEN THE WORKLOAD WAS VERY HIGH AND A SIMPLE MISTAKE OF NOT HITTING MY SIDE HARD ENOUGH OR FORGETTING TO BRING IT OVER TO THE ACTIVE SIDE. WE ARE TRAINED TO 'IDENT' EVERYTHING, BUT DID NOT GET A CHANCE TO DO ALL THREE BEFORE WE WENT THROUGH RWY 26R LOC.

  461.  
  462. Accession Number: 411715
    Synopsis: FLC OF AN EMBRAER 145 (E145) OVERSHOT ASSIGNED ALT DURING GAR CLB. RPTR COMPLAINS OF LACK OF AUTOPLT ALT CAPTURE, WORKLOAD AND FATIGUE.
    Narrative: ON APPROX 2 MI FINAL TO ILS RWY 4R MY FO QUESTIONED EWR TWR AS TO WHETHER OR NOT THE ACFT AHEAD CLRED THE RWY. ON SHORT FINAL, EWR TWR TOLD US TO 'GAR.' EWR TWR OFFERED A R VISUAL PATTERN TO LAND ON RWY 29 BUT WE WERE NOT ABLE TO KEEP THE ARPT IN SIGHT VISUALLY, SO WE WERE SEQUENCED BACK FOR ANOTHER ILS TO RWY 4R. WE DECLARED MINIMUM FUEL -- ADVISORY FUEL WITH 60 MINS OF FUEL REMAINING. ON OUR GAR THE ACFT BLEED #2 OVERHEAT WARNING WENT OFF. WE WERE TOLD TO FLY 060 DEGS AND MAINTAIN 1500 FT ON THE GAR. I CLBED TO 1700 FT AND THEN WENT BACK DOWN TO 1500 FT. THE AUTOPLT AND FLT GUIDANCE CTLR ON THE EMB145 ACFT IS VERY SLOW AND MAKES MANY ERRORS. THE FLT DIRECTOR BARS DID NOT CAPTURE THE 1500 FT ALT. OUR COMPANY SHOULD HAVE ORDERED THE BETTER COMPUTER. THE HONEYWELL SYS IS OVERLOADED. OTHER FACTORS INCLUDE LONG DUTY DAY OF 12+ HRS AND COMMUTE TIME OF 6 HRS. FLT FROM CVG TO EWR HAD MANY DELAYS AND HOLDING. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT HE DOES NOT KNOW FOR SURE IF THE ALT CAPTURE FOR 1500 FT WAS ENTERED BY THE FO IN SUFFICIENT TIME TO ALLOW THE AUTOPLT TO CAPTURE THE ALT. HE DID REITERATE THAT THE HONEYWELL SYS WAS NORMALLY VERY SLOW TO REACT TO NOT ONLY ALT CHANGES, BUT ALSO HDG CHANGES. HE BELIEVES THAT IT IS A DESIGN CHARACTERISTIC OF THE AUTOFLT SYS. HE ADMITTED THAT HE SHOULD HAVE MONITORED THE ALT TO WHICH HE WAS ASSIGNED FOR GAR MORE CLOSELY AS HE WAS USED TO THE SLOW REACTION OF THE AUTOPLT SYS. HE FURTHER STATED THAT EVEN THOUGH THIS EQUIP IS NOT AS DEPENDABLE AS OTHER AUTOPLTS BY THE SAME MANUFACTURER ON OTHER ACFT HE HAS OPERATED, AND THE ENG FADEC COMPUTER SYS HAS CREATED UNWARRANTED ENG SHUTDOWNS, HE BELIEVES THAT THE ACFT IS A GOOD ACFT AND HAS HAD VERY FEW PROBS FOR A NEWLY DESIGNED ACFT.

  463.  
  464. Accession Number: 411760
    Synopsis: A CLBING MD80 OVERSHOT ITS ASSIGNED ALT OF FL280 BY 1200 FT WHEN THE ALT ALERTER WINDOW WAS SET TO FL290 VERSUS FL280.
    Narrative: I WAS PNF ON AUG/TUE/98, WHICH WAS IN PROCESS OF LEVELING OFF AT FL290 1000 FT ABOVE FL280 ASSIGNED. CTLING AGENCY ZAU RECLRED FLT TO FL280 WHILE CLBING TO FL230 ON MKE-STL LEG. THE CAUSE OF THE OVERSHOOT, I BELIEVE, WAS A COCKPIT PREOCCUPATION WITH THE CAPT'S PROB TRIMMING THE ACFT PLUS A POSSIBLE MOVEMENT OF THE ALT WINDOW DIGIT FROM 28000 FT TO 29000 FT AFTER THE ALT WAS SET. TO MY KNOWLEDGE I SET AND ARMED 28000 FT AND POINTED TO THE WINDOW TO DOUBLE CHK AND THEN TO THE YELLOW 'ALT' READOUT ON THE MD80 FLT MGMNT ANNUNCIATOR WINDOW. DURING THE CLB THE CAPT ASKED ME SEVERAL QUESTIONS ABOUT THE ACFT TRIM AND IN MY RESPONSE I MENTIONED THAT I USUALLY JUST TRIM WITH AILERON AND WORRY ABOUT RUDDER TRIM ADJUSTMENTS AFTER LEVELOFF. HE CONTINUED TO EXPLORE THE TRIM PROB UNTIL I FELT THE ACFT LURCH FORWARD IN PITCH AND I SAW 29200 FT ON MY ALTIMETER. IF 29000 FT WAS MISSING IN WINDOW IT SHOULD'VE LEVELED OFF AT 29000 FT SO I BELIEVE SOMEHOW ALT SETTING SLIPPED 1 DIGIT AND DISARMED THE ALT WITHOUT PF OR PNF (ME) SEEING IT. RECOMMEND: 1) CHK WITH MANUFACTURER TO SEE IF ALT WINDOW CAN 'AUTONOMOUSLY' SLIP 1 DIGIT AND DISARM AFTER IT HAS BEEN SET AND ARMED? 2) PLTS BE ENCOURAGED NOT TO DISCUSS ANY NON ESSENTIAL SUBJECTS WHILE ALTIMETER IS MOVING, ESPECIALLY DURING THE INITIAL CLBOUT WHEN ACTIVITY SLOWS DOWN.

  465.  
  466. 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.

  467.  
  468. Accession Number: 411990
    Synopsis: B737 ACFT WITH AUTOMATED FLT GUIDANCE SYS DEVIATED 200 FT ABOVE CLRED ALT BEFORE CAPT CORRECTED IT.
    Narrative: FO WAS THE PF. ACFT AUTOPLT WAS ENGAGED ENTIRE LEG FROM MSP TO MDW. DURING THE TIME OF OCCURRENCE, HOWEVER, I'M NOT SURE IF FMS WAS ENGAGED OR ALT HOLD. WE WERE CLRED FOR THE ILS RWY 4R APCH TO MDW (IN VMC CONDITIONS) AND INSTRUCTED TO 'MAINTAIN 4000 FT UNTIL CADON, CLRED FOR ILS RWY 4R APCH, CONTACT TWR FAF INBOUND.' APPROX 2-3 MI FROM CADON, FO CALLED FOR FLAPS 5 DEGS. UPON REACHING BACK FROM THE FLAP HANDLE, I NOTICED THE ACFT CLBING THROUGH 4200 FT. I SIMULTANEOUSLY TOLD THE FO TO CHK HIS ALT, DISCONNECTED THE AUTOPLT AND RETURNED TO 4000 FT MSL. AT NO TIME WAS ANOTHER ACFT OBSERVED IN THE AREA NOR AN ALERT GIVEN (OR WARNING) BY TCASII OR ATC.

  469.  
  470. Accession Number: 412030
    Synopsis: CL60 HAD AN AIRSPACE INCURSION WITH AN MD80, FLYING PARALLEL SIMULTANEOUS APCHS TO RWY 26 AND RWY 27 AT IAH.
    Narrative: THE CHALLENGER WAS EQUIPPED WITH TCASII AND DID NOT HAVE A TA. THE MD80 APPARENTLY DID HAVE A TA. DURING A FLT FROM OMA TO IAH, THE CREW MADE A SLIGHT DEV FROM THE RWY 26 APCH, WHICH WITH RWY 27 HAS SIMULTANEOUS ILS APCH AUTH. THERE WAS NEVER A POINT DURING THE APCH THAT THE ACFT EXCEEDED THE PROTECTED DEV AREA OF THE ILS APCH. THE NARROW SEPARATION DISTANCE BTWN THE 2 APCHS OF 1 MI AND THE PROX OF ANOTHER ACFT ON THE RWY 27 APCH PROMPTED A TARGET ALERT ON THE OTHER ACFT. BUT DID NOT CAUSE A TARGET ALERT ON THE CHALLENGER. SEQUENCE OF EVENTS: THE CREW OF THE CHALLENGER WAS GIVEN A R TURN TO 260 DEGS, CLRED FOR APCH AND CONTACT TWR. THE CAPT ACKNOWLEDGED THE CLRNC AS THE COPLT WAS ENGAGED IN OTHER COCKPIT DUTIES. THE ACFT WAS ON AUTOPLT SO THE CAPT TURNED THE HDG BUG TO 260 DEGS AND ENGAGED THE APCH MODE ON THE FLT DIRECTOR. AT THAT POINT THE CAPT WAS CONCERNED BECAUSE THE ASSIGNED HDG APPEARED TO BE TOO SHALLOW TO INTERCEPT THE ILS COURSE BEFORE THE OM. THE CDI INDICATOR WAS SHOWING FULL DEFECTION L. THE HDG WOULD HAVE BEEN FINE IF THE ACFT WAS ON OR ALMOST ON COURSE. AT THIS POINT THE CAPT LOOKED AT THE FMS EXTENDED CTRLINE FROM THE OM ON THE MFD WHICH SHOWED THAT THE ACFT WAS ON COURSE FOR THE ILS RWY 26. THE CAPT AGAIN CHKED THE CDI AND IT WAS STILL FULL DEFLECTION L. AT THIS TIME THE CAPT SAID TO THE COPLT, 'THIS IS NOT RIGHT, THE FMS DOES NOT AGREE WITH THE ILS.' THE COPLT CHKED THE APCH CHART AND SAID, 'I GAVE YOU THE FREQ FOR RWY 27.' HE CHANGED THE CAPT'S ILS FREQ. THE CAPT IMMEDIATELY TURNED THE HDG BUG TO 280 DEGS SO THE ACFT WOULD INTERCEPT THE RWY 26 LOC. AT THE SAME TIME, THE CAPT SAW A WHITE DC9 AT ABOUT 10 O'CLOCK LOW AND NOTED THAT IT APPEARED TO BE STARTING A LEVEL L TURN. THE DISTANCE LOOKED TO BE OVER 1 MI AHEAD AND ABOUT 800-1000 FT LOWER. THE CHALLENGER'S ALT WAS ABOUT 3500 FT AT THE COMPLETION OF THE TURN. THE CAPT ALSO NOTED THAT THE GS INDICATOR WAS CTRED AND THE CDI WAS 1/2 DEFLECTION TO THE R SO HE CONTINUED THE APCH FOR RWY 26. APCH CTL CAME ON THE FREQ AND ASKED IF WE WERE ON FREQ. THE COPLT ACKNOWLEDGED THE CALL. THE CTLR SAID TO LEVEL AT 3000 FT WHICH THE CAPT DID. THE CAPT TOLD THE COPLT TO RPT SEEING THE OTHER ACFT AND THAT THE ARPT WAS IN SIGHT. AT THIS TIME THE ACFT APPEARED TO BE SLIGHTLY L OF RWY 26 CTRLINE AND THE CDI WAS LESS THAN 1/2 DEFLECTION. THE COPLT ACKNOWLEDGED THAT THE ARPT WAS IN SIGHT AND TOLD APCH CTL WHICH TOLD THE CREW TO CONTACT TWR. THE COPLT TOLD THE TWR THE ARPT WAS IN SIGHT, AT WHICH TIME THE TWR CLRED THE ACFT FOR A VISUAL APCH. CONCLUSION: THE CREW OF THE CHALLENGER ERRED IN NOT PUTTING THE CORRECT ILS FREQ IN THE NAV RADIO, BUT WERE ABLE TO CORRECT THE MISTAKE BEFORE THEY EXCEEDED THE LIMITS OF THE ILS. THE SIMULTANEOUS ILS APCH TO IAH FOR RWY 27 AND RWY 26 ARE ONLY 1 MI APART. THE PROTECTED AREA OF BOTH ILS APCHS OUTSIDE THE OM'S CROSS INTO THE OTHER'S PROTECTED BOUNDARY. BECAUSE OF THIS, AUTH FOR SIMULTANEOUS APCH OPS HAVE SPECIAL RULES. BOTH ACFT WILL MONITOR THE SAME FREQ AND IF THE GND CTLR DETECTS A DANGEROUS SIT THE ORDER TO BREAK OR DISCONTINUE THE PLTS OF BOTH ACFT ARE OBLIGATED TO BREAK OFF THEIR APCH AND TURN IN APPROPRIATE DIRECTION. THE L APCH BREAKS L, THE R BREAKS R. THIS MONITORING SHOULD BE ON BOTH APCH FREQ AND TWR. IN THIS CASE THE TWR WAS THE ONLY COMMON FREQ. IT WOULD BE PRUDENT FOR ARPT CTLRS TO MAKE SURE BOTH ACFT ARE ON THE SAME APCH FREQ AS WELL AS THE TWR FREQ. THE CHANCE THAT THE 2 ACFT WILL HAVE PREMATURE TFC ALERTS, AS ONE OF THESE ACFT HAD, IS MORE LIKELY WHEN THE ACFT ARE HDG IN OPPOSITE DIRECTIONS FOR A MOMENT DURING THEIR FINAL TURN INBOUND DURING THE APCH. IT IS MUCH LESS CHANCE OF A FALSE ALERT OR A REAL CONFLICT ONCE BOTH ACFT ARE ON THEIR INBOUND COURSE. ANOTHER CHANGE IN PROC WOULD BE TO HAVE INFORMED BOTH ACFT OF THE OTHER BEFORE THE APCH BEGINS. IN THIS SIT, NEITHER ACFT WAS INFORMED OF THE OTHER. IF A FALSE TFC ALERT ACCRUES AND THE CREW CAN IDENT AND VERIFY THE PRESENCE OF THE OTHER VISUALLY, THE TA CAN BE JUST A WARNING AND NOT A DEV. SUPPLEMENTAL INFO FROM ACN 412031: THE CAPT NOTICED THAT THE LOC NEEDLE DEFLECTION AND THE RWY 26 COURSE CTRLINE THAT WAS PROGRAMMED INTO THE SPERRY FMS DID NOT AGREE. I IMMEDIATELY CHKED ALL THE NAV FREQS AND FMS SET-UP CONFIRMING THE ERROR WAS WITH THE WRONG ILS FREQ SET IN. I HAD BOTH RWY 27 AND RWY 26 ILS FREQS PREPROGRAMMED.

  471.  
  472. Accession Number: 412150
    Synopsis: FLC OF AN ATR72 DSNDED BELOW ASSIGNED ALT DUE TO THE AUTOPLT NOT CAPTURING THE ALT DUE TO THE INCORRECT ALT WAS SET IN THE AUTOPLT ALT SELECT.
    Narrative: AUTOPLT FAILED TO LEVEL AT THE ASSIGNED ALT DURING A DSCNT. ALT WAS NOT SET CORRECTLY BEFORE THE DSCNT WAS STARTED. WE WERE 500 FT BELOW THE ASSIGNED ALT WHEN WE CAUGHT THE ERROR AND CLBED BACK. THE AUTOPLT CAN CHANGE ALT WITHOUT THE ALT PRESELECT BEING SET.

  473.  
  474. Accession Number: 412360
    Synopsis: EMB145 CREW DSNDED BELOW CLRED ALT UNTIL THE GPWS ACTIVATED.
    Narrative: DURING VECTOR FOR ILS APCH, VOR AND ILS EQUIP WERE BEING USED AS PRIMARY FLT INSTS AND FMS WAS BEING USED AS BACKUP DISPLAYED ON THE MULTI-FUNCTION DISPLAY. THE CAPT (MYSELF) WAS FLYING THE ACFT. DURING INITIAL CONTACT I THOUGHT THE CTLR SAID TO EXPECT THE ILS TO RWY 28L. THE FO HEARD TO EXPECT RWY 28R CORRECTLY. WE EACH PROGRAMMED OUR FMS EQUIP ACCORDINGLY. WHEN I DISCOVERED WE WERE GOING TO RWY 28R, I ASKED THE FO TO SET MY FMS TO THE PROPER APCH AND I SET MY VHF RADIOS TO THE PROPER FREQ. WE WERE DSNDING TO 3000 FT AT THE TIME. WE WERE GIVEN FURTHER DSCNT TO 2500 FT, BUT THE ALT PRESELECT WAS NOT SET PROPERLY AND WE DSNDED TO 2000 FT, AT WHICH TIME OUR ACFT GPWS TOLD US WE WERE TOO LOW, GEAR NOT DOWN, 1000 FT AGL. I ASKED ATC WHAT ALT I SHOULD BE AT. HE CLBED US TO 3000 FT AND WE FINISHED THE APCH WITHOUT INCIDENT. THIS PROB I THINK WAS DUE TO SPENDING TIME PROGRAMMING THE FMS, WHICH WAS NOT NEEDED TO START WITH, AND NOT FOLLOWING PROPER PROCS FOR SETTING THE ALT PRESELECT AND CONFIRMING BTWN THE 2 PLTS.

  475.  
  476. Accession Number: 412420
    Synopsis: B737-500 CREW EXCEEDS 250 KTS BELOW 10000 FT IN IAH AIRSPACE.
    Narrative: APCHING IAH FROM THE NW, WE HAD BEEN CLRED FOR THE COAST ARR, DIRECT TO HOAGI AND ASKED TO KEEP THE SPD UP UNTIL REACHING 10000 FT, AND NOT TO SLOW TO 250 KTS UNTIL THEN. 6000 FT HAD BEEN SET IN THE ALT WINDOW AS THE LOWEST ALT ON THE COAST ARR WHEN WE WERE INITIALLY CLRED FOR THE COAST ARR. WHEN ASKED TO KEEP THE SPD UP, THE FO (HE WAS FLYING) DISENGAGED VNAV AND SELECTED VERT SPD. THIS TOOK PLACE APCHING HOAGI AND JUST PRIOR TO HDOF TO APCH. (AIRSPD 310 KTS, VERT SPD 2000 FPM.) WE HAD THE COMPUTER SET UP FOR THE COAST ARR AND RWY 26. WHEN WE CHKED IN WITH APCH, HE CLRED US DIRECT TO VETTE FOR THE RWY 14L APCH. WE HAD NOT YET REACHED 10000 FT AT HOAGI. BY SELECTING DIRECT TO VETTE AND RWY 14, WE REMOVED THE COAST ARR AND OUR 10000 FT PROTECTION. WHILE THE FO WAS REPROGRAMMING THE COMPUTER, I WAS RETUNING THE ILS AND CHANGING THE INBOUND COURSE ON THE MCP. WE BOTH LOOKED UP AT THE SAME TIME AND WE WERE DOING 310 KTS AT 9000 FT. THE FO DISCONNECTED THE AUTOPLT AND ARRESTED THE DSCNT AND AIRSPD.

  477.  
  478. Accession Number: 412570
    Synopsis: B737. FO INCORRECTLY PROGRAMMED FMC.
    Narrative: ATC INDICATED CLRNC LIMIT WAS CLUCK INTXN, DUE TO DEPARTING TFC AT SITKA, WHICH I EXPLAINED TO THE COPLT, TO WHOM I WAS GIVING IOE. HE APPARENTLY THOUGHT HE HEARD ATC SAY 'CLRED DIRECT CLUCK' VERSUS 'CLRED TO CLUCK.' HE PUT DIRECT CLUCK IN THE FMC WITHOUT SAYING ANYTHING AND I MISSED THE CHANGE. A SHORT TIME LATER (5 MINS) ATC INFORMED US WE WERE ON THE WRONG AIRWAY WHICH HAPPENED TO COINCIDE WITH OUR DIRECT ROUTING. NO CONFLICT WITH OTHER TFC, BUT IT TOOK A WHILE TO SORT OUT THE MISTAKE SINCE I WAS QUITE SURE THE CORRECT ROUTING WAS IN THE BOX AND COULDN'T FIGURE OUT WHY A WAYPOINT (LYRIC) HAD DISAPPEARED. THROW IN A SHORT LEG, JNU-SIT, BAD WX, TURB, APCH TO MINIMUMS, NEW COPLT, AND THE POTENTIAL FOR CONFUSION RAPIDLY INCREASES. LESSONS LEARNED: 1) CLRED TO A FIX DOESN'T NECESSARILY MEAN CLRED DIRECT. 2) VERBALIZE AND XCHK EACH OTHER WHEN MAKING CHANGES TO THE BOX (FMC). 3) WHEN IN DOUBT -- ASK.

  479.  
  480. Accession Number: 412710
    Synopsis: A DSNDING MD80 OVERSHOT ITS ASSIGNED ALT BY 400 FT WHILE ON AUTOPLT, ALT CAPTURE MODE.
    Narrative: CLRED TO CROSS RIDGY AT FL240 ON RBV 1. FL240 SET AND ARMED FOR ALT CAPTURE. WITH HIGH DSCNT RATE, ACFT WENT THROUGH FL240 BY 300-400 FT AND DID NOT CAPTURE ALT. AUTOPLT ON. IMMEDIATELY MANUALLY LEVELED AT FL240. CTR SAID NOTHING.

  481.  
  482. Accession Number: 412850
    Synopsis: A CPR JET, DSNDING, OVERSHOT ITS ASSIGNED ALT WHEN DISTR BY PASSING TFC. THE ALT CAPTURE WAS NULLIFIED BY THE CAPT'S MISUSE OF THE ACFT'S HORIZ STABILIZER'S TRIM WHEEL.
    Narrative: AT APPROX XA40Z NEAR KRENA INTXN ON V100 W OF OBK VOR, I HAD AN ALTDEV. I HAD BEEN CLRED TO DSND TO 11000 FT FROM FL230. I WAS FLYING THE AIRPLANE ON THE AUTOPLT. OUT OF 12000 FT, OUR TCASII GAVE A TA, AN INBOUND B737 INTO ORD. THIS TFC WAS MAINTAINING 10000 FT AND WAS APCHING US ON A 1 O'CLOCK TO 7 O'CLOCK PATH. MY CO-CAPT GOT A VISUAL ON THE TFC AND I ROLLED IN SOME NOSE-UP TRIM TO SLOW OUR VERT CLOSURE WITH THE TFC. THIS WAS MY FIRST MISTAKE. AS THE BOEING PASSED IN FRONT OF US AND OFF OUR L SIDE AND I TOOK MY ATTN OFF THE FLT DIRECTOR AND OBSERVED IT (MISTAKE #2), AS I LOOKED BACK AT THE EFIS I SAW THE FLT DIRECTOR HAD NOT CAPTURED 11000 FT AND WAS CONTINUING OUR DSCNT. I DISENGAGED THE AUTOPLT AND PITCHED UP. WE DSNDED TO ABOUT 10700 FT AND WERE PROBABLY 2 OR 3 MI BEHIND THE B737. AS WE RETURNED TO 11000 FT, CTR ASKED FOR A VERIFICATION OF OUR ALT. THIS WAS VERY EMBARRASSING AND HUMBLING AND COULD HAVE EASILY HAD VERY SERIOUS CONSEQUENCES. IN HINDSIGHT, THERE WERE SEVERAL HUMAN FACTORS. FIRST, WAS MY FAILURE TO USE THE PROPER TECHNIQUE IN APPLYING TRIM WHEN THE AIRPLANE IS BEING FLOWN BY THE FLT DIRECTOR. EVERY AIRPLANE I HAVE FLOWN WILL DISCONNECT ALT CAPTURE IF YOU MANUALLY TRIM WHILE THE FLT DIRECTOR IS TRYING TO CAPTURE AN ALT. WHY I DID THIS AND DIDN'T SEE THE ANNUNCIATION THAT I HAD LOST ALT CAPTURE IS A MYSTERY TO ME. THIS IS ONE 'GOTCHA' THAT WON'T BITE ME IN THE FUTURE. MY SECOND MISTAKE WAS TO AVERT MY ATTN FROM MY AIRPLANE AND A FAILURE TO CLOSELY MONITOR THE AUTOPLT'S FLYING. I VIOLATED THE CARDINAL RULE OF A PLT -- 'FLY YOUR AIRPLANE.' IF I HAD BEEN WATCHING MY INSTS INSTEAD OF THE B737, I WOULD HAVE NOTICED OUR AIRPLANE WAS NOT GOING TO LEVEL OFF AT 11000 FT AND COULD HAVE TAKEN APPROPRIATE AND TIMELY ACTIONS TO DO SO. PERSONALLY, THIS FAILURE IS THE MOST DAMNING AND SHOWS A BREAKDOWN OF PERSONAL DISCIPLINE, SOMETHING I HAVE ALWAYS STRIVED FOR. IT HAS CAUSED A SELF-EXAM OF MY FLYING HABITS, PRIORITIES AND JUDGEMENT. I FEEL PRETTY BADLY ABOUT THIS INCIDENT AND THE AREAS WHERE I WAS DEFICIENT. I PLEDGE TO DO MUCH BETTER IN THE FUTURE.

  483.  
  484. Accession Number: 413289
    Synopsis: B767-300 FLC DISCONNECTS AUTOTHROTTLES IN DSCNT. WHEN LEVELING THEY FAIL TO ARM AUTOTHROTTLES AGAIN AND LOSE ALT AND AIRSPD. STICK SHAKER ACTIVATES.
    Narrative: FLT WAS CLRED BY NEW YORK COM RADIO FOR ILS RWY 30 APCH TO BERMUDA (TXKF) TO CROSS REEF INTXN INBOUND AT 3000 FT. BERMUDA RADAR WAS INOP. CAPT WAS FLYING ACFT WITH AUTOPLT ENGAGED AND AUTOTHROTTLES WERE DISCONNECTED IN DSCNT (FLT LEVEL CHANGE) AS THEY HAD NOT RESPONDED FAST ENOUGH MOMENTS EARLIER. FO WAS ON RADIO WITH BDA OPS REGARDING PAX PROB AT TIME OF OCCURRENCE -- ABOUT 8 MINS OUT. SPD BUG WAS SET AT 190 KTS, FLAPS 15 DEGS. AUTOPLT LEVELED ACFT AT 3000 FT AND SECONDS LATER I OBSERVED AIRSPD DECAYING THROUGH 145 KTS. I IMMEDIATELY APPLIED MAX PWR AND DISCONNECTED AUTOPLT TO INITIATE RECOVERY. STICK SHAKER OCCURRED BRIEFLY. ACFT LOST 180-200 FT ALT DURING RECOVERY. THERE WERE NO ENG EXCEEDANCES AND LOWEST OBSERVED AIRSPD WAS 128-130 KTS. ACFT WEIGHED APPROX 295000 LBS. VREF 30 WAS 140 KTS.

  485.  
  486. Accession Number: 413415
    Synopsis: AN MD11 IN CRUISE AT FL370 WITH AUTOPLT IN ALT HOLD MODE BEGAN A SMOOTH GENTLE CLB TO FL378 WITH NO ALT ALERT WARNING. ALT SELECT STILL INDICATED FL370.
    Narrative: AT FL370 WHILE IN CLR, DAYLIGHT, SMOOTH CONDITIONS, THE ACFT BEGAN A SMOOTH CLB. THE CAPT NOTICED IT FIRST, CALLED IT TO MY ATTN (I WAS LOOKING AT ANOTHER MD11 BELOW US). I DISCONNECTED THE AUTOPLT AND RETURNED TO FL370. WE HAD BEEN AT FL370 FOR ABOUT 6 HRS (FLT WAS LAX-NRT) AND THE ONLY FMS INPUT WAS FOR A DSCNT TO CROSS A FIX INBOUND TO NRT. THE ONLY GLARESHIELD (AUTOFLT) INPUT WAS A HDG CHANGE. THE CAPT SAW FL370 STILL IN ALT WINDOW DURING THIS EXCURSION. WE WERE DSNDING BACK TO FL370 WHEN TOKYO ASKED IF WE WERE AVOIDING WX. WE SAID NO, WE WERE RETURNING TO FL370. NO CONFLICT AROSE AND NOTHING FURTHER WAS SAID. REMAINDER OF FLT UNEVENTFUL. THE MECH IN NRT RAN A DIAGNOSTIC ON THE AUTOFLT/FMS/GLARESHIELD AND FOUND ONLY A SPURIOUS SPD INPUT TO FMS DSCNT. HE FELT IT HAD NOTHING TO DO WITH THIS EVENT. I HAVE HEARD OF ONLY 1 OTHER SUCH TYPE EXCURSION AND HAVE BEEN ON THIS ACFT FOR 6 YRS. I AM UPSET THAT I DO NOT KNOW HOW OR WHY IT OCCURRED OR HOW TO PREVENT IT FROM RECURRING. I WILL VISIT WITH OUR MD11 TYPE MGR NEXT WEEK TO RESEARCH THIS MATTER. I WOULD BE MOST APPRECIATIVE IF YOU HAVE ANY INFO ON WHAT MIGHT HAVE CAUSED THIS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR STATED THE ACFT BEGAN A SLOW SMOOTH GENTLE CLB FROM FL370 TO FL378 WHEN THE DEV WAS DISCOVERED. THE RPTR SAID AT NO TIME DID THE ALT ALERT SOUND AND THE ALT SELECT STILL READ FL370. THE RPTR STATED THE RPT WAS WRITTEN UP AND TOKYO MAINT DID A COMPREHENSIVE TEST OF THE AUTOFLT, FMS AND GLARESHIELD COMPONENTS AND FOUND NOTHING THAT WOULD CAUSE THE ALTDEV. THE RPTR SAID THE OUTBOUND CAPT WHO HAD EXTENSIVE MD11 EXPERIENCE WAS ADVISED OF THE EVENT AND COMMENTED IT HAD HAPPENED ONCE BEFORE. THE RPTR HAS 6 YRS FLYING THE MD11 WITH NO PREVIOUS EXPERIENCE OF ALTDEV FROM THE FLT CTL COMPUTER. THE RPTR STATED A VISIT WAS MADE TO ACR MD11 FLT MGR TO REQUEST INFO ON PREVIOUS AUTOPLT ALT HOLD RPTS ON THE MD11 BUT NONE WERE IN THE MAINT HISTORY.

  487.  
  488. Accession Number: 413720
    Synopsis: MD88 CREW DEVIATES FROM CLRED COURSE IN ZOB AIRSPACE.
    Narrative: ON CLBOUT FROM PITTSBURGH, I WAS GIVEN A HDG TO INTERCEPT THE AGC 221 DEG RADIAL TO BURGS INTXN, THEN AS FILED. ANTICIPATING THIS CLRNC, I HAD LOADED IT INTO THE FMS. WHEN CLRED TO INTERCEPT, I WAS HAND FLYING THE ACFT, SO I HAD THE CAPT SELECT THE INTERCEPT IN THE FMS. I WAS WATCHING THE FMS XTRACK TO SEE THE INTERCEPT. AS WE GOT CLOSE TO THE INTERCEPT ON THE MAP DISPLAY, I SWITCHED TO ARC ON MY DISPLAY TO XCHK THE RADIAL FROM AGC (WHICH I HAD TUNED IN). I IMMEDIATELY NOTICED WE WERE PAST THE RADIAL AND CONFIRMED IT ON MY RMI. I TURNED TO PARALLEL COURSE AND ASKED THE CAPT ABOUT THE FMS. WE WERE ON THE 212 DEG RADIAL WHEN INDIANAPOLIS ASKED ABOUT OUR CLRNC. WE TOLD HIM WE WERE CORRECTING BACK TO THE 221 DEG RADIAL. HE SAID JUST TO PROCEED TO HVQ VOR (CHARLESTON) AND THEN AS FILED. AFTER DISCUSSING THIS WITH THE CAPT, WE FIGURED HE MUST HAVE RELOADED THE FMS INCORRECTLY WHEN WE RECEIVED THE CLRNC. I DID NOT REALIZE HE HAD CHANGED WHAT I HAD LOADED. I SHOULD HAVE CHKED THE FMS MORE CLOSELY AND MONITORED MY RMI MORE CLOSELY.

  489.  
  490. Accession Number: 414116
    Synopsis: AN ACR MLG ON APCH TO ORD RWY 14R EXPERIENCES AN ALT EXCURSION PRIOR TO REACHING THE NDB. THE CREW HAD 'BUILT' AN NDB APCH INTO THEIR FMC, BUT THE FIX WAS DEPICTED IN THE WRONG AREA. CREW STARTED DSCNT WITH A PREMATURE NEEDLE SWING. CFIT.
    Narrative: AS THE FO AND PF, I BRIEFED THE NDB RWY 14R APCH AT ORD. BECAUSE AN NDB IS A RARE OCCURRENCE IN OUR OP, WE DECIDED TO 'BUILD' AN NDB APCH WITH THE FMC. DOING THIS WOULD GIVE US A BACKUP ON OUR POS AND A WAY TO ANTICIPATE THE XING OF THE FAF. THE ONLY PROB IS THAT THE CONSTRUCTED APCH DEPICTED 'OR' BEACON 5.2 MI N OF ITS ACTUAL POS. ORD APCH CTL WAS VERY BUSY AND AFTER SEVERAL RADAR VECTORS, LEFT US ON A 140 DEG HDG BUT DID NOT CLR US FOR THE APCH. WITH A STRONG W WIND WE WERE DRIFTING E OF FINAL. AFTER RECEIVING APCH CLRNC, IT WAS A SCRAMBLE TO REINTERCEPT AND GET THE ACFT IN THE LNDG CONFIGN PRIOR TO THE FAF. RAW DATA WAS BEING DISPLAYED ON BOTH THE RDMI AND THE NAV DISPLAY. I THOUGHT WE WERE VERY CLOSE TO THE BEACON AND WHEN I SAW A 10 DEG SWING ON THE ADF NEEDLE, I ASSUMED WE WERE AT 'OR.' WE DSNDED ABOUT 500 FT WHEN APCH CTL SAID THEY HAD A LOW ALT ALERT ON US. WE CLBED BACK TO 2400 FT AND THEN REALIZED WHAT HAD HAPPENED. FACTORS WERE: INFO OVERLOAD, INACCURATE INFO (FMC FIX), HIGH WORKLOAD PORTION OF FLT, NONROUTINE OP, FIRST CREW PAIRING (2ND LEG). SUPPLEMENTAL INFO FROM ACN 414118: IT WAS A HURRIED TURN BACK TO INTERCEPT THE COURSE, BECAUSE THE FMC SHOWED US ALMOST AT THE NDB. WE BOTH SAW THE NEEDLE START TO SWING AND THE FO CALLED FOR THE NEXT ALT. I SELECTED THE NEXT ALT, STARTED THE TIME, AND GOT READY TO CALL THE TWR. TWR FREQ WAS BUSY SO I DIDN'T GET A CALL IN RIGHT AWAY. AFTER DSNDING ABOUT 500 FT, THE TWR GAVE US AN ALT ALERT. WE HAD BEEN DSNDING IN VFR CONDITIONS AND HAD GND CONTACT FROM ABOUT 7000 FT. WE COULD SEE THAT THERE WERE NO OBSTACLES IN OUR VICINITY AND WE WERE STILL ABOUT 1200 FT ABOVE THE GND. THEN WE BOTH LOOKED AT THE ADF NEEDLE AND SAW THAT IT WAS STILL POINTING UP. THE FMC SHOWED THE NDB FURTHER OUT ON THE APCH THAN IT SHOULD HAVE BEEN. A DOUBLECHK MIGHT HAVE CAUGHT THE ERROR. POOR RADAR VECTORS. IT CAUSED US TO BE IN A SLIGHT RUSH TO COMPLETE ALL RECEIVED CONFIGNS AND CHKLISTS. THE NDB'S AND OTHER NON PRECISION APCHS WE FLY AT RECURRENT TRAINING REQUIRE A DSCNT STARTED ALMOST IMMEDIATELY AT STATION PASSAGE. OTHERWISE, THE ACFT WON'T BE AT MDA IN TIME FOR A NORMAL APCH TO THE RWY.

  491.  
  492. Accession Number: 414120
    Synopsis: AN MD88 FLC DOES NOT START DOWN AFTER RECEIVING THEIR DSCNT CLRNC. THE CREW WAS INTERRUPTED BY THE FLT ATTENDANT AND THE CTR CTLR HAD TO ASK THE CREW ABOUT THEIR ALT.
    Narrative: AT FL310, TOP OF DSCNT, COPLT'S LEG, FLT RDU-CVG CLRED DIRECT DRESR TO CROSS IT AT FL240. I CALLED OUT OF FL310, SAW COPLT SET UP FMS AND AUTOPLT FOR DSCNT. AT SAME TIME, FLT ATTENDANT CALLED TO OFFER BREAKFAST. AS HE BROUGHT FOOD FORWARD, ZID ASKED OUR ALT AND IF WE WOULD MAKE THE RESTR AT DRESR. I LOOKED UP AT THE ALTIMETERS. WE WERE STILL AT FL310. I PUT ACFT INTO RAPID DSCNT (IAS MODE, .80 MACH, IDLE, SPD BRAKES). WHEN WE WERE 2 MI FROM DRESR AT FL260, DSNDING AT OVER 6000 FPM, CTLR GAVE US A 90 DEG TURN TO R. WE TURNED LESS THAN 30 DEGS BEFORE HE CLRED DIRECT TO OUR NEXT NAV POINT. I CHKED TCASII. THERE WAS NOT ANOTHER ACFT FOR 20 MI. I DO NOT BELIEVE THERE WAS A LOSS OF SEPARATION. IF THERE IS A LESSON LEARNED FOR ME, THIS ACFT'S AUTOMATION HAS CERTAIN PITFALLS THAT I MUST BE SPECIALLY AWARE OF. ALSO, WHEN I AM THE PNF, I NEED TO CHK WHAT THE PF IS DOING, RELIGIOUSLY, AND LEARN TO FILTER OUT DISTRS. SUPPLEMENTAL INFO FROM ACN 414123: BEGAN DSCNT VIA VNAV PATH, CAPT CALLED OUT OF FL310. ACFT INTERCEPTED AND BEGAN DSCNT. AT THIS TIME FLT ATTENDANT KNOCKED ON DOOR TO OFFER BREAKFAST. SHORTLY AFTER THIS, CTR ASKED OUR ALT. WE CHKED AND ACFT WAS BACK AT FL310 IN VNAV LEVEL. THE ACFT HAD DSNDED 300 FT INITIALLY, BUT AT SOME TIME DURING THIS PERIOD MUST HAVE RETURNED TO VNAV LEVEL UNNOTICED BY MYSELF OR THE CAPT. WE LEVELED AT FL240 OVER DRESR AND PROCEEDED WITH CONTINUATION OF ARR/APCH. XING ALT WOULD HAVE BEEN MADE, BUT WE HAD RPTED OUT OF FL310 EARLIER AND WERE STILL LEVEL AND WERE UNSURE AT TIME IF WE WOULD MAKE ALT RESTR.

  493.  
  494. Accession Number: 414810
    Synopsis: ACR ACFT MISSES XING RESTR IN ZNY AIRSPACE.
    Narrative: ATC XING RESTR OF FL240 AT NEWES INTXN. ACFT PROGRAMMED, CREW DISTR WITH OTHER CONCERN. FMS DID NOT COMPLY. ATC CALLED PRIOR TO REACHING NEWES INTXN. THEN GIVEN 13000 FT XING AT RAALF INTXN, WHICH WAS COMPLIED WITH. ATC APPEARED TO HAVE NO PROB -- NEITHER DID WE. AT ALL TIMES WE WERE COMMUNICATING.

  495.  
  496. Accession Number: 415220
    Synopsis: AN F100 FLC IS RPTED OFF COURSE ON THEIR ARR PROC TO DFW BY THE ZFW CTLR. FO HAD NOT PROGRAMMED THEIR FMC IN ACCORDANCE WITH THE CHART, LEAVING OUT THE MAMEE TRANSITION.
    Narrative: AFTER DEPARTING MCI, ZKC RERTED US VIL-TUL-BYP3. FMS WAS PROGRAMMED TUL DIRECT BYP THEN BYP3. AFTER TUL, ZFW QUESTIONED OUR POS, SAYING WE WERE W OF COURSE. WE WERE AT FL280. FMS WAS IMPROPERLY PROGRAMMED, LEAVING OUT THE MAMEE TRANSITION. WE DID NOT CHK THE FMS AGAINST THE CHART AS WE SHOULD HAVE. IN THE FUTURE, WILL ENSURE THAT CLRNC FMS AND CHART ALL AGREE. SUPPLEMENTAL INFO FROM ACN 415221: CTLR SAID WE SHOULD BE ON THE 035 DEG RADIAL INBOUND TO BYP (VIA MAMEE).

  497.  
  498. Accession Number: 415300
    Synopsis: MD80 CREW HAD AN ALT EXCURSION WHEN THE AUTOPLT MADE AN UNCOMMANDED CLB.
    Narrative: WE HAD A NORMAL CLBOUT AND LEVELOFF AT FL310. AFTER THE CRUISE CHKLIST WAS COMPLETED, I BEGAN MY ENRTE PA. WE HAD BEEN LEVEL FOR ALMOST 10 MINS WHEN THE FO ANNOUNCED FL320 FOR FL330. I ASKED WHEN WE HAD BEEN CLRED TO FL330, AND WE BOTH THOUGHT UH-OH. I WAS ABOUT TO TELL ATC WE WERE RETURNING TO ALT WHEN HE ASKED ABOUT OUR CLB. HE OFFERED US FL350 IF WE WANTED IT, BUT WE HAD ALREADY DISCUSSED WITH THIS CTLR ABOUT THE RIDES AND HAD PREVIOUSLY STATED WE WERE GOING TO STAY AT FL310. I ASKED IF THERE HAD BEEN ANY CONFLICT, AND HE STATED NO PROBS AT ALL. WE THEN DISCUSSED WHAT HAPPENED. NEITHER OF US COULD REMEMBER HAVING BEEN ANYWHERE NEAR THE ALT KNOB. WE HAD BEEN LEVEL FOR NEARLY 10 MINS PRIOR TO THE TRANSGRESSION AND WERE MYSTIFIED AS TO WHY THE AIRPLANE CLBED. HOWEVER, I DO HAVE A WORKING THEORY, ALTHOUGH I CANNOT VERIFY ANY OF THE SCENARIO, AS I DID NOT SEE ANY OF IT. WHILE LEVEL, THE FO WAS NAVING VIA HDG SELECT TO CTY VOR. THE VOR CAP HAD BEEN WANDERING AS IT NORMALLY DOES AND HE WAS MAKING GOOD MANUAL CORRECTIONS. I BELIEVE HE MAY HAVE INADVERTENTLY BUMPED THE ALT KNOB, OR EVEN TURNED IT THINKING IT WAS THE HDG KNOB. A COMMON MISTAKE. HE HAD BEEN IN PERFORMANCE CRUISE. WHEN THE ALT GOT TO FL330 IN THE WINDOW, THE PERFORMANCE WENT TO CLB MODE. WE HAD A BRIEF DISCUSSION AS TO THE DESIRED ENRTE MACH, AND WHEN HE ENTERED THIS, IT WAS ON THE CLB PAGE WITH A VALID ALT SELECTED. THE TRI WAS IN CRUISE, SO THE PWR APPLICATION AND PITCH CHANGE WERE VERY SLIGHT AND DIFFICULT TO NOTICE, ESPECIALLY IN THE CHOPPY AIR WE WERE ENCOUNTERING. WE NOTICED THE CLB, BUT NOT SOON ENOUGH. I BELIEVE WE WERE AS ATTENTIVE AS WE COULD HAVE BEEN IN THAT PHASE OF FLT. WE WERE DISCUSSING THE BUMPS AND ENRTE SPD AT THE MOMENT OF THE DEV. IT WAS A VFR DAY AND THE OUTSIDE VIEW WAS NICE. I WOULD SAY IT WAS LESS THAN 20 SECONDS OF CLB THAT TOOK PLACE BEFORE IT WAS ARRESTED. CHALK ONE UP TO EXPERIENCE. READ THE PMS CLOSER. WATCH YOUR HANDS -- AND HIS.

  499.  
  500. Accession Number: 415330
    Synopsis: THE CAPT OF A DC10-30 OVERSHOT ASSIGNED ALT DURING DEP CLB RESULTING IN A TCASII RA AND ATC REQUESTING HIS ALT. THE CAPT BECAME DISTR WITH A DISAGREEMENT BTWN THE 2 NAV RECEIVERS, WHICH AFFECTED THE 2 FLT DIRECTORS, AND FORGOT TO ARM THE AUTOPLT ALT CAPTURE.
    Narrative: WE DEPARTED FROM EBRU (BRUSSELS, BELGIUM) WITHOUT A PROB. UPON PASSING 10000 FT, I CALLED IN TIMES TO HANDLING AND OBTAINED A SELCAL. JUST AS I FINISHED GETTING SELCAL THE, THE TCASII GAVE A TA, THEN SHORTLY AFTER, AN RA. THE CAPT PROMPTLY DISENGAGED THE AUTOPLT AND BEGAN TO DSND TO COMPLY WITH THE RA. BY THE TIME I TURNED MY SEAT AROUND TO LOOK FOR TFC WE WERE LEVELING AT 17000 FT AND THE TCASII SAID 'TFC NO FACTOR.' WHAT I BELIEVE HAD HAPPENED, WAS THE AUTOPLT FAILED TO CAPTURE AND, BEING AT A FAIRLY LIGHT WT, CLBED THROUGH OUR ASSIGNED ALT OF 17000 FT. THE CAPT CAUGHT THE PROB AND BEGAN THE CORRECTION AND SPOTTED THE TFC XING ON A NON COLLISION COURSE TO OUR R SIDE PASSING IN BACK OF US. SUPPLEMENTAL INFO FROM ACN 415123: THE ALT ARM FEATURE OF THE FMS HAD BECOME UNARMED (UPON ANALYSIS AFTER THE INCIDENT) AND I ALLOWED THE ACFT TO CLB TO 17300 FT PRIOR TO DISENGAGING THE AUTOPLT AND DSNDING BACK TO 17000 FT. THE ERROR ON MY PART RESULTED IN AN ULTIMATE ALTDEV OF 500 FT (17500 FT BY THE TIME I HAD DISCONNECTED THE AUTOPLT AND DSNDED THE ACFT).

  501.  
  502. Accession Number: 415410
    Synopsis: FLC OF AN LGT UNDERSHOT DSCNT ALT FIX DUE TO NOT SETTING THE PROPER MODE OPTION WHEN PROGRAMMING THE FMC. THIS MISTAKE WAS NOT RECOGNIZED BY THE CREW IN SUFFICIENT TIME TO MAKE THE DSCNT REQUIRED FOR THE FIX XING AS THE CREW WAS DISTR BY COM WITH FLT ATTENDANT AND COMPANY CALLS.
    Narrative: WHILE WE WERE CRUISING AT FL290, ZNY CLRED US TO CROSS HARTY INTXN AT FL230, 250 KTS. FMS WAS PREPROGRAMMED FOR HARTY AT FL230. PF PLACED FL230 IN AUTOPLT MCP AND THEN ENTERED 'HARTY 250 DEG RADIAL, 230 KTS' INTO FMS. I BELIEVE THAT AS THIS INFO WAS BEING ENTERED, THE PREVIOUS 'TOP OF DSCNT' POINT WAS REACHED AND THE MCP WENT INTO AN 'ALT HOLD/SPD' CONFIGN. AS THE RESTRS WERE THEN EXECUTED, THE PF BELIEVED THE AUTOPLT WAS IN AN LNAV/VNAV MODE AND THE ACFT WOULD COMPLY. WE WERE BOTH SLIGHTLY DISTR BY CALLS FROM FLT ATTENDANTS AND COMPANY IN RANGE AND ATIS MONITORING. APPROX 4 MI W OF HARTY, CAPT NOTICED WE HAD NOT STARTED DOWN AND COMPLIANCE WITH THE RESTRS WAS IMPOSSIBLE. WE IMMEDIATELY BEGAN MAX RATE DSCNT AND REQUESTED RADAR VECTORS FOR SEPARATION AND DISTANCE TO COMPLY. CTR STATED THAT THEY NEEDED US BELOW FL250 AND THAT HARTY WAS BEHIND US. WE LEVELED AT FL230 ABOUT 3 MI E OF HARTY. NO CONFLICT WAS NOTED, AND IN LATER QUERY, ZNY STATED THAT 'THERE WAS NO PROB.'

  503.  
  504. Accession Number: 415555
    Synopsis: A B757-200 LOSES AIRSPD SHORTLY AFTER REACHING CRUISE ALT AND HAS TO DSND 2000 FT TO REGAIN PROPER AIRSPD IN ZMP AIRSPACE.
    Narrative: ATC INQUIRED IF WE WERE ABLE TO CLB TO FL410 (FOR TFC REASONS) ON A W TO E TRANSCONTINENTAL FLT. MAX SVC CEILING FOR OUR ACFT DUE TO WT RESTRS WAS FL400, AS A RESULT ATC REQUESTED US TO CRUISE AT FL390 TO ACCOMMODATE ANOTHER ACFT ON A SIMILAR RTE AT FL370. WE ACCEPTED THE CLRNC TO FL390. AN FMC CLB TO FL390 WAS INITIATED AND UPON REACHING FL390 WE PROGRAMMED A SLIGHTLY REDUCED MACH SPD TO MAXIMIZE THE BUFFET BOUNDARY AT THE NEW ALT. AT SOME POINT AFTER LEVELOFF AND STABILIZATION AT THE NEW SPD, AIRSPD BEGAN TO DISSIPATE AT AN EXTREMELY SLOW RATE THAT WENT UNDETECTED BY BOTH CREW MEMBERS. SOMETIME LATER WE FELT A VERY SLIGHT ACFT VIBRATION THAT WE INITIALLY ASSUMED TO BE CAUSED BY AN ENG BEING OUT OF SYNCHRONIZATION. WHEN WE REALIZED THE VIBRATION THAT WE HAD DETECTED WAS ACTUALLY THE ONSET OF LOW SPD BUFFET, WE IMMEDIATELY ADVANCED THE THROTTLES (WHICH WERE ALREADY AT A NEAR CRUISE PWR SETTING) AND INITIATED A SLOW DSCNT IN ORDER TO REGAIN REQUIRED AIRSPD. SIMULTANEOUSLY, I DIRECTED THE FO TO REQUEST A LOWER ALT FROM ATC. THE CTLR ADVISED THAT LOWER WAS NOT AVAILABLE DUE TO TFC AND REQUESTED THE NATURE OF OUR DIFFICULTY. WE ADVISED ATC THAT WE HAD AN AUTOPLT MALFUNCTION AND THAT WE WERE DSNDING IN ORDER TO AVOID AN ACFT UPSET AND WE WOULD ACCEPT A VECTOR OFF COURSE. WE WERE ABLE TO STABILIZE THE SPD OF THE ACFT AT FL382 AND TURNED TO THE CTLR'S OFF COURSE VECTOR HDG TO AVOID CONFLICT WITH THE TFC AT FL370. AFTER SEPARATION WAS ACHIEVED (INSURED) ATC CLRED US TO MAINTAIN FL370. WE DISCOVERED THAT THE AUTOTHROTTLES HAD SOMEHOW DISENGAGED DURING OUR CRUISE AT FL390. THE LAST PWR SETTING BEFORE THE DISENGAGEMENT OF THE AUTOTHROTTLES WAS JUST SLIGHTLY BELOW THE SETTING NECESSARY TO MAINTAIN PROPER AIRSPD. NO EICAS OR OTHER WARNINGS ACTIVATED (NORMALLY MASTER WARNING LIGHTS AND HORN) THAT WOULD ALERT US TO THE AUTOTHROTTLE DISCONNECT. AUTOTHROTTLES WERE RE-ENGAGED AND WORKED NORMALLY THROUGHOUT THE REMAINDER OF THE FLT. THIS FLT WAS CONDUCTED USING INTEGRATED FMC AUTOPLT OPS FROM 1000 FT AGL. THERE WAS NO CHANCE THAT EITHER PLT INADVERTENTLY INTERRUPTED THE PROGRAMMING SEQUENCE AND CAUSED THE AUTOTHROTTLES TO DISENGAGE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THEY NEVER GOT AN EICAS MESSAGE OR AN AURAL CAUTIONARY WARNING THAT THEY HEARD OR SAW WHEN THE AUTOTHROTTLES WERE DISENGAGED. HOWEVER, THE THROTTLE ANNUNCIATION WAS NOT OBSERVED. RPTR COULD NOT RECALL WHEN THAT ANNUNCIATION DISAPPEARED FROM THE ADI SCREEN. RPTR FEELS THE FLC WOULD HAVE HEARD THE WARNING SOUND OF DISCONNECT, BUT CANNOT EXPLAIN HOW THE THROTTLE ANNUNCIATION WOULD HAVE DISAPPEARED WITHOUT THEIR KNOWLEDGE. ACFT HAD BEEN AT CRUISE ALT ABOUT 15 MINS WITH DECAYING AIRSPD WHEN THE BUFFETING BEGAN.

  505.  
  506. Accession Number: 415803
    Synopsis: B737 CAPT MISREAD THE ACARS TKOF PERFORMANCE INFO AND USED REDUCED TKOF THRUST LOWER THAN REQUIRED.
    Narrative: WHILE I WAS PROGRAMMING THE FMC PRIOR TO DEP, I INCORRECTLY ENTERED A WARMER THAN CORRECT REDUCED THRUST TEMP. I PULLED, VIA ACARS, THE REDUCED TEMP FOR DEP FROM PDX RWY 28R. THAT TEMP WAS 40 DEGS C FOR OUR WT THAT DAY (INCLUDING THE NOTAM NON AVAILABILITY OF THE LAST 1000 FT OF RWY 28R). HOWEVER, I PROGRAMMED THE FMC WITH 48 DEGS C WHICH CAUSED THE REDUCED PWR TKOF SETTING TO BE MUCH LOWER THAN APPROPRIATE AND, THEREFORE, LENGTHENING THE TKOF ROLL NEARLY INTO THE LAST 1000 FT OF THE RWY, WHICH WAS NOTAMED OTS DUE TO EQUIP WORKING ON THE END OF RWY. CONTRIBUTING TO THIS INCIDENT WAS 40 DEGS AND 48 DEGS (48 DEGS IS THE REDUCED NUMBER 8 OUT OF 10 TIMES) LOOK VERY SIMILAR ON THE SMALL ACARS PRINTOUT, MY COPLT MISSED THE PROGRAMMING ERROR, AND FINALLY MY MISSING THE XCHK ON THE PRETKOF CHK THAT THE PROGRAMMED NUMBER WAS REALLY THE CORRECT NUMBER. IT WAS DISCOVERED BECAUSE I WAS UNCOMFORTABLE WITH THE SEPARATION ON TKOF BTWN OURSELVES AND THE EQUIP. IN THE FUTURE, I WILL INSIST THAT THE PRINTOUT BE XCHKED WITH FMC AND THE PRINTOUT BE DISPLAYED IN A PROMINENT PLACE DURING TAXI OUT.

  507.  
  508. Accession Number: 416150
    Synopsis: AN F100 EXITS THE BOUNDARIES OF THE PUBLISHED HOLDING PATTERN 40 MI W OF FWA. CTLR GIVES THE CREW A 'WAKE UP' CALL.
    Narrative: ASSIGNED TO HOLD AT FWA. ENTERED HOLD AND ESTABLISHED. WE WERE WORKING ON CALCULATING ALTERNATES, FUEL, AND TIME REMAINING, WHEN ATC CALLED AND SAID WE WERE 40 MI W OF THE HOLD. WE WERE ASSIGNED A HDG BACK TO FWA AND RE- ENTERED THE HOLD. LOOKING BACK, WE DISCOVERED WE HAD INADVERTENTLY GOTTEN INTO A HDG MODE WHILE WE WERE DOING OUR CALCULATIONS. THE ONLY EXPLANATION WE COULD COME UP WITH FOR THIS DEV WAS THAT ONE OF US HAD BRUSHED AGAINST THE HDG KNOB OF THE AUTOPLT WHICH THEN PUT US INTO A HDG MODE. BECAUSE WE WERE DEEPLY INVOLVED IN OUR FUEL CALCULATIONS, WE FAILED TO NOTICE THAT THE ACFT WAS PROCEEDING OUT OF THE HOLD. WE WENT BACK TO THE HOLD AND THE FLT CONTINUED WITH A NORMAL LNDG AT ORD.

  509.  
  510. Accession Number: 416600
    Synopsis: FLC OF AN MDT DSNDED BELOW ASSIGNED XING ALT DUE THE FO TURNING THE ALT PRESELECT KNOB INSTEAD OF THE DESIRED AIRSPD SETTING KNOB OF THE FLT GUIDANCE SYS. THE FO NOTICED HIS MISTAKE AND CORRECTED BACK TO ASSIGNED AT ONCE.
    Narrative: WE HAD A CLRNC TO CROSS TARNE AT 11000 FT AND 250 KTS. THE FO WAS FLYING AND HAD 11000 FT SET IN THE ALT PRESELECT. I WAS LOOKING AT THE ARR CHART AND THE APCH PLATE AS WE NEARED 11000 FT. ON THIS ACFT, THE ALT SELECT KNOB AND THE AIRSPD SELECT KNOB LOOK AND FEEL SIMILAR. IT WAS DARK IN THE COCKPIT. AS WE APCHED 11000 FT, THE FO THOUGHT HE HAD THE AIRSPD KNOB AND WAS TRYING TO SELECT 250 KTS, BUT WAS ACTUALLY TURNING THE ALT KNOB. THE ALT PRESELECT KNOB WAS INADVERTENTLY SET TO AN ALT BELOW 11000 FT, SO WE DSNDED THROUGH 11000 FT. I LOOKED UP AS WE PASSED 11000 FT AND THE FO CAUGHT IT AT THE SAME TIME ALSO. HE IMMEDIATELY CORRECTED, HOWEVER, WE DSNDED TO 10500 FT BEFORE WE GOT THE DSCNT STOPPED. WE HAD BEEN HANDED OFF BY CTR JUST PRIOR TO THIS, AND CHKED IN WITH APCH AFTER CORRECTING THE ALT. NOTHING WAS SAID. I'LL TRY TO KEEP MY HEAD UP AS WE APCH ASSIGNED ALTS, AND WE'LL BOTH BE MORE CAREFUL IN PROGRAMMING THE AUTOMATION.

  511.  
  512. Accession Number: 416710
    Synopsis: FLC ON WDB AT MAN, FO, DSNDED THROUGH ASSIGNED 4000 FT. FO WAS PF AND HAD SET AND ARMED 4000 FT.
    Narrative: FO FLYING ACFT WITH AUTOPLT COUPLED. RECEIVED CLRNC TO DSND AND MAINTAIN 4000 FT. FO SET AND ARMED 4000 FT AND I CONCURRED. FO STARTED THE DSCNT. AS WE APCHED THE TARGET ALT, I WAS DISTR BY CHKING THE ILS IDENT. WHEN I LOOKED UP I SAW WE WERE PASSING THROUGH 3700 FT AND DSNDING. TOLD FO WE WERE BELOW ASSIGNED ALT. LOOKED AT BOTH FLT MODE ANNUNCIATORS AND BOTH SHOWED ALT HOLD ANNUNCIATED -- CAPT'S PITCH BAR IN ALT HOLD POS, FO'S PITCH BAR INDICATING A FLY UP COMMAND. APCH CTL CALLED AND ASKED IF WE WERE AT 4000 FT. I ACKNOWLEDGED 4000 FT. FO FLEW ACFT BACK TO 4000 FT. WE DID NOT GET AN ALT ALERT WHEN WE DEVIATED FROM 4000 FT.

  513.  
  514. Accession Number: 417260
    Synopsis: AN ACR MLG EXPERIENCES A HDG TRACK POS DEV WHEN THE CAPT PUSHES THE WRONG BUTTON ON THE GPS NAV SYS. ATC GETS THEM ON TRACK.
    Narrative: OVER VXV, NOTICED NOTWO INTXN CAME UP IN GPS. I KNEW WE WERE FILED OVER J46 TO ATHENS. ASKED FOR DIRECT ALMA (AMG -- ALSO ON FLT PLAN). CTLR QUERIED OUR ROUTING, GAVE US L TURN TO REINTERCEPT, AND RECLRED DIRECT ALMA (AMG). I CHKED WAYPOINTS ON GND (NOT SURE HOW NOTWO GOT IN GPS), RECHKED GPS WAYPOINT INFLT ALL CORRECT. MUST HAVE MADE OR ACCIDENTLY PUSHED (NRST) NEAREST WAYPOINT BUTTON ON BOX. CAUGHT IT ONLY BECAUSE VORS WERE ON CORRECT FIX. NO TFC CONFLICT AROSE, HOWEVER, CTR SAID ANOTHER 5 MINS WE WOULD HAVE.

  515.  
  516. Accession Number: 417680
    Synopsis: THE CREW WAS ISSUED A DSCNT CLRNC WHICH THE CAPT AND FO HEARD DIFFERENT ALTS. THE CAPT READ BACK THE WRONG ALT AND NEITHER THE CTLR NOR THE FO NOTICED THE ERROR. THE CTLR ALERTED THE CREW WHEN THEY WERE PASSING 1000 FT BELOW THE ASSIGNED ALT AND THEN ISSUED A NEW ALT.
    Narrative: CRUISING AT FL330, GIVEN CLRNC TO A LOWER FLT LEVEL. I UNDERSTOOD FL290 AND SET IT ACCORDINGLY. I BEGAN TO PROGRAM THE FMS AND WAS ADVISED BY CAPT NEW CLRNC WAS TO FL240. I SET FMS AND AUTOPLT ACCORDINGLY. AFTER RECEIVING THE CLRNC, THE CAPT ACKNOWLEDGED CTR RESPONDING WITH FL240. I DID NOT NOTICE THE DIFFERENCE BTWN HIS READBACK AND MY AUTOPLT SETTING OF FL290. AT FL280 AND DSNDING, CTR ADVISED OUR CLRNC WAS TO FL290. I ARRESTED THE DSCNT AT ABOUT FL278. CAPT RESPONDED TO CTR HE UNDERSTOOD CLRNC TO FL240 AND READ THAT BACK. CTR THEN CLRED US TO FL270. PROBABLE CAUSE: I DID NOT QUESTION THE DISCREPANCY BTWN MY AUTOPLT SETTING AND THE ALT THE CAPT ADVISED TO SET IN THE FMS. FUTURE PREVENTION: NOTICING AND QUESTIONING ALT DISCREPANCIES.

  517.  
  518. Accession Number: 418060
    Synopsis: A B737-800 PROCEEDS TO SSM INSTEAD OF FLYING TOWARDS BUF ON J95 LIKE THE FLT PLAN SAYS TO DO.
    Narrative: ROUTING ON PDC FOR FLT EWR-SEA SHOWED EWR 6 DEP TO GAYEL, J95 BUF, SSM. I, AS FO, CHKED THE RTE TWICE IN THE FMC AND IT WAS THE SAME AS THE PDC. AFTER DEP, WE FLEW THE RTE ON J95 TO CFB AND THE ACFT PROCEEDED DIRECT TO SSM OMITTING BUF. ABOUT 20 MI OUT OF CFB ZOB ASKED US OUR ROUTING. WE NOTICED THE DISCREPANCY AND TOLD HIM WE WOULD PROCEED TO BUF, WHICH WE DID. THE ONLY THING THAT WE THOUGHT COULD HAVE HAPPENED SINCE NEITHER OF US DELETED BUF IN THE FMC IS THAT WE INADVERTENTLY DOWNLOADED A SECOND FLT PLAN INTO THE FMC AFTER I CHKED THE FIRST DOWNLOADED FLT PLAN AND THE POSSIBLY SECOND DOWNLOADED FLT PLAN HAD CFB DIRECT SSM.

  519.  
  520. Accession Number: 419020
    Synopsis: FLC WAS FLYING OFF COURSE DUE TO FMC EQUIP PROB.
    Narrative: ZOB ASKED US IF WE WERE CLRED DIRECT PMM OR ON OUR FLT PLANNED RTE. I REPLIED FLT PLANNED RTE. AFTER LOOKING AT FMC, WE REALIZED DEWIT INTXN AND POSSIBLY FNT DROPPED OUT. NEVER HAVE SEEN THIS BEFORE. WE CHKED OUR POS WITH NAVAID AND WE WERE 4 NM FROM CTRLINE.

  521.  
  522. Accession Number: 419055
    Synopsis: B767 CREW STARTED TO DSND LATE. WHEN INFORMED, THE CTLR REMOVED THE RESTR, AND ISSUED A PLT'S DISCRETION DSCNT.
    Narrative: ACR FLT XXX RETURNING FROM MADRID, SPAIN, 8 HR 56 MIN FLT TIME, CRUISING AT FL390. ZTL GAVE US A RESTR TO CROSS 50 MI E OF ODF AT FL350. THE COPLT WAS FLYING. THE FLT ATTENDANT CAME UP WITH A FORM ON CABIN DISCREPANCIES TO BE ENTERED INTO THE ACARS. ABOUT 5-10 MI PRIOR TO 50 MI E, I NOTICED THAT WE HAD NOT LEFT FL390. WE IMMEDIATELY NOTIFIED ZTL. THEY CLRED US TO FL240, PLT'S DISCRETION OUT OF FL310. WE HAD PROGRAMMED THE FMS FOR THE FL350 RESTR BUT FAILED TO RESET THE ALT TO FL350 ON THE FMC. THE DISTR WAS JUST ENOUGH FOR BOTH PLTS TO NOT CHK THAT THE PLANE WAS ON ITS PROPER DSCNT PROFILE. THEY SHOULD PUT AN ACARS SCREEN IN THE PAX CABIN FOR FLT ATTENDANTS TO ENTER THEIR OWN MAINT PROBS RATHER THAN OURS. THIS ALWAYS HAPPENS ON DSCNT, OR NEAR TO THIS POINT IN THE FLT.

  523.  
  524. Accession Number: 420130
    Synopsis: B737 FLC RECEIVED MULTIPLE HDG AND ALT CLRNCS DURING TKOF AND INITIAL CLB. WHILE RESOLVING TCASII RA, AN ALTDEV OCCURRED.
    Narrative: B737-300 OKLAHOMA CITY TO DALLAS. TKOF WAS ON RWY 31. WX WAS NOT A FACTOR. TKOF CLRNC WAS FLY HDG 010 DEGS AND CLB TO 5000 FT AND TWR ADVISED THAT A LIGHT ACFT WAS ORBITING N OF THE FIELD VFR. THE FO ASKED TWR IF THEY STILL WANTED US TO FLY A 010 DEG HDG. TWR CONFIRMED A 010 DEG HDG. AFTER TKOF, DURING THE TURN TO 010 DEGS, TWR AMENDED THE ALT CLRNC TO 4000 FT. DEP SUBSEQUENTLY ISSUED HDG OF 070 DEGS AND THEN 090 DEGS. TWR DID NOT GIVE ANY FURTHER CALLS ABOUT THE LIGHT ACFT TFC. AT ABOUT 3000 FT, THE CAPT ENGAGED THE AUTOPLT IN THE COMMAND MODE WITH 4000 FT IN THE ALT CLRNC WINDOW (AUTOMATIC ALT ACQUIRE WAS ARMED). APCHING 090 DEG HDG AND 4000 FT, A TCASII TA/RA ANNOUNCED 'REDUCE VERT SPD.' THIS WAS THE FIRST WARNING OF POTENTIAL TFC CONFLICT. THE CREW DIVERTED THEIR ATTN TO THE TCASII AND ACQUIRING THE SECOND ACFT VISUALLY. AT THE TCASII ALERT, THE LIGHT ACFT WAS DIRECTLY ON OUR NOSE AND ABOUT 1300 FT HIGH. BOTH THE CAPT AND FO GAVE THE POP UP TFC TA/RA OUR UNDIVIDED ATTN. THE CREW PICKED UP A VISUAL ON THE LIGHT ACFT WITHIN 5 SECONDS (AT 12 O'CLOCK, 3 NM, SLIGHTLY HIGH) AND VERIFIED THAT ADEQUATE SEPARATION EXISTED. WHEN THE CREW LOOKED BACK INSIDE THE COCKPIT AT ALT FOLLOWING VISUAL ACQUISITION OF THE LIGHT ACFT, BOTH THE CAPT AND THE FO REALIZED THAT ALT HOLD HAD NOT ENGAGED, AND THAT OUR ACFT HAD CLBED THROUGH THE ASSIGNED ALT BY 400 FT TO 4400 FT. THE CAPT IMMEDIATELY CORRECTED THE ALTDEV -- DSNDING BACK DOWN TO 4000 FT. THE LIGHT ACFT PASSED DIRECTLY OVERHEAD AS WE DSNDED TOWARDS 4000 FT AND AT THE SAME TIME, DEP CTL DIRECTED US TO MAINTAIN 4000 FT. THE MINIMUM ACFT SEPARATION WAS APPROX 1000 FT. AT NO TIME WAS ANY EVASIVE ACTION REQUIRED OR TAKEN. LESSONS LEARNED: THIS CAPT AND FO LEARNED THAT EXTRA ATTN TO ACFT PARAMETERS IS REQUIRED DURING TCASII EVENTS TO PREVENT ALT, AIRSPD, OR HDG DEVS WHILE THE CREW'S ATTN IS DISTR. THE TCASII ALERT, AS WE WERE ROLLING OUT AND LEVELING OFF, WAS TOTALLY UNEXPECTED AND DIVERTED OUR ATTN AWAY FROM MONITORING THE LEVELOFF. THIS INITIALLY CAUSED US TO MISS THE FACT THAT THE AUTOPLT DID NOT ACQUIRE THE 4000 FT ALT AND LEVELOFF. FOLLOWING THE TA/RA, WE REFED THE TCASII SCOPE AND THEN LOOKED OUTSIDE, WE FELT THAT THE MOST CRITICAL ACTION AT THAT MOMENT WAS TO GET A TALLY ON THE LIGHT ACFT AND TO VISUALLY GUARANTEE SAFE SEPARATION. FROM THE VIEWPOINT OF AIR TFC CTL, WE BELIEVE THAT IT WOULD HAVE BEEN POSSIBLE TO COMPLETELY AVOID ANY POSSIBLE ACFT CONFLICT BY VECTORING OUR ACFT TO STAY LATERALLY CLR OF THE LIGHT ACFT. VECTORING US W AND THEN S OR FURTHER TO THE N BEFORE TURNING E WOULD HAVE TOTALLY AVOIDED THE POSSIBILITY OF ANY TCASII ALERTS OR ACFT CONFLICTS. ADDITIONALLY, HAD ATC POINTED OUT THE LIGHT TFC AS WE CLBED OUT, WE COULD HAVE ATTEMPTED TO PICK UP A VISUAL PRIOR TO ANY TCASII ALERTS. HAVING A VISUAL PRIOR TO THE TCASII TA/RA WOULD HAVE ALLOWED THE FO TO NOTE THE ALERT AND QUICKLY CONFIRM THAT WE HAD VISUAL ON THE TFC WHILE THE CAPT CONTINUED TO FLY THE PARAMETERS ASSIGNED BY ATC.
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