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Incidents related to Issue 4 incidents related to this issue.

Issue: automation information in manuals may be inadequate (Issue #140)
Description: Manuals provided to pilots may contain incomplete, unclear, or erroneous information about automation, possibly leading to poor pilot performance.

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  2. Accession Number: 385762
    Synopsis: AN ACR B757 FLC HAD TO SWITCH TO THE ALTERNATE PITOT STATIC SOURCE TO RECOVER THE CAPT'S INSTS, BUT THEY WERE UNABLE TO INHIBIT THE GPWS WARNING SYS SO IT SOUNDED THE 'DON'T SINK' WARNING DURING THEIR APCH AT DEST.
    Narrative: WE HAD OBTAINED A 10000 FT RWY (4R) AT BOSTON FOR DEP, WHICH GAVE US MORE TIME TO REACT AT V1 '141 KTS' WHEN CAPT'S PITOT-STATIC INSTS FAILED. FO PERFORMED THE TKOF IN HIS USUAL OUTSTANDING PROFESSIONAL MANNER AS A SOLO UNTIL CAPT'S FLT INSTS COULD BE RECOVERED BY USE OF THE ALTERNATE AIR DATA SOURCE. ON LNDG AT LAX THE AURAL WARNING 'DON'T SINK' WAS PRESENT FROM 2000 FT AGL DOWN TO 200 FT AGL, WHILE ACFT WAS IN PROPER LNDG CONFIGN AND ON GS. BECAUSE THE WARNING WAS SO LOUD, OUR COMS WERE DANGEROUSLY COMPROMISED AND WE WERE UNABLE TO STOP THE GPWS WARNING IN SPITE OF HITTING ALL THE GPWS INHIBIT BUTTONS. WHY NO INFO ABOUT HOW TO SILENCE ERRONEOUS GPWS WARNINGS?

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  4. Accession Number: 398690
    Synopsis: B757 ACFT HAD INOP L INERTIAL REF UNIT WHICH MADE GPWS INOP. FLC THOUGHT THE TCASII WAS STILL WORKING, THOUGH THE GND CHK FAILED, BUT WITH GPWS INOP THE TCASII IS INOP. MEL DOESN'T REFLECT THAT AND RPTR FLC SAYS THE MEL SHOULD BE UPDATED.
    Narrative: LOCATION: 30 DME W OF BOS. ACFT ARRIVED WITH INOP L INERTIAL REF UNIT. GPWS WAS PLACARDED INOP IN ACCORDANCE WITH MEL. DURING GND CHKS TCASII SYS CHK FAILED. CAPT AND I MISREAD MEL AND ASSUMED THAT TCASII WAS OK, JUST FAILED CHK DUE TO L INERTIAL REF UNIT OFF AND GPWS INOP. MAINT ADVISED THAT THE TCASII IS DISABLED BY THE GPWS BEING TURNED OFF, BUT THE MEL DOESN'T ADDRESS THIS FACT OR REQUIRE A PLACARD. SUGGEST THE MEL BE UPDATED TO REFLECT TCASII LOSS WITH L INERTIAL REF UNIT FAILURE, AND GPWS OFF, WITH PLACARD WARNING ADDED. WE MADE AN ERRONEOUS ASSUMPTION AND SHOULD HAVE HAD THE TCASII PLACARDED BEFORE WE DEPARTED.

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  6. Accession Number: 399970
    Synopsis: L1011 ACFT ON SID AND LEVELING AT 5000 FT WITH AUTOTHRUST FMS ENGAGED, THE THROTTLES DIDN'T RETARD QUICKLY ENOUGH TO MAINTAIN REQUIRED 250 KTS. RPTR CAPT DISCONNECTED AND RETARDED THEM MANUALLY.
    Narrative: ON INITIAL CLB TO ASSIGNED SID ALT OF 5000 FT MSL, THE FMS AUTOTHRUST/THRUST MGMNT WERE ENGAGED AND APPEARED TO BE FUNCTIONING NORMALLY. REACHING INTERMEDIATE ALT OF 5000 FT MSL, THE ACFT WAS LEVELED OFF. AT THAT TIME THE THRUST LEVERS FAILED TO RETARD AS PRESCRIBED TO MAINTAIN 250 KTS. I DISENGAGED THE AUTOTHRUST AND IMMEDIATELY REDUCED PWR TO IDLE. DESPITE IMMEDIATE CORRECTIVE ACTION, THE ACFT ATTAINED A SPD OF 265 KIAS BEFORE CORRECTIVE ACTION TOOK EFFECT. THE FMS AND ASSOCIATED SYS WERE SET UP AND OPERATED IN ACCORDANCE WITH PUBLISHED PROCS. MY COPLT WAS A CHK AIRMAN AND CLAIMED THAT THE SYS WERE INCAPABLE OF MANAGING THE ACFT SPD IN THIS SCENARIO, EVEN THOUGH PUBLISHED GUIDANCE SAYS THAT IT WILL. THIS TYPE OF SPD OVERSHOOT SEEMS TO BE INEVITABLE WHEN USING OUR PUBLISHED PROCS. MOST CREWS DO NOT USE THE FMS FOR INITIAL CLB BECAUSE OF THIS PROB. I NEEDED TO USE IT IN ORDER TO DEMONSTRATE TO THE CHK AIRMAN MY ADHERENCE TO STANDARD PROCS.

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  8. Accession Number: 400550
    Synopsis: A BAE100 AFTER TKOF IN CLB ACFT LOST THE ATTITUDE HDG REF SYS AND RETURNED TO THE FIELD. FAILURE CAUSED BY SWITCHING THE PWR. NO REF IN THE QRH WARNING THAT THIS PWR SWITCHING COULD CAUSE FAILURE OF THE ATTITUDE HDG REF SYS.
    Narrative: DURING CLBOUT, WE EXPERIENCED 2 EFIS PROBS. THE TCASII FAIL LIGHT CAME ON AND THE ALT SELECT FEATURE OF THE FLT DIRECTOR WOULD NOT WORK IN MANUAL OR WITH AUTOPLT. REFERRING TO THE QRH DID NOT HELP SINCE THESE FAILURES WERE NOT IDENTED OR DISCUSSED. SINCE WE WERE DEPARTING A HIGH DENSITY ARPT AREA, BOTH SYS WERE DESIGNED TO EASE PLT WORKLOAD AND ASSIST IN TFC AVOIDANCE. WITHOUT GUIDANCE FROM THE QRH, WE RESORTED TO QUICKLY CHKING CIRCUIT BREAKERS AND SWITCH POS. AS WE WERE DOING THIS WE ALSO ENCOUNTERED SOME TURB (JET WASH). WHILE WIGGLING THE AVIONICS SWITCHES TO ENSURE THEY WERE 'ON' THE ATTITUDE/HDG REF SYS HDG SYS FAILED. NOW WITH OUR BIGGER PROB, WE REFERRED TO THE QRH AND RETURNED TO DEP ARPT. WX CONDITIONS AT ALL TIMES WERE VFR. I BELIEVE THAT MOVING THE SWITCHES IN TURB CAUSED A PWR INTERRUPTION TO THE ATTITUDE/HDG REF SYS. LATER ON THE GND, I FOUND A SENTENCE IN THE FLT STANDARDS HANDBOOK (SYS CHAPTER) THAT MENTIONS THAT RECYCLING THE AVIONICS SWITCH INFLT WILL CAUSE LOSS OF THE ATTITUDE/HDG REF SYS. HOWEVER, RECYCLING ON THE GND WILL NOT RESULT IN LOSING ATTITUDE/HDG REF SYS. I AM CONCERNED THAT THIS FACT IS NOT A 'WARNING' IN THE QRH! THE QRH SHOULD AT LEAST MENTION ALL THE SYS PWRED BY THE AVIONICS MASTER SWITCH AND INCLUDE THE WARNING ABOUT LOSS OF ATTITUDE/HDG REF SYS INFLT.
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