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Incidents related to Issue 13 incidents related to this issue.

Issue: crew assignment may be inappropriate (Issue #142)
Description: When two pilots with little automation experience are assigned to an advanced technology aircraft, errors related to automation use may be more likely.

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  2. Accession Number: 50529
    Synopsis:
    Narrative: DESCENDING INTO SFO, CLRD TO 11,000', ACFT ON VERTICAL NAV ON FMC AND PROGRAMMED TO MAKE CROSSING RESTRICTION AND LATERAL NAV FLYING INBOUND COURSE, CTLR ISSUED "CLRD DIRECT BRIJJ (COMPASS LOCATOR), MNTN 16,000." BRIJJ WAS NOT A WAYPOINT IN THE FMC MEMORY, BUT ANTICIPATING WE MIGHT BE CLRD TO IT I HAD PREVIOUSLY PROGRAMMED IT INTO THE FMC TEMPORARY MEMORY BANK. I STARTED PRESSING BUTTONS TO HAVE THE FMC NAVIGATE US TO BRIJJ--THE ACFT STARTED TO TURN--AND I SELECTED ADF ON THE VOR TO COMPARE IT WITH THE FMC BEARING. THERE APPEARED TO BE ABOUT A 20 DEG DIFFERENCE IN BEARING FROM WHERE THE ACFT WAS HDG. I MENTIONED THIS TO THE COPLT AND HE BEGAN TO PULL UP THE WAYPOINT (BRIJJ). WE HAD SET IN TO CONFIRM IT. AT THIS POINT THE CTLR CALLED "OBSERVE YOU GOING 400' LOW, MAINTAIN 15,000 AND TURN LEFT HDG (?) FOR TFC." NEITHER OF US HAD SET THE NEW ALT IN THE MCP. CONTRIBUTING FACTORS--THIS WAS MY SECOND TRIP SERIES IN THE MLG--LESS THAN 35 HRS. THE FMC AND INDEED R-NAV WAS NOT FAMILIAR TO ME. COPLT WAS ALSO NEW IN ACFT--LESS THAN 1 MONTH. BASIC CAUSE--ALLOWING UNUSUAL EVENT (NAVAID DISAGREEMENT) TO DISTRACT ME FROM ROUTINE HABIT PATTERN (SETTING ALT WHEN CLRD). DIFFICULT TO KEEP NEW "TOYS" IN COCKPIT FROM DISTRACTING AND PREOCCUPYING YOU. I FEEL FMC IS TOO TIME INTENSIVE FOR USE IN TERMINAL AREA, ESPECIALLY WHEN NEW IN ACFT AS WELL AS TO THIS SYSTEM. I HAVE REVERTED TO USING THE BASIC FAMILIAR INSTRUMENTS AND NAV SYSTEMS BELOW 18,000' UNTIL I AM MUCH MORE COMFORTABLE IN THE ACFT.

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  4. Accession Number: 63447
    Synopsis: WDB LANDED ON THE WRONG PARALLEL RWY.
    Narrative: NEARING COMPLETION OF A 3 HR FLT. THE FLT WAS CLEARED FOR A NIGHT VISUAL APCH TO RWY 35R AT DFW. THE ACFT WAS HIGH ON DOWNWIND, W OF THE ARPT. TFC WAS LIGHT AND THE VISIBILITY WAS EXCEPTIONALLY GOOD. THE PLT FLYING (F/O) HAD APPROX 100 HRS IN THE ACFT. A SHORTENED APCH WAS COMMENCED WITH AN ANGLING LEFT TURN NEBND. THE FMS WAS PROGRAMMED FOR RWY 35R AND THE PF WAS USING THE MAP DISPLAY ON THE HSI FOR LINEUP AS THE RWY LIGHTS WERE NOT YET VISIBLE. JUST AS THE 36 L/R LIGHTS WERE COMING INTO VIEW, THE TWR OFFERED 35L AND THE CREW ACCEPTED (NO ILS ON 35L). AFTER FURTHER CHECKING THE HSI DISPLAY FOR LINEUP, THE PF LOOKED OUT AND SAW THE 36 L/R LIGHTS AND MISTOOK THE RWY PAIR AS RWY 35 L/R. THE LACK OF ILS INFO AND THE INTENSE LIGHTING OF A RELATIVELY NEW RWY (31L) ADDED TO THE CONFUSION. THE PF LINED UP ON 36L AND AS CLRNC TO LAND (ON 35L) HAD ALREADY BEEN GIVEN, A LNDG WAS MADE. NOTHING FURTHER WAS HEARD FROM THE TWR. JUST PRIOR TO TOUCHDOWN, BOTH PLTS REALIZED THE ERROR, BUT A GO-AROUND WAS NOT FEASIBLE AT THAT POINT. THE TWR OPERATOR THEN CLEARED THE ACFT TO TAXI ACROSS 36R AND TO THE GATE. THE FOLLOWING FACTORS WERE BELIEVED TO HAVE CONTRIBUTED TO THIS EVENT: A) F/O, PF, HAD MINIMUM TIME IN THE ACFT. B) CHANGING OF APCH FROM 35R TO 35L LATE ON FINAL, THUS INVOLVING A REPROGRAMMING OF FMS, DIVERTING NEEDED ATTN FROM OUTSIDE AT CRITICAL TIME. C) ATTEMPTING TO CALL RAMP FREQ ON FINAL TO GET GATE ASSIGNMENT AND ADVISE OF ETA FOR RIGHT CONNECTIONS EQUALS DISTRACTION. D) UNUSUALLY CLEAR VISUAL CONDITIONS AND FAMILIAR ARPT WHICH SEEMED TO UNDERMINE THE NORMAL LEVEL OF ALERTNESS OF CREW. E) MINIMUM NIGHTTIME STAFFING OF TWR. ONE MAN CONTROLLING TWR, GND CTL AND CLRNC DELIVERY DIVERTED HIS ATTN FROM LINE-UP. F) MOST IMPORTANTLY, PREOCCUPATION BY CREW ON FMS/INSTRUMENTATION LATE IN THE APCH WHEN OUTSIDE VIGILANCE WAS NECESSARY/MORE IMPORTANT. G) SINCE THE ACFT NEVER CAPTURED THE EXISTING ILS LOCALIZER (35L) THE RAW DATA AVAILABLE SEEMED TO INDICATE "LINED UP LEFT" WHICH WAS COMPATIBLE WITH THE SITUATION, THEREFORE DISREGARDED. IN CONCLUSION IT IS ALMOST INCOMPREHENSIBLE THAT 2 EXPERIENCED COMMERCIAL PLTS COULD LAND VFR AT A FAMILIAR ARPT, WITH NO ATC COMMENTS, ON THE WRONG RWY. THE HUMAN TENDENCY TO LET YOUR GUARD DOWN IN GOOD WX IN FAMILIAR SURROUNDINGS IS, RESULTANTLY, A VERY DANGEROUS FACTOR IN AVIATION. THE LESSON HERE IS THAT WE ALL NEED TO BE EXTRA VIGILANT DURING THESE PERIODS AND PERHAPS MORE EMPHASIS PLACED ON THIS REALM DURING OUR TRAINING FOR THESE SITUATIONS SEEM TO HAPPEN FREQUENTLY AND WE SEEM TO BE ILL PREPARED WHEN THEY DO OCCUR.

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  6. Accession Number: 177588
    Synopsis: ALT DEVIATION ALT OVERSHOT ON SID WHEN FMC DROPS SID AND ROUTE OUT OF DATA BASE.
    Narrative: AFTER TKOF AT APPROX 400' AGL, ALL INFO RE: CURRENT FLT DUMPED FROM THE FMC EXCEPT THE DEP ARPT AND THE DEST ARPT IN THE RTE. AFTER GEAR UP AND THROUGH 400', NOTICED NO MAGENTA LINE AND ADVISED CAPT. HE PROCEEDED TO FLY THE DEP PROC NOISE ABATEMENT VISUALLY. ALSO AFTER CALLING CLB DERATE 2, THE FMC WOULD NOT CTL THE AUTO THROTTLE, SO CAPT MANUALLY PULLED THROTTLES TO WHAT HE THOUGHT WAS A DERATED CLB. FURTHER WE WERE BOTH DISTRACTED BY THIS MISHAP AND WE WENT 250' ABOVE ASSIGNED ALT, BUT IMMEDIATELY RECAPTURED 3000'. I DON'T BELIEVE ANOTHER CREW COULD HAVE HANDLED THE SITUATION MUCH DIFFERENTLY. PERSONALLY I HAD NEVER BEEN TO SNA PRIOR TO THIS--THE CAPT HAD. IF WE WERE NOT VFR, WE WOULD HAVE HAD NO WAY TO NAV. LUCKILY, THE CAPT KNEW WERE THE VIS REFS WERE TO THE SID. I HAD LESS THAN 60 HRS IN TYPE AS WELL AS THE CAPT. ALTHOUGH I DON'T KNOW IF THIS WAS CONTRIBUTING, PERHAPS A MORE EXPERIENCED CREW COULD HAVE REACTED FASTER? PS: THE CAPT NOTIFIED SCHEDULING PRIOR TO THE TRIP SEQUENCE ABOUT THE LACK OF CREW EXPERIENCE. HE WAS ASSURED IT WAS LEGAL, BUT IN MY OPINION IT WAS NOT SAFE.

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  8. Accession Number: 188375
    Synopsis: ALT DEV ALT OVERSHOT.
    Narrative: FIRST OF ALL, MY PRESENCE IN THE COCKPIT FOR DEP WAS NOT REQUIRED SINCE I WAS THE RELIEF PLT. HOWEVER, GENERALLY SPEAKING, MOST RELIEF PLTS SIT IN THE COCKPIT FOR TKOF AND LNDG. THE CAPT HAD JUST COME OFF OF NEWLY QUALIFIED STATUS WHEREAS THE FO WAS STILL NEWLY QUALIFIED. OUR FLT HAD BEEN CLRED THE KENNEDY 5 DEP WITH A CARNARSIE CLB WHICH INCLUDES A MAINTAIN 5000 FT ALT. JUST PRIOR TO TKOF THE ALT WAS CHANGED TO 4000 FT. AFTER TKOF I HEARD DEP CTL ISSUE A 90 DEG HDG. HOWEVER, THE SOFT-SPOKEN AND APPARENTLY SLOW TO COMPREHEND FO READ BACK 9000 FT AND 90 DEG (ACCORDING TO HIM) OF WHICH I ONLY HEARD 90 DEG. HE SUBSEQUENTLY RESET THE ALT ALERTER TO 9000. DURING THIS PERIOD OF TIME MY ATTN WAS FOCUSED ON THE CAPT'S FLYING SINCE HE WAS ATTEMPTING TO NAV TO CARNARSIE VOR WITHOUT THE FMS BEING PROGRAMMED IN NAV OR ANY SPECIFIC HDG SELECTED. CONSEQUENTLY, I FOUND MYSELF DISTR BY LOOKING OUTSIDE TO VERIFY OUR GND TRACK SINCE THE CAPT NEVER REALLY BRIEFED HOW HE WAS GOING TO FLY THE DEP TO CARNARSIE VOR. ALSO, WHILE THE FO WAS OCCUPIED WITH HIS SLOW RESPONSE TO DEP CTL, I NOTICED THE AIRSPD RAPIDLY APCHING THE SLAT LIMIT SPD TO WHICH I CALLED OUT 'SLATS'. BOTH CAPT AND FO SEEMED TO BE BEHIND THE AIRPLANE. I FELT OVERWHELMED BY THE AMOUNT OF XCHKING I WAS DOING. ANYWAY, AS WE TURNED TO THE 90 DEG HDG, DEP CTL CALLED OUT TFC AT 4500 FT WHICH WE SAW, ACKNOWLEDGED AND RECKONED TO BE NO FACTOR. AS WE WENT THROUGH ABOUT 5000-6000 FT DEP ASKED WHAT ALT WE WERE CLBING TO. WHEN THE FO RESPONDED 9000 FT, WE WERE TOLD THAT 4000 FT WAS OUR CLRED ALT, HOWEVER, CONTINUE CLB TO 9000 FT. IN HINDSIGHT, AN OBVIOUS CAUSE OF THIS PROBLEM WAS THE PAIRING OF A CAPT WITH JUST OVER 100 HRS AND A FO WITH LESS THAN 100 HRS IN AN ADVANCED/AUTOMATED 2 PLT ACFT. MORE FLT TIME IN ACFT TYPE SHOULD BE REQUIRED BEFORE SUCH PAIRINGS ARE ALLOWED. ALSO, CHANGING THE ALT OF THE SID JUST PRIOR TO DEP TO ALLOW FOR TCA TFC AT 500 FT INTERVALS IS ASKING FOR PROBLEMS DURING THIS CRITICAL PHASE OF FLT. SUCH OTHER TFC SHOULD HAVE BEEN CLRED OUTSIDE OUR WINDOW OF 2500- 5000 FT ON THIS DEP AND FINALLY, IF THE CAPT HAD USED ALL AVAILABLE NAVAIDS, MORE ATTN COULD HAVE BEEN GIVEN TO OTHER ASPECTS OF THE DEP BY EXTRA CREW MEMBERS.

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  10. Accession Number: 189654
    Synopsis: ACR FLC IN NEW MODEL WDB HAS ALT DEV ALT OVERSHOT ALT EXCURSION DUE TO WRONG ALTIMETER SETTING.
    Narrative: I WAS THE FO AND WAS RESPONSIBLE FOR COMPUTER ENTRIES AND RADIO COM. WE WERE CLRED OUT OF FL230 TO 10000 FT BY TOKYO CENTER. WE WERE GIVEN A XING RESTRICTION OF AT OR BELOW 15000 FT AT MELON INTXN. IN SHORT ORDER, WE WERE GIVEN REVISED CLRNC TO 11000 FT THEN HANDED OFF TO TOKYO NARITA APCH WHO THEN GAVE A CLRNC TO HOLD AT ARIES INTXN. WE WERE PERHAPS 20 DME FROM THE FIX. AN ALREADY BUSY ARR WAS MADE MORE SO BY THE FOLLOWING FACTORS: 1) WX - TSTMS, TURB. CAPT WAS CLOSELY MONITORING RADAR. 2) WX AT DEST - RPTED AT MINS. CREW DURING DSCNT WAS DISCUSSING POSSIBLE DIVERT TO OSHKA. INTL OFFICER FELL OUT OF LOOP WHILE GETTING OSHKA WX AND MONITORING ATIS. NEW ATIS INDICATED RWY CHANGE. 3) I WAS OVERLY OCCUPIED WITH COMPUTER DUTIES - HOLDING, NEW ARR, NEW APCH. I DID NOT MONITOR DSCNT CLOSELY ENOUGH. 4) LANGUAGE - THE CTLR WAS DIFFICULT TO UNDERSTAND. I REQUIRED REPEATS OF SEVERAL OF THE TRANSMISSIONS. I ALSO HAD TO ASK FOR EFC. 5) WE WERE DSNDED LATE - CAPT ELECTED TO HAND FLY THE ACFT TO MAKE THE XING RESTRICTION. THE AUTO PLT OFF ALARM DISTRACTED ME FOR A FEW MOMENTS AT A CRITICAL TIME ABOUT 17000 FT (TA 14000 FT). I HAD COMPLETED THE DSCNT CHKLIST TO 18000 FT (OR TRANS ALT). AFTER THE AUTOPLT OFF ALARM I WENT BACK TO THE COMPUTER AND WAS SO ENGAGED WHEN NARITA APCH TOLD US WE WERE BELOW ALT AND TO CLB AND TURN. THE CAPT REACTED IMMEDIATELY. WE HAD FAILED TO RESET ALTIMETERS FROM 29.92 TO 29.19 AT TRANSITION ALT. NOBODY WAS THINKING DSCNT CHKLIST. IT IS EXTREMELY DIFFICULT TO MAINTAIN COCKPIT AWARENESS AND SCAN IN FMC ACFT WHEN RAPID CHANGE IS REQUIRED. PARTICULARLY WITH THE HEAD DOWN KEYPAD. CONTRIBUTING FACTORS: 1) HIGH WORKLOAD ACFT WITH RELATIVELY LOW TIME CREW DSNDING INTO AREA OF HVY WX. 2) LAST MIN HOLDING INSTRUCTIONS TOOK THE FO OUT OF THE LOOP WHILE REPROGRAMMING THE COMPUTER. 3) I NOW BACKING FO UP ON GETTING THE TRANSITION ALT CHKLIST COMPLETED. 4) CAPT NOT DOUBLECHKING TO SEE THAT ALL THE CHKLIST ITEMS HAD BEEN COMPLETED. LESSONS TO BE LEARNED: 1) ALL CREW MEMBERS NEED TO INSURE CHKLIST IS COMPLETE (INCLUDING THE ONE WHO IS FLYING). 2) ALL CREW MEMBERS NEED TO BE IN THE LOOP DURING APCH, PARTICULARLY WHEN WX, LANGUAGE DIFFERENCES, AND LAST MIN CLRNCS COULD COMPLICATE THE APCH.

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  12. Accession Number: 245915
    Synopsis: ALTDEV ALT OVERSHOT IN NON ADHERENCE TO ATC CLRNC.
    Narrative: WE DEPARTED DFW ON A WORTH 5 DEP -- TUCUMCARI TRANSITION WITH AN ASSIGNED ALT OF 10000 FT. THE CAPT WAS HAND FLYING THE ACFT. ON CLBOUT, DEP ASSIGNED US A WESTERLY HDG AND ADVISED THAT, DUE TO WX, WE WERE TO BE ASSIGNED TO INTERCEPT THE DFW 262 DEG RADIAL OUTBOUND WITH FURTHER CLRNC TO COME FROM ZFW. AS PNF, I ATTEMPTED TO ENTER THE NEW ROUTING INTO THE FMC USING MY FMC CTL DISPLAY UNIT (CDU). MEANWHILE, THE CAPT (UNKNOWN TO ME, HEAD DOWN FEVERISHLY WORKING ON MY CDU) SELECTED MANUAL VOR TUNING ON 117.0 AND WAS READY TO USE THE SINGLE POINTER (SELECTED TO VOR) AND RDMI TO COMPLETE THE INTERCEPT. I INFORMED THE CAPT OF MY DIFFICULTIES, HE DIVERTED HIS ATTN TO HIS CDU TO SEE WHAT I HAD DONE. ABOUT THEN, WE PASSED THROUGH 10000 FT. I THINK THE ALT ALERT LIGHT AND CAUTION SIGNALS ACTIVATED. THE CAPT PROMPTLY RETURNED THE ACFT TO 1000 FT. THE CTLR CALLED US AND STARTED TO ASK A QUESTION, BUT THEN STOPPED. END OF OCCURRENCE. FACTORS -- THIS WAS MY SECOND FLT AS PNF IN ACFT TYPE. ALL OF MY PREVIOUS FLYING WAS IN NON ADVANCED COCKPIT TYPE ACFT. MY INEXPERIENCE LED ME TO ATTEMPT TO GENERATE A COMPUTER SOLUTION FOR A SIMPLE MANUAL VOR PROB. THE CAPT (WITH 20 PLUS YRS AS CAPT BUT ONLY 100 HRS IN ACFT TYPE) ALLOWED ME TO DISTRACT HIM AT AN INOPPORTUNE MOMENT. ATTEMPTING TO REDUCE THE WORKLOAD THROUGH AUTOMATION CREATED A MORE DEMANDING SIT, DISTRACTING US FROM THE BASICS OF FLYING. RECOMMENDATION -- INTERNAL ACFT ALT ALERTS SHOULD BE SET TO ALERT FLCS FOR CORRECTIVE ACTION BEFORE ALTDEV REACHES SAFETY LIMITS/ FAA ALERT PARAMETERS. THIS WOULD PROVIDE FOR EARLIER CORRECT FLC RESPONSE WHEN THEY ARE MOMENTARILY DISTRACTED BY ANY OF A MYRIAD OF POSSIBLE SITS. SUPPLEMENTAL INFO FROM ACN 245833: 2 NEW 'GUYS' TRYING TO KEEP UP WITH THE COMPUTER -- I REVERTED TO A MANUAL INTERCEPT.

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  14. Accession Number: 251361
    Synopsis: ACR MLG MISSES AIRWAY TURN WHILE FLYING IN SOVIET FAR E.
    Narrative: AFTER XING THE TA RADIO BEACON IN THE SOVIET FAR EAST, OUR OMEGA DID NOT TURN ON AIRWAY A81 NEBOUND. OUR HDG REMAINED 091 DEGS FOR ABOUT 20 MI UNTIL WE NOTICED WE WERE OFF COURSE. WE IMMEDIATELY MADE A L TURN TO CORRECT THE PROB AND WITHIN 10 NM, WE WERE BACK ON COURSE ON THE 067 DEG BEARING ON A81 TO MA (THE NEXT FIX). WE SHOULD HAVE MONITORED THE OMEGA MORE CLOSELY, BUT, SINCE THE CAPT HAD NEVER USED THE OMEGA EXCEPT FOR THIS TRIP, AND I HAVE NOT USED IT FOR 5 YRS, I THINK OUR COMPANY SHOULD PROVIDE MORE TRAINING.

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  16. Accession Number: 380172
    Synopsis: A B757-200 DSNDING IN OAK, CA, AIRSPACE, ASSUMES DSCNT IS AUTOMATICALLY AUTH WHEN CLRED FOR AN APCH.
    Narrative: WE WERE LEVEL AT 8000 FT MSL ON AN ASSIGNED HDG (APPROX 210 DEGS MAGNETIC) DURING THE APCH INTO SFO. I WAS FLYING AND THE CAPT WAS WORKING THE RADIOS. THE WX WAS VFR, WITH HIGH THIN CLOUDS AND VISIBILITY GREATER THAN 10 NM. APCH CTL HAD PREVIOUSLY ASKED IF WE COULD ACCEPT THE FMS BRIDGE VISUAL RWY 28R, TO WHICH WE REPLIED YES. THE CTLR NOW TELLS US TO MAINTAIN ASSIGNED HDG TO INTERCEPT THE FMS RWY 28R. THE CAPT READ BACK THE CLRNC. BOTH THE CAPT AND I WERE RELATIVELY NEW TO 'HIGH TECH' AIRPLANES. (I HAD APPROX 6 MONTHS EXPERIENCE AND THE CAPT APPROX 2 MONTHS.) SINCE NO SPECIFIC ALT RESTRS WERE GIVEN, I INTERPED THIS CLRNC AS ALLOWING US TO INTERCEPT THE FMS RWY 28R BOTH LATERALLY AND VERTLY. OUR HDG PUT OUR INTERCEPT POINT RIGHT AT ARCHI ON THE APCH. A FEW MOMENTS LATER, HE CLRED US TO 7000 FT AND TOLD US TO CONTACT THE FINAL CTLR. WE THEN SWITCHED OVER AND CHKED IN WITH THE FINAL CTLR. WE LEVELED OFF AT 7000 FT JUST PRIOR TO ARCHI. WITH VNAV/LNAV ARMED AND THE AUTOPLT ENGAGED, WE INTERCEPTED THE FMS RWY 28R APCH AT ARCHI INTXN. THE APCH SHOWS THE ARCHI XING ALT AT OR ABOVE 7000 FT. AFTER ARCHI, THE AUTOPLT FLEW THE LNAV/VNAV TRACK, STARTING A DSCNT TO CROSS TRDOW AT OR ABOVE 6000 FT. AT APPROX 6600 FT THE CTLR ASKED WHAT OUR ALT WAS. THE CAPT REPLIED 6600 FT AND DSNDING. THE CTLR SAID WE SHOULD BE LEVEL AT 7000 FT. THE CAPT STATED THAT WE HAD BEEN CLRED FOR THE FMS RWY 28R APCH. THE CTLR REPLIED THAT HE WAS THE ONLY ONE WHO CAN ISSUE THE APCH CLRNC. HE THEN IMMEDIATELY RECLRED US TO 6000 FT. A FEW MOMENTS LATER HE ISSUED US AN APCH CLRNC. WE WERE THEN HANDED OFF TO TWR AND CONTINUED THE APCH AND LNDG WITHOUT FURTHER INCIDENT. POINTS TO PONDER: 1) BOTH THE CAPT AND I THOUGHT THAT THE CLRNC TO INTERCEPT THE FMS RWY 28R APCH (A VISUAL PROC) WITH NO ALT RESTRS ALLOWED US TO INTERCEPT LATERALLY AND VERTLY. WERE WE INCORRECT IN THIS THINKING? 2) WHAT IS THE PROPER ATC PHRASEOLOGY USED FOR AN FMS APCH WHEN YOU ARE NOT TO DSND? FOR AN ILS APCH, IT USUALLY IS 'INTERCEPT THE LOC.' WHAT IS THE FMS EQUIVALENT PHRASE?

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  18. Accession Number: 386989
    Synopsis: AN MD11 MAKES AN APCH INTO SUBIC BAY, PHILIPPINES, AND PROGRAMS THE FMS IN ERROR. THE FLC ASSUMES THAT THE ACFT WILL FOLLOW AN OUTBOUND RADIAL, HOWEVER THE NAV SYS WILL NOT DO THAT AND THEY FLY OFF COURSE. APCH CTLR GETS THEM BACK ON COURSE.
    Narrative: THE PROB AROSE DUE TO CONFUSION BTWN FMS AND HARD VOR INFO RECEIVED. THE CAPT AND FO ARE NEW IN ACFT TYPE NEITHER ONE EVER HAVING FLOWN THE MD11. THE PROB WAS DISCOVERED WHEN THE FO QUESTIONED THE (TO) POINT ON FMS INFO. ACFT WAS NOT NAVING TO THE VOR AND OUTBOUND ON THE OUTBOUND RADIAL AS PROGRAMMED (OR THOUGHT TO BE). APCH QUESTIONED WHAT WE WERE DOING ON THE WRONG RADIAL WHEN WE SIMULTANEOUSLY FIGURED OUT WHERE WE WERE. CORRECTED OUR FLT PATH AND THE CAPT CONTINUED THE APCH AND LNDG WITHOUT FURTHER COMPLICATIONS. BOTH CREW MEMBERS ARE NEW IN THE ACFT AND FLYING IN UNFAMILIAR SURROUNDINGS. BUSY TIME OF FLT -- IE, CAPT WAS DOING AN APCH CHKLIST WHEN IT WOULD BE BETTER TO PAY ATTN. BACK SIDE OF CLOCK -- BOTH CREW MEMBERS TIRED.

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  20. Accession Number: 391520
    Synopsis: MD88 ACFT IN CRUISE WAS GIVEN CLRNC TO CLB AND FLC DIDN'T START CLB UNTIL QUESTIONED BY CTLR.
    Narrative: AFTER DEP FROM CVG, DURING CLB TO CRUISE ALT, ATC (ZID) ASSIGNED A HEADING. WHILE STILL ON THAT HEADING, WITH ACFT LEVEL AT FL230, ATC ASSIGNED 'MAINTAIN PRESENT HEADING, CLB MAINTAIN FL310.' THE FO (PNF) RESPONDED AND PUT THE ALT IN THE ALT WINDOW. WITH THE AUTOPLT ENGAGED, I (PF) SHOULD HAVE PUT THE ASSIGNED ALT IN THE WINDOW. NO ACTION WAS TAKEN TO INITIATE THE CLB. SHORTLY THEREAFTER ATC AGAIN ASSIGNED, 'CLB MAINTAIN FL310.' I NOTICED FL310 WAS ALREADY IN THE WINDOW AND I INITIATED THE CLB. ATC DID NOT MENTION ANY TFC CONFLICT AND SOUNDED NORMAL (DID NOT SOUND CONCERNED). I AM NOT CERTAIN HOW MUCH TIME PASSED BTWN CLRNCS. FACTORS: 1) INEXPERIENCE. I AM RELATIVELY NEW CAPT (LESS THAN 200 HRS), SECOND MONTH. THE FO WAS ONLY 3 MONTHS IN HIS FIRST R SEAT WITH THE COMPANY, AND NEW TO FMS ACFT. 2) FATIGUE. I HAD ARRIVED HOME PAST MIDNIGHT THE PREVIOUS EVENING AFTER COMPLETING A 4 DAY TRIP WITHOUT MUCH SLEEP OPPORTUNITY, THEN GOT CALLED OUT ON RESERVE FOR THIS TRIP. 3) FIRST FLT WITH THE OTHER CREW MEMBER. 4) FMS ON MD88 DOES NOT INITIATE AUTOMATIC CLB WITH NEW ALT IN THE WINDOW. MY PREVIOUS ACFT (B767) DID. INTERRUPTION OF NORMAL HABIT PATTERNS PROBABLY CAUSED THE EVENT (PF PUTS ALTS IN WINDOW WITH THE AUTOPLT ENGAGED), COMBINED WITH FATIGUE. MORE CLOSELY MONITOR SIT WITH LESS EXPERIENCED CREW MEMBERS.

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  22. 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.

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  24. Accession Number: 410029
    Synopsis: FLC OF A CANADAIR REGIONAL JET, CL65, FAILED TO FOLLOW THE PUBLISHED STAR ARR PROC RESULTING IN ATC INTERVENTION TO TURN THEM BACK ON COURSE AND DEPART A 'HOT' MIL OP AREA (MOA).
    Narrative: UPON PASSING THE OKK VOR NBOUND I PROCEEDED DIRECT OXI VOR. BOTH THE PNF AND MYSELF UNDERSTOOD THIS TO BE OUR CLRNC. AT THE SAME TIME WE RECEIVED A FREQ CHANGE WHICH INCLUDED A REMINDER THAT WE WERE CLRED VIA THE OKK ONE ARR. WE THEN BOTH CHKED THE ARR CHART AND REALIZED THAT WE WERE NOT TO PROCEED DIRECT OXI VOR BUT A NBOUND RADIAL OUTBOUND. AS WE CONTACTED THE NEXT CTR FREQ WE WERE TURNING TO THE OUTBOUND RADIAL. SINCE THE MDA WAS HOT WE APPARENTLY VIOLATED THE AIRSPACE WITH A POTENTIAL CONFLICT. UPON LNDG IN ORD I CALLED THE CTR SUPVR AS REQUESTED AND EXPLAINED THE CONFLICT (INCIDENT). HE TOLD ME THERE HAD NOT BEEN A CONFLICT ALTHOUGH 2 F-16'S WERE ASKED TO LEVEL OFF 1000 FT BELOW US. I BELIEVE THE LOW TIME IN TYPE AND TURBOJET, PERIOD, AND INEXPERIENCE WITH FMS AND GPS NAV SYS OF THE CREW TO BE A CONTRIBUTING FACTOR. ALSO THE FACT THAT WE USUALLY GET CLRED OKK DIRECT OXI CONDITIONED US TO EXPECT IT THIS TIME.

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  26. Accession Number: 411191
    Synopsis: B737-800. IOE CHK AIRMAN, WAS GIVING TRAINING TO A NEW PLT, AND ACCIDENTALLY TAXIED ONTO THE DEP RWY.
    Narrative: DESCRIPTION: AS WE TAXIED OUT FOR DEP AT LAX WE RECEIVED A CHANGE OF PLAN WHICH REQUIRED US TO REPROGRAM THE FMS. BOTH COCKPIT CREW MEMBERS ARE NEW TO THE B737-800 FMC SET-UP. WE WERE TAXIING SLOWLY AND CAUTIOUSLY WITH THE NEW AIRPLANE, 31 MIN TAXI OUT, AS WE WANTED TO MAKE SURE THE FMC WAS PROGRAMMED PROPERLY FOR DEP. GND CTL TOLD US TO 'EXPECT NO DELAY AT THE END' AND THERE WAS NO ONE IN LINE AT THE END. AS WE CONTINUED, THE TKOF REF SPDS CONTINUED TO DROP OUT AND WE RECEIVED MULTIPLE UPLINK MESSAGES. THE AUTOMATED COCKPIT WAS WORKING AGAINST US SO WE DROPPED DOWN TO THE MANUAL MODE. THE FO I BELIEVE WAS DISTRACTED BY THE FACT THAT THE TKOF REF PAGE DID NOT DISPLAY PREFLT COMPLETE AS IN THE B737-300 AND B737-500. I SHOULD EXPLAIN AT THIS POINT THAT I AM A NEW CAPT (194 HRS) ATTEMPTING TO CHK OUT AN FO WHO HAD NEVER SEEN THIS FMS SET-UP IN THE ACTUAL AIRPLANE -- ALL FAA APPROVED. THE FO CORRECTLY BROUGHT TO MY ATTN THAT THE TKOF REF PAGE DID NOT DISPLAY PREFLT COMPLETE. I VERIFIED THAT THE TEMP, TKOF REF SPDS, AND DEP WERE ALL PROPERLY PROGRAMMED AND ALL WAS READY. I WAS BEING CAUTIOUS IN THE TURN WITH THE 'LONGER' B737-800 TO SQUARE THE TURN. I WAS ALSO LOOKING OUT THE FINAL APCH TO THE E TO OBSERVE THE TFC SIT AND XCHKING THE DATA ENTRY AS IS NORMAL CREW DUTY. I DO NOT KNOW WHY I DIDN'T SEE THE HOLD SHORT LINE. I HAVE ASKED MYSELF A THOUSAND TIMES WHY I DIDN'T SEE IT. I HONESTLY DO NOT RECALL WHAT EFFECT THE ANGLE OF THE LATE AFTERNOON SUN MAY HAVE HAD ON GLARING THE HOLD SHORT SIGNAGE. WE ENDED UP STOPPING AT THE RWY BOUNDARY. BEFORE WE COULD RPT OUR ERROR, ATC CONFIRMED THAT WE WERE PAST THE HOLD LINE AND TO TAXI ON ACROSS TO CLR THE RWY. THE TFC ON FINAL THAT I HAD OBSERVED EARLIER WAS NOW RPTED TO BE 4 MI OUT. NO TFC PRIORITY WAS NEEDED NOR RECEIVED. LATER MY TELEPHONE CONVERSATION WITH THE LAX TWR REVEALED THAT WE WERE THE 2ND ERROR OF THE DAY AND THE 6TH IN THE PREVIOUS 2 WKS. CHAIN OF EVENTS: THE PROB AROSE WITH A CHANGE OF PLAN IN A NEW AIRPLANE WITH A NEW CAPT CHKING OUT AN FO NEW TO THE FMS SET-UP. THE PROB WAS DISCOVERED ABRUPTLY AS THE RWY APPEARED DIRECTLY IN FRONT OF US. CONTRIBUTING FACTORS WERE HIGH WORKLOAD, MULTIPLE DISTRACTIONS, AND REDUCED VISIBILITY DUE TO SUN GLARE. CORRECTIVE ACTION WAS TO TAXI ON ACROSS THE RWY WITH CLRNC TO DO SO. HUMAN PERFORMANCE CONSIDERATIONS: I PERCEIVED ERRONEOUSLY THAT THE DISTANCE TO THE RWY FROM THE PARALLEL TXWY WAS GREATER THAN IT ACTUALLY WAS. I PERCEIVED ERRONEOUSLY THAT THERE WOULD BE NO DELAY AT THE END DUE TO THE RADIO ADVISORY AND OBSERVED TFC. I HAD EVERY INTENTION OF STOPPING BUT MISJUDGED THE DISTANCE DUE TO NOT SEEING THE HOLD SHORT SIGNAGE. FACTORS AFFECTING THE QUALITY OF HUMAN PERFORMANCE WERE WORKING WITH NEW EQUIP IN NEW SITS AND I BELIEVE OUR HUMAN PERFORMANCE WAS DEGRADED BY ACTUALLY TRYING TOO HARD TO ACCOMPLISH EVERYTHING CORRECTLY. PREVENT A RECURRENCE, SEVERAL STEPS CAN BE TAKEN: 1) IN GND, ACROSS THE TXWY, HOLD SHORT LIGHTING AND WIG-WAG LIGHTS WOULD HAVE BEEN EXTREMELY HELPFUL. IN THIS CASE FOG WAS NOT A PROB FOR VISIBILITY BUT THE SUN VERY WELL MAY HAVE BEEN. IT SEEMS TO INDICATE SOME SORT OF COMMON PROB SINCE WE WERE THE SECOND ERROR OF AUG/FRI/98, AND THERE WERE 6 SIMILAR IN 2 WKS. 2) I REMEMBER WHEN WE CHKED OUT ON THE EFIS B737- 500'S, SEVERAL YRS AGO, WE HAD AN EFIS TRAINING DEVICE AND TRAINED ON THE GND. I THINK A GND BASED TRAINING DEVICE (ACARS INTERFACE) WOULD BE BETTER THAN ACFT TRAINING. ISN'T THAT WHY WE HAVE SIMULATORS? 3) EVEN THOUGH FAA APPROVED, PERHAPS WE SHOULD RE-EVALUATE WHETHER IT IS A GOOD IDEA TO USE NEW LINE CAPTS TO FAMILIARIZE 'NEW TO THE AUTOMATION' CREW MEMBERS, WITHOUT THE BENEFIT OF CHK AIRMAN TRAINING. I'M SUGGESTING THAT THE CAPT SHOULD HAVE AT LEAST 3-5 LONG LEGS OF EXPERIENCE BEFORE PASSING ON HIS KNOWLEDGE TO OTHERS. 4) CONTINUE AND RE-EMPHASIZE AWARENESS THAT PERTAIN TO SITS LIKE THIS, IE, ASRS NEWSLETTER, STATISTICS AND DISCUSSIONS IN RECURRENT TRAINING. 5) PUBLISH PROB AREAS (DISSEMINATE THE INFO) ENCOUNTERED ON THE LINE SOONER AND MORE THOROUGHLY PERTAINING TO ACARS INTERFACE, UPLINK PROMPTS, AND MESSAGES THAT CAN'T BE FOUND OR HAVE NO MEANING. I TRULY HOPE THAT THIS RPT CAN ENHANCE AIR SAFETY. SUPPLEMENTAL INFO FROM ACN 411871: THE NEW B737-800 HAS A HIGHLY AUTOMATED DATA UPLINK TO LOAD ALL THE PERTINENT INFO INTO THE FMC'S, SUPPOSEDLY DURING PREFLT. THIS UPLINK IS QUITE SLOW IN SUPPLYING THE NEEDED INFO. PRIOR TO PUSHBACK, THE DATA WE KNEW (TEMP, DEP RWY, SID) WERE LOADED. UPON CALLING GND CTL OUR ASSUMED DEP RWY OF 25R WAS CHANGED TO RWY 24L. CONTACTING N COMPLEX GND WE WERE TOLD TO EXPEDITE AND EXPECT NO DELAY AT THE RWY. THE CAPT WAS PRUDENT IN TAXIING SLOWLY, SQUARING OFF TURNS BECAUSE OF THIS BEING A CONSIDERABLY LONGER ACFT. THE PERFORMANCE INIT, TKOF DATA (INCLUDING V SPDS) AND CRUISE WIND DATA HAD YET TO ARRIVE THROUGH THE DATA LINK. I SUGGESTED WE STOP UNTIL WE WERE READY. JUST THEN THE PERFORMANCE INIT AND TKOF DATA ARRIVED INTO THE FMC'S, FOR RWY 25R. THE V SPDS ARE RWY SPECIFIC. TRYING TO LOAD THE CORRECT DATA 3 TIMES MANUALLY WAS UNSUCCESSFUL. THE V SPDS KEPT DROPPING OUT. I AGAIN RECOMMENDED STOPPING, MYSELF NOR THE MAGIC BOXES WERE READY. AT THIS POINT I ESTIMATE MY HEAD HAD BEEN DOWN 60-70 SECONDS, WAY TOO LONG. CAPT SAID TRY AGAIN. ON THE 4TH ATTEMPT THE BOX ACCEPTED THE SPDS, I DON'T KNOW WHY, NOTHING DIFFERENT HAD BEEN DONE. ABOUT THIS TIME I BECAME AWARE OF A VERY PROMINENT SHIFT IN SUNLIGHT ENTERING THE COCKPIT. I LOOKED UP, GOT MY BEARINGS AND SHOUTED 'STOP.' WE WERE ACROSS THE HOLD SHORT LINE FOR RWY 24L AND APPROX 25 FT FROM THE RWY. I LOOKED R AND SAW AN ACFT A GOOD DISTANCE OUT (SEVERAL MI) ON FINAL FOR ONE OF THE RWY 24'S. THE TWR CALLED US STATING 'WE SHOW YOU ACROSS THE HOLD SHORT LINE FOR RWY 24L, TFC IS AN ACR MD80 ON 4 MI FINAL RWY 24L. CLRED TO CROSS RWY 24L, HOLD SHORT OF RWY 24R.' NO GAR BY THE ACR WAS NECESSARY. WHAT CAN YOU SAY? IT COULD HAVE BEEN A LOT WORSE. COMMENTS/CONCLUSIONS: 1) FOR WHAT IT'S WORTH, I HAD ALL RELEVANT TRAINING BULLETINS INSTRUCTING ME WHILE TRYING TO LOAD DATA AT THE GATE. ONLY THE RTE INFO CAME THROUGH 'AS ADVERTISED.' THE REMAINDER ARRIVED DURING TAXI, A TERRIBLE TIME TO BE DISTRACTED. HAD THIS INFO BEEN IN A MORE TIMELY MANNER, IE, AT THE GATE, I DOUBT I'D BE WRITING THIS AND YOU WOULD NOT HAVE TO BE READING IT. 2) THIS WAS THE CAPT'S 2ND TIME IN THE ACFT AFTER A QUICK INITIAL CHK OUT FROM DCA TO EWR. THE CAPT IS NOW 'QUALIFIED' TO TRAIN ME ON MY FIRST LEG. THIS IS APPROVED BY THE FAA. 3) DON'T MOVE THE ACFT UNTIL ALL IS DONE, OR IF MOVING, STOP TILL EVERYTHING IS RIGHT. 4) GND CTL (OR TWR) SHOULD NOT HURRY YOU ALONG. IT CAN LEAD TO MISTAKES. THANK YOU. P.S. AFTER THIS RPT WAS WRITTEN, I AGAIN HAD THE DUBIOUS HONOR OF FLYING THE B737-800. THE UPLINK WORKED PRETTY MUCH THE SAME. WE LANDED EVERYTHING MANUALLY AT THE GATE THIS TIME. I WON'T ALLOW MYSELF TO GET SET UP AGAIN.
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