FDAI logo   ::  Site Map  ::   
Home  |  About This Website  |  Contact Us
About This Website » ASRS Incident Report Analysis » Incidents related to Issue

Incidents related to Issue 1 incident related to this issue.

Issue: instructor training requirements may be inadequate (Issue #143)
Description: Automation training requirements for instructor/check pilots may not be well defined, possibly leading to inadequately qualified instructor/check pilots.

  1.  
  2. 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.
Flight Deck Automation Issues Website  
© 1997-2013 Research Integrations, Inc.