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Incidents related to Issue 21 incidents related to this issue.

Issue: mode selection may be incorrect (Issue #145)
Description: Pilots may inadvertently select the wrong automation mode or fail to engage the selected mode, possibly causing the automation to behave in ways different than intended or expected.

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  2. Accession Number: 50805
    Synopsis:
    Narrative: NO. 1 AUTOPLT FAILED DURING CLIMB. THE CAPT'S FLIGHT DIRECTOR ALSO WAS INOPERATIVE. DURING TROUBLESHOOTING THE FLIGHT DIRECTOR CIRCUIT BREAKER WAS RESET, WHICH RESULTED IN DISARMING THE AUTOMATIC ALT CAPTURE FUNCTION OF THE NO. 2 AUTOPLT. AS THIS OCCURRED APCHING LEVEL OFF (FL350) IT WAS NOT NOTICED UNTIL APPROX 300 TO 350' ABOVE FL350. THE ACFT WAS IMMEDIATELY DESCENDED TO FL350 DURING WHICH TIME SLC CENTER ADVISED US TO CHECK ALT AS WE WERE SHOWING 400' TOO HIGH.

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  4. 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.

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  6. 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.

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

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  10. 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.

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  12. Accession Number: 368799
    Synopsis: DC10 DSNDING TO 6000 FT. FO, PF, INADVERTENTLY GOT INTO VERT SPD MODE ON THE AUTOPLT RESULTING IN OVERSHOOTING ALT 300 FT.
    Narrative: ALTDEV OF ABOUT 350 FT. WE HAD BEEN CLRED FROM 8000 FT TO 6000 FT. FO FLYING, AUTOPLT ENGAGED. WE ALL OBSERVED ALT CAPTURE ON FMA AT ABOUT 6400 FT, HOWEVER, A FEW SECONDS LATER THE ALT WAS OBSERVED AT 5700 FT WITH ACFT STILL IN A SHALLOW DSCNT AND AUTOPLT IN VERT SPD MODE. AN IMMEDIATE CLB WAS INITIATED BACK TO 6000 FT. WE DON'T KNOW WHETHER FO ACCIDENTALLY BUMPED VERT SPD KNOB AFTER ALT CAPTURE, OR IF AUTOPLT LOST CAPTURE DUE TO TURB. REVIEWED PROPER AUTOPLT TECHNIQUE WITH FO AND CAUTIONED HIM TO KEEP HAND AWAY FROM VERT SPD KNOB AFTER ALT CAPTURE. SUPPLEMENTAL INFO FROM ACN 368990: WE WERE IN MODERATE TURB DUE TO ASSOCIATED BUILDUPS OF TSTMS AT THE TIME.

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  14. 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.

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  16. Accession Number: 370510
    Synopsis: B767-300 FO MISUSES THE AUTOPLT FOR A DSCNT PROC AND AIRSPD RESTR DURING THE CIVET STAR ARR PROC, RESULTING IN A SPD DEV.
    Narrative: INITIALLY WE WERE ASSIGNED A SPD OF 320 KTS OR GREATER UNTIL ADVISED. AT 5-7 MI PRIOR TO THE ARNES INTXN WE WERE ADVISED TO CROSS ARNES AT 250 KTS. THE AUTOPLT WAS IN THE VNAV MODE AND PROGRAMMED FOR ARNES AT 245 KTS. SPD BRAKES WERE USED TO SLOW THE ACFT. SHORTLY THEREAFTER WE WERE CLRED FOR THE ILS RWY 25L APCH. THROUGH HABIT I ENGAGED THE 'APCH' MODE OF THE AUTOPLT ON RECEIVING THAT CALL. THAT ENGAGED THE SPD AT THE EXISTING SPD OF ABOUT 280 KTS. I THEN REALIZED I STILL NEEDED THE AUTOPLT IN VNAV FOR THE STEPDOWN FIXES ON THE APCH. SINCE THE AUTOPLT HAD ALREADY ENGAGED IN THE APCH MODE, I HAD TO DISENGAGE THE AUTOPLT AND BOTH FLT DIRECTORS BEFORE RE-ENGAGING IN VNAV. THROUGH ALL OF THIS, WE CONTINUED OUR DSCNT TOWARD THE NEXT FIX, SUZZI, AT 9000 FT. ONCE THE AUTOPLT WAS RE- ENGAGED IN VNAV, I NOTICED THE AIRSPD ABOUT 280 KTS. WE SLOWED TO 250 KTS RESULTING IN 1-2 MINS BELOW 10000 FT ABOVE 250 KTS. DURING THIS BRIEF PERIOD THE CAPT WAS BUSY IDENTING THE ILS FREQ AND STARTING THE APCH CHKLIST.

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  18. Accession Number: 371630
    Synopsis: FLC OF ACR FAILS TO MAKE XING RESTR DUE TO INABILITY TO QUICKLY LOCATE THE INTXN. RECEIVED VECTOR UPON INFORMING ATC AND WHILE COMPUTING APCH SPDS FLC DSNDED BELOW ASSIGNED ALT.
    Narrative: FO FLYING LEG FROM PVD-BWI. GIVEN CLRNC TO CROSS TROYZ INTXN ON V378 AT 12000 FT. AFTER FINDING THE LOCATION FOR TROYZ (NON FMS EQUIPPED) WE WERE LATE IN GETTING DOWN. FO DEPLOYED SPD BRAKE, TOOK AUTOPLT OUT OF PMS MODE TO CWS MODE AND WAS MAKING RAPID DSCNT. I NOTIFIED ZNY THAT WE WERE UNABLE TO MEET THE RESTR. CTR TURNED US TO THE R. MY ATTN WAS DISTR WHILE GETTING APCH SPDS AND WHEN I LOOKED UP WE WERE DSNDING THROUGH 12000 FT. I TOLD THE FO '12000 FT, 12000 FT.' AND BEFORE HE COULD ARREST THE DSCNT, WE REACHED 11600 FT. PRIMARY FACTORS WERE A CLRNC THAT REQUIRED AN IMMEDIATE DSCNT AND THE FO TAKING THE AUTOPLT OUT OF A MODE THAT WOULD HAVE LEVELED THE ACFT AT 12000 FT.

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  20. 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.

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  22. 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.

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  24. 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.

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  26. Accession Number: 386746
    Synopsis: AN ACR B737 FLC DSNDS BELOW THEIR XING ALT WHEN THE CAPT SELECTS THE WRONG AUTOFLT SYS MODE AND SETS THE ALT ALERTER SELECTOR BELOW THEIR XING ALT.
    Narrative: ZLA CLRED ACFT TO BANDS INTXN WITH MULTIPLE SHORT DSCNTS OF 1000 FT - 2000 FT. CAPT USED VERT SPD MODE TO ACCOMPLISH TASK. DURING TRANSITION TO SOCAL APCH, CLRNC ABOVE WAS RECEIVED. THIS WAS TO BE AN FMC FUNCTION. WE WERE ANTICIPATING A VISUAL APCH, SHORTCUTTING THE ARR. INSTEAD OF RE-ENGAGING VNAV, FIRST THE CAPT SET 2200 FT IN ALT WINDOW -- THAT WOULD HAVE BEEN OK, BUT VNAV HAS TO BE ENGAGED TO READ FMC ALTS. VERT SPD LET THE ACFT DSND BELOW (BANDS, 7000 FT). DUTIES OF CREW MEMBERS WERE DIVIDED. CAPT WITH VISUAL, FO WITH ARR, STAR AND APCH CHKLIST ITEMS. OTHER DISTRS: ATIS ONLY RECEIVES CLOSE IN AS DOES COMPANY FREQ. THE ABILITY TO BACK EACH OTHER UP WAS NOT THERE 'AS USUAL' -- XCHKS OF EACH OTHER NOT DONE DUE TO DIVISION OF DUTIES. ALSO TOO DISTR BY RA WHILE WITH ZLA BY KING AIR PASSING 500 FT OVER US. SUPPLEMENTAL INFO FROM ACN 386755: CLRNC: TO KAYOH, CROSS KAYOH AT 7000 FT, 190 KTS. THEN CLRED TO DSND EASTSIDE 2 ARR, TRANSITION TO RWY 19R. ACFT B737 FMC EFIS. DURING TRANSITION TO SOCAL APCH, CLRNC ABOVE WAS RECEIVED. THIS WAS TO BE AN FMC FUNCTION. WE WERE ANTICIPATING A VISUAL APCH, SHORTCUTTING THE ARR. INSTEAD OF RE-ENGAGING VNAV FIRST, THE CAPT SET 2200 FT IN ALT WINDOW. THAT WOULD HAVE BEEN OK, BUT VNAV HAS TO BE ENGAGED TO READ FMC ALTS. LET THE ACFT DSND BELOW (KAYOH INTXN 7000 FT).

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  28. Accession Number: 391243
    Synopsis: FLC OF AN MLG DSNDED 1000 FT BELOW AN ALT FIX ON A BACK COURSE LOC APCH, AND THEN CORRECTED BACK AS SOON AS IT WAS NOTICED. ATC RECEIVED A LOW ALT ALERT IN THE CTL ROOM, BUT DID NOT PASS IT ON TO THE RPTR.
    Narrative: PLEASE REFER TO BOISE, ID, COMMERCIAL CHART AUGUST 1996, LOC (BACK COURSE) RWY 28L. WE WERE VECTORED TO INTERCEPT THE BACK COURSE BTWN THE D9.1 AND D15.1 FIXES AT 6500 FT MSL AND CLRED FOR THE APCH. MY (CAPT/PF) EHSI WAS CONFIGURED TO RAW DATA ONCE WE WERE ESTABLISHED ON THE INTERCEPT COURSE. FO EHSI WAS ALSO CONFIGURED FOR RAW DATA, ALTHOUGH HIS INTENTION WAS TO HAVE BEEN IN A MAP CONFIGN, HE REMEMBERS BEING DISTRACTED AS HE REACHED FOR THE MODE SELECTOR. THE FO HAD CONFIGURED THE FMC TO DISPLAY FIX XING ALTS ON ANY EHSI IN MAP MODE AS A XCHK. I BELIEVE THAT I CALLED FOR THE MCP ALT WINDOW TO BE SET TO 5900 FT. WE AGREED AS A CREW THAT THIS WAS CORRECT, BUT 4900 FT WAS SET INSTEAD AND I DID NOT CHK IT PER SOP OR, I INCORRECTLY CALLED FOR 4900 FT AND THE FO SET THIS IN THE WINDOW WITHOUT CHKING ITS VALIDITY. I USED A VERT SPD MODE TO DSND (AUTOPLT IN COMMAND MODE AND AUTOTHROTTLES ENGAGED PER SOP) AS I INTENDED TO DSND ONLY 600 FT AND HAD PERHAPS 6 MI TO THE D9.1 STEP-DOWN FIX. APCH HANDED US OFF TO TWR AT ABOUT THIS POINT. GEAR DOWN WAS SELECTED DURING THIS DSCNT AND THE 'FINAL DSCNT CHKLIST' WAS ACCOMPLISHED BEFORE MAKING A VHF CALL TO BOISE TWR. AS I CONCENTRATED ON TRACKING THE BACK COURSE WITH THE HEADING SELECT MODE (PER SOP), I HAD THE SENSATION OF LEVEL FLT (THROTTLES MOVING FORWARD WITH GEAR DOWN). WE DISCOVERED THE DISCREPANCY AS WE WERE LEVELING AT 4900 FT AT APPROX D11.0. I INITIATED A CLB TO CORRECT AS OUR SIT BECAME CLR, BUT THE D9.1 FIX WAS SOON ACHIEVED AND 4900 FT WAS REACQUIRED. THE APCH WAS CONTINUED TO LNDG. AWARENESS OF PROGRESS ON THE APCH WAS NEVER LOST. INST SCAN BROKE DOWN HOWEVER, AND ALT AWARENESS WAS LOST. THE LOC WAS TRACKED CLOSELY, WITHIN 1/4 DOT. HIGHEST TERRAIN WAS CLRED BY 1000 FT, HIGHER TERRAIN IS CHARTED AT 5000 FT PERHAPS 2.5 MI N OF THIS APCH SEGMENT. NO GPWS ALERT WAS EXPERIENCED. NO WARNING WAS GIVEN BY APCH CTL OR TWR. I INITIATED A PHONE CALL TO THE APCH CTLR LATER AND LEARNED THAT A LOW ALT ALERT HAD IN FACT BEEN TRIGGERED, BUT NOT PASSED TO US.

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  30. Accession Number: 391408
    Synopsis: A B737-400 FO SUFFERED A COURSE DEV WHEN ATTEMPTING A HAND FLOWN ILS INTO KTS, AK. FLT RECEIVED AN ENHANCED GPWS SIGNAL.
    Narrative: I ROUTINELY FLY INST APCHS IN THE WX USING RAW DATA AND FLT DIRECTOR OFF SO AS NOT TO LOSE MY INST FLYING SKILLS. THIS NIGHT, FOR THE FIRST TIME EVER, I INADVERTENTLY SET MY EHSI MODE SELECTOR TO 'EXP NAV' INSTEAD OF 'EXP VOR/ILS.' THIS MODE DISPLAYS LATERAL AND VERT NAV GUIDANCE ORIENTED TO AIRPLANE TRACK WITH THE FMC AS THE NAV SOURCE INSTEAD OF THE LOC AND GS. THERE WERE SEVERAL CLUES I DID NOT PICK UP ON DURING THE APCH. 1) BECAUSE OF STRONG HEADWINDS ON THE PROC TURN OUTBOUND, I DELAYED THE INBOUND TURN TO KEEP FROM OVERSHOOTING THE LOC. I HAVE DONE THIS NUMEROUS TIMES ON THIS APCH WITH STRONGER WINDS, AND WAS SURPRISED I OVERSHOT THIS TIME. I REINTERCEPTED WHAT I THOUGHT WAS THE LOC. 2) I PROGRAMMED A VNAV PATH TO THE RWY ON THE CDU WHICH GAVE ME A GS ON MY EHSI WHICH IS WHAT I NORMALLY SEE IN 'EXP VOR/ILS' MODE. HAD I NOT DONE THIS, I WOULD NOT HAVE HAD THE EHSI GLIDE PATH. 3) THE CAPT SELECTED EGPWS AND I HAD WX RADAR. MY EHSI SHOWED NUMEROUS WX RETURNS WHICH ALONG WITH THE YOKE, BLOCKED MY VIEW OF THE MISSING LOC FREQ THAT SHOULD HAVE BEEN IN THE BOTTOM R CORNER OF THE EHSI. 4) I DID NOT NOTICE THAT 'TRK' WAS DISPLAYED AT THE TOP OF EHSI INSTEAD OF 'HEADING' (BIG CLUE). 5) THE CDI WAS TOO STABLE FOR A LOC SIGNAL. I THOUGHT I WAS FLYING A GOOD APCH. APPROX 2000 FT MSL, SEVERAL THINGS HAPPENED AT ONCE. WE BROKE OUT AND THE CAPT SAID THE RWY LIGHTS WERE SLIGHTLY TO THE L AND THE EGPWS TRIGGERED 'CAUTION TERRAIN.' WE BOTH CHKED OUR NAV SETUP AND I ASKED FOR WIPERS BECAUSE MY FORWARD VISIBILITY WAS LIMITED DUE TO RAIN. I STARTED TO CORRECT BACK TO CTRLINE AS A 2ND AND 3RD 'CAUTION TERRAIN' SOUNDED. AT THE FIRST 'CAUTION TERRAIN,' THE CAPT SAW YELLOW TERRAIN TO THE R OF OUR COURSE. OUR EGPWS GIVES US THIS 'SOFT ALERT' APPROX 60 SECONDS IN ADVANCE OF TERRAIN AND IS REPEATED AFTER 7 SECONDS, IF STILL IN THE CAUTION ENVELOPE. DURING A TERRAIN CAUTION ALERT, AREAS WHERE TERRAIN VIOLATES THE TERRAIN CAUTION ENVELOPE ALONG THE ACFT TRACK AND WITHIN +/-90 DEGS OF ACFT TRACK ARE PAINTED IN YELLOW. AFTER CORRECTING TO COURSE, IT WAS AN UNEVENTFUL LNDG. I SHOULD HAVE DOUBLE CHKED MY NAV SETUP EARLIER AND PURSUED THE NUMEROUS CLUES SOONER. THE CAPT WAS BACKING ME UP MAINLY WITH THE HUD AFTER RECENTLY BEING CHKED OUT ON THE SYS. IN THE FUTURE, I WILL HEED WARNING SIGNS EARLIER AND DOUBLE CHK EVERYTHING, AND MAKE SURE THE CAPT IS BACKING ME UP USING MORE THAN 1 SYS. I AM VERY GLAD WE HAVE THE EGPWS WHICH PROVIDES MORE ADVANCE NOTICE THAN THE OLD SYS.

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  32. Accession Number: 392939
    Synopsis: A320 ACFT ON VECTOR HEADING FOR INTERCEPT AND ALT RESTR, ACFT ARMED FOR APCH CAPTURES GS PRIOR TO LOC INTERCEPT AND COMMENCES DSCNT BELOW ASSIGNED. TCASII RA ALERTS FLC TO ANOTHER ACFT ON APCH TO PARALLEL RWY. RPTR CAPT SAYS HE MAY HAVE PULLED INSTEAD OF PUSHING THE FCU (FLT CTL UNIT).
    Narrative: WHILE ON A 240 DEG VECTOR TO FINAL APCH COURSE TO RWY 21L AT DTW, WE WERE CLRED TO 'MAINTAIN 5000 FT UNTIL ROBBI, CLRED FOR THE ILS RWY 21 APCH.' THE FCU APPR (APCH) PUSH BUTTON WAS PUSHED AND THE AUTOPLT WAS ARMED TO CAPTURE THE LOC COURSE AND THE GS. THE GS WAS CAPTURED BEFORE THE LOC COURSE AND DSCNT FROM 5000 FT WAS INITIATED BY THE AUTOPLT. WHILE I ATTEMPTED TO DETERMINE IF WE HAD PASSED 'ROBBI,' WE FLEW THROUGH THE LOC COURSE (THE AUTOFLT SYS DID NOT CAPTURE THE LOC FOR REASONS UNKNOWN). AS I USED THE HEADING CTL KNOB OF THE FCU TO TURN BACK TO THE LOC COURSE, A TA FOLLOWED BY AN RA WAS GENERATED BY THE TCASII SYS FOR AN ACFT BELOW US ON THE PARALLEL APCH (RWY 21R). WE LEVELED OFF AT APPROX 4600 FT MSL AND CONTINUED THE TURN BACK TO THE LOC COURSE AND INTERCEPTED THE FAC. WHEN ESTABLISHED ON THE LOC (WELL ABOVE THE GS) AND AFTER THE TCASII AURAL 'CLR OF CONFLICT' MESSAGE WAS RECEIVED, I DISCONNECTED THE AUTOFLT SYS AND FLEW THE ACFT DOWN TO THE GS AND CONTINUED THE APCH TO A LNDG IN VMC. THE INCIDENT WAS INITIATED BY A FAILURE OF THE AUTOPLT TO CAPTURE THE LOC COURSE. THIS MAY HAVE RESULTED FROM MY POSSIBLY PULLING THE FCU HEADING CTL KNOB AFTER THE APCH PUSH BUTTON HAD BEEN PUSHED AND THE LOC AND GS ARMED FOR AUTOPLT CAPTURE. THIS WAS EXACERBATED BY MY FAILURE TO RECOGNIZE THE FAILURE TO CAPTURE THE LOC SOONER. THAT WAS BECAUSE I BECAME PREOCCUPIED WITH IDENTING 'ROBBI' (OUR 5000 FT RESTR). THE ILS RWY 21L HAS NO DME AND ROBBI WAS NOT DISPLAYED ON OUR EFIS NAV DISPLAY (A 'VIA' HAD NOT BEEN SELECTED ON THE FMGC APCH MENU). 'ROBBI' IS IDENTED BY THE CRL VOR/DME WHICH WAS NOT MANUALLY TUNED, AND BOTH VOR RECEIVERS WERE AUTO TUNED TO DXO VOR/DME. THE A320 FMGC IS PROGRAMMED TO ALLOW THE AUTOFLT SYS TO CAPTURE THE GS SIGNAL PRIOR TO THE LOC SIGNAL WHICH CAN CAUSE A DSCNT TO BE INITIATED BEFORE THE ACFT IS ESTABLISHED ON THE FAC. ANOTHER MISTAKE MADE WAS MY FAILURE TO DISCONNECT THE AUTOPLT IMMEDIATELY FOLLOWING THE TCASII RA. THIS RESULTED IN A SLOWER DIVERGENCE FROM THE RA TFC AND A SLOWER CORRECTION BACK ONTO THE GS, RESULTING IN A HIGH RATE OF DSCNT ONCE THE AUTOPLT WAS DISCONNECTED.

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  34. Accession Number: 393942
    Synopsis: CAPT OF A B757 DISCONNECTED THE AUTOPLT AND INCREASED THE RATE OF DSCNT IN RESPONSE TO A TCASII RA CAUSING A POTENTIAL COLLISION WITH THE OTHER ACFT BY DECREASING SEPARATION INSTEAD OF INCREASING IT. THE OTHER ACFT'S MODE C XPONDER WAS NOT RPTING THE SAME ALT AS THE PLT HAD GIVEN TO ATC.
    Narrative: 20 MI E OF TORCH ON EL NIDO ARR 12000 FT. RECEIVED VFR TA 1 O'CLOCK POS AT 11500 FT. SHORTLY THEREAFTER RECEIVED A TA WITH TARGET AT 200 FT ABOVE US, 1 O'CLOCK POS AND CLOSING. ZOA THEN CLRED US TO DSND TO 11000 FT. AS THE DSCNT WAS STARTED THE TA CHANGED TO AN RA WITH A DSND COMMAND. AUTOPLT WAS DISENGAGED AND DSND COMMAND FOLLOWED AT 1300 FPM RATE. PASSING 11700 FT WE FINALLY SPOTTED THE TFC AT 11500 FT AND CLOSING RAPIDLY AT WHICH TIME I INCREASED DSCNT RATE BEYOND COMMANDED RATE TO AVOID THE TFC. TFC PASSED BEHIND US WITH BTWN 1/4 TO 1/2 MI HORIZ SEPARATION. ZOA WAS ADVISED OF THE RA. THEY THEN ADVISED THE TFC TO CHK ALT, MODE C SHOWED 12200 FT. THIS WHOLE CHAIN OF EVENTS TOOK LESS THAN 45 SECONDS. WE WERE IN VISUAL CONDITIONS. IF WE WERE IMC OR DID NOT VISUALLY SPOT THE TFC, I THINK THAT THIS EVENT WOULD HAVE ENDED MUCH LESS FAVORABLY. I SUSPECT THIS EVENT WAS CAUSED BY THE ERRONEOUS MODE C OF THE VFR TFC THAT TOLD OUR TCASII IT WAS 200 FT ABOVE US WHEN IT WAS REALLY 500 FT BELOW US. THIS LED TO A DSND COMMAND WHEN WE NEEDED TO MAINTAIN ALT. THIS EVENT FURTHER REINFORCES THE SEE AND AVOID CONCEPT IN VISUAL CONDITIONS AND THE NEED TO AGGRESSIVELY MAINTAIN SITUATIONAL AWARENESS.

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  36. 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.

  37.  
  38. 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.

  39.  
  40. 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.

  41.  
  42. 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.
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