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Incidents related to Issue 13 incidents related to this issue.

Issue: pilots may under-rely on automation (Issue #146)
Description: Pilots may not use automation when they should, possibly leading to unsafe conditions or reduced operating efficiency.

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  2. Accession Number: 68578
    Synopsis: ACR WDB ALT DEVIATION OVERSHOT DURING CLIMB. POSSIBLE LESS THAN STANDARD SEPARATION WITH CROSSING TRAFFIC.
    Narrative: COMPLACENCY AND INATTN STRIKE AGAIN. DEPARTED SEA ON LOVELY CLEAR MORNING. CLEARED TO MAINTAIN 15000 FOR CROSSING TFC. COPLT FLYING MANUALLY WITHOUT FLT DIRECTOR. NICE VIEW OF MT RANIER OFF THE RIGHT. SOME DISCUSSION OF BEST WAY TO CLIMB THE MOUNTAIN WHEN I HEARD THE ALT WARNING HORN GO OFF. I NOTICED WE HAD GONE THROUGH 15000 AND PUSHED FORWARD ON THE YOKE TO ALERT THE COPLT. WE PEAKED AT 15800 AND RETURNED RAPIDLY TO 15000. CENTER INQUIRED WHAT OUR ALT WAS. WE ADMITTED WE HAD OVERSHOT AND WERE RETURNING TO 15000. I BELIEVE HE THEN GAVE US CROSSING TFC AT 10 O'CLOCK AND 5 MI. THIS MAY NOT HAVE CAUSED A CONFLICT ALERT BUT IT SURE GOT OUR ATTN. I DID NOT HEAR THE ALT WARNING THAT SHOULD HAVE OCCURRED PRIOR TO 15000. IT MAY HAVE BEEN COVERED BY RADIO TRANSMISSION OR CONVERSATION BETWEEN CREW AND 2 EXTRA CREW IN COCKPIT. HAD THE COPLT USED THE FLT DIRECTOR FOR CLIMB IT WOULD HAVE GIVEN HIM LEVEL OFF SIGNALS. HAD THE AUTOPLT BEEN USED AS IS COMMON AT THIS POINT IN THE CLIMB, IT WOULD HAVE LEVELED US AUTOMATICALLY AS THE ALT WAS PROPERLY ARMED. BUT EVEN BETTER IF THE CAPT HAD BEEN PAYING ATTN, RATHER THAN ASSUMING THAT THE COPLT WOULD MAKE A PROPER LEVEL OFF, THIS SITUATION COULD HAVE BEEN AVOIDED.

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  4. Accession Number: 168761
    Synopsis: ACR X NON ADHERENCE TO ATC CLRNC.
    Narrative: ACR X AFTER TKOF ON RWY 4L AT EWR ON THE EWR 3 DEP. WE WERE TO LEVEL OFF AT 2500', AS PER THE SID. THE COPLT WAS FLYING AND I WAS WORKING THE RADIOS. AT 2000' I CALLED 500' TO LEVEL OFF, AND WE GOT A TCAS TFC ADVISORY WITH AN AMBER SOLID CIRCLE AND AURAL WARNING, "TFC, TFC." I CALLED OUT THE BEARING AND DISTANCE AS PER OUR COMPANY PROCS, AND THEN WE BOTH LOOKED OUTSIDE FOR THE TFC. WE SAW THE TFC AND IT WAS NO FACTOR, BEING 2 MI ABEAM OF US AND HDG IN THE OPP DIRECTION. HOWEVER, WE WERE NOW AT 3000' AND THE CTLR REMINDED US THAT WE WERE TO MAINTAIN 2500'. WHILE WE WERE DSNDING BACK TO 2500' THE CTLR THEN ISSUED A CLRNC TO CLB TO 8000'. I THINK HE NOTICED OUR MISTAKE AND MADE US LEGAL BY GIVING US A HIGHER ALT TO CLB TO. I BELIEVE SOME FACTORS WERE: 1) THE F/O AND I WERE DISTRACTED AT A CRITICAL POINT IN THE DEP BY THE TCAS WARNING WHICH WAS NEW TO BOTH OF US. 2) THE F/O SHOULD HAVE ENGAGED (AND I SHOULD HAVE ENCOURAGED HIM TO ENGAGE) THE AUTOMATION OF THE ACFT AUTOPLT/FLT DIRECTOR ON THAT PARTICULAR DEP BECAUSE OF THE HEAVY WORKLOAD THAT IT IMPOSES ON THIS TYPE OF ACFT WITH ONLY 2 PLTS. IN RETROSPECT, I THINK THAT WE WERE BOTH SURPRISED BY THE TCAS WARNING WHICH DISTRACTED BOTH OF US. NEXT TIME I WILL NOT BE SO READY TO DEVOTE SO MUCH OF MY TIME AND ATTN TO FINDING THE TFC, UNLESS IT IS A RESOLUTION ADVISORY, AND PAY MORE ATTN TO WHAT THE ACFT IS DOING.

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  6. Accession Number: 371730
    Synopsis: FLC OF B767 WITH NEW CAPT ON IOE HAS ALTDEV ON CLBOUT. ALT ALERTER GETS THEIR ATTN.
    Narrative: FLT MCO-CLT. CONDUCTING IOE FOR NEW CAPT, SECOND LEG ON ACFT. INSTRUCTED BY DEP CTL TO CLB TO 14000 FT. CAPT WAS FLYING, I WAS CONCERNED WITH WX RADAR AT THE TIME AND GETTING VECTORS FROM ATC. NEXT OCCURRENCE WAS ALT ALERTER GOING OFF. OUR ALT WAS 14300 FT. WE LEVELED OFF AT 14000 FT. NO EVASIVE ACTION OR ATC RESPONSE. CONTRIBUTING FACTORS: NEW CAPT. INSTRUCTION. ATTN DIVERTED TO WX ACTIVITY. I DID NOT KNOW CAPT (STUDENT) HAD DISENGAGED THE AUTOPLT! HE WAS TRYING TO HAND-FLY A SIT IN WHICH AUTOPLT WOULD HAVE ENHANCED SAFETY.

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  8. Accession Number: 372082
    Synopsis: A FLC FLYING AN L1011-500 FINDS THE DEP PROC SO COMPLEX OUT OF AMS THAT THEY EXCEED THE CLRED ALT BY 300 FT.
    Narrative: THIS SID IS NO PROB FOR A GLASS COCKPIT, BUT REQUIRES A LOT OF SUPPORT ON THE L1011. TKOF RWY 24 AND TRACK 240 DEGS TO 3.8 NM ON VOR #1, TURN L TO 226 DEGS, TRACK TO INTERCEPT A RADIAL OUTBOUND ON VOR #2 TO 19 NM, TO BEGIN TURN JUST PRIOR TO ADF #1, PASSING ABEAM OF IT ABOVE 3000 FT, TO INTERCEPT AND TRACK OUT THE 331 DEG RADIAL OF ADF #1 UNTIL INTERCEPTING AND TRACKING N OUTBOUND OF VOR #3. CONTACTING DEP CTL AT 2000 FT, TRANSITION ALT OF 3000 FT, CLB LIMIT OF FL60. CAPT HAD JUST A FEW DEPS PREVIOUSLY OUT OF AMS, FE HAD NEVER BEEN OUT OF THERE BEFORE. THOROUGHLY BRIEFED THE DEP EARLIER, AND THEN IN DETAIL AGAIN AS WE WERE TAKING THE RWY, INCLUDING REQUESTING THE FE TO BACK US UP ON THE 2000 FT AND 3000 FT REQUIREMENTS. THE SID ALSO PRESCRIBES A MAX OF 220 KTS IN THE TURNS, WHICH ALTERS OUR AFTER TKOF CLEAN-UP TO LEAVE THE FINAL FLAP/SLAT SETTING (CLEAN SPD WAS WELL ABOVE 220 KTS), WHICH MEANS THAT YOU CLB RAPIDLY INSTEAD OF ACCELERATING. TRACKING OUTBOUND ON THE ADF AND SETTING UP FOR THE INTERCEPT OF VOR #3 TO GO NBOUND ON 1000 FT CALL ('5000 FT' FOR '6000 FT') WAS MADE, SO I MADE THE CALLOUT AT ABOUT 5200 FT AND REALIZED THAT THE CAPT HAD NOT YET CALLED DEP CTL (WHICH WAS REQUIRED AT 2000 FT), AND TOLD HIM. BY THE TIME HE MADE CONTACT, I WAS LEVELING AT 6000 FT AND DEP CTL WAS REQUESTING WE CHK OUR XPONDER MODE C (ALT). WE WERE STILL AT AN ALTIMETER SETTING OF ABOUT 29.58 INCHES INSTEAD OF THE REQUIRED 29.92 INCHES (1013.2 MILLIBARS) AT 3000 FT, AND WERE ABOUT 300 FT HIGH. I IMMEDIATELY CORRECTED BACK TO FL60, AND ACCELERATED TO 250 KTS. IN SPITE OF THOROUGH BRIEFINGS -- TWICE -- THE CAPT AND I BOTH MISSED THE FREQ CHANGE AT 2000 FT AND THE ALTIMETER SETTING CHANGE AT 3000 FT, AND THE FE DID NOT CATCH US ON IT. THE CAPT WAS BUSY SETTING CLB PWR, RAISING FLAPS, ADJUSTING HDG TO MAINTAIN A TRACK, RETUNING HIS VOR THAT WAS SET FOR THE 3.8 NM TURN, THEN RETUNING MINE FOR THE NBOUND INTERCEPT OF #3 AFTER PASSING THE ADF, PLUS WAS UNFAMILIAR WITH THE DEP. I WAS ATTEMPTING TO FLY A VERY PRECISE GND TRACK BECAUSE IT'S A VERY NOISE SENSITIVE DEP, AND THE L1011 FOR OUR COMPANY HAS HAD A NUMBER OF VIOLATIONS FOR THAT. HAVE NOT HAD A PROB WITH THIS SID IN THE PAST, EITHER AS PF OR PNF, BUT WITH OTHER 2 CREW MEMBERS INEXPERIENCED WITH ANY ARPT IN THE FUTURE, I WILL USE MORE AUTOMATION (IE, AUTOPLT) EARLIER. TO MY KNOWLEDGE, THERE WAS NO TFC CONFLICT. TERRIBLE SID FOR NON GLASS ACFT! CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR FEELS THE DEP IS SO COMPLEX THAT TOO MUCH IS HAPPENING TO LET IT BE FLOWN ACCURATELY. HE STATED HE WAS VERY PRECISE IN HIS DEP BRIEFING, BUT THE OTHER FLC MEMBERS WERE TOO BUSY DOING OTHER TASKS. THE CAPT WAS BUSY RETRACTING FLAPS AND MONITORING CLB, BUT HE FORGOT TO CALL THE TRANSITION ALT AS THEY PASSED 3000 FT. ALTIMETERS WERE NOT RESET. THE SO DID NOT BACK UP ANY OF THE OTHER FLC MEMBERS ALTHOUGH HE WAS SPECIFICALLY BRIEFED TO DO THAT. RPTR FEELS A GLASS COCKPIT ACFT IS THE ONLY TYPE OF ACFT THAT CAN ACCURATELY FLY THAT COMPLEX OF A DEP. THE SO WAS OF NO HELP, THE CAPT WAS BEHIND IN ALL OF HIS DUTIES. THE RPTR ALSO FEELS THAT ON HIS NEXT DEP FROM AMS, HE IS GOING TO USE THE AUTOPLT THROUGHOUT THE DEP.

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  10. Accession Number: 377977
    Synopsis: CAPT OF A B777 MOMENTARILY LOST CTL OF ACFT DURING INITIAL CLB AFTER TKOF WHEN REACHING TO RESET, AND TURN ON, THE WX RADAR WHILE TURNING AND LOWERING THE ACFT NOSE TO ACCELERATE. WHEN HE NOTICED THE ACFT DSNDING, INSTEAD OF CLBING, HE IMMEDIATELY CORRECTED BY PITCHING UP AND 'FIREWALLING' THE THROTTLES. AT THE SAME INSTANCE THE GPWS WARNING TO 'CLB, CLB' TOGETHER WITH 'WHOOP-WHOOP' SOUNDED.
    Narrative: CHAIN OF EVENTS: WE HAD A MECHANICAL PROB WHICH DELAYED OUR DEP 45 MINS. OUR PREFLT SEEMED RUSHED AS OTHER PERSONNEL KEPT ASKING FOR INFO (LIKE THE FLT ATTENDANTS AND GATE AGENTS). TAXIING OUT OUR CLRNC WAS CHANGED AND INSERTED INTO FMS. THESE LED TO THE WX RADAR BEING LEFT OFF AS WE DEPARTED INTO RAINSHOWERS. THE CAPT WAS HAND- FLYING AND AFTER THE GEAR WAS CALLED FOR (UP), HE BEGAN A TURN TO THE TWR ASSIGNED HEADING. ABOUT THIS TIME WE WERE ABOVE OUR ACCELERATION HT, AND HE STARTED TO LOWER THE NOSE TO ACCELERATE. SIMULTANEOUSLY, WE ENTERED THE CLOUDS AND THE CAPT THEN WENT TO TURN ON THE WX RADAR. NORMALLY THIS IS AS SIMPLE AS HITTING A SWITCH ON THE EFIS CTL PANEL, HOWEVER, THE WX RADAR CTL PANEL WAS STILL SET IN TEST AND +15 DEG PITCH. SO, THE CAPT REACHED DOWN TO CHANGE THE PANEL ON THE AISLE STAND. UNFORTUNATELY, I ALSO LOOKED AT THE PANEL, BECAUSE WHEN I LOOKED UP, I SAW A DSCNT OF THE VERT SPD. I IMMEDIATELY CALLED OUT 'WE'RE SINKING, WE'RE SINKING, PULL UP.' AT THIS TIME THE CAPT PULLED THE NOSE UP SLOWLY THEN THE GPWS WARNING 'TERRAIN, TERRAIN' AND 'WHOOP-WHOOP PULL UP' SOUNDED. THE CAPT AGGRESSIVELY PULLED THE NOSE UP TO 15-20 DEGS NOSE UP AND FIREWALLED THE THROTTLES. REST OF FLT WAS NORMAL, ALTHOUGH THE 3 OF US WERE PRETTY SHAKEN. LESSONS LEARNED -- PREFLT DISTRACTIONS HAVE TO BE DEALT WITH. PLANNING AHEAD WOULD HAVE PREVENTED THE RADAR FUMBLING, OR TO USE THE AUTOPLT. AND FINALLY, THE FO, OR IN THIS CASE, THE RELIEF PLT IS A VALUABLE ASSET IN MONITORING THE AIRPLANE.

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  12. Accession Number: 378065
    Synopsis: THE ACR FLC OF A B777 STARTS A DSCNT WHILE STILL IN THE FLAP RETRACTION PHASE OF THE CLBOUT. THE GPWS AND THE INTL RELIEF PLT ALERT THEM TO THE FACT THAT THEY WERE APCHING THE GND AND THE FLC RECOVERS. THE FLC REMARK ON THE UNUSUAL PITCH TRIM CHARACTERISTICS ON THE B777.
    Narrative: DURING CLB OUT OF IAD, FLAPS WERE CALLED FOR UP BY PF (CAPT). AT THIS TIME I REALIZED WE WERE GOING INTO THE CLOUD BASE AND DECIDED TO ACTIVATE THE RADAR. THE FO WAS HEAD DOWN IN THE COCKPIT CHANGING FREQS, SO I TURNED ON WX RADAR MYSELF, ALSO GOING HEADS DOWN. WHILE ADJUSTING RADAR, I NOTICED FLAPS STILL IN 1 DEG POS AND WAITED UNTIL FO WAS OFF RADIO AND AGAIN ASKED FOR FLAPS UP. AT THIS TIME THE RELIEF FO CALLED ACFT NOSE DOWN. I BEGAN A GENTLE RECOVERY AND WAS SOON JOLTED BY A WHOOP WHOOP PULL UP TERRAIN MESSAGE. 15 DEG NOSE UP ATTITUDE AND FULL THROTTLE WERE INITIATED AND RECOVERY MADE AT ABOUT 1000 FT RADIO ALT. FACTORS IN CONSIDERATION WERE A MAINT DELAY IN WHICH ACFT WAS TAKEN OUT OF ETOPS STATUS AND A NEW FLT PLAN WAS ADOPTED, RESULTING IN LAST MIN RUSH WHERE USE OF WX RADAR WAS OVERLOOKED ON PRE-TKOF BRIEFING. A FURTHER RE-CLRNC WAS ISSUED BY ATC DURING TAXI WHICH PUSHED ANY THOUGHTS OF RADAR USE OUT OF MY MIND. TKOF WAS MADE TO THE NW (RWY 30) WHERE THE RISING TERRAIN OF THE BLUE RIDGE MOUNTAINS CONTRIBUTED TO THE WARNING. LESSONS LEARNED -- USE OF AUTOPLT ON 2 PLT ACFT IS OFTEN OVERLOOKED WHEN WORKLOAD HIGH. ALSO, IN THIS CASE, NO USE OF RELIEF PLT MADE. I HAD LOWERED NOSE BELOW ATTITUDE BAR TO INCREASE ACCELERATION THROUGH FLAP SPDS -- NO MORE. ACFT WAS B777 WHICH HAS PITCH NEUTRAL TRIM. AS I LOOKED AWAY FROM THE FLT DISPLAY, I THOUGHT (AS IN OTHER ACFT) THAT I WAS TRIMMING NOSE UP. IN FACT I DID NOTHING AS THE YOKE WAS NEUTRAL AT THE TIME. LASTLY, THIS WAS A WAKE-UP CALL FOR COMPLACENCY. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR IS A FAIRLY NEW CAPT ON THE B777-200 AND HE SAID THAT HE WAS AWARE OF THE PITCH NEUTRAL TRIM SYS, AT LEAST FROM AN ACADEMIC STANDPOINT. HOWEVER, HE ADMITTED THAT HE HAD SIMPLY ACTIVATED THE TRIM SWITCH WITHOUT APPLYING PRESSURE TO THE CTL COLUMN AND THEREFORE, THE STABILIZER DID NOT MOVE. THE CAPT SAID THAT HE HAD LOWERED THE NOSE OF THE ACFT IN ORDER TO ACCELERATE FASTER THAN USUAL BECAUSE HE WANTED THE FO TO RETRACT THE FLAPS AS SOON AS POSSIBLE, BUT DID NOT REALIZE THAT THE NOSE WAS THAT FAR BELOW THE HORIZON. HE SAID THAT HE SIMPLY LOST SITUATIONAL AWARENESS AND THE THIRD PLT AND THE GPWS SURPRISED HIM WITH THEIR WARNINGS. HE ALSO SAID THAT HE SHOULD HAVE ENGAGED THE AUTOPLT BEFORE ATTEMPTING TO TURN ON AND ADJUST THE RADAR. THE AUTOPLT WOULD HAVE CONTINUED THE CLB PROFILE AT THE TIME OF ENGAGEMENT AND USE OF THE AUTOPLT IN THIS PHASE OF FLT IS STANDARD. THE CAPT SAID THAT HE WANTED TO ALERT OTHERS ABOUT THE UNUSUAL TRIM SYS IN AN ACFT THAT, OTHERWISE, APPEARS TO BE SIMILAR TO PREVIOUS ACFT FROM THE SAME COMPANY AND WHOSE SYS, AS FAR AS THE FLC IS CONCERNED, APPEAR TO FUNCTION THE SAME AS IN PREVIOUS MODELS. THE RPTR FEELS THAT THE TRIM SYS WILL SURPRISE OTHER PLTS IN THE FUTURE.

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  14. Accession Number: 380317
    Synopsis: B757 FLC TALE OF AN ALT OVERSHOOT THAT WAS PROMOTED BY A FAILURE OF THEIR AUTOTHROTTLE SYS AND OTHER DISTRS. NEITHER PLT LIKES THE NOISE ABATEMENT PROC AT SNA.
    Narrative: THE NOISE ABATEMENT TKOF FROM SNA IS DEMANDING WHEN EVERYTHING GOES RIGHT. WHEN SOMETHING MINOR GOES WRONG, THINGS GET BUSY REAL QUICK. AFTER TKOF WITH THE FMC AND AUTOTHROTTLES PROGRAMMED CORRECTLY, THE PWR DID NOT REDUCE WHEN VNAV WAS SELECTED AT 800 FT. THE CAPT FLEW THE PROFILE WHILE I ATTEMPTED TO GET THE PWR REDUCED. WE WERE HANDED OFF TO SOCAL DEP. THEY GAVE US A WESTERLY HDG AND A CLB TO 10000 FT. I WAS STILL WORKING WITH THE THRUST MGMNT COMPUTER AND THE MCP AS WE APCHED 10000 FT. WHEN I LOOKED UP, WE WERE AT 10300 FT AND CLBING. THE CAPT IMMEDIATELY DSNDED TO 10000 FT AS I CHKED ON ANOTHER FREQ. NO MENTION WAS MADE BY ATC AND WE WERE CLRED TO 16000 FT. OUR MAX ALTDEV WAS 500 FT. SNA IS BY FAR THE MOST DIFFICULT DEP IN OUR SYS. NOT BECAUSE THE PROC IS THAT DIFFICULT, BUT BECAUSE IT IS COMPLETELY DIFFERENT FROM ANYTHING ELSE IN OUR SYS. IT IS A MAJOR DEP FROM NORMAL SOPS THAT CAUSES DISTRS NOT ONLY IN THE DEP AREA BUT WELL BEYOND. THE NTSB AND FAA SHOULD RE-EVALUATE THE SAFETY OF THIS PROC DICTATED TO MANY AIRLINES BY ONE CITY IN THE COUNTRY. SUPPLEMENTAL INFO FROM ACN 380202: THE ACFT WAS VERY LIGHT CLBING AT 5000 FPM AND TO A CLRED ALT OF 10000 FT. PASSING ABOUT 9000 FT WE WERE SWITCHED TO ZLA. AT THE SAME TIME WE ENCOUNTERED UNEXPECTED MODERATE CLR AIR TURB. FO WAS IN THE PROCESS OF SWITCHING FREQS AND DID NOT NOTICE CAPT'S FAILURE TO LEVEL AT 10000 FT. WHEN ZLA ANSWERED OUR CHK-IN THEY IMMEDIATELY CLRED US TO A HIGHER ALT. THE CREW ALLOWED THEMSELVES TO BECOME OVERLY OCCUPIED WITH THE ANTICIPATED PROB OF NOISE EXCEEDANCE AND FAILED TO ADEQUATELY FOCUS ON THE CONTINUING CLBOUT. THE HIGH RATE OF CLB, AUTOTHROTTLE PROB, FREQ CHANGE, MODERATE TURB, ALL WITHIN THE FIRST 2 MINS OF FLT, RESULTED IN A VERY HIGH WORKLOAD SIT. THE WORKLOAD COULD HAVE BEEN MODERATED IF THE AUTOPLT HAD BEEN ENGAGED, BUT IT WAS NOT. THE SNA NOISE SIT IS AN EXAMPLE OF HOW PRIORITIES CAN BE MISPLACED WHEN THERE IS ANY GLITCH IN THE PLANNED DEP, SUCH AS OUR AUTOTHROTTLE PROB.

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  16. Accession Number: 384160
    Synopsis: AN ACR FLC IN AN LGT GETS DISTRACTED SEARCHING FOR TFC AND THE FO DSNDS TOO LOW AT A XING POINT. THE ERROR WAS, IN PART, DUE TO USING IMPROPER TECHNIQUE AND MODE SELECTION.
    Narrative: ZLA CLRED US TO DSND VIA THE CIVET 2 ARR. MY COPLT WAS FLYING. I OBSERVED THAT MY COPLT WAS DSNDING WITH THE AUTOPLT ENGAGED IN VNAV. HE HAD SET 14000 FT IN THE AUTOPLT ALT WINDOW AND WAS SETTING EACH SUBSEQUENT XING RESTR AS WE CROSSED FIXES CIVET AND BREMR. EACH TIME THE AUTOPLT LEVELED OFF IN ALT HOLD, HE RE-SELECTED VNAV IN ANTICIPATION OF DSNDING TO THE NEXT ALT RESTR. THIS METHOD IS CONSIDERED TECHNIQUE, AND ALTHOUGH NOT MY TECHNIQUE, HE WAS DOING IT CORRECTLY. APCHING ARNES WE WERE CLRED FOR THE ILS RWY 25L APCH. MY COPLT THEN SET 3500 FT IN THE ALT WINDOW. BY SELECTING THE FINAL ALT RESTR PRIOR TO COMMENCING THE ILS APCH HE WOULD ONLY HAVE TO MONITOR VNAV IN THE DSCNT. THIS IS THE TECHNIQUE MOST COMMONLY USED. AT ARNES WE BEGAN TO DSND ON THE APCH. I REMINDED HIM NOT TO ENGAGE APCH MODE UNTIL PASSING HUNDA. SOCAL APCH HAD ISSUED TFC AT 1 TO 2 O'CLOCK POS THAT WOULD ENTER ON R BASE AND PRECEDE US TO RWY 25L. I BEGAN TO SCAN FOR THE TFC, BUT COULD NOT SEE IT AND ADVISED THEM SO. I RETURNED MY SCAN TO THE PANEL AND OBSERVED WE WERE BELOW 9000 FT AND HAD NOT YET REACHED SUZZI. I IMMEDIATELY CALLED THIS TO MY COPLT'S ATTN AND INSTRUCTED HIM TO RETURN TO 9000 FT. I THEN NOTICED THAT FLT LEVEL CHANGE WAS THE DSCNT MODE. (WE WERE NO LONGER IN VNAV.) I LOOKED AT THE AUTOPLT AND OBSERVED IT WAS NOT ON. I RE- ENGAGED VNAV MYSELF AND INSTRUCTED HIM TO USE HIS FLT DIRECTOR AND VERT DEV INDICATOR TO XCHK HIS DSCNT WITH REF TO EACH OF THE XING RESTRS. ONCE WE REGAINED THE APCH PROFILE WE REMAINED WELL ABOVE ALL SUBSEQUENT XING RESTRS. THIS DEV OCCURRED BECAUSE MY COPLT HAND FLEW THE ACFT WITH NO FMS GUIDANCE AND FAILED TO MAINTAIN ALT AWARENESS. WE DEBRIEFED THE APCH AT THE GATE WITH EMPHASIS ON DIFFERENCES BTWN VNAV AND FLT LEVEL CHANGE WITH REGARD TO THE XING RESTRS. IN THE FUTURE I WILL REQUIRE THAT A DISCUSSION OF DSCNT TECHNIQUE BE MADE A PART OF THE BRIEFING FOR THIS APCH. I WILL MAKE AUTOPLT ENGAGEMENT AND VNAV USE MANDATORY, CITING VISUAL TFC SCANNING AS A HIGH PRIORITY, AND AUTOFLT AS A TOOL TO REDUCE WORKLOAD.

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  18. Accession Number: 390899
    Synopsis: FO OF AN AIRBUS A320 OVERSHOT XING ALT DURING SID DEP RESULTING IN ATC PROVIDING THE NEXT 1000 FT HIGHER ALT THAT WAS ALSO OVERSHOT. THE PROB WAS DUE TO THE CAPT'S UNFAMILIARITY WITH THE FMS TO OBTAIN DESIRED RESULTS AND THE FO DISCONNECTING THE AUTOPLT TO FLY THE ACFT MANUALLY. BOTH CREW MEMBERS WERE UNFAMILIAR WITH THE SID.
    Narrative: CLBING OUT OF SJC ON RWY HDG, DANVILLE 1 DEP, CTLR CLRED US TO FL230, TURN R DIRECT TO SJC AT OUR DISCRETION TO MAKE XING AT SJC AND MAINTAIN 250 KTS. ACCORDING TO OUR CALCULATIONS WE COMMENCED TURN TO MAKE SURE WE WOULD BE AT 12000 FT OVER SJC, THINKING THAT THE RESTR TO MAINTAIN 12000 FT HAD BEEN DELETED WHEN WE WERE CLRED TO FL230. ACFT CLBING OUT IN MANAGED NAV AND EXPEDITE CLB, VERT ASCENT WAS QUITE HIGH. ONCE WE ASCERTAINED THAT WE WOULD MAKE THE 12000 FT MANAGED VERT WAS SELECTED, BUT ACFT OVERSHOT THE 12000 FT ALT. PF WAS THE FO. HE DISCONNECTED THE AUTOPLT IN ORDER TO RECOVER TO 12000 FT. I QUESTIONED THE CTLR ON WHETHER WE WERE TO CROSS SJC AT 12000 FT, OR AT OR ABOVE 12000 FT AND CLB TO FL230. HE CONFIRMED THAT WE WERE TO CROSS AT 12000 FT, BUT SINCE WE WERE ALREADY ABOVE 12000 FT TO CONTINUE CLB TO 13000 FT. THE FO HAD HIS HANDS FULL, TRYING TO HAND FLY THE ACFT MAINTAINING 13000 FT AND THE RESTR AIRSPD OF 250 KTS. WHEN ACFT WAS IN EXPEDITE CLB, AIRSPD AND ALT RESTRS IN THE MCDU WERE NEGATED. DUE TO MY RECENCY OF EXPERIENCE IN THIS ACFT, NOT BEING USED TO THIS PARTICULAR DEP, AND BEING REQUESTED TO ACCOMPLISH SEVERAL COMMANDS WITH THE CONFUSION OF AN ALT CLRNC WITH OR WITHOUT THE SAME XING RESTR AS ON THE DEP, WAS SOMEWHAT OVERWHELMING TO THIS SHORT PERIOD OF TIME. MAYBE IN THE FUTURE THE CTLR COULD CONFIRM THE XING ALT THEN ADVISE OF A NEW CLRNC ALT.

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  20. 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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  22. Accession Number: 411340
    Synopsis: FLC OF A B757 OVERSHOT ASSIGNED ALT DURING DEP CLB DUE TO DISTR OF WORKLOAD AND TASKS ASSOCIATED WITH ATC CLRNC AND FREQ CHANGES.
    Narrative: FO FLYING INST DEP FROM LGA VMC. LGA HAD SWITCHED DEP RWYS WHEN TAXIING OUT TO A MUCH MORE COMPLICATED DEP PAGE. LGA 8 DEP WITH 'CONEY CLB' FROM RWY 13. CREW WAS PREPARED TO DO THIS RATHER COMPLICATED PROC AT DEP END. UNEVENTFUL TKOF. INITIATED R TURN TO 175 DEGS AND SWITCHED TO DEP CTL 120.4 MHZ. SWITCHED, HIGHER ALT GIVEN, 10000 FT, THEN SWITCHED AGAIN TO SECOND DEP CTL FREQ 124.75. JUST STARTING AFTER TKOF CHKLIST, AND CHKING FOR TFC. DEP CTL AGAIN CHANGED CLRNC TO PROCEED TO COL VOR, INTERCEPT THE COL 204 DEG RADIAL TO WHITE, AS FILED. THE FO WAS HAND FLYING. JUST AFTER ACKNOWLEDGING THAT CLRNC, DEP SWITCHED US TO ZNY FREQ. AFTER TUNING THAT AND CHKING IN, BOTH PLTS WERE IMMEDIATELY MADE AWARE THE ACFT HAD GONE THROUGH THE ASSIGNED ALT OF 10000 FT, TRIGGERING AN ALT ALERT AND CAUTION. THE FO IMMEDIATELY RETURNED THE ACFT TO 10000 FT, HAVING GONE NO HIGHER THAN 10300 FT. NO TCASII ALERT, ACFT CONFLICT OR CTR CONFLICT VERBALIZED OR NOTED. I BELIEVE THIS IS A CLASSIC EXAMPLE OF TASK SATURATION AND NOT KEEPING UP WITH THE PRIMARY TASK OF FLYING THE ACFT DUE TO 'TOO MUCH' HAPPENING IN TOO SHORT A TIME. EVEN THOUGH BOTH PLTS WERE AWARE OF 10000 FT BEING THE LEVELOFF ALT (IT WAS IN THE ALT REMINDER WINDOW AND POINTED TO BY BOTH PLTS), IT IS DIFFICULT TO STAY AHEAD OF THE GAME WHEN OVERLOADED WITH CLRNCS AND FREQ CHANGES IN BUSY AIR CORRIDORS. RECOMMEND HOOKING UP THE AUTOPLT TO EASE THE WORKLOAD IN THESE SITS IN THE FUTURE!

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  24. Accession Number: 411580
    Synopsis: CAPT OF A SAAB 340A (SF34-L) OVERSHOT ASSIGNED ALT AFTER TKOF DUE TO DISTR OF HAND FLYING THE ACFT AND LACK OF SLEEP. DEP CTLR INTERVENED AND ALERTED HIM AT 300 FT ABOVE ASSIGNED. THE FO WAS BUSY WITH AFTER TKOF CHKLIST.
    Narrative: DURING THE CLB AFTER TKOF I CLBED BEYOND OUR INITIAL ALT ASSIGNMENT BY APPROX 300 FT. OUR ASSIGNED ALT WAS 2500 FT MSL. I WAS HAND FLYING WITHOUT THE FLT DIRECTOR OR AUTOPLT. WHEN THE ROCKFORD DEP CTLR VERIFIED OUR INDICATED ALT AND POS AFTER THE INITIAL CALL FROM THE FO THE ALT ERROR WAS NOTICED. I IMMEDIATELY STARTED A DSCNT BACK TO THE ASSIGNED ALT. DURING THE DSCNT WE WERE THEN CLRED TO 7000 FT MSL. I THEN BEGAN TO CLB AGAIN TO THE NEW ALT ASSIGNMENT. THERE WERE NO OTHER ACFT INVOLVED. CONTRIBUTING FACTORS AND HUMAN PERFORMANCE CONSIDERATIONS: I WAS PRIMARILY FOCUSED ON THE AIRSPD, ATTITUDE AND CLB RATE. I WAS NOT AS VIGILANT OF THE ACFT'S ALT AS AT MOST OF THE ARPTS THE INITIAL CLB ALT IS ABOVE 4000 FT MSL. I WAS TOO CONDITIONED TO THIS. THE FO WAS BUSY WITH THE AFTER TKOF CHKLIST AND DID NOT NOTICE THE ALT EXCURSION. IT DOESN'T TAKE US MUCH TIME TO GET TO 2500 FT. THE FLT WAS THE SECOND HALF OF A CONTINUOUS DUTY OVERNIGHT. WE ONLY HAD 4 HRS OF REST SINCE ARRIVING IN ROCKFORD AFTER XA00. THE FO AND FLT ATTENDANT BOTH SLEPT ON THE VAN RIDE FROM THE HOTEL TO THE ARPT. I WAS FORMULATING OPTIONS FOR AVOIDING THE LINE OF WX WE WOULD HAVE TO CROSS TO GET TO OUR DEST. I HAD AVERAGED ONLY 5 HRS OF SLEEP THIS MONTH DURING THE TRIPS. I WAS UNABLE TO GET CAUGHT UP ON REST DURING THE DAYTIME BTWN TRIPS. CONCLUSION: I NEED TO USE THE SYS THAT ARE AVAILABLE TO ME LIKE THE FLT DIRECTOR AND AUTOPLT. ESPECIALLY WHEN I AM SLEEP DEPRIVED AND FATIGUED. I TYPICALLY DID NOT USE THEM UNTIL CRUISE FLT. THIS IS DUE TO THE FACT THAT IT WOULD GET PRETTY BORING WATCHING THE AIRPLANE DO THE FLYING. I CAN DO WITHOUT THE ADRENALINE SHOT OF AN ALT EXCURSION HOWEVER. WHENEVER I AM AT AN ARPT WITH A LOWER THAN NORMAL INITIAL CLB RESTR I MUST BRIEF THIS WITH THE FO SO THAT WE CAN BOTH BE VIGILANT OF IT. PERHAPS THE CHKLIST CAN BE DELAYED UNTIL A BIT LATER WITHOUT COMPROMISING SAFETY.

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  26. Accession Number: 412066
    Synopsis: A B767-300 AT CRUISE, FL360, RECEIVES A GPWS FROM KNOWN TFC BELOW AT FL350. SINCE THE TCASII HAD BEEN TURNED OFF DUE TO 'NUISANCE TA WARNINGS,' THE FLC CLBS OUT OF FL360. IN THE PROCESS OF ATTEMPTING TO USE THE GPWS GEAR OVERRIDE SWITCH, THE PIC DROPS THE LNDG GEAR. CREW WANTS THE NORTH ATLANTIC REDUCED VERT SEPARATION MINIMUMS PROCS TO BE MODIFIED TO PRECLUDE A REPEAT OF THIS EVENT.
    Narrative: OVER THE ATLANTIC ENRTE MXP (MILAN) TO IAD (DULLES) B767- 300 AT FL360. ANOTHER ACFT FLYING BELOW AT FL350 REMAINED DIRECTLY BENEATH OUR ACFT FOR AN EXTENDED PERIOD OF TIME (30+ MINS). THOUGH WE COULD NOT SEE HIM VISUALLY, WE COULD SEE THE TCASII TARGET. WE RECEIVED REPEATED AND FREQUENT TA AURAL WARNINGS 'TFC, TFC.' THEN THE GPWS ALARM BEGAN SOUNDING REPEATEDLY 'TOO LOW TERRAIN, TOO LOW TERRAIN...ETC.' AS A RESULT OF OUR GPWS TRAINING AND FEAR THE ACFT BELOW MIGHT BE CLBING INTO US, WE IMMEDIATELY PULLED THE NOSE UP INTO A CLB. WE KNEW FROM THE PREVIOUS HRS OF TCASII OBSERVATION THAT THERE WAS NO TFC ABOVE AT FL370. WHILE ATTEMPTING TO INHIBIT THIS LOUD CONTINUOUS DISTRACTING AURAL WARNING, I INADVERTENTLY ACTIVATED THE ALTERNATE LNDG GEAR EXTENSION SWITCH WHILE TRYING TO ACTIVATE THE GPWS GEAR OVERRIDE. THERE WAS THEN A VERY LOUD ROARING NOISE IN THE COCKPIT FURTHER AGGRAVATING OUR ANXIETY. I THOUGHT MOMENTARILY WE MIGHT HAVE ACTUALLY MADE CONTACT WITH THE OTHER ACFT. THE GEAR EXTENDING ALSO CAUSED A NOSE DOWN PITCH WHICH FURTHER STIMULATED US TO APPLY YOKE BACK PRESSURE. PRIOR TO COMPLETE GEAR EXTENSION, I REALIZED MY ERROR AND I RAISED THE GEAR WITH THE GEAR LEVER. WE HAD CLBED TO APPROX FL368 AND SINCE WE COULD NOW SEE THE ACFT BELOW WE RETURNED IMMEDIATELY TO FL360 AND PROCEEDED TO DEST WITHOUT FURTHER INCIDENT. THERE WERE NO INJURIES OR DAMAGE CAUSED BY THIS INCIDENT. I BELIEVE PROCS SHOULD BE DEVELOPED TO PREVENT THIS TYPE OF GPWS ALARM ACTIVATION WITH THE NEW 1000 FT VERT SEPARATION. TO MY KNOWLEDGE THIS HAS NEVER OCCURRED BEFORE AND IS A MOST DISCONCERTING EVENT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE CAPT SAID THAT HE HAD FILED A COMPANY RPT AND HAD SUGGESTED THAT THEY INCLUDE THE EVENT IN THEIR NEXT SAFETY PUB FOR INFO DISSEMINATION. IN RETROSPECT, HE SAID THAT HE WOULD CONSIDER AN OFFSET MANEUVER IN THE FUTURE. THE REASON FOR HIS NOT USING THAT PROC DURING THIS INCIDENT WAS THAT HE HAD BELIEVED THAT THE OFFSET MANEUVER WAS TO BE USED ONLY FOR WAKE TURB AVOIDANCE FROM A PRECEDING ACFT NEAR HIS FLT LEVEL. HIS COMPANY DOES HAVE A POLICY OF NOT TURNING OFF THE TCASII INFLT. HE HAD NOT ESTABLISHED 2 WAY COMS ON 131.8 WITH THE OTHER ACFT BUT WILL IN THE FUTURE. BOTH ACFT WERE AT CRUISE MACH .80. AT THE TIME OF THE GPWS ALERT HE REALLY FELT THAT THE OTHER ACFT MIGHT BE INITIATING A CLB. WITH THE TCASII TURNED OFF HE FELT THAT HE HAD REDUCED HIS OPTIONS QUITE A BIT SO THEREFORE STARTED A CLB. SUPPLEMENTAL INFO FROM ACN 412067: AN ACFT WAS DIRECTLY BELOW US AT FL350, SAME SPD. WE TURNED TCASII OFF DUE TO CONTINUOUS NUISANCE WARNINGS 'TFC, TFC.' WE THEN HAD LOUD AND CONTINUOUS GPWS WARNINGS, 'TOO LOW TERRAIN, TOO LOW....' THE CAPT (PF) AND I IMMEDIATELY GRABBED THE CTLS AND CHKED THE RADAR ALTIMETER THINKING THE ACFT BELOW US WAS CLBING INTO US. WE STARTED A SHALLOW CLB. I THEN WENT TO THE OFFSET MODE OF THE FMC RTE PAGE. THE CAPT UNINTENTIONALLY MOVED THE ALTERNATE GEAR EXTENSION SWITCH, A NEGATIVE XFER FROM B727 SWITCH. POSTFLT INSPECTION BY MAINT REVEALED NO DAMAGE TO THE ACFT. THERE WERE NO RPTED INJURIES FROM THE CABIN. 1000 FT SPACING ON NAT'S NEEDS TO BE MODIFIED WITH PROCS LIKE TIMING OR OFFSETS. THE CURRENT PROC IS DANGEROUS. WE SHOULD NOT BE TURNING OFF TCASII OR GETTING GPWS WARNINGS FROM OTHER ACFT. SUPPLEMENTAL INFO FROM ACN 412226: I WAS CURRENTLY ON MY SCHEDULED BREAK (3 PLT CREW), SITTING IN PAX SEAT RESERVED FOR BREAK PLT. THE ACFT BEGAN VIBRATING/RUMBLING NOTICEABLY AND HAD THE SENSATION OF A PITCH-UP. I RETURNED TO THE COCKPIT, OBSERVED WE WERE AT FL360 AND ON FMS COURSE. I DETERMINED FROM THE CAPT THAT NO ASSISTANCE WAS NEEDED AND RETURNED TO MY BREAK.
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