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Incidents related to Issue 4 incidents related to this issue.

Issue: automation use may slow pilot responses (Issue #161)
Description: When using automation, pilot response to unanticipated events and clearances may be slower than it would be under manual control, possibly increasing the likelihood of unsafe conditions.

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  2. Accession Number: 125527
    Synopsis: ACR WDB ALT DEVIATION UNDERSHOT ALT CROSSING RESTRICTION.
    Narrative: AT FL240 WE WERE CLEARED TO CROSS 20 NW SFO AT 250 KTS AND 11,000'. WE CROSSED THE 20 MI FIX AT 250 KTS BUT AT ABOUT 12,500'. WE WERE LEVEL AT 11,000 AT 16 MI NW SFO. NEW CAPT, LESS THAN 100 HRS IN TYPE. WE WERE SET UP ORIGINALLY FOR ANOTHER ARRIVAL FROM THE NW INSTEAD OF THE SE. THIS WAS WITH FAIRLY SHORT NOTICE. WITH THIS CHANGE IN ROUTING AND SUBSEQUENT DSNT CLRNC, THE CAPT BEING SOMEWHAT PREOCCUPIED WITH PROGRAMMING THE FMS, "GOT BEHIND". I WAS MONITORING THE SFO DME AND GIVING HIM THIS INFORMATION THAT WE WERE CLOSE IN AND NEEDED TO "GET DOWN". HE GOT THE FMS PROGRAMMED AND EXECUTED THE CLRNC, JUST A LITTLE LATE.

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  4. Accession Number: 130037
    Synopsis: ALT DEVIATION. DESCENT CROSSING RESTRICTION NOT MET.
    Narrative: WE WERE FLYING FROM LAS TO SNA IN AN MLG EQUIPPED WITH A SINGLE FMS CDU ON THE LEFT SIDE OF THE FORWARD ELECTRONIC PANEL (FORWARD OF THE THRUST LEVERS), AND ELECTRO-MECHANICAL FLT INSTRUMENT DISPLAYS. WE HAD BEEN CLEARED TO FLY THE KAYOH ONE ARR, AND HAD PROGRAMMED THE FMC FOR A VNAV DSNT TO CROSS DAWNA (HDF 353/29) AT 13,000, AND THEN CROSS KAYOH (SLI 075/23) AT 210 KTS AND 8000. BEFORE REACHING DAWNA WE WERE CLEARED DIRECT TO HDF. ZLA BROADCAST A SIGMET THAT FORECAST OCCASIONAL SEVERE TURBULENCE BELOW 10,000 IN THE AREA THAT WE WOULD BE MAKING OUR FINAL DSNT, FOLLOWED IMMEDIATELY BY A CLRNC FOR US TO CROSS 20 NE OF HDF AT 14,000. WE BOTH REMARKED THAT HDF WAS NOT SHOWING A DME SIGNAL, SO RAW DATA DISTANCE WAS NOT AVAILABLE. I ASKED THE F/O IF HE WOULD LIKE ME TO ENTER THE RESTRICTION INTO THE FMC (SINCE IT'S AWKWARD TO MAKE DATA ENTRIES FROM HIS SIDE OF THE COCKPIT) AND ENTERED HDF 010/20 AT 14,000. THE F/O INDICATED AGREEMENT WITH THE DATA ENTRY, AND I TOLD HIM I'D BE "OFF THE RADIO" WHILE I DISCUSSED THE ANTICIPATED TURBULENCE WITH THE CABIN CREW. DURING THAT DISCUSSION I OBSERVED THE F/O INITIATE A RAPID DSNT, CHECKED THE CDU, AND WAS SURPRISED TO SEE THAT THE WAYPOINT I HAD JUST ENTERED WAS NO LONGER DISPLAYED (SINCE WE HAD JUST PASSED IT). THE F/O TOLD ME THAT WE HAD CROSSED THE 20 MI FIX PASSING THROUGH 17,000, AND THAT CENTER'S ONLY COMMENT WAS, "YOU MISSED IT". I BELIEVE THAT THIS INCIDENT WAS NOT DUE TO ANY INATTENTION, BUT RATHER TO HUMAN FACTORS PROBLEMS INVOLVED WITH THE AUTOMATED COCKPIT AND ATC. I ALSO BELIEVE THAT IT WOULDN'T HAVE HAPPENED IN AN OLDER-TECHNOLOGY ACFT (WHICH I ALSO FLY). FOR EXAMPLE: 1) IN THE OLDER-TECHNOLOGY ACFT, I WOULDN'T'T HAVE ACCEPTED THIS CLRNC, ONCE I REALIZED THAT HDF HAD NO DME. I ASSUME THAT THE CTLR WOULDN'T HAVE ISSUED IT UNLESS HE KNEW THE ACFT WAS RNAV EQUIPPED. 2) I'M NOT USED TO RECEIVING CLRNCS TO A "DISTANCE" POINT ASSOCIATED WITH A NON-DME FAC. I ASSOCIATE THE PHRASEOLOGY, "CROSS TWENTY NE OF XYZ" WITH A DME FIX, WHERE I CAN QUICKLY LOOK AT A RAW-DATA DME DISPLAY AND MAKE AN IMMEDIATE JUDGEMENT THAT A DSNT MUST BE INITIATED. I LOOKED FOR RAW DATA. IT WASN'T AVAILABLE, SO I MENTALLY SHIFTED FROM THE OLD-TECHNOLOGY (RAW DATA) MODE TO THE AUTOMATED COCKPIT (DATA ENTRY AND COMPUTED SOLUTION) MODE. 3) MOST CLRNCS I'VE RECEIVED THAT REQUIRE RNAV INVOLVE NAMED FIXES WHICH ARE USUALLY IN THE FLT PLAN OR DATABASE. I CAN MAKE A RAPID (4 KEYSTROKES) DATA ENTRY FOR A RNAV POSITION/ALT IF IT WAS PREVIOUSLY PROGRAMMED INTO THE ROUTE, IE, DIRECT HDF. THE CLRNC IN THIS INCIDENT REQUIRED 15 KEYSTROKES, AND TOOK CONSIDERABLY MORE TIME. 4) WHEN I FLY AN AUTOMATED ACFT, I HAVE TO SPEND SOME AMOUNT OF TIME PROGRAMMING AND MONITORING THE COMPUTER. THE DECISION OF WHEN TO DO THIS AND WHEN IT ISN'T APPROPRIATE IS A SUBTLE ONE, AND LENDS ITSELF TO GENERALITIES SUCH AS, "DON'T PROGRAM IN THE TERMINAL AREA." IN THIS CASE, "DON'T PROGRAM IN SOUTHERN CALIFORNIA" WOULD HAVE BEEN APPROPRIATE. THE DATA WE NEEDED (PRESENT DISTANCE TO HDF) WAS AVAILABLE IN THE CDU, SO IF WE HAD TREATED IT AS IF WE DIDN'T HAVE RNAV AVAILABLE WE MIGHT HAVE BEEN ABLE TO MAKE THE MENTAL CALCULATION IN TIME TO MEET THE RESTRICTION. IN THE ENRTE ENVIRONMENT HOWEVER, EXPERIENCE LED ME TO THE SUBCONSCIOUS DECISION THAT THERE WAS TIME AVAILABLE TO REPROGRAM THE FMC. 5) THE CTLR ISSUED A CLRNC THAT WAS PROBABLY DELAYED DUE TO THE SIGMET BROADCAST. AS IT WAS, THE CLRNC WAS MADE SO CLOSE TO THE FIX THAT BY THE TIME IT WAS PROGRAMMED INTO THE FMC AND DSNT COMPUTATIONS MADE, IT WAS NOT POSSIBLE TO MEET THE RESTRICTION. 6) IT WASN'T UNTIL THE NEXT DAY AND A DISCUSSION EXPLORING BOTH OF OUR THOUGHT PROCESSES THAT WE FOUND ANYTHING WE (AS OPPOSED TO THE CTLR) COULD HAVE DONE DIFFERENTLY UNDER THE CIRCUMSTANCES TO PREVENT THIS INCIDENT. WHEN EITHER OF US IS THE PLT FLYING AND MAKES A DATA ENTRY, WE EACH MAKE A MENTAL VALIDITY CHECK USING SOME RULE OF THUMB, IE, "I'M 13 MI FROM THE FIX AND 6000' HIGH, SO I'VE GOT TO START DOWN NOW!" IN THIS CASE, ALTHOUGH I MADE THE DATA ENTRY I DIDN'T MAKE THE VALIDITY CHECK BECAUSE I WAS NOT FLYING, AND PREOCCUPIED WITH MY CONCERN FOR THE SAFETY OF THE PAX AND CABIN CREW IN THE CONTEXT OF THE EXPECTED SEVERE TURBULENCE. I HAD SUBCONSCIOUSLY PLACED A HIGHER PRIORITY ON COMMUNICATING WITH THE CABIN CREW THAN ON DOUBLE-CHECKING THE COMPUTER. IT HAS NOT ESCAPED ME THAT NOT DOUBLE-CHECKING THE COMPUTER OR THE PLT FLYING CAN LEAD TO A BUSTED ALT AND HENCE A MIDAIR COLLISION, WHICH SHOULD HAVE BEEN A HIGHER PRIORITY. THE F/O INDICATED THAT SINCE I HAD MADE THE DATA ENTRY HE ASSUMED THAT THE DATA WAS VALID (IT WAS, BUT TOO LATE) AND DIDN'T DOUBLE-CHECK IT.

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  6. Accession Number: 383607
    Synopsis: FLC OF MD83 MAKING A CAT II LNDG HAS LOSS OF ACFT CTL DUE TO RWY COVERED WITH SNOW AND ICE. BRAKING RPTED AS FAIR BUT ACTUALLY NIL.
    Narrative: I WAS FLYING AS FO IN AN MD80. THE FLT WAS FROM SEA TO ANC. WX IN ANC WAS 600 FT OVCST, 1/4 MI VISIBILITY WITH BLOWING SNOW AND MIST. THE WIND WAS 330 DEGS AT 14 KTS, AND WE WERE LNDG RWY 6R. RWY 6R WAS COVERED WITH SNOW AND ICE WITH BRAKING ACTION RPTED AS FAIR. BECAUSE OF THE LOW WX MINIMA, AND THE FACT THAT THE CAPT WAS RESTR TO A CAT II LNDG (DUE TO BEING A NEW CAPT), WE FLEW A CAT II AUTOLAND APCH. THE APCH WAS NORMAL AND THE AUTOLNDG WAS NORMAL. UPON ROLLOUT THE ACFT DEVIATED (1/4 DOT RMI) FROM THE CTRLINE (ALSO NORMAL), AND INITIATED A CORRECTION N. THE CORRECTION WAS CORRECT AND WITHIN NORMAL LIMITS, BUT THE ACFT BEGAN TO SLIDE TOWARD THE N SIDE OF THE RWY. THE CAPT DISCONNECTED THE AUTOPLT AND TOOK OVER MANUALLY. BRAKING AND STEERING WERE INEFFECTIVE, SO THE ACFT WAS BROUGHT TO A STOP AND DIRECTIONAL CTL MAINTAINED USING DIFFERENTIAL REVERSE THRUST. THE ACFT RAN OVER AND DESTROYED 5 RWY EDGE LIGHTS. THE ACFT WAS INSPECTED ON THE TXWY BY MAINT AND NO DAMAGE WAS FOUND. CONTRIBUTING FACTORS WERE BALD, BUT WITHIN LIMITS OF WEAR, MAIN TIRES. A 14 KT XWIND AND A RWY BRAKING CONDITION OF NIL, BUT RPTED AS FAIR. ADDITIONAL FACTORS MAY BE ATTRIBUTED TO THE FEDERAL REQUIREMENT THAT THE LOW TIME CAPT MAKE A CAT II AUTOLAND. THE CAT II AUTOLAND RESTRICTS THE PLT FROM DEVELOPING A FEEL FOR THE ACFT UNTIL AFTER LNDG. A CAT II LNDG FROM AN ILS, THAT IS, NOT AN AUTOLNDG, MIGHT HAVE PREVENTED THE RWY DEV.

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  8. Accession Number: 397450
    Synopsis: FLC OVERSHOT ASSIGNED ALT OF FL250 WHEN FO'S ALTIMETER WAS NOT RESET TO 29 PT 92 AT FL180.
    Narrative: WE TOOK OFF FROM IAD WITH AN ALTIMETER SETTING OF 29.52. IT WAS THE COPLT'S LEG. WE WERE CLBING TO FL250. AT FL180, I RESET MY ALTIMETER TO 29.92 WHILE TALKING ON THE PA TO THE PAX. THE COPLT, NEW TO THE COPLT SEAT, FAILED TO RESET HIS ALTIMETER. AT FL240 I CALLED THAT ALT AND NOTED 1000 FT TO LEVELOFF. AT FL251 I TOLD HIM TO STOP HIS CLB. HE DID NOT REACT FAST ENOUGH AND THEN AT FL252 HE DISCONNECTED THE AUTOPLT AND LEVELED OFF AT FL252.5 AND THEN RETURNED TO FL250. THE CTR NOTED OUR DEV. BECAUSE I WAS TALKING ON THE PA, PASSING FL180, THE CLB CHKLIST WAS NOT VERBALIZED. I SHALL NO LONGER DO ANYTHING IN THE COCKPIT PRIOR TO TRANSITION ALT. ONE THING AT A TIME WHEN IT COMES TO TRANSITION ALT -- BOTH CLBING AND DSNDING.
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