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Incidents related to Issue 3 incidents related to this issue.

Issue: task management may be more difficult (Issue #167)
Description: The use of automation may make task management more difficult for flightcrews, possibly leading to unsafe conditions.

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  2. 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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  4. Accession Number: 363330
    Synopsis: B737-300 MAX GROSS TKOF RWY 35R CLBING TO 10000 FT. COMPLETING AFTER TKOF CHKLIST AND VECTORED TO 100 DEGS PLUS TA GIVEN. AUTOPLT WOULD NOT ENGAGE AND NOTED ALT 10150 FT CLBING. DSNDED TO 9900 FT WHEN CTLR QUESTIONED ALT. TCASII TA AND RA AND SAW TFC VISUALLY 500 FT ABOVE. WHEN CLR OF TFC CLRED TO 16000 FT.
    Narrative: WE WERE MAKING A MAX GROSS WT TKOF ON RWY 35R AT COS USING IMPROVED CLB, BLEEDS OFF, FLAPS 1 DEG. THE CLRNC WAS RWY HEADING CLB TO 10000 FT MSL. AFTER LIFT-OFF I PROCEEDED ON RWY HEADING AND THE TWR TOLD US TO TURN TO 010 DEGS AND CONTACT DEP CTL. THE ACFT WAS BEING CLEANED UP AS WE CONTACTED DEP. HE GAVE US A TURN TO 100 DEGS TO INTERCEPT THE 349 DEG RADIAL OFF PUB. I CALLED FOR THE AFTER TKOF CHKLIST AND RESET THE BLEEDS AS WE LEVELED AT 10000 FT TURNING TO 100 DEGS. DEP CTL ADVISED US OF VFR TFC AT 2 O'CLOCK. THE COPLT WAS LOOKING FOR TFC AS I ATTEMPTED TO ENGAGE THE AUTOPLT. IT WOULD NOT ENGAGE SO I ATTEMPTED IT AGAIN WITHOUT SUCCESS. I LOOKED BACK AT THE ALTIMETER AND NOTICED WE WERE AT 10150 FT IN A CLB. I IMMEDIATELY PUSHED THE NOSE DOWN TO REGAIN 10000 FT. AT THIS TIME DEP CTL ASKED IF WE WERE CLBING BECAUSE OF A POSSIBLE CONFLICT WITH THE VFR TFC. BY THIS TIME WE WERE AT EXACTLY 9900 FT SO WE TOLD HIM WE WERE AT 10000 FT. WE THEN PICKED UP THE TFC VISUALLY AND ON TCASII, WHICH SHOWED HIM AT 500 FT ABOVE US CLOSING. SOON AFTERWARD WE GOT A TA FOLLOWED BY AN RA FROM THE TCASII. WE STAYED AT 9900 FT UNTIL HE PASSED BECAUSE WE HAD HIM VISUALLY. DEP CTL THEN GAVE US A CLB TO 16000 FT AND CONTACT ZDV. LOOKING BACK I SHOULD HAVE EITHER ENGAGED THE AUTOPLT EARLIER TO REDUCE THE WORKLOAD OR WAITED TILL WE HAD BEEN CLRED TO CLB TO 16000 FT. THERE IS JUST TOO MUCH GOING ON IN THE ATA ESPECIALLY WHEN VFR ACFT ARE FLYING OVER THE TOP.

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  6. Accession Number: 390873
    Synopsis: FLC OF B757 HAS LEADING EDGE FLAP DISAGREE INDICATION ON DSCNT FOR APCH. RECEIVING CLRNC FOR A HOLD TO TROUBLESHOOT THE PROB, THEY NEGLECT TO REPROGRAM THE ALT. ALTDEV OCCURS.
    Narrative: ON ARR TO EGE WE WERE E OF RLG AT 15000 FT SLOWING THROUGH 220 KTS FOR 210 KTS WHEN FO, FLYING, CALLED FOR FLAPS 1 DEG. EICAS DISPLAYED TRAILING EDGE FLAP DISAGREE MESSAGE. I FELT PRETTY SURE WE WOULD NOT COMPLETE THE APCH TO EGE AND ASKED ZDV IF WE COULD HOLD AT RLG TO SORT IT OUT. THEY CLRED US TO HOLD N AT 15000 FT. AS WE WERE AT 15000 FT WE HAD ALREADY SET 13100 FT IN THE ALT WINDOW FOR THE NEXT LEG OF THE APCH. BY THE TIME WE GOT HOLDING INSTRUCTIONS WE WERE NEARLY OVER RLG AND THE FMC WOULD NOT ACCEPT A HOLD. I WAS IN VOR RAW DATA AND SET THE INBOUND RADIAL AND TOLD THE FO TO START OUT IN RAW DATA AND I WOULD SET HOLDING. AFTER PASSING RLG I WAS ABLE TO SET THE HOLD BY DIRECT INTERCEPT RLG, THEN SETTING UP THE HOLDING PAGE. THE FO SET EVERYTHING BACK UP AND AS WE PATTED OURSELVES ON THE BACK FOR OVERCOMING AUTOMATION AND GETTING OURSELVES SET TO SOLVE OUR FLAP PROB DEN ASKED OUR ALT AND THEN CLRED US TO 14000 FT. AS SOON AS WE HAD CROSSED RLG AND HEADING SELECTED OURSELVES INTO THE HOLDING PATTERN WITH VOR RAW DATA, VNAV CONTINUED TO OPERATE AS ADVERTISED AND BEGAN A SLOW DSCNT TO 13000 FT, OUR NEXT ALT. DEN WASN'T UPSET BUT IT WAS A SOBERING REMINDER THAT IF YOU KILL THE AUTOMATION MAKE SURE YOU KILL IT ALL.
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