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Incidents related to Issue 28 incidents related to this issue.

Issue: automation use may be vulnerable to cockpit distractions (Issue #171)
Description: Distractions in the cockpit may lead to disruptions in control or monitoring of automation.

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  2. Accession Number: 358110
    Synopsis: BOTH PLTS INPUT INFO TO THE AUTOPLT AND ONE CANCELLED THE OTHER RESULTING IN CLBING ABOVE ASSIGNED ALT.
    Narrative: IN CRUISE FLT AT 16000 FT WE WERE GIVEN A REVISED ALTIMETER SETTING WHICH CAUSED A SIGNIFICANT CHANGE IN INDICATED ALT. WE WERE ALSO GIVEN A DSCNT CLRNC IN THE FORM OF A XING RESTR. THE PF COMMANDED HIS FLT DIRECTOR TO 'CLB' IN AN EFFORT TO CORRECT THE INDICATED ALT CHANGE CAUSED BY THE NEW ALTIMETER SETTING. THE AUTOPLT FOLLOWED THIS COMMAND, HOWEVER, THE PNF HAD SET THE ALT GIVEN IN THE DSCNT CLRNC IN THE ALT PRE-SELECTOR. THIS ACTION REMOVED THE ALT REF FOR THE AUTOPLT 'CLB' FUNCTION. CONCURRENT TO THESE EVENTS, BOTH PLTS BECAME DISTR DISCUSSING A PLAN TO DEVIATE AROUND PRECIP BEING DEPICTED BY RADAR. DUE TO THE IMPROPER AUTOPLT INPUT THE AIRPLANE DEVIATED VERTLY (CLBED ABOVE) FROM THE ASSIGNED ALT. UPON NOTICING THE DEV WE DISCONNECTED THE AUTOPLT AND MANUALLY FLEW THE AIRPLANE BACK TO THE CORRECT ALT. AFTER THE SIT WAS CORRECT WE QUERIED THE CTLR, RPTING OUR DEV AND ASKING IF THIS HAD CAUSED ANY PROB. HE REPLIED IT DID NOT. BETTER COCKPIT COMS AND DIVISION OF TASKS, WITH REGARD TO THE RADAR DISTR, WOULD HAVE PREVENTED THIS EVENT.

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  4. Accession Number: 358642
    Synopsis: MLG CLRED TO CROSS HAYED INTXN AT FL190. DSCNT BEGUN IN VERT SPD THEN CHANGED TO VNAV. SOMEHOW, VNAV WAS NOT ENGAGED OR BECAME DISENGAGED AND ACFT APCHED HAYED AT FL240. ATC GAVE FLT A 360 DEG TURN IN ORDER TO MAKE THE ALT XING RESTR.
    Narrative: ON THE WILLIAMSPORT 1 ARR (FQM.FQM1), CLRED TO CROSS HAYED INTXN AT FL190. IT WAS SET UP IN THE FMC. DSCNT WAS INITIATED IN VERT SPD, THEN VNAV WAS SELECTED. I WAS DISTRACTED BY A CALL FROM A FLT ATTENDANT IN THE CABIN AND DID NOT CATCH THE VNAV NOT ENGAGED. ZNY CALLED ABOUT 5 NM BEFORE HAYED AND ASKED IF WE WERE GOING TO MAKE THE XING RESTR. WE THEN RECEIVED VECTORS FOR A 360 DEG TURN TO DSND. THERE APPEARED TO BE NO TFC CONFLICT. CONTRIBUTING FACTOR WAS THAT FO WAS OFF FREQ TALKING TO COMPANY AND GETTING ATIS.

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  6. Accession Number: 359700
    Synopsis: FLC OF AN MLG UNDERSHOT DSCNT ALT DURING A STAR ARR CAUSING ATC TO INTERVENE AND TURN THEM OFF COURSE IN ORDER TO PROVIDE THE APPROPRIATE SEPARATION OF OPPOSITE DIRECTION TFC.
    Narrative: AS FLT LEVELED OFF AT CRUISE ALT FL290, CAPT PROGRAMMED ARR ROUTING INTO FMC WHILE FO FLEW ACFT. FLT CROSSED STAR INTXN #1 AT FL240 AND WAS THEN CLRED TO FL230. ON THE ARR FLT ENCOUNTERED MODERATE CLR AIR TURB AT FL230 AND FO WENT OFF PRIMARY ATC RADIO FREQ TO MAKE PA TO PAX, WITH CAPT ASSUMING CTL OF ACFT AND CLRNC TO FL220, CROSS WHIGG INTXN AT 11000 FT. DSCNT TO FL220 WAS INITIATED AND ACFT LEVELED AT FL220, WITH ALT ALERTER SET AT 11000 FT. TURB AVOIDANCE BECAME PRIMARY FOCUS OF AIRCREW AND FMC COMPUTER WAS NOT UPDATED WITH 11000 FT ALT RESTR AT WHIGG (FMC DSCNT PROFILE WAS COMPUTED TO ARRIVE AT LAS FIELD ONLY). UPON COMPLETION OF PA, FO ASSUMED CTL OF ACFT AND CAPT LEFT PRIMARY ATC FREQ TO COORDINATE TURB ACTIONS WITH FLT ATTENDANTS AND PAX. FO FOLLOWED FMC-PROGRAMMED DSCNT PROFILE AND APPROX 5 MI FROM WHIGG INTXN CTLR ASKED IF FLT WOULD BE ABLE TO COMPLY WITH THE ASSOCIATED ALT RESTR. ACFT WAS NOT ABLE TO DSND TO MEET RESTR AND WAS VECTORED AWAY FROM ARR CORRIDOR AND INSTRUCTED TO MAINTAIN ALT FOR OPPOSITE DIRECTION TFC TO PASS BY. AIRCREW COMPLIED WITH REVISED INSTRUCTIONS AND WAS SUBSEQUENTLY RECLRED FOR ARR INTO LAS WITH NO FURTHER COMPLICATIONS. THIS SEEMS LIKE A HUMAN PERFORMANCE AND COM FAILURE BTWN THE PLTS FLYING WITH ASSUMPTION BY FO THAT BOTH ARR ROUTING AND ALT RESTRS WERE ENTERED INTO FMC WHEN THIS WAS NOT THE CASE. TURB ISSUES DISTRACTED AIRCREW FROM BACKING EACH OTHER UP.

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  8. Accession Number: 361890
    Synopsis: RPTR ERROR ADMITTED IN GROSS NAV ERROR, OVERWATER OP. AFTER AN AUTOPLT DISCONNECT, FLC FAILED TO RE-ENGAGE THE AUTOPLT MODE SELECTOR TO INS NAV POS FROM THE HDG POS.
    Narrative: SHORTLY AFTER REACHING CRUISE AND SELECTING INS NAV, AN ELECTRICAL SYS SPIKE TRIPPED OFF THE AUTOPLT. THE AUTOPLT WAS RE-ENGAGED USING THE NORMAL INITIAL SETUP OF 'F-H-A' FLT DIRECTOR HDG ALT. SIMULTANEOUSLY, ATC ISSUED A FREQ CHANGE, AND WE WERE PASSING THE FIRST RPTING POINT. CONTACT WAS MADE WITH NY RADIO AND THE STANDARD POS RPT MADE. THOUGH WE FAILED TO RE-ENGAGE INS/NAV THE NEXT POS RPT CAME WITHIN 1 MIN OF THE ETA AT THAT POINT. ALL APPEARED NORMAL UNTIL NY RADIO ADVISED US TO CONTACT ZNY ON VHF. WE WERE ADVISED THAT IT APPEARED THAT WE WERE APPROX 45 MI E OF THE AIRWAY. A CHK OF INS COORDINATES CONFIRMED OUR POS. THE FLT WAS CLRED DIRECT TO THE NEXT WAYPOINT AND WAS COMPLETED WITHOUT FURTHER INCIDENT. ALTHOUGH THE AUTOPLT RE-ENGAGEMENT TO 'F-H-A' WAS ANNOUNCED THE IMMEDIATE FREQ CHANGE AND POS RPT DISTR THE CREW FROM MAKING THE USUAL XCHK AND THE SUBSEQUENT RE- ENGAGEMENT OF INS NAV. SUPPLEMENTAL INFO FROM ACN 361732: WHEN RE-ENGAGED AUTOPLT WAS IN HDG MODE AND NOT NAV MODE ALLOWING ACFT TO DRIFT OFF COURSE.

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  10. Accession Number: 362093
    Synopsis: HDG TRACK POS DEV WHEN FLC FAILS TO NOTE PASSING AN ENRTE VOR AND FAILS TO ADJUST TO NEW OUTBOUND HDG.
    Narrative: CAPT WAS FLYING THE ACFT USING HDG SELECT TO TRACK THE AIRWAYS. THE NORMAL ROUTINE WOULD HAVE BEEN TO HAVE THE AUTOPLT COUPLED TO THE OMEGA AND TRACKING THE AIRWAYS. HOWEVER, THIS WAS NOT POSSIBLE SINCE THIS ACFT HAD THE OMEGAS REMOVED AND THE NEW GPS INSTALLED. I WAS DISTR BY OPERATING THE GPS AND THE CAPT DID NOT NOTICE VOR STATION PASSAGE. THIS RESULTED IN A COURSE DEV. CTR THEN PROVIDED US WITH A VECTOR TO REINTERCEPT THE AIRWAY. ALTHOUGH NO CONFLICT RESULTED, ANOTHER REMINDER NOT TO ALLOW A DISTR TO RESULT IN AN ERROR.

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  12. 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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  14. Accession Number: 365130
    Synopsis: FLC OF A B767-200 OVERSHOT DSCNT XING ALT DURING A STAR ARR DUE TO THE CAPT SELECTING THE WRONG FMC MODE CTL.
    Narrative: FLT WAS ON BOARD A B767-200 AND WAS CLRED TO DSND VIA THE CIVIT ARR TO LAX. THE CAPT WAS PF. I WAS BUSY WITH COMPANY DUTIES, EG, CALLING COMPANY OPS FOR GATE ASSIGNMENT, ALERTING THE CABIN CREW TO PREPARE FOR ARR. ORIGINALLY, THE CAPT WAS DSNDING USING VNAV AND IT HAD BEEN PERFORMING SATISFACTORY. I RECALL BEING GIVEN AN AIRSPD ASSIGNMENT OF '300 KTS OR GREATER.' I NOTICED THAT HIS AIRSPD BUG DROPPED TO 250 KTS (DUE TO VNAV PREPARING TO DSND BELOW 10000 FT OR POSSIBLY BEING PROGRAMMED TO CROSS BREMR AT 250 KTS AND GREATER THAN OR EQUAL TO 12000 FT. WHEN PAUSING BTWN TASKS, I NOTICED WE WERE 8 NM FROM BREMR AND WERE DSNDING THROUGH APPROX 13300 FT. I NOTICED THAT THE CAPT WAS TRYING TO OVERRIDE THE SPD REDUCTION BY SELECTING 300 KTS ON THE MCP. I ASSUMED THAT HE WAS USING VNAV SPD INTERVENTION. THEREFORE, I ASSUMED THAT THE AUTOPLT WAS GOING TO LEVEL OFF AT 12000 FT TO MAKE THE XING AT BREMR AT OR ABOVE 12000 FT (D40 LAX). AFTER MY INCORRECT ASSUMPTION, I ADVISED THE CAPT THAT WE WERE GOING THROUGH 12000 FT -- A RECHK OF THE SID CONFIRMED THE REQUIREMENT. WE WERE 4 MI FROM BREMR AND DSNDING THROUGH 11700 FT! THE CAPT AND I WERE BOTH PERPLEXED AS TO WHY THE AUTOPLT DID NOT LEVEL OFF AT 12000 FT. IT TURNS OUT THAT THE AUTOPLT WAS DOING EXACTLY AS IT WAS TOLD TO DO. THE CAPT HAD SELECTED FLT LEVEL CHANGE, 10000 FT WAS THE SELECTED ALT -- THE LOWEST ALT ON THE ARR. THE CAPT WAS FIXATING ON HIS AIRSPD, I WAS DISTR BY MISC DUTIES AND FAILED TO XCHK THE AUTOFLT MODE IN USE.

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  16. Accession Number: 371170
    Synopsis: ARR DC10 DSNDS BELOW ASSIGNED ALT WHEN ALT AUTO CAPTURE FEATURE OF THE AUTOPLT FAILS TO LEVEL THE ACFT AT 10000 FT. FLC WAS DISTR WITH AN AMENDED CLRNC AND A RWY CHANGE, RETRIEVAL OF OTHER APCH PLATES.
    Narrative: ACFT LEVELED AT 10000 FT WITH AUTOPLT ENGAGED. WHILE SLOWING TO 250 KTS WAS GIVEN A HDG CHANGE AND ALSO A RWY CHANGE FROM RWY 1 TO RWY 19. AS ACFT WAS IN TURN, ACFT DSNDED TO 9500 FT WITHOUT AN ALT WARNING FROM THE ALT WARNING SYS. DISENGAGED AUTOPLT AND CLBED BACK TO 10000 FT. SUPPLEMENTAL INFO FROM ACN 370799: AFTER FINDING THE NEW APCH PLATE ALL 3 CREW MEMBERS NOTICED SIMULTANEOUSLY THAT OUR ALT WAS 9600 FT. THE AUTOPLT ALT CAPTURE HAD FAILED TO ARM. CONTRIBUTING FACTORS: MOMENTARY DISTR OF A RWY CHANGE GIVEN LESS THAN 1000 FT FROM LEVELOFF ALT. CREW FATIGUE DUE TO INBOUND LEG FROM EUROPE. XA00 RPT TIME FOR THIS FLT. THIS WAS DAY 3 OF A 9 DAY PATTERN TO EUROPE WHICH INCLUDED 6 OCEAN XINGS.

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  18. Accession Number: 371460
    Synopsis: ACR LGT WAS TOO HIGH ON THE APCH DURING STAR ARR INTO LAX AFTER A RWY CHANGE WAS MADE. ACFT WENT AROUND FOR ANOTHER APCH. INITIAL CONFUSION OCCURRED OVER WHICH RWY WAS ASSIGNED AND THE FAILURE TO SET THE ALT WINDOW FOR DSCNT.
    Narrative: DSNDING INTO LAX ON THE (STAR) CIVET ONE ARR, JUST PRIOR TO 'BREMR' INTXN, APCH CTL CHANGED OUR RWY TO RWY 25R. HOWEVER, THERE WAS SOME CONFUSION IN COCKPIT AS EACH PLT 'HEARD' A DIFFERENT RWY. THE DISTR RESULTED IN OUR FAILURE TO CROSS 'ARNES' INTXN AT 10000-11000 FT PER THE STAR. FURTHER, WE GOT SO FAR BEHIND ON THE APCH THAT WE ELECTED TO DISCONTINUE THE APCH AT THE OM. WE WERE THEN VECTORED TO AN APCH AND LNDG ON RWY 24R. LAX CONTINUES TO BE A DIFFICULT ARPT TO OPERATE INTO. THERE ARE 4 RWYS WITH SIMILAR SOUNDING NAMES, SO IT IS EASY TO SAY ONE RWY AND THINK ANOTHER. ONCE AGAIN THOUGH, THE OLD ADAGE ABOUT 'SOMEONE MUST FLY THE AIRPLANE' HAS BEEN PROVEN WISE. THE COPLT, WHO WAS FLYING, GOT DISTRACTED WITH ME AND FAILED TO FLY THE AIRPLANE TO THE REQUIRED XING ALT. ALSO, THE ADDED BUSY WORK OF THE GLASS COCKPIT CONTRIBUTED TO OUR INABILITY TO COMPLETE THE APCH AND LNDG. SUPPLEMENTAL INFO FROM ACN 371434: APCHING BREMR WE WERE GIVEN A RWY CHANGE TO RWY 25R. THE PNF THOUGHT THAT THE RWY THAT WE HAD BEEN GIVEN WAS RWY 24R. THERE WAS A ZLA CTLR WHO WAS ON THE JUMP SEAT, WE ASK WHAT HE HAD HEARD. HE INDICATED HE HEARD RWY 25R. THERE IS 7 MI BTWN BREMR AND ARNES AND AT A SPD OF 210 KTS TAKES APPROX 2 MINS. THE CAPT WAS THE FIRST TO NOTICE THAT WE HAD NOT RESET OUR ALT WINDOW TO 10000 FT AFTER XING BREMR TO MEET THE BELOW 11000 FT ABOVE 10000 FT FOR ARNES. WE CONTINUED THE APCH BUT WERE HIGH AND MADE A GAR AND LANDED RWY 24R. I PERSONALLY BLAME MYSELF FOR BECOMING DISTRACTED AND NOT MONITORING THE FLT PATH OF THE ACFT. ALTHOUGH A RWY CHANGE APPEARS TO BE A SIMPLE PROC, THIS PHASE OF THE APCH IS BUSY ENOUGH WITHOUT ADDING A NEW SET OF PROBS. SET PRIORITIES AND HAVE THE SELF DISCIPLINE TO MAINTAIN THOSE PRIORITIES. POSSIBLY USING SCENARIOS SIMILAR TO THE ONE WE EXPERIENCE, IN TRAINING WOULD HELP TEACH SOME OF THESE POINTS.

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  20. 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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  22. 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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  24. Accession Number: 373730
    Synopsis: AN ACR A320 FLC EXCEEDS 250 KIAS BELOW 10000 FT WHEN THE FO, ON HIS IOE, SELECTS 'OPEN DSCNT' MODE ON THE AUTOFLT SYS. THE CAPT NOTES THE HIGH SPD AT 9700 FT AND INSTRUCTS THE FO TO SLOW.
    Narrative: WE WERE ON THE PULLMAN FOUR ARR TO ORD BTWN PIVOT AND STOREY, LEVEL AT 12000 FT, 300 KTS (BEST FORWARD SPD). WE WERE SWITCHED TO CHICAGO APCH. APCH CLRED US TO 10000 FT. FO BEGAN DSCNT WITH AUTOPLT ENGAGED. AT APPROX 10500 FT, APCH CTL CLRED US TO 8000 FT, PNF (ME) SET ALT ALERTER TO 8000 FT. FO POINTED TO NEW ALT AND REPEATED '8000' FT. AS ACFT APCHED 10000 FT, FO PUSHED VERT SPD KNOB (PUSH TO LEVEL OFF) ACFT BEGAN TO SLOW, BUT CONTINUED TO DSND BELOW 10000 FT TO APPROX 9700 FT AS SPD SLOWED TO 280- 270-265-260-250 KTS. I DIRECTED FO TO AGGRESSIVELY SLOW AND CLB BACK 10000 FT. HE SLOWED THE ACFT, BUT ONLY GOT BACK UP TO TO 9800 FT BEFORE SPD REACHED 250 KTS. CONTINUED DSCNT FOR ROUTINE APCH AND LNDG. PROB AROSE DUE TO INEXPERIENCED COPLT AND HIS OVER-RELIANCE ON AUTOFLT SYS. WITH INEXPERIENCED COPLT, I SHOULD HAVE BEEN WATCHING/MONITORING MORE CLOSELY. SHOULD HAVE PHYSICALLY TAKEN OVER CTL OF ACFT -- DID NOT, DUE TO IOE. SUPPLEMENTAL INFO FROM ACN 373922: THE CAPT CHANGED THE RWYS, BUT FOR SOME REASON THE MAP STILL SHOWED SOME FIXES ON THE WRONG SIDE OF THE ARPT. AS I WAS TRYING TO DECIPHER WHAT THEY WERE AND WHY THEY WERE THERE, WE WERE TOLD TO DSND TO 7000 FT MSL. STILL MOSTLY PREOCCUPIED WITH THE ND MAP, I PULLED OPENED DSCNT, AND THEN ASKED THE CAPT ABOUT THE ERRONEOUS MAP INDICATIONS WHICH HE WAS ALREADY BEGINNING TO CLR OUT OF FMC. IT WAS THEN THAT WE REALIZED THAT WE HAD DSNDED BELOW 10000 FT MSL ABOVE 300 KIAS. I DISCONNECTED THE AUTOPLT AND LEVELED AT 9800 FT AND SLOWED TO 250 KIAS. I FEEL THAT THE DISTR OF MY PRE- OCCUPATION WITH THE ND MAP COUPLED WITH MY BEING USED TO THE ACFT SLOWING ON ITS OWN IN MANAGED SPD MODE, CAUSED ME TO FORGET THAT WE WERE IN SELECTED SPD MODE AND SUBSEQUENTLY NOT SLOWING THE ACFT BELOW 10000 FT MSL. ALSO A BIG FACTOR WAS FATIGUE. ALTHOUGH IT WAS THE FIRST FLT OF THE DAY, I HAD AWAKEN AT XD45 AM EASTERN WHICH IS REALLY XA45 AM PACIFIC TO MY BODY. IT WAS ALSO DIFFICULT TO FALL ASLEEP THE NIGHT BEFORE AS I AM ACCUSTOMED TO SLEEP AROUND XV30 OR XW00 PM PACIFIC, WHICH WOULD BE XA30 OR XB00 LCL EASTERN TIME, RESULTING IN ONLY A COUPLE OF HRS OF SLEEP.

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  26. Accession Number: 375098
    Synopsis: B757 FLC WAS DISTRACTED AFTER TKOF BY AUTOTHROTTLE PROB AND WHEN ENGAGING LNAV THE ACFT TURNED, NOT IN ACCORDANCE WITH THE DEP PROC. DEP CTLR QUESTIONED THEIR TURN.
    Narrative: ON TKOF ROLL CAPT COULD NOT GET AUTOTHROTTLES ENGAGED (RWY 24L LAX). DECISION TO GO AND SOLVE PROB IN THE AIR. ONCE AIRBORNE AND GEAR UP FLAP RETRACTION ON SCHEDULE, CAPT TRIED MANY DIFFERENT THINGS TO SOLVE PROB, IE: RECYCLING FMC, DIRECT VNAV/LNAV, AND FLT DIRECTORS. I WAS FLYING THE AIRPLANE. THE CAPT AND I THOUGHT IT WAS A TMC PROB (THRUST MODE CTL). I COMMUNICATED TO HIM I HAD A LIST OF CIRCUIT BREAKERS FOR THAT HIGHLIGHTED IN MY BOOK. I THEN NOTICED THAT DURING HIS TRYING DIFFERENT THINGS HE LEFT THE FLT DIRECTORS OFF. I ASKED HIM TO TURN THE FLT DIRECTORS ON AND ENGAGE VNAV/LNAV. AS I WATCHED HIM DO THIS, I NOTICED THE AUTOTHROTTLES SWITCH WAS OFF. AS THE LNAV ENGAGED AND COMMENCED A L TURN I FOLLOWED THE FLT DIRECTOR AND POINTED OUT THE SWITCH TO THE CAPT. HE TURNED ON THE SWITCH AND SOLVED OUR PROB. AT WHICH TIME ATC CALLED AND ASKED WHY WE WERE TURNING OFF. THE SID (LAXX2) RWY 24L CALLS FOR A 250 DEG HDG FOR VECTORS. BY ENGAGING LNAV THE FLT DIRECTORS COMMANDED US TO FLY THE SID. FORTUNATELY THERE WERE NO OTHER ACFT IN THE AREA. THE CAPT MISSED PART OF HIS PREFLT FLOW, THERE WAS NO CHKLIST ITEM TO BACK IT UP. I ALLOWED MYSELF TO BE DISTR FROM MY DUTY OF FLYING THE AIRPLANE AND GET INVOLVED IN THE PROB SOLVING. ANOTHER KEY LESSON HERE IS TO NOT LET THE TECHNOLOGY RUN YOU AS A PLT. THE PLT HAS TO RUN/MANAGE THE TECHNOLOGY.

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  28. Accession Number: 376720
    Synopsis: EMB120 FLC OVERSHOT THEIR ALT DURING DSCNT. CREW WAS BUSY AND FAILED TO PAY ATTN TO THEIR DSCNT PROFILE. ACFT WAS BEING OPERATED WITHOUT THEIR TCASII SYS. OTHER ACFT NOTED THEIR PRESENCE, APPARENTLY WITH THEIR TCASII.
    Narrative: THE WX AT TLH REGIONAL ARPT WAS IFR WITH A 500 FT OVCST AND THE TOPS WERE ABOUT 2000 FT. THE WX ON TOP WAS VMC WITH GOOD VISIBILITY. AT APPROX AX25 WE WERE LEVEL AT 9000 FT AND CLRED DOWN TO 7000 FT AND WERE ALSO ASSIGNED A HDG. THE CAPT, WHO WAS THE PF, STARTED THE DSCNT AND ASKED FOR THE IN-RANGE CHKLIST AND THE INST APCH CHKLIST. I, THE FO AND PNF, PERFORMED THE IN-RANGE CHKLIST. I THEN BEGAN THE INST APCH CHKLIST BY FIRST BRIEFING THE ILS TO RWY 27 AND THEN I BEGAN PERFORMING THE OTHER CHKS INCLUDED, WHEN I HAD A QUESTION CONCERNING THE CHKING OF THE RADAR ALTIMETERS. THE CAPT EXPLAINED TO ME THE ANSWER TO MY QUESTION AND AT THE SAME TIME WE BOTH LOOKED UP AND REALIZED WE WERE AT 6500 FT AND DSNDING. THE CAPT IMMEDIATELY ARRESTED THE SINK RATE AND BEGAN A CLB AT 6450 FT. AT ABOUT THE SAME TIME THE ACFT OFF OUR R WING AND SLIGHTLY AHEAD QUERIED THE CTLR ABOUT OUR ALT. THE CTLR THEN GAVE US OUR ORIGINAL ALT OF 7000 FT AGAIN AND GAVE US A HDG OF 10 DEGS TO THE L. THE REST OF THE FLT AND APCH WAS UNEVENTFUL. AT THE TIME THE CTLR GAVE US 10 DEG TURN TO THE L WE WERE AT 6700 FT AND CLBING. SOME OF WHAT I BELIEVE TO BE THE CONTRIBUTING FACTORS ARE: 1) FOR SOME REASON THE ALT ALARM DID NOT GO OFF. 2) I AS THE FO HAD A QUESTION ABOUT AN ITEM ON THE CHKLIST THAT I SHOULD HAVE KNOWN. 3) THE CAPT (PF) AND MYSELF (PNF) WERE PREOCCUPIED AND NOT FLYING AND MONITORING THE AIRPLANE PROPERLY. 4) THE TCASII WAS INOP. 5) I BELIEVE THAT ALSO, ON A SMALL SCALE, WE WERE A LITTLE TIRED, WE WERE IN THE LAST 20 MINS OF A 12 HR DUTY DAY, ON THE LAST DAY OF A 4- DAY SCHEDULE.

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  30. 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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  32. Accession Number: 378980
    Synopsis: A B737-300 APCHING LAX, DSNDS LATE TO CROSS CIVET AT ASSIGNED ALT IN ZLA, CA, AIRSPACE.
    Narrative: FMC VNAV SYS WAS PROGRAMMED TO CROSS CIVET AT FL180. WE HAD BEEN CLRED DIRECT TO CIVET FROM SOMEWHERE IN ARIZONA. ABOUT 15 MI FROM CIVET AND PRIOR TO DSCNT WITH VNAV I NOTICED THE ACFT WAS TRACKING SEVERAL MI S OF COURSE. I SELECTED HEADING MODE ON THE MODE CTL PANEL AND TURNED THE ACFT MORE TO THE N TO INTERCEPT THE LAX RWY 25L LOC. WHEN I PUSHED THE HEADING MODE BUTTON I DIDN'T NOTICE THAT THE FMC DROPPED OUT OF VNAV MODE. WHEN I DID NOTICE, WE WERE ONLY 3 MI FROM CIVET AND STILL AT FL240. I IMMEDIATELY STARTED A MANUAL DSCNT TO FL180. ABOUT 2 MI FROM CIVET ZLA ASKED WHAT ALT WE WERE LEAVING. I RESPONDED FL240. ZLA THEN GAVE US A HDG OF 200 DEGS AND CLRED US TO 14000 FT. ADDING TO THE CONFUSION IN THE COCKPIT WAS THE FO BEING DISTRACTED BY A FLT ATTENDANT IN THE COCKPIT SHOWING HIM PICTURES IN AN ALBUM. NEXT TIME, I WILL INSURE THAT ALL EYES ARE ON THE JOB AT HAND.

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  34. 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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  36. Accession Number: 380970
    Synopsis: FLC OF WDB ACFT CHKS FLT PLAN AS LOADED INTO COMPUTER AND QUESTIONS ONE LEG. DUE TO INTERRUPTIONS THEY FAIL TO CHK THAT LEG AND END UP OFF COURSE ONCE AIRBORNE.
    Narrative: AS A RESERVE PLT, GOT CALL FOR FLT WHICH WAS TO DEPART DTW AT XY00. I ARRIVED AT ACFT APPROX XX25-XX30, WHICH DID NOT ALLOW A LOT OF TIME. AFTER CAPT LOADED FLT PLAN INTO COMPUTER, MY JOB IS TO CHK RTE AND LEGS OF FLT PLAN. ON THE DEP, WE WERE TO FLY RWY HEADING, RADAR VECTORS TO DUNKS INTXN, AS FILED, J-70, ETC. DUNKS WAS IN THE COMPUTER, THEN BAE, NOT J-70. I ASKED CAPT IF DUNKS TO BAE IS J-70, AND HE SAID HE WOULD LOOK IT UP ON MAP. I SAID I WOULD LOOK IT UP TOO. HOWEVER, I THEN CONTINUED CHKING THE REMAINDER OF THE RTE AND LEGS, ASSUMING HE WAS LOOKING IT UP. AT THIS POINT AN AGENT CAME INTO THE COCKPIT, ALONG WITH OTHERS, AND WE WERE DISTRACTED AND WE BOTH FORGOT TO GO BACK AND CHK THE CHART. I DID FINISH CHKING RTE AND LEGS, BUT DID NOT DOUBLE-CHK MY QUESTION. ON DEP WE WERE CLRED DIRECT DUNKS, AS FILED. WE SHOULD HAVE FLOWN DUNKS, J-70 PMM, BAE, ETC. AFTER DUNKS, WE STARTED HEADING FOR BAE (ON LNAV). ATC QUESTIONED OUR NAV SOON AFTER PASSING DUNKS, SAID WE WERE 10 MI N OF COURSE. WE REQUESTED DIRECT BAE AND IMMEDIATELY WERE GRANTED OUR REQUEST. NO FURTHER COMMENTS FROM ATC. I LET MYSELF GET TOO HURRIED WHICH LED TO MY MISTAKE. IT IS A VERY BUSY TIME BEFORE DEP WITH A LOT TO DO. WHEN TIME IS SHORT AND WITH SUBSEQUENT DISTRACTIONS IT IS EVEN MORE CRITICAL TO CHK OUT QUESTIONS AT THE TIME THEY ARISE AND NOT PUT THEM OFF, SO THEY CAN BE FORGOTTEN.

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  38. Accession Number: 383500
    Synopsis: AN ACR FK10 FLC GOT OFF COURSE WHEN THEY ENTERED THE PLANNED RTE IN THE FMC RATHER THAN THE CLRED RTE. AN ALERT ARTCC CTLR CALLED THE ERROR TO THEIR ATTN.
    Narrative: FMC ROUTING DISCUSSED PRIOR TO DEP AT MCI, BUT ATTN WAS DIVERTED TO ANOTHER EVENT. ATC QUERIED US AT CAP AS TO REMAINDER OF FLT PLAN. WE TOOK IMMEDIATE ACTION TO CORRECT THE STORED DATABASE FLT PLAN. NO PROBS WERE OTHERWISE ENCOUNTERED.

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  40. 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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  42. Accession Number: 387393
    Synopsis: AN ACR MLG FLC HAS THEIR AUTOFLT SYS INTERCEPT A DIFFERENT APCH FROM THE ONE THAT THEY WERE ASSIGNED. THE FMS HAD DEFAULTED TO A STORED APCH AND THE FLC WERE NOT MONITORING THE RAW DATA.
    Narrative: EARLY IN FLT, INSTALLED GLASR 3 ARR PER FLT PLAN RTE AND CHKED FMS RTE AGAINST STAR BEFORE STARTING ARR. AFTER PASSING GLASR INTXN, INSTALLED THE RWY 16R INTO FMS, BRIEFED VISUAL APCH BACKING IT UP WITH ILS, AND COMPLETED CHKLIST FOR ARR. IN A TURN TO R, APCH ASKED IF WE WERE TURNING ON ARR (INFORMED YES). APCH AT THIS POINT GAVE US HDG AND STATED THERE HAS BEEN A PROB ON THIS ARR WITH FMS EQUIPPED ACFT. AFTER PARKED, EXAMINED SIT AND CONCLUDED THAT THE ACFT FMS AUTOMATICALLY INSERTS JACKSN FMS WITHOUT SELECTING IT. THE ACFT FMS SHOULD ALWAYS INSTALL APCHS OR NEVER INSTALL APCHS -- NOT SOMETIMES INSTALL THEM. TURN WAS MADE EARLY AND NOT CAUGHT BY PF BECAUSE OF SPD CHANGE REQUEST BY ATC AT JAKSN AND FMS ONLY SHOWS DISTANCE TO POINT, AND CHKED EARLIER INFLT AND CORRECT. TURN MADE APPROX 2 MI EARLY.

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  44. Accession Number: 391630
    Synopsis: B737-300 FLC MISPROGRAMS FMS ON RECEIVING DSCNT CLRNC CHANGE AND HAS AN ALTDEV.
    Narrative: WE WERE FLT PLANNED TO ARRIVE DFW VIA THE BOWIE (UKW) ARR. FMS WAS PROGRAMMED TO CROSS KAJAY INTXN AT THE EXPECTED ALT OF FL240, AND ALSO PROGRAMMED TO CROSS BAMBE INTXN AT 11000 FT. PRIOR TO REACHING THE UKW 287 DEG RADIAL, IN THE VICINITY OF TXO, WE WERE RECLRED DIRECT UKW, WHICH ELIMINATED THE FMS PROGRAMMED DSCNT TO FL240 AT KAJAY. FMS DSCNT PROFILE IS NOW COMPUTED TO CROSS BAMBE AT 11000 FT. WHILE PROCEEDING DIRECT UKW, WE WERE CLRED TO CROSS 40 DME W OF UKW AT FL240, PLT DISCRETION. WE REPROGRAMMED THE FMS WITH A NAV POINT 40 DME W OF UKW, BUT APPARENTLY FAILED TO INCLUDE THE ALT CONSTRAINT OF FL240, SO THE FMS DSCNT PROFILE WAS PREDICATED ON REACHING BAMBE INTXN AT 11000 FT. THE REASON FOR THIS OVERSIGHT IS UNKNOWN, BUT PROBABLE CAUSES ARE CREW INVOLVEMENT WITH ARR PROCS (APCH BRIEFING, CONTACTING COMPANY FOR GATE ASSIGNMENT, ETC) AND DISTR DUE TO A CALL FROM THE LEAD FLT ATTENDANT TO RPT CABIN MAINT DISCREPANCIES OR PAX SPECIAL ASSISTANCE REQUESTS UPON ARR. IN ANY CASE, THE FMS VNAV FUNCTION INITIATED ITS DSCNT ACCORDING TO THE PROFILE FOR MEETING THE BAMBE AT 11000 FT RESTR. WHILE IN THE DSCNT, CTR SUBSEQUENTLY CLRED US TO CROSS BAMBE AT 11000 FT, WHICH LEGALLY CANCELED THE 40 DME AT FL240 RESTR. APCHING THE 40 DME FIX, WE REALIZED WE WERE TOO HIGH TO REALISTICALLY MEET THE PREVIOUS RESTR, AND QUESTIONED OURSELVES AS TO WHY WE WERE IN THAT POS, AND THE MOST LOGICAL REASON WAS THAT WE PROBABLY FAILED TO ENTER THE ALT CONSTRAINT INTO THE FMS AND FAILED TO BACK IT UP WITH RAW DATA NAV DUE TO CREW PREOCCUPATION WITH ANCILLARY DUTIES. LESSON LEARNED IS NOTHING NEW: THE PRIORITIES ARE 1) AVIATE, 2) NAV, 3) COMMUNICATE, AND 4) CHKS.

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  46. Accession Number: 394900
    Synopsis: FLC OF AN MD88 FAILED TO RESET ALTIMETERS DURING DSCNT THROUGH FL180 RESULTING IN OVERSHOOTING STAR XING ALT DUE TO DISTR OF AN ACFT EQUIP PROB. AS THEY WERE CORRECTING BACK TO THE XING ALT, ATC INTERVENED TO INQUIRE ABOUT THEIR ALT.
    Narrative: WE WERE DSNDING ON THE GLEN ROSE 3 ARR INTO DFW. PASSING 20000 FT THE FLT ATTENDANTS CALLED BUT WERE UNABLE TO HEAR US THROUGH THE INTERPHONE. THE CAPT AND I DISCUSSED WHETHER WE SHOULD PUT THIS IN THE LOGBOOK AND IF WE HAD TIME TO CALL AHEAD AND NOTIFY MAINT (WE DID NOT). THE CAPT THEN QUERIED APCH CTL ABOUT THE SPD RESTRS AND APCH SAID WE COULD DELETE ALL RESTRS EXCEPT AT DELMO, THE LAST FIX ON THE ARR. I DELETED ALL PREVIOUS SPDS IN THE FMS BUT ALSO INADVERTENTLY DELETED THE 11000 FT ALT RESTR AT HIRST, WHICH STILL APPLIED. ALTHOUGH THE FMS SHOWED WE WERE ON THE CORRECT DSCNT PROFILE, THIS WAS FOR THE SPD AND ALT AT DELMO, NOT HIRST. THE CAPT NOTICED WE WERE HIGH AND DEPLOYED THE SPD BRAKE. WE LEVELED AT 11000 FT INDICATED AND IMMEDIATELY REALIZED WE HAD BEEN DISTRACTED (BY THE INTERPHONE PROB AND BY TRYING TO MAKE THE 11000 FT ALT AT HIRST WHICH WAS NOT PROPERLY PROGRAMMED IN THE FMS) AND HAD NOT PERFORMED A DSCNT CHK. ALTIMETERS WERE STILL READING 29.92, AND SINCE THE LCL SETTING WAS APPROX 29.62, WE WERE 300 FT LOW. WE INITIATED A CLB AS ATC CALLED TO QUESTION OUR ALT.

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  48. Accession Number: 395103
    Synopsis: B737-400 ACFT ON COUPLED APCH, PF, FO DSNDS BELOW THE APCH PROFILE, BUT CORRECTS BACK WHEN RECOGNIZING THE 'PICTURE' DOESN'T LOOK RIGHT. COCKPIT CONFLICT CONTRIBUTES.
    Narrative: THE EVENT BEGAN WITH THE EXECUTION OF AN RNP APCH. WE SET UP THE APCH AS TRAINED AND FOLLOWED THE APPROPRIATE CHKLIST. 99% OF THE TIME I HAND FLY APCHS, SO AT 10000 FT ON THIS APCH, I UNCOUPLED THE AUTOPLT. AS SOON AS I DID THE CAPT GOT UPSET AND SAID, 'WHAT ARE YOU DOING? WE HAVE TO LEAVE IT COUPLED!' WHICH IS NOT TRUE. NOT WANTING TO CREATE ANY CONFLICT, I RE-ENGAGED THE AUTOPLT. THEN HE MADE A COMMENT LIKE, 'OH, GO AHEAD AND HAND FLY IT.' I CHOSE NOT TO. WE ENTERED VMC CONDITIONS PRIOR TO THE FAF, AT WHICH POINT I QUIT REFING MY APCH PLATE. INSTEAD I WAS LOOKING OUT AT THE ARPT THINKING ABOUT LNDG ON RWY 8. I SOON REALIZED THAT 'THE PICTURE' DIDN'T LOOK RIGHT AND THAT WE WERE MUCH LOWER THAN WE SHOULD HAVE BEEN. WE WERE APCHING 800 FT MSL INSTEAD OF BEING AT 1270 FT WHERE WE SHOULD HAVE BEEN. WITHOUT HESITATION, I DISCONNECTED THE AUTOPLT AND AUTOTHROTTLES AND CLBED BACK UP TO 1000 FT MSL. AT THIS POINT WE WERE NEAR CGL NDB. ONCE PAST CGL I MADE THE TURN THROUGH 'THE CUT' TO LINE UP AND LAND ON RWY 8. I BELIEVE THAT THE PROB STEMMED FROM: 1) MY NEWNESS TO THE AIRPLANE. 2) BEING ON REVERSE AND VERY SELDOM FLYING (COMMON COMPLAINT WITH NEW B737-400 FO'S HERE AT ACR X). 3) SECOND TIME I'VE FLOWN THE APCH (FIRST TIME AS THE PF). 4) CAPT WAS VERY CTLING, NONSTANDARD (I'D BEEN INFORMED OF THIS THE DAY BEFORE BY A CHK AIRMAN AND ALSO TOLD BY THIS PERSON THAT 'A LOT OF FO'S DON'T LIKE TO FLY WITH THIS GUY') AND HE WAS ABRASIVE WHICH CAUSED ME TO MENTALLY DISTANCE MYSELF FROM THE COCKPIT. 5) CAPT 'PLAYED' BY HIS OWN RULES, WHICH MADE MATTERS VERY CONFUSING SINCE I WAS NEVER SURE WHAT HE WANTED AND HE COULDN'T RELATE WHAT HE WANTED. SINCE THE CAPT HAD BEEN AT ACR X FOR 14 YRS AND ACTED LIKE HE WAS VERY KNOWLEDGEABLE ABOUT FLYING IN SOUTHEAST ALASKA, I TENDED TO LET MYSELF BE LED LIKE A STUPID SHEEP OUT TO SLAUGHTER. I NEED TO NOT ALLOW MYSELF TO BE INTIMIDATED BY CAPTS LIKE THIS. ALTHOUGH I'M NEW AND RELATIVELY INEXPERIENCED IN THE AIRPLANE, I KNOW BETTER THAN TO STOP MONITORING THE COUPLED APCH, EVEN IN VMC.

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  50. Accession Number: 396430
    Synopsis: A B737-500 IS 2000 FT HIGH XING THE ASSIGNED INTXN DURING DSCNT INTO ZHU, TX, AIRSPACE.
    Narrative: WAS TOLD BY ZHU TO CROSS SMITH INTXN AT 10000 FT AND 250 KTS. HAD NOT PROGRAMMED COMPUTER FOR 10000 FT BUT HAD PROGRAMMED ILS RWY 27 AT IAH. COMPUTER STARTED ACFT DOWN BASED ON FINAL APCH FIX ALT WHICH PUT US 2000 FT HIGH AT 300 KTS AT SMITH. DIDN'T REALIZE I WAS HIGH UNTIL 8 MI OUTSIDE OF SMITH WHEN ZHU ASKED IF WE WOULD MAKE XING RESTR. PROB WAS CAUSED BY TWO OF MOST COMMON CAUSES. AUTOMATION COMPLACENCY ON MY PART, AND DISTR CAUSED BY FLT ATTENDANT BEING IN COCKPIT AT CRITICAL TIME.

  51.  
  52. Accession Number: 396950
    Synopsis: FO OF A B767 MISSET FMS DURING AN ARR STAR RESULTING IN EXCEEDING A SPD XING RESTR.
    Narrative: DSNDING ON THE CHINS 2 ARR IN SEA, VERY FAMILIAR WITH THIS PROC. I CONSIDER MYSELF ADEPT AT ALL LEVELS OF AUTOMATION ON B767 AND MOVE COMFORTABLY BTWN THE VARIOUS LEVELS. HAD PREVIOUSLY PROGRAMMED THE VNAV WITH 250 KT SPD AT AUBURN INTXN BUT WAS USING FLT LEVEL CHANGE. WHEN THE ACFT REACHED SELECTED ALT, IT REVERTED TO THE HIGH SPD SET IN THE MCP, AS IT IS PROGRAMMED TO DO. BOTH THE CAPT AND I WERE BUSY DURING THE ARR. AFTER PASSING AUBURN AND TURNING TO 340 DEG HDG, I REALIZED I HAD FAILED TO SLOW TO 250 KTS. THE TURN WAS FURTHER WIDENED BY THE FACT I HAD NEGLECTED TO DESELECT THE 2.5 DEG BANK ANGLE I USE ABOVE FL180 (AND NORMALLY RESET ON DSCNT THROUGH FL180). I BELIEVE APCH CAUGHT MY ERRORS WHEN THEY ASKED 'WERE YOU GIVEN THE CHINS ARR?' MINOR CONTRIBUTING FACTOR WAS AN INTERMITTENT AUTOTHROTTLE PROB THAT HAD SEEMED TO FIX ITSELF. PAYING CLOSE ATTN TO XING RESTRS AND WHERE THE AUTOMATION IS SET TO TAKE YOU IS THE ACTION NECESSARY TO PREVENT THIS TYPE OF OCCURRENCE.

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  54. Accession Number: 397100
    Synopsis: MLG ACFT WITH XING ALT RESTR IN DSCNT WAS HIGH ON PROFILE AND WAS NOT CAPTURED BY FMC. FLC REQUESTED AND RECEIVED A 360 DEG TURN TO LOSE ALT IN ORDER TO MAKE RESTR.
    Narrative: WE WERE CLRED TO CROSS PLSNT INTXN (PXR 321 DEG RADIAL 35 DME) AT 12000 FT AND 280 KTS. THE ACFT WAS IN VNAV AND APPEARED TO BE GRADUALLY DSNDING TO 12000 FT WHILE INTERCEPTING THE DSCNT PROFILE. APPARENTLY IT MISSED THE PROFILE AND WE WERE WAY HIGH AND FAST. WE WERE ABLE TO GET A 360 DEG AND DSCNT TO THE FIX FROM ZAB PRIOR TO HDOF. HAD WE BEEN ABLE TO GET UNDER THE PROFILE AND NOT TRY TO INTERCEPT IT FROM ABOVE, THE FLT PATH WOULD HAVE BEEN CAPTURED MORE EASILY. CONTRIBUTING FACTORS INCLUDE MY GETTING THE ATIS AND TROUBLESHOOTING SOME MINOR UNRELATED ELECTRICAL MALFUNCTIONS. I COULD HAVE QUERIED THE CAPT AS TO WHAT EXACTLY HE WANTED THE AIRPLANE TO DO. AS IT WAS, IT INITIALLY APPEARED THAT WE WERE GOING TO MAKE THE RESTR WITHOUT A PROB.

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  56. Accession Number: 399890
    Synopsis: B767-200 ACFT ON STAR ARRIVAL WAS GIVEN A NEW STAR. FLT CREW PROGRAMMED FMS FOR THE NEW ARRIVAL, BUT DIDN'T MAKE THE CROSSING RESTRICTION ON THE NEW ARRIVAL.
    Narrative: APPROACHING CIVIT INTXN OUR ARRIVAL WAS CHANGED FROM THE CIVET TO THE MITTS ARRIVAL WITH INSTRUCTIONS FOR INTERCEPTING THE RWY 24R LOCALIZER. THE FMS WAS PROGRAMMED (I THOUGHT) FOR THE MITTS AND WE WERE CLRED FOR THAT ARRIVAL. APPROACHING MITTS INTXN, MY CO-PLT ADVISED ME THAT IT LOOKED AS IF THE ACFT WAS NOT PROPERLY DSNDING. I CHECKED THE HSI AT THE SAME TIME AS A FLT ATTENDANT ENTERED THE COCKPIT AND I MISINTERPRETED THE DISPLAY AS BEING OK. IT WASN'T. WE CROSSED MITTS ABOUT 600 FT HIGH. I REESTABLISHED THE CORRECT VERT PATH AND NOTICED THAT THE 'EXEC' LIGHT ON THE FMS WAS ILLUMINATED. THIS ARRIVAL IS A RELATIVELY NEW AND NOT OFTEN USED PROC. THIS INCIDENT RESULTED FROM THE LAST MINUTE CHANGE IN ARRIVAL, A POSSIBLE ERROR IN PROGRAMMING THE FMS, AN INTERRUPTION IN THE COCKPIT, AND MY UNFAMILIARITY WITH THE PROC.
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