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Incidents related to Issue 7 incidents related to this issue.

Issue: failure recovery may be difficult (Issue #23)
Description: When automation fails, pilots may have difficulty taking over monitoring, decision making, and control tasks.

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  2. Accession Number: 237133
    Synopsis: AUTOPLT FAILURE CAUSED WDB TO DSND AND EXCEED MAX SPD.
    Narrative: AFTER DEPARTING SFO WITH CAPT FLYING, I ENGAGED #1 AUTOPLT IN VERT SPD MODE AT APPROX 10000 FT. SET VERT SPD AT 1000 FPM CLB TO ACCELERATE TO TARGET CLB SPD OF 309 KTS. AT 309 KTS I ENGAGED IAS HOLD FUNCTION OF FLT GUIDANCE SYS AND FLT GUIDANCE SYS ANNUNCIATOR PANEL SO INDICATED. SPD CONTINUED TO BUILD, BUT FLT DIRECTOR PITCH COMMAND BAR OVERLAID THE ACFT INDICE ON THE ADI, INDICATING THAT THE IAS HOLD WAS STILL ENGAGED. AS SPD INCREASED, I TRIED TO REGAIN CTL OF AIRSPD WITH VERT SPD WHEEL. AT THIS POINT, 'VERT SPD' SHOWED IN FLT GUIDANCE SYS ANNUNCIATOR AND FLT DIRECTOR PITCH BAR OVERLAID THE ACFT INDICE. ALTHOUGH AUTOPLT OUT OF TRIM LIGHT DIDN'T ILLUMINATE, I WAS CONCERNED ABOUT DISCONNECTING AUTOPLT AFTER SUDDEN SPD BUILDUP. STABILIZER TRIM INDICATOR DIDN'T SEEM TO BE MOVING. I FEARED EXCESSIVE STRUCTURAL LOAD IF AUTOPLT WAS DISCONNECTED WITH ACFT OUT OF TRIM AT SPD IN EXCESS OF VMO. AS AIRSPD APCHED 390 KTS, I REDUCED THRUST TO NEAR IDLE AND DISCONNECTED AUTOPLT. THERE WAS NO OUT OF TRIM LURCH. NORMAL CLB WAS RESUMED ON AUTOPLT #2 AND SFO MM (SAM) WAS SUBSEQUENTLY NOTIFIED OF ELECTRO- MECHANICAL IRREGULARITY. SUPPLEMENTAL INFO FROM ACN 237134: NONE OF US HEARD THE AIRSPD CLACKER GO OFF AS WE PASSED VMO (BARBERPOLE ALS). MAINT WAS CALLED, THE #1 AUTOPLT WAS TAGGED OTS, AND A LOGBOOK ENTRY WAS MADE. WE WERE CLRED TO CONTINUE WITH THE #1 AUTOPLT INOP. THE REMAINDER OF THE FLT TO KONA AND BACK WAS UNEVENTFUL. THE PROB HERE IS THAT WE WERE SO ENGROSSED IN THE CAUSE OF THE PROB THAT NONE OF US THOUGHT ABOUT THE AIRSPD EXCURSION ABOVE VMO. THE AIR WAS VERY SMOOTH AND WE NEVER FELT ANY 'G' DURING THE ACCELERATION OR THE DECELERATION SO NONE OF US FELT THE OVERSPD WAS A CONCERN. CORRECTIVE ACTION MIGHT BE TO INCLUDE CLEAN OVERSPD PROCS IN THE FOM/FLT HANDBOOK TO INCLUDE THE NECESSITY FOR AN OVERSPD INSPECTION AND NOTIFICATION GIVEN TO MAINT OF THE OVERSPD. WE MAY ALSO WANT TO INCREASE CLACKER VOLUME SO WE HEAR IT BETTER. THE CLACKER WAS WORKING, BUT WAS NOT LOUD ENOUGH TO HEAR WITH ALL SYS AND ENGS RUNNING. WE ALSO NEED AN 'MRM' CODE FOR AN OVERSPD. SUPPLEMENTAL INFO FROM ACN 237135: THE ACFT EXCEEDED THE VMO BY APPROX 40 KIAS.

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  4. Accession Number: 252461
    Synopsis: FLC OF A WDB ACR ACFT BECAME DISTRACTED BY A MALFUNCTIONED AUTO THROTTLE CTL INPUT AND FAILED TO TURN AS REQUIRED BY SID RESULTING IN LESS THAN LEGAL SEPARATION TO ANOTHER DEPARTING ACFT ON SEPARATE PARALLEL RWYS.
    Narrative: WE DEPARTED ON RWY 25R AT LAX AND OUR CLRNC WAS FOR A LOOP 9 DEP TO MAINTAIN 2000 FT. THE LOOP 9 DEP CALLS FOR A TURN TO A HDG OF 235 DEGS UPON XING THE SANTA MONICA VOR (SMO) 160 DEG RADIAL. THIS IS AN AUTOMATED AIRPLANE SO WE WERE USING THE FLT DIRECTOR AND AUTO THROTTLES. THE TKOF WAS NORMAL. WE LEVELED AT 2000 FT, AND THE AUTO THROTTLES CAME BACK AND SET THE THRUST TO MAINTAIN 250 KIAS. JUST PRIOR TO XING THE SMO 160 DEG RADIAL, LAX DEP CTL ISSUED US A CLB CLRNC. IN ACCORDANCE WITH OUR FLT MANUAL PROC, I COMMANDED THE FO TO PUSH THE FLT LEVEL CHANGE BUTTON ON THE MODE CTL PANEL AND SET 250 KTS IN THE SPD WINDOW: 'FLCH 250.' PUSHING THE 'FLCH' BUTTON CAUSES THE AUTO THROTTLES TO MOVE THE THRUST LEVERS TO CLB THRUST, AND IT ALSO CAUSES THE PITCH COMMAND BARS TO COMMAND AN ANU PITCH THAT WILL MAINTAIN THE SELECTED SPD (IN THIS CASE 250 KTS). FOR SOME REASON, THE AUTO THROTTLES DID NOT RESPOND. THEY REMAINED AT THEIR PRESENT THRUST SETTING AND THE ACFT DID NOT GO INTO A CLB MODE. WE WERE DISTRACTED BY THIS MALFUNCTION AND WERE LATE IN INITIATING OUR TURN TO 235 DEGS. BECAUSE OF OUR LATE TURN AND BECAUSE OF THE FACT THAT WE WERE ALSO LATE IN STARTING OUR CLB, WE CAME CLOSE ENOUGH TO TFC THAT HAD DEPARTED RWY 24L THAT WE GOT AN RA ON OUR TCASII SYS. THE FO MADE VISUAL CONTACT WITH THE TFC AND ESTIMATED THAT OUR LATERAL SEPARATION WAS AROUND 6000 FT AND THE TCASII READOUT INDICATED A VERT SEPARATION OF 400 FT. WE MANUALLY SET THE THROTTLES TO CLB THRUST, AND AS SOON AS WE INITIATED THE TURN AND STARTED THE CLB THE RA ENDED.

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  6. Accession Number: 362571
    Synopsis: PIC OF AN MLG SETS COCKPIT UP FOR A CAT III APCH. SELECTS #2 AUTOPLT PRIOR TO ARMING THE APCH MODE. AUTOPLTS DISCONNECT AND ACFT GOES THROUGH LOC, CREATING A POTENTIAL CONFLICT LTSS WITH ACFT Y.
    Narrative: FOR CERTIFICATION PURPOSES IT WAS DECIDED THAT THE CAPT (PF) WOULD EXECUTE THE CAT III AUTOLAND TO RWY 36L AT CVG. CONDITIONS WERE DAYTIME AND VFR, APCH AGREED TO OUR REQUEST. AFTER BEING GIVEN A HEADING TO INTERCEPT THE FINAL APCH COURSE THE CAPT SELECTED THE SECOND AUTOPLT BEFORE ARMING THE 'APCH MODE.' THIS WAS INCORRECT AND CAUSED BOTH AUTOPLTS TO DISENGAGE. THIS THEN LED TO SOME CONFUSION IN THE COCKPIT AS WE ATTEMPTED TO CORRECT THE PROB. DURING THIS TIME WE WERE STILL ON OUR ASSIGNED INTERCEPT HEADING AND ULTIMATELY OVERSHOT THE FINAL APCH COURSE. THERE WAS PARALLEL TFC INBOUND TO RWY 36R WHICH WE CAME WITHIN 1 MI OF AND LED TO A TA FROM TCASII. AT THIS TIME WE ABANDONED THE AUTOLAND APCH, CORRECTED BACK TO THE FINAL APCH COURSE AND CONTINUED A MANUAL APCH. NO EVASIVE ACTION WAS NEEDED. THE DISENGAGEMENT OF THE BOTH AUTOPLTS WAS A DISTR FOR BOTH OF US WHICH LED TO REDUCED SITUATIONAL AWARENESS. SUPPLEMENTAL INFO FROM ACN 362570: I DECIDED TO FLY AN AUTOLAND APCH IN ORDER TO FINISH MY CERTIFICATION FOR CAT III OPS.

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  8. Accession Number: 395563
    Synopsis: A320 ACFT ARRIVING FOR APCH HAD DUAL FMGC TIMEOUTS WHICH CAUSED LOSS OF AUTOPLTS, AUTOTHRUST, FLT DIRECTORS AND NAV DISPLAYS. PNF, CAPT BECAME DISTR IN RESETTING THE FMGC'S AND FLC LANDED WITHOUT TWR CLRNC.
    Narrative: FLYING DIRECT TO FAF IN A320 ACFT, BOTH FMGC'S TIMED OUT CAUSING LOSS OF AUTOPLTS, AUTOTHRUST, FLT DIRECTORS, AND ALL NAV DISPLAY. NOTIFIED ATC OF LOSS AND RECEIVED VECTORS FOR VISUAL APCH. I WAS PF AND AM NEW IN THIS TYPE ACFT, SO ALL THE LOSSES OF DATA AND AIDS FORCED ME TO CONCENTRATE HEAVILY ON FLYING ACFT MANUALLY. CAPT HANDLED RADIOS AND WORKED ON GETTING FMGC'S BACK ON LINE. PROCEEDED TO LAND NORMALLY WITHOUT A CHANGE IN ACFT STATUS. UPON TAXIING CLR OF RWY, I CALLED TWR TO SAY WE WERE CLR, BUT RADIO WAS STILL TUNED TO APCH. I SUSPECT WE LANDED WITHOUT TALKING TO TWR OR GETTING CLRNC. WHEN WE CALLED GND CTL NO ONE SAID ANYTHING TO US, AND WE DID NOT PUSH THE ISSUE. APPARENTLY CAPT WAS ENGROSSED WITH MALFUNCTION AND FAILED TO CALL TWR PRIOR TO LNDG, AND WITH MY EXTRA CONCENTRATION ON FLYING MANUALLY, I FAILED TO CATCH IT. I THINK CHKLISTS FOR EVEN NORMAL OPS SHOULD HAVE 'LNDG CLRNC RECEIVED' AS PART OF THE LNDG/FINAL CHKLIST. I AM NOT AWARE OF ANY AIRLINES DOING THIS NOW.

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  10. Accession Number: 407712
    Synopsis: A B737-400 ON APCH TO CLT, NC, HAS A 30 DEG BANK COMMANDED BY THE AUTOFLT SYS. FLC HAS DIFFICULTY DISCONNECTING THE AUTOPLT BUT WHEN IT IS DISCONNECTED, THEY ENCOUNTER A TCASII RA.
    Narrative: APCHING CLT TERMINAL AREA OFF OF THE MAJIC ARR WE WERE GIVEN A VECTOR OF 210 DEGS TO INTERCEPT THE LOC BACK COURSE RWY 23 APCH. WE WERE 16.5 MI FROM THE CLT VORTAC AND LEVELING AT 4000 FT MSL. THE RWY AND ARPT ENVIRONMENT WERE IN SIGHT AT THIS TIME AND COURSE WAS SLOWLY INTERCEPTING WHEN THE ACFT BANKED SUDDENLY TO THE L IN A 30 DEG BANK OPPOSITE OF INTENDED PATH. MODE CTL PANEL WAS SET UP ON LEVEL CHANGE FOR DSCNT AND HEADING FOR ROLL AT THE TIME. ACFT AUTOPLT FAILED TO DISCONNECT ON THE YOKE UNTIL 6-10 ATTEMPTS WERE MADE. ATC ORDERED AN IMMEDIATE CLB TO 5000 FT MSL, WHICH WAS THEN FOLLOWED BY A TCASII ALERT. I CLBED IMMEDIATELY AT THAT TIME TO AVOID THE CONFLICT. I APPLIED FIREWALL PWR AND A 30 DEG PITCH ATTITUDE. SUBSEQUENTLY, A ROUTINE APCH AND LNDG WAS MADE. AN APPROPRIATE LOGBOOK ENTRY WAS MADE UPON ARR AT THE GATE.

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  12. Accession Number: 409730
    Synopsis: ACR MD88 FLC EXPERIENCED AN AC ELECTRICAL BUS FAILURE ON DEP, DRIFTING OFF COURSE UNTIL SYS FAILURE COULD BE OVERCOME. FLT RETURNED TO LAND WITHOUT FURTHER DIFFICULTY.
    Narrative: DURING CLB, LOST L AC ELECTRICAL BUS BAR, THUS AUTOPLT, AUTOTHROTTLES AND COURSE GUIDANCE DISAPPEARED. TOOK A WHILE TO FIND ANOTHER WAY TO MONITOR COURSE. DURING THIS TIME, THE SID COURSE HAD CHANGED AND AS A RESULT, WE WERE OFF COURSE, PROBABLY A COUPLE OF MI. THERE WAS NO LOSS OF SEPARATION. IT JUST TOOK A WHILE AFTER LOSING FMS AND MAP TO FIGURE OUT HOW TO USE CDI WITHOUT COURSE SELECT WINDOW WORKING. SUPPLEMENTAL INFO FROM ACN 410003: ZFW QUERIED US STATING HE SHOWED US ABOUT 4 MI N OF COURSE. AN APPARENT EQUIP PROB WITH OUR ACFT FMS. DEAD RECKONING MESSAGES STARTED TO APPEAR. MAP DISPLAYS WERE SHIFTED NOTICEABLY TO THE L. FMS VOR AND DME UPDATING FUNCTIONS WERE NOT OPERATING PROPERLY. UPDATED POS OVER KNOWN POINT AND ALL MALFUNCTIONS RETURNED TO NORMAL.

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  14. Accession Number: 414510
    Synopsis: A SAAB 340 WAS VECTORED TO TURN ON FINAL THAT WAS TOO SHORT FOR ILS RECEIVER TO CAPTURE SIGNAL. CREW WAS NOT GIVEN FREQ CHANGE TO TWR BEFORE PRELNDG COCKPIT DUTIES DISTR THEM FROM REQUESTING LNDG CLRNC.
    Narrative: BEING VECTORED FOR ILS APCH TO PITTSBURGH. FINAL CTLR TURNED US ON TIGHT. AUTOPLT DIDN'T CAPTURE LOC AND WE DIDN'T CAPTURE GS BECAUSE LOC WASN'T CAPTURED. CALLED FOR FLAPS 15 DEGS, AUTOPLT DIDN'T HOLD ALT. DISENGAGED AUTOPLT AND BEGAN HAND FLYING INSIDE FAF. FO HAD LESS THAN 100 HRS IN ACFT. WE WERE VERY BUSY ON SHORT FINAL AND THE FINAL APCH CTLR NEVER HANDED US OVER TO TWR. WE WERE VERY BUSY AND LANDED WITHOUT CONTACTING THE TWR.
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