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Incidents related to Issue 28 incidents related to this issue.

Issue: failure assessment may be difficult (Issue #25)
Description: It may be difficult to detect, diagnose, and evaluate the consequences of automation failures (errors and malfunctions), especially when behavior seems 'reasonable', possibly resulting in faulty or prolonged decision making.

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  2. Accession Number: 62623
    Synopsis: TRACK DEVIATION AND UNAUTH PENETRATION OF AIRSPACE BY FLT. FAA NOTICE OF VIOLATION FOR DEVIATION TO ANOTHER FLT.
    Narrative: WHILE NAVIGATING ON FMS AND SBND ON A DIRECT CLRNC FROM NATLE TO SWL (J174) CENTER NOTIFIED US OF AN EASTWARD EXCURSION TOWARD THE WARNING AREA. THEY GAVE US A 270 DEG HDG FOR CORRECTION WHICH WE IMMEDIATELY COMPLIED WITH. APPARENTLY OUR NAV SYSTEM HAD MALFUNCTIONED AND THE STRONG WEST WIND (270/130 KTS) CAUSED AN UNDETECTED COURSE DEVIATION. I RECOMMEND CLOSER MONITORING OF AUTOMATIC EQUIPMENT BY FLT CREWS AND CLOSER MONITORING OF COURSE TRENDS BY ATC ON AIRWAYS THAT ARE SO CLOSE TO WARNING AREAS. SUPPLEMENTAL INFORMATION FROM ACN 62624: I WAS NOTIFIED OF POSSIBLE ALLEGED PENETRATION OF WARNING AREA 108. THE F/O AND I EACH VERIFIED THE PROGRAMMING AND OPERATION OF OUR OMEGA NAV AND ALL OTHER NAVIGATION EQUIPMENT PRIOR TO DEPARTURE. IN FLT, THE VOR/DME ALSO VERIFIED THE ACCURACY OF OUR OMEGA. WE WERE NEVER QUESTIONED BY ATC CONCERNING OUR FLT TRACK OR WAS ANY MENTION OF PROBLEMS OF OUR NAVIGATION IN OR NEAR ANY WARNING/RESTRICTED AREAS EVER MADE TO US. TO THE BEST OF OUR KNOWLEDGE, WE DID NOT PENETRATE ANY RESTRICTED/WARNING AREA. WHILE ON WASHINGTON CENTER, WE DO RECALL A QUITE ACTIVE AND ANIMATED CONVERSATION BETWEEN ATC AND SOME OTHER FLT WHICH, ACCORDING TO ATC, WAS EITHER NEAR OR ALREADY IN SOME WARNING/RESTRICTED AREA. I DO NOT RECALL THE FREQ OR THE ID OF THE OTHER ACFT SINCE IT DID NOT CONCERN OUR FLT BUT THE ATC TAPES SHOULD HAVE THAT INFO.

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  4. Accession Number: 66046
    Synopsis: ACR WDB ALT DEVIATION OVERSHOT DURING DESCENT.
    Narrative: F/O FLYING THIS SEGMENT ON AFDS (AUTOPLT F/D SYSTEM). ENROUTE ATL-CVG. ON DESCENT INTO CVG, ATC HAD CLEARED OUR FLT DIRECT FLM, DIRECT CVG, WITH AN INTERIM CLRNC TO DESCEND TO FL240. DESCENDING THROUGH FL245+, AN UNACCOUNTED FOR ELEVATOR SERVO INPUT DISCONNECTED THE AUTOPLT WHILE SIMULTANEOUSLY NUMEROUS HYDRAULIC AND ELECTRICAL ABNORMAL INDICATIONS OCCURRED. EICAS (ENGINE INDICATING AND CREW ALERT SYSTEM) CRT MESSAGES FILLED UPPER SCREEN AND 3 MAINTENANCE MESSAGES APPEARED ON LOWER CRT -- "FUEL QUANTITY CHANNEL", "AUTO 2 CABIN ALT", AND "AIR/GND DISAGREE". CENTER HYDRAULIC PRESS LOW LIGHTS AND UTILITY ELECTRICAL BUS INOP LIGHTS CAME ON ON OVERHEAD PANEL. ALERT MESSAGES APPEARED SO RAPIDLY THEY COULD NOT ALL BE UNDERSTOOD ESPECIALLY IN VIEW OF THE FACT THAT NEITHER THE F/O NOR MYSELF HAD BEEN FLYING ACFT TYPE FOR MORE THAN 150 HRS TOTAL. THE F/O RESUMED MANUAL CONTROL OF THE ACFT AS I TURNED ON THE APU PRECAUTIONARY TO AN AC BUS OR GENERATOR LOSS. IT WAS AT THIS TIME THAT I REALIZED THE ACFT HAD DESCENDED THROUGH FL240. I ALERTED THE F/O AND TOOK CONTROL, STOPPING THE DESCENT AT FL235. F/O RESUMED CONTROL AND CLIMBED BACK TO FL240. WHEN THE APU CAME ON LINE ALL SYSTEMS RETURNED TO NORMAL. ONLY THE 3 EICAS MESSAGES ON THE LOWER CRT REMAINED. REMAINDER OF THE FLT WAS ROUTINE. ON GND IN CVG, MECHANICS SUSPECTED CAUSE OF OCCURRENCE WAS INDICATIVE OF AN ENGINE GENERATOR ATTEMPTING TO DISCONNECT ITSELF FROM THE AC SYSTEM. THIS PARTICULAR WDB HAD HAD A HISTORY OF SPURIOUS ELECTRICAL QUIRKS THAT ALWAYS SEEMED TO CORRECT THEMSELVES. THIS TYPE OF OCCURRENCE IS NOT OVERLY TROUBLESOME IN A 3 PLT COCKPIT. IN A 2 PLT ENVIRONMENT IN WHICH WHAT WAS FORMERLY THE SECOND OFFICER/FLT ENGINEERS FUNCTIONS ARE NOW TOTALLY AUTOMATED, AN APPARENT FAILURE OF THE AUTOMATION IS PARTICULARLY DISTRACTING TO THE CAPT AND F/O. THE CREW MEMBER FLYING BECOMES IMMEDIATELY ABSORBED IN DETERMINING WHICH FLT INSTRUMENTS ARE RELIABLE WHILE THE REMAINING CREW MEMBER SEEKS THE SOURCE OF THE PROBLEM. THIS RESULTS IN A BRIEF INTERVAL WHEN HDG AND ALT ARE OF SECONDARY CONCERN. STABILIZED FLT IS FIRST. EMPHASIS ON HDG AND ALT RETURNS ALMOST IMMEDIATELY BUT ONLY AFTER THE PRIMARY CONCERN IS CONFIRMED. ALT EXCURSIONS OCCUR DURING THESE BRIEF PERIODS, UNLESS SUCH AN ABNORMALITY OCCURS IN STABILIZED STRAIGHT AND LEVEL FLT. A 2 PLT CREW CONCEPT WORKS GREAT, BUT ONLY AS LONG AS THE AUTOMATIC BLACK BOX ITEMS WHICH HAVE REPLACED THE S/O ARE FEEDING THE CAPT AND F/O ACCURATE INFO.

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  6. Accession Number: 67462
    Synopsis: ACR MLG OVERSHOT ALT ON CLIMG.
    Narrative: THE ACFT HAD BEEN WRITTEN UP BY THE PREVIOUS CREW AS HAVING AN INTERMITTENT #1 VHF. IT WAS REPLACED IN MEM PRIOR TO OUR DEP AND APPEARED TO OPERATE NORMALLY WHEN WE CHECKED IT. THE AUTOLAND CHECK INDICATED THE AUTOPLT SYSTEM WAS OK ALSO. AFTER TKOF I ATTEMPTED TO ENGAGE THE #1 AUTOPLT. IT WOULD NOT ENGAGE. (OUR #1 VHF APPEARED TO WORK NORMALLY WHEN IN FACT IS WAS CUTTING IN AND OUT.) IN AN EFFORT TO RESTORE THE AUTOPLT SYSTEM, AS NEITHER #1 NOR #2 WOULD ENGAGE, WE WENT THROUGH THE NORMAL CIRCUIT BREAKER PULL AND RESET ROUTINE AS WELL AS SWITCHING FLT DIRECTOR AND AIR DATA COMPUTERS FROM BOTH POSITION TO #1 AND #2 POSITION. DURING THE PROCESS WE "DUMPED" THE DIGITAL FLT GUIDANCE COMPUTER OFF THE LINE AND RESTORED IT WHEN THE CIRCUIT BREAKERS WERE RESET. ABOUT THE TIME WE WERE GOING THRU 22000-23000' I WAS ABLE TO ENGAGE THE #2 AUTOPLT, BUT FAILED TO NOTE THAT THE ALT READ 27000' ON THE DFGS (WHICH WAS NOT THE ALT WE HAD SET IN OR WERE CLRD TO). ALSO ABOUT THIS SAME TIME WE RECEIVED A CALL FROM MEM CENTER ASKING IF WE READ THEM. MY F/O ANSWERED TO THE AFFIRMATIVE AND THEN MEM CENTER SAID IT WAS HIS 4TH CALL TO US AND THAT WE WERE SUPPOSED TO LEVEL AT 24000'. I LOOKED UP FROM MY #1 VHF TO THE ALTIMETER JUST AS IT WAS READING 24000' (OUR INDICATED AIRSPEED APPROX 320 KIAS WITH ABOUT 1500-2000 FPM RATE OF CLIMB). I DISCONNECTED THE AUTOPLT AND PUSHED THE ACFT OVER TO STOP THE CLIMB AT ABOUT 24700', THEN LEVELED AT 24000'. I DO NOT BELIEVE WE SET 27000' IN THE DFGS EITHER ACCIDENTALLY OR ON PURPOSE. AFTER TALKING TO OUR MECHANICS IN NEW YORK, I LEARNED THAT IF THE DFGS COMPUTER IS "DUMPED" AND COMES BACK ON THE LINE, THAT IT CAN RESET TO A RANDOM ALT, NOT NECESSARILY THE ALT TO WHICH IT HAD BEEN SET PRIOR TO BEING "DUMPED". THE POINT IS THAT THE DFGS ALT READOUT SHOULD EITHER GO TO ALL ZEROS AFTER BEING DUMPED AND COMING BACK ON THE LINE, OR RETURN TO THE PREVIOUSLY SET ALT. IF A FLT CREW DOES NOT CATCH THE ERROR OR RANDOM ALT SELECTED BY THE DFGS WHEN IT COMES BACK ON THE LINE, THE RESULT COULD BE DISASTROUS.

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  8. Accession Number: 74831
    Synopsis: ACR WDB SPEED DEVIATION AND ALT DEVIATION EXCURSION FROM CLRNC ALT.
    Narrative: TRIP LEFT TUS AND CLIMBED TO FL410 FOR THE LEG TO ATL. THE RIGHT ENGINE (OVER SPEED/OVER TEMP) LIMITER WAS INOP AND CARRIED ON THE C.I. LIST. NEAR MEI, I NOTICED THAT THE LEFT FMC HAD FAILED. THE RIGHT FMC LOOKED NORMAL, SO I DISCONNECTED THE LEFT AUTOPLT AND CONNECTED UP THE RIGHT AUTOPLT. I RESET THE CIRCUIT BREAKERS FOR THE LEFT FMC, IT CAME BACK ON AND LOOKED NORMAL. A FEW SECONDS LATER, WE HEARD AN AURAL WARNING TONE AND EICAS MESSAGE APPEARED ON THE CENTER CRT, "AUTOPLT". I DISCONNECTED THE AUTOPLT AND NOTICED THAT THE AUTOTHROTTLE AIRSPEED BUG WAS SET TO APPROX 240 KTS, BUT THE AIRSPEED POINTER WAS DOWN TO APCH 200-210 KTS. BY THE TIME THE AUTOPLT WARNING MESSAGE HAD APPEARED THE ACFT HAD DESCENDED TO FL407. I ASKED THE F/O TO CALL MEMPHIS ATC AND REQUEST FL370. I THEN PUSHED BOTH THROTTLES FORWARD TOWARDS THE CRUISE EPR LIMIT BUGS. BY THE TIME DESCENT CLRNC WAS RECEIVED, THE ACFT HAD DESCENDED TO APPROX FL405. WE THEN DESCENDED, REGAINING AIRSPEED, DOWN TO FL370. DURING DESCENT, THE F/O NOTED THAT THE RIGHT ENGINE HAD OVERTEMPED SO I RETARDED THE THROTTLE TO REDUCE THE EGT. THE LEFT ENGINE HAD NOT EXCEEDED ITS LIMITS, DUE TO ITS LIMITER BEING OPERATIVE. AT FL370, AUTOPLT AND FMC WAS RECONNECTED AND TRIP WAS CONTINUED TO ATL WITH NO OTHER PROBLEMS. I CAN ONLY GUESS AT WHAT CAUSED THE ACFT TO SLOW DOWN WAS WHEN THE LEFT FMC FAILED, THE THROTTLES MAY HAVE RETARDED SOMEWHAT AND THEN STOPPED GETTING THRUST COMMANDS FROM THE FMC SYSTEM. THE AUTOPLT WAS ATTEMPTING TO HOLD ALT AS THE SPEED WAS DECREASING AND FINALLY GAVE UP AND SOUNDED THE WARNING AFTER ALT WENT BELOW FL410.

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  10. Accession Number: 109569
    Synopsis: ACR MLG SPEED DEVIATION. NON ADHERENCE TO SPEED RESTRICTION BELOW 10000'.
    Narrative: AFDS/FMC CAUSED ACFT TO ACCELERATE TO APPROX 285K BELOW 10,000' (APPROX 9500' MSL). CREW DISTRACTED BY OTHER DUTIES OR CORRECTIVE ACTION COULD HAVE BEEN MADE SOONER. THERE IS NO ALERT IF AFDS FAILS. NO SPEED WAS INDICATED IN WINDOW. COULD NOT SET BUG WITH AFDS SPEED KNOB. ACFT WAS FLOWN MANUALLY WITH NO OTHER INCIDENT.

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  12. Accession Number: 110142
    Synopsis: ADVANCED TECHNOLOGY ALT SELECTOR SPONTANEOUSLY CHANGED 1000' CAUSING ALT DEVIATION.
    Narrative: CLRED AFTER TKOF TO CLB ON S COURSE OF ILS (164 DEGS) TO 15000', ETC. ACFT IS MLG WITH FMC, AUTOPLT, ETC. ALT ON MCP OF AUTOPLT FLT DIRECTOR SYS (AFDS) WAS SET AT 15000' AND SHOULD GIVE NORMAL AUDIO & VIS WARNINGS APCHING AND ALSO IF AUTOPLT ENGAGED, LEVEL ACFT AT SET ALT. THE ALT IS SET BY MANUAL DRUM KNOB AND INDICATED ELECTRONICALLY. IT IS PART OF A SYS. THE COPLT WAS FLYING AND WE BOTH ASCERTAINED THE ALT SET AT 15000'. SOMETIME DURING CLB THE ALT SET (15000') IN MCP CHANGED TO 16000'. WE WERE DETRACTED OUTSIDE LOOKING FOR TFC AND COPLT NAVIGATING AND DID NOT REALIZE ALT CHANGE UNTIL APCHING 15000'. AS COPLT FLEW THROUGH 15000' AND TRYING TO SMOOTHLY CORRECT ERROR WE WERE CLRED HIGHER. WE OBVIOUSLY BOTH WERE SURPRISED TO SEE 16000' ALT SELECTED. I LATER CALLED RNO DEP CTLR (HE WAS A SUPVR) AND DISCUSSED THE SITUATION WITH HIM. HE DID AN EXCELLENT JOB AND WAS VERY PROFESSIONAL AND CAPABLE. HE SAID HE COULD SEE THE PROB COMING AND THERE WAS NO INCIDENT OR ANYTHING FURTHER. I DESIRE HE & ATC NOT BE BROUGHT INTO THIS AS WE HAD A VERY RESPECTFUL ATTITUDE OF COOPERATION AND TRUST AND I WOULDN'T WANT TO DAMAGE THAT. THE PROC OCCURRED WHEN WE WERE BUSY AND OCCUPIED WITH NUMEROUS OBLIGATIONS. TRUE, WE SHOULD NOT COMPLETELY RELY ON AN ALT WARNING AND AUTOMATIC LEVEL OFF, BUT AT TIMES, POSSIBLE DUE TO COMPLACENCY, WE DO RELY ON IT. FORTUNATELY IN THIS CASE, NOTHING SERIOUS OCCURRED, BUT IT COULD. MAINT ADVISED THIS HAS OCCURRED BEFORE W/THE SYS. A FIX SHOULD BE FOUND & IMPLEMENTED.

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  14. Accession Number: 137229
    Synopsis: ACR ADVANCE COCKPIT LGT OVERSHOOTS ALT BY 700' DURING CLIMB, PARTLY AS A RESULT OF AUTOTHROTTLE MALFUNCTION.
    Narrative: AFTER TKOF FROM DTW WE WERE TOLD TO MAINTAIN 250 KTS AND TO CLB TO 13000'. PASSING THROUGH 10000' I SELECTED 250 KTS ON THE AUTOPLT "SPD SELECT". THE INDICATION ON THE FCU (FLT CTL UNIT) SHOWED THAT SELECTED SPD OF 250 KTS WOULD BE MAINTAINED, HOWEVER THE ACFT CONTINUED TO ACCELERATE AS IF IT WERE STILL IN "MANAGED" SPD. IT CONTINUED TO ACCELERATE. WHEN WE GOT THE OVERSPD WARNING THE AUTOPLT KICKED OFF. IN TRYING TO DETERMINE WHAT WAS HAPPENING WITH THE AUTOPLT/AUTOTHRUST SYS THE ACFT WAS ALLOWED TO CLB TO 13700'. I DISCONNECTED THE AUTOTHROTTLES AND PULLED THE PWR OFF AND DSNDED BACK TO 13000'. THE AUTOPLT WAS RECONNECTED AS WERE THE AUTOTHROTTLES AND EVERYTHING WORKED O.K. EVEN AT A SELECTED SPD OF 250 KTS. WE WERE THEN GIVEN 16000' AS AN ALT AND WHEN A "LEVEL CHANGE" WAS MADE EVERYTHING WORKED NORMAL. I STILL DON'T KNOW WHAT THE PROB WAS UNLESS THE AUTOTHRUST SYS WAS NOT ACTIVE AND WE HAD NO INDICATION THAT IT WAS NOT ENGAGED. IT SHOULD HAVE BEEN ENGAGED OR SOME INDICATION THAT IT WASN'T ENGAGED. THIS WAS ONLY MY SECOND TRIP ON THE LGT AFTER MY INITIAL CHKOUT AND IT CAME AFTER BEING OFF FOR 2 WKS. HOWEVER, THE F/O AND I DISCUSSED THE SITUATION AND NEITHER OF US KNOWS WHY THE AUTOTHRUST SYS DID NOT RESPOND PROPERLY. I DID NOTICE THAT THE EXTREME LEFT HAND COLUMN ON THE FMA WAS BLANK BUT IN THE CONFUSION FAILED TO NOTICE IN THE FAR RIGHT HAND COLUMN OF THE FMA WHETHER THE AUTOTHRUST WAS ENGAGED. I ASKED THE F/O IF HE COULD HAVE ACCIDENTALLY DISCONNECTED THE AUTOTHRUST WHEN I ASKED HIM TO ENGAGE THE AUTOPLT WHEN WE LEFT 3000' AGL SINCE THE AUTOTHRUST ENGAGE/DISENGAGE PUSHBUTTON IS RIGHT NEXT TO THE AUTOPLT PUSHBUTTON. HE SAID "HE DIDN'T THINK SO". THIS WHOLE INCIDENT PROBABLY WOULD NOT HAVE HAPPENED IF I HAD BEEN MORE OBSERVANT OF THE FMA (FLT MODE ANNUNCIATOR) INDICATIONS.

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  16. Accession Number: 142355
    Synopsis: ACR MLG TRACK DEVIATION USING IRS NAVIGATION SYSTEM.
    Narrative: ACFT WAS RPTED BY ATC AS 4 MI N OF COURSE. IRS NAV SHOWED ON COURSE. WHEN WE SWITCHED TO VOR'S TO VERIFY COURSE, WE FOUND ATC WAS CORRECT. SHORTLY THEREAFTER, WE GOT FMC MESSAGE, "VERIFY POS." SOMEHOW AN ERROR HAD ENTERED THE IRS NAV SYS AND THE MESSAGE WAS NOT DISPLAYED ON THE FMC BEFORE ATC HAD NOTED THE 4-5 MI ERROR. VOR/ILS WAS USED FOR THE REST OF THE FLT.

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  18. Accession Number: 152852
    Synopsis: ACR MLG TRACK HEADINTG DEVIATION. THE FMC HAD FAILED AND THE FLT CREW SAYS THEY ARE NOT ACCUSTOMED TO TRACKING AN AIRWAY USING 'JUST CHARTS'.
    Narrative: FMC INOPERATIVE AFTER TKOF (SCREEN BLANK). CREW HAD TO CONTINUALLY ENTER MAGNETIC HDG CONFUSION AS TO WHAT WAS WORKING AND WHAT WASN'T. PNF MISREAD CHART AND INSTRUCTED PF TO TRACK J-191 INSTEAD OF J-193 AT THE DIVERGENCE POINT OF THESE 2 ARWYS. CTR ADVISED THAT WE WERE 7 MI W OF J-193 AND DIVERGING. INTERCEPT HDG ISSUED AND WE RESUMED CORRECT NAV. CONTRIBUTING FACTORS. FAILURE TO PAY ATTN TO DETAILS ON MY PART. CONFUSION REGARDING FMC FAILURE. NOT SEEN THAT OFTEN WHERE THE SCREEN IS COMPLETELY BLANK. HAD BECOME UNACCUSTOMED TO EXPLICITLY FOLLOWING JET ARWYS FROM A CHART RATHER THAN RELYING ON FMC AND IRS. CREW COORD, PF NOT CHALLENGING AN OBVIOUS ERROR BY THE PIC. SUPPLEMENTAL INFO FROM ACN 152667. AT HUBBS INTXN WE HAD A DOUBLE FMC FAILURE. WITH THE ARWYS BECOMING MORE CONDENSED IT IS VERY EASY TO MISREAD AN ARWY R TO A VOR. WE HAVE EXCELLENT ENRTE CHARTS, BUT SOMETIMES THE CHARTS CAN BE CLUTTERED WITH TOO MUCH INFO.

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  20. Accession Number: 174632
    Synopsis: ADVTECH ACR WDB EXPERIENCES MINOR FMS PROBLEM, BUT FAILS TO CATCH ERROR AND SUFFERS TRACK DEVIATION AND ALT UNDERSHOOT DUE MISSET ALTIMETER.
    Narrative: AFTER TKOF FROM LAX WBND, WE WERE CLRED LEFT TURN DIRECT LAX VOR, AS FILED. PASSING LAX, THE FMC CALLED FOR A RIGHT TURN TO SLI VOR. F/O HAND-FLYING. I NOTICED ON MAP DISPLAY AFTER SLI RTE WAS ALMOST 90 DEG LEFT TURN TO DAG. REQUESTED DIRECT DAG AND RECEIVED DIRECT. MOMENTS LATER ATC ASKED IF WE KNEW WHERE WE WERE, AND THAT WE WERE 15 MI S OF LOOP 8 DEP RTE. WE WERE TOLD TO TURN LEFT TO 330 DEG HDG AND THEN CLRED DIRECT DAG. SOMEHOW THE FMC HAD DUMPED OUT THE LOOP 8 DEP AND HAD US GOING TO SLI AND THEN DAG. WHILE WE WERE DOING THIS CLRNC AND TRYING TO FIGURE OUT WHAT MAY HAVE GONE WRONG, WE PASSED 18000' AND DIDN'T SET ALTIMETERS TO 29.92. AFTER LEVEL OFF AT 37000', ATC ASKED OUR ALT AND I REPLIED 37000'. WE WERE TOLD MODE C HAD US 300' LOW. ALTIMETER WAS 30.23". SET ALTIMETER AND REMAINDER OF FLT WAS NORMAL. ONE OF THE PROBS WAS THAT I WAS RELYING ON THE FMC TOO MUCH FOR DEP AND NOT X-CHKING WITH DEP PLATE. NEW, FIRST GLASS COCKPIT. SUPPLEMENTAL INFO FROM ACN 174704: CAPT AND I REVIEWED THE SID SEVERAL TIMES AND THE MADE CHANGES IN THE PROC WHEN WE WERE GIVEN A RWY CHANGE. WE WERE EXPECTING LAX 24L AND WE TOOK OFF ON 25R. I MADE THE CHANGES IN THE FMC AND EVERYTHING PROCEEDED NORMALLY. WE BRIEFED THE CHANGES AND INSTALLED A FIX IN THE FMC TO AID IN THE DEP. LATER FOUND OUT THERE IS A SOFTWARE GLITCH IN THE LOOP 8 SID THAT HAS NOT BEEN CORRECTED. THIS OCCURS WHEN THERE IS A RWY CHANGE, WHICH IS WHAT HAPPENED TO US. ONE CAN GET LOST OR MISDIRECTED, EVEN WITH ALL THE LATEST NAV TECH. IN THE FUTURE I WILL RELY MORE ON TRADITIONAL NAVAIDS FOR FMC BACKUP. I ALSO MADE THE MISTAKE OF USING TOO SMALL A SCALE FOR THE NAV DISPLAY. ON A LARGER SCALE I WOULD HAVE SEEN THE ERROR AND WOULD NOT HAVE FLOWN TO THE S.

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  22. Accession Number: 182888
    Synopsis: ACR MLG ALT DEVIATION UNDERSHOT ALT CROSSING RESTRICTION.
    Narrative: WHILE CRUISING AT FL370 IN VMC CONDITIONS, ZNY ISSUED US A XING RESTRICTION (30 W OF SWEET INTXN AT FL180). AT THIS TIME WE WERE ABOUT 800 DME FROM THE FIX. THE XING RESTRICTION AND ALT WERE CORRECTLY PROGRAMMED INTO THE FMC. THE NEW ALT WAS SELECTED INTO THE ALT ALERT WINDOW OF THE MCP, AND VNAV WAS SELECTED AND VERIFIED OPERATIONAL (VNAV LIGHT ON). THE CAPT'S FMC WAS IN THE "LEGS" PAGE (FLT PLAN) AND MY FMC WAS DISPLAYING THE "DSNT" PAGE (FLT PATH ANGLE, RATE OF DSNT REQUIRED ARE DISPLAYED ON THIS PAGE). MY PARTICULAR FMC DISPLAY ON THIS ACFT WAS VERY DIM AND THE LIGHT INTENSITY COULD NOT BE INCREASED AND FURTHER. BOTH PLTS WERE FLYING INTO THE SUN AND WEARING SUNGLASSES, WHICH MADE MONITORING MY PARTICULAR FMC EVEN HARDER. SOMETIME BTWN 80 DME AND 60 DME FROM THE FIX, WITH FMC AND MCP ACCURATELY PROGRAMMED AND WITH THE APPROPRIATE DISPLAYS IN VIEW, THE VNAV PORTION OF THE FMC/MCP INTERFAC MALFUNCTIONED AND DID NOT COMMAND THE REQUIRED DSNT AT THE TOP OF DSNT POINT (NO MESSAGE WAS EVER DISPLAYED ON THE FMC'S TO ALERT US OF THE MALFUNCTION). AT 60 DME FROM THE FIX I BECAME AWARE THAT THE FMC WAS NOT INITIATING THE EXPECTED DSNT, AND ADVISED THE CAPT (WHO WAS FLYING) OF THE NEED TO GET DOWN. THIS DAY WE HAD IN EXCESS OF 80 KTS OF WIND ON THE TAIL. THE CAPT INITIATED A HIGH RATE OF DSNT, AND I ADVISED ZNY IMMEDIATELY THAT WE WERE UNABLE TO COMPLY WITH THE RESTRICTION. ZNY DID NOT RESPOND, EVEN AFTER A SECOND RADIO CALL. EVENTUALLY WE WERE VECTORED (CENTER DID NOT SEEM ALARMED). THE FAILURE OF THE VNAV MODE W/O A STATUS (MALFUNCTION) DISPLAY EITHER IN THE FMC OR MCP, IN CONJUNCTION WITH THE "DIM" FMC DISPLAY ON THE COPLT'S SIDE CONTRIBUTED TO THE "TOP OF DSNT" POINT BEING OVERFLOWN W/O THE REQUIRED DSNT BEING INITIATED.

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  24. Accession Number: 219689
    Synopsis: HDG TRACK POS DEV IN A GROSS NAV ERROR DURING APCH PROC STAR.
    Narrative: CLRED FOR THE CIVET. CIVET 3 PROFILE DSCNT INTO LAX I STARTED TO FLIP MY VOR FROM AUTO-TUNE TO ILS/DME FREQ 109.9 ILAX AND BACK TO AUTO-TUNE AT ABOUT 160 NM FROM LAX ACCORDING TO THE FMS. THE FIRST TIME I SWITCHED, THE DME SHOWED ABOUT 110 IN THE OVERRIDE MODE AND SINCE WE WERE 160 OUT ACCORDING TO THE FMS/RNAV I ASSUMED THE DME WAS FROM SOME OTHER 109.9. I FLIPPED BACK AND FORTH SEVERAL MORE TIMES IN THE NEXT FEW MINS AND BECAME VERY CONCERNED WHEN THE DME FINALLY SHOWED 56 AND THE FMS/RNAV SAID 106, SINCE I KNEW THERE COULD BE NO OTHER ILS/DME WITHIN 100 OF LAX ON FREQ 109.9. AT THAT POINT, I TOLD THE CAPT THERE WAS SOMETHING SCREWY GOING ON WITH MY DME VERSUS RNAV. WE STARTED TO COMPARE HIS VOR TO MINE AND THE RNAV, BUT WITHIN 30 SECONDS, CTR CALLED TO CONFIRM OUR CLRNC ON THE CIVET 3 PROFILE. WE AGREED WE HAD BEEN CLRED FOR IT AND HE REPLIED WE WERE S OF COURSE, GAVE US A VECTOR TO INTERCEPT THE LOC AND ASSIGNED A XING ALT AT ARNES. SINCE WE WERE AT 49 DME WHEN THE CONVERSATION STARTED, WE WERE ALREADY INSIDE CIVET AND LATER ESTIMATED WE MUST HAVE BEEN AT LEAST 1500 FT HIGH XING ABEAM IT. WE WERE BACK ON THE PROFILE BY ARNES. WE DON'T KNOW WHERE OR WHEN THE RNAV GOT LOST, BUT WE DO KNOW THE WAYPOINT COORDINATES WERE CORRECT. THE BOTTOM LINE IS THE OVERALL SYS WORKED. WHILE WE TRUSTED THE RNAV, WE DID START TO XCHK IT, THEN QUESTION IT, AND THE MOMENT THE CTLR CONFIRMED OUR SUSPICIONS, CORRECTED IT BY SWITCHING BACK TO THE OLD- FASHIONED, MANUAL METHOD. SUPPLEMENTAL INFO FROM ACN 219990: I ESTIMATE WE WERE 2-3 MI S WHEN CALLED. EVIDENTLY OUR AUTO NAV SYS HAD MALFUNCTIONED ALTHOUGH WE HAD NO FLAGS. AFTER LNDG WE CHKED OUR INS COORDINATES AND BOTH INS WERE CORRECT. WE SUSPECTED PROBLEM IN RNAV SYS AND ADVISED MAINT TO CHK IT OUT. ONE METHOD OF PREVENTION OR CORRECTION WOULD BE TO XCHK MANUAL SYS A BIT FARTHER AWAY AND MAYBE XCHK MORE THAN ONCE. IN MY 4 YRS AND OVER 2800 HRS USING INS NAV, I'VE ALWAYS FOUND THE SYS TO BE VERY ACCURATE UNTIL THIS INSTANCE.

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  26. Accession Number: 234792
    Synopsis: GROSS NAV ERROR EVOLVES FROM HDG TRACK POS DEV. ACFT EQUIP PROB MALFUNCTION.
    Narrative: THIS FLT WAS THE 2ND ALL NIGHTER ON THE BACKSIDE OF THE BACKSIDE OF THE CLOCK. ALL THE CREW WERE NOT TIME ZONED YET. AFTER PASSING CHKPOINT OMLET, FO MADE A RANDOM HDG CHK AND DISCOVERED ACFT WAS APPROX 13.5 DEGS FROM PROPER HDG. WINDS WERE WESTERLY APPROX 150 KTS. WE WERE HDG S AT FL370. AUTOPLT ROLL COMPUTER HAD FAILED. I 'THE CAPT' TRIED TO SLEW ACFT TO PROPER HDG WITH 'HDG SELECT' KNOB. NO RESPONSE. TRIED 'HDG HOLD' MODE. NO RESPONSE. THEN DISCONNECTED AUTOPLT AND HAND FLEW ACFT TO PROPER HDG TO REINTERCEPT AIRWAY. WHEN THE ROLL COMPUTER FAILED ACFT WENT INTO A 2-3 DEG L BANK, NOT ENOUGH OF A BANK TO NOTICE. THIS TURN PLUS WESTERLY WIND OF 150 KTS BLEW US APPROX 45 NM E OF COURSE BEFORE WE REALIZED SOMETHING WAS AMISS. UNTIL I DISCONNECTED THE AUTOPLT, EVEN THOUGH THE ROLL COMPUTER HAD FAILED (WE DID NOT KNOW WHAT WAS WRONG WITH THE ACFT UNTIL THE NEXT NIGHT'S FLT WHEN I CHKED WITH MAINT) THE AUTOPLT STAYED ENGAGED AND NOTHING ABNORMAL WAS ANNUNCIATED. THIS IS PARTICULARLY INSIDIOUS BECAUSE AT HIGH ALTS, LOW AIRSPDS, HIGH WINDS 150-200 KTS, CRAB ANGLE CAN EXCEED 20 DEGS. I REESTIMATED THE NEXT CHKPOINT 7 MINS LATER TO TYO CTL. 5 MINS LATER THEY CALLED BACK AND ASKED US TO CONFIRM OUR ESTIMATE. WE DID AND THAT WAS IT SO FAR. LESSONS LEARNED: 1) SOMETHING IS NEEDED TO ANNUNCIATE A MASSIVE COURSE DEV SUCH AS WE EXPERIENCED. 2) WHEN THE ENTIRE CREW IS VERY TIRED IT IS ESSENTIAL THAT CONSTANT ACFT CHKS ARE MADE. I HAVE FLOWN INTL APPROX 6 YRS OF MY CAREER AND THIS IS THE FIRST TIME SOMETHING THIS GROSS HAS HAPPENED TO ME. IT WILL NOT HAPPEN AGAIN!

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  28. Accession Number: 361969
    Synopsis: THE ACR FLC OF A B737-300 HAS BOTH IRU'S DRIFT OFF DURING THE DEP PROCESS AND THEY GET OFF COURSE BEFORE THEY COULD SELF-CORRECT. NEITHER OF THE FLC WAS MONITORING THE RAW DATA FROM THE DEP VORS.
    Narrative: WE DEPARTED ONT FROM RWY 8L WITH THE FO HAND FLYING USING THE FLT DIRECTOR IN VNAV AND LNAV WITH THE INITIAL COMMANDS BEING A HDG TO 250 DEGS. PRIOR TO INTERCEPTING THE 143 DEG RADIAL OF POM PER THE SID AND FMC ROUTING, WE WERE CLRED BY SOCAL DEP 'DIRECT TO POM AND THE REMAINDER OF THE ONT 2, COMPLY WITH RESTRS.' I SELECTED 'DIRECT INTERCEPT' TO POM AND WE PROCEEDED IN LNAV. JUST PRIOR TO REACHING POM WE HEARD A CLRNC FOR ANOTHER ACFT TO 'TURN IMMEDIATELY TO A 230 DEG HDG,' BUT HEARD NO MENTION OF THE LOCATION OF TFC NOR ANY MENTION FROM THE CTLR THAT OUR POS MAY HAVE CAUSED THE NECESSITY FOR ANOTHER ACFT TO DEVIATE. NO FURTHER MENTION EITHER TO ANOTHER ACFT OR OURSELVES WAS MADE, SO WE RESUMED OUR CLB AND LEVELED AT 9000 FT MSL PRIOR TO REACHING THE GASKI INTXN. UPON NOTING 'ALT HOLD' ANNUNCIATED ON THE EADI, I SELECTED THE CLRED ALT OF 14000 FT MSL INTO THE ALT WINDOW OF THE MCP AND AFTER PASSING GASKI, VNAV WAS SELECTED AND A CLB INITIATED. THE DEP CTLR ISSUED US A CLRNC TO 'TURN 20 DEGS L AND INTERCEPT THE POM 323 DEG RADIAL' AND ADDED THAT WE 'WEREN'T AT POM.' BOTH OF OUR FMC MAP TRACKS SHOWED US ON THE POM 323 DEG RADIAL SLIGHTLY PAST GASKI ON COURSE TO KELSE. DOUBTFUL OF THE CTLR'S CLRNC, I TYPED POM INTO THE FIX PAGE OF THE CDU AND ALSO TYPED IN THE 323 DEG RADIAL WHICH OVERLAPPED THE TRACK DISPLAYED ON BOTH EHSI'S. AFTER CONFIRMING OUR POS IN THIS MANNER, THE POS OF THE ACFT WAS DISPLAYED TO THE L (W) OF COURSE AND I QUERIED THE CTLR IF HE 'WANTED US TO INTERCEPT THE POM 323 DEG RADIAL, BUT I WAS SHOWING US TO THE L OF COURSE.' THE CTLR RESPONDED THAT WE WERE SHOWING TO THE 'R OF COURSE' AND THAT WE MUST HAVE SELECTED PDZ INSTEAD OF POM. AT THIS TIME, THE FO SELECTED HIS VOR INTO THE MANUAL MODE ON THE 323 DEG RADIAL OF POM (WHICH AS PREVIOUSLY MENTIONED, HAD BEEN BOTH PRESELECTED AND CONFIRMED ON THE GND PRIOR TO OUR DEP). TRUE TO THE CTLR'S INDICATIONS, THE VOR COURSE SHOWED US TO BE TO THE R (E) OF COURSE. WE BOTH SELECTED THE MANUAL MODE OF OUR VORS AND FLEW THE REMAINDER OF THE DEP IN THE MANUAL MODE WITHOUT FURTHER INCIDENT. UPON RESELECTING THE MAP MODE ON MY EHSI, I NOTICED IN THE L-HAND CORNER 2 INDICATIONS THAT THE IRU POS WERE ABOUT 1.7 TO 1.8 MI OFF THE FMC POS. AS THE FLT CONTINUED TOWARD SFO, THE DISCREPANCY BTWN THE IRU'S AND THE FMC CLOSED UNTIL IT WAS ABOUT .4 TO .5 MI AND ALL LNAV FUNCTIONS OPERATED NORMALLY. OBVIOUSLY THERE WAS SOME ERROR IN THE POS INDICATION OF OUR FMC MAP TRACK. I HAVE NOT YET BEEN ABLE TO REACH A CONCLUSION ABOUT THE REASON FOR THE DISCREPANCY IN THE FMC POS ON THIS PARTICULAR FLT, AND HAVE NEVER BEFORE ENCOUNTERED AN INCIDENT LIKE THIS IN NEARLY 4000 HRS OF GLASS ACFT EXPERIENCE. I HAVE EXPERIENCED MINOR MAP SHIFTS, BUT NEVER SUCH A DISCREPANCY THAT WASN'T IMMEDIATELY VERIFIABLE. IN RETROSPECT, MY FIRST ACTION SHOULD HAVE BEEN TO IMMEDIATELY SELECT MY VOR TO MANUAL AND ASCERTAIN THE POS OF THE ACFT FROM POM RATHER THAN PLACING POM INTO THE FIX PAGE AND ESSENTIALLY CONFIRMING AN ERRONEOUS POS WITH MORE INCORRECT INFO.

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  30. Accession Number: 364937
    Synopsis: MD88 ACFT IN CLB INCREASED PITCH AFTER ENG ANTI-ICE WAS TURNED OFF DUE TO INCREASED PWR AND VNAV MODE. CLB RATE VERY HIGH AND ALT CAPTURE WAS ANNUNCIATED ON MODE PANEL AT 31000 FT FOR A 35000 FT LEVELOFF. AIRSPD BLED OFF, AUTOTHROTTLES DIDN'T CORRECT NOR DID PITCH ATTITUDE. FLC HAD TO DISCONNECT AUTO SYS AND PUSH OVER TO REGAIN AIRSPD.
    Narrative: CLBING IN VERT AND HORIZ NAV MODES OF AUTOPLT (NORMAL OP) ON SCHEDULED FLT IN MD88 FROM BOS TO ATL. UPON LEAVING CLOUD DECK, ENG ANTI-ICE WAS TURNED OFF AT FL290. ADDITIONAL THRUST FROM THIS ACTION (APPARENTLY) CAUSED ACCELERATION TO MACH .78, ABOUT .02 ABOVE NORMAL CLB MACH. ACFT CLB RATE INCREASED TO 5000-6000 FPM AND VNAV CAPTURE APPEARED ON 'FLT MODE ANNUNCIATOR PANEL,' INDICATING AUTOPLT CAPTURE OF FL350. THIS OCCURRED AT FL310. MACH WAS APPROX .76 AT THIS POINT (APPROX 260 KIAS) AND DECREASING, HOWEVER, AUTOPLT DID NOT PITCH OVER TO MAINTAIN CLB SPD -- IT CONTINUED ON A CAPTURE PROFILE THAT WAS APPARENTLY BASED ON THE CLB RATE AT CAPTURE INITIATION. THE AIRSPD BLED OFF WITH FULL CLB PWR APPLIED UNTIL THE AUTOPLT WAS DISCONNECTED AT 214 KIAS ABOVE FL340. A DSCNT OF NEARLY 1000 FT WAS REQUIRED TO GAIN ENOUGH AIRSPD FOR THE ACFT TO ACCELERATE TO NORMAL CLB SPD OF APPROX 260 KIAS AT THIS ALT. LIGHT PRESTALL BUFFET WAS EXPERIENCED. I HAVE NO DOUBT THE ACFT WOULD HAVE STALLED AT NEARLY FL350 IF THE AUTOPLT HAD NOT BEEN DISCONNECTED. 'WHAT REALLY CAUSED THE PROB, AND WHAT CAN BE DONE TO PREVENT A REOCCURRENCE, OR CORRECT THE SIT?' THIS IS THE SAME PROB THAT CAUSED THE A330 FLT TEST ACCIDENT AT TOULOUSE. GIVEN DIFFERENT CIRCUMSTANCES AND DISTRACTIONS IT COULD HAVE CAUSED SERIOUS INJURY OR AN ACCIDENT. PLTS ARE TERRIBLE MONITORS OF SYS THAT WORK WELL FOR 99.99% OF THE TIME, ESPECIALLY, SYS THAT REDUCE WORKLOAD SO THAT 2 PLTS CAN DO THE JOB. IF WE CAN'T TRUST AUTOPLTS TO WORK CORRECTLY OR TELL US WHEN THEY ARE MALFUNCTIONING, WE CANNOT OPERATE WELL IN HIGH WORKLOAD SITS. CERTIFICATION STANDARDS SHOULD BE CHANGED TO REQUIRE SAFE OP IN ALL POSSIBLE SITS AND NOT RELY ON PLT INTERVENTION TO INSURE SAFETY. SITS BEYOND NORMAL CTL OF THE AUTOPLT OR CONFLICTS BTWN DIFFERENT INPUT DEVICES (EG, PITCH WHEEL AND ALT SET WINDOW) SHOULD CAUSE ERROR MESSAGES AND INACTION UNTIL THE CONFLICT IS RESOLVED, OR DISCONNECTION OF THE AUTOPLT AND HIGH LEVEL DISCONNECT WARNINGS. WE MUST BE ABLE TO TRUST AUTOMATION!! AUTOMATION CERTIFICATION STANDARDS MUST BE IMPROVED.

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  32. Accession Number: 366354
    Synopsis: A320 ACFT ON APCH AND APPARENTLY NOT PROPERLY SET UP FOR THE APCH WAS GIVEN A GAR BY THE APCH CTLR. THE GAR WAS INITIATED, BUT WITHOUT TOGA THRUST UNTIL THE CAPT RPTR TOLD THE FO TO USE TOGA. AT THAT TIME, UNKNOWN TO THE FLC, THE ACFT CHANGED MODES AND IGNORED THE PREVIOUS INPUTS SET INTO THE FMGC.
    Narrative: DUE TO DETERIORATING WX CONDITIONS AND ABNORMALLY HIGH WINDS AT ALT VERSUS ON THE GND, DTW APCH CTL DIRECTED A GAR: MAINTAIN 3000 FT, TURN L 220 DEGS AND SPD OF 170 KTS. I RECOMMENDED TO THE FO TO GO TO THE TOGA THEN BACK TO CLB TO RESEQUENCE THE FMGC FOR THE ADDITIONAL APCH. THE ACFT STARTED CLBING, DISREGARDING THE 3000 FT FCU ALT. I DISCONNECTED THE AUTOPLT AND TOOK CTL OF THE ACFT TO RETURN IT TO 3000 FT. THE FO SAID WATCH YOUR AIRSPD WHICH WAS RAPIDLY INCREASING. THE FMGC IS SUPPOSED TO HONOR THE APCH SPD (140 KTS) OR FCU SELECTED AIRSPD (170 KTS) WHICHEVER IS HIGHER. IT DISREGARDED BOTH. I DISCONNECTED THE AUTOTHRUST AND RETARDED THE THRUST LEVERS. APPARENTLY THE FMGC STUCK IN THE GAR PHASE EVEN THOUGH THE THRUST LEVERS WERE IN THE CLB DSCNT. IN RETROSPECT WHAT WAS UNSETTLING WAS HOW LONG IT TOOK TO RECOGNIZE THE PROB THAN DEAL WITH IT. IN KNOW OUR FMGC'S HAVE BEEN EXPERIENCING NUMEROUS PROBS WHICH HAVE GOTTEN WORSE OVER TIME. I DON'T KNOW IF THIS HAD ANYTHING TO DO WITH THE ABOVE PROB.

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  34. Accession Number: 368760
    Synopsis: FLC OF A B737 WERE NOT ON THE STAR ARR ROUTING DUE TO AN ACFT NAVIGATIONAL POS COMPUTING ERROR RESULTING IN ATC INTERVENTION TO BRING RPTR BACK TO ASSIGNED ROUTING TRACK.
    Narrative: GIVEN CLRNC TO DSND ON THE ARR INTO OAK. STARTED DSCNT AND NOTICED TCASII TFC WITHIN 8 NM AND 200 FT VERT. CTR THEN ASKED IF WE WERE ON THE ARR. OUR NAV EQUIP CONFIRMED WE WERE (OR WITHIN 2 NM MAX ERROR PASSING OVER VOR DUE TO SLANT RANGE PROBS). WE RECEIVED A TCASII TA AND TURNED AWAY FROM TFC. I LATER TALKED WITH CTR AND THEY SAID WE WERE ABOUT 7 MI L OF COURSE. OUR EQUIP NEVER INDICATED THAT MUCH ERROR. ENRTE TO OAK EVERYTHING APPEARED OKAY.

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  36. Accession Number: 370430
    Synopsis: A B767 DEPARTS OUT OF ZURICH, SWITZERLAND, AND HAS A COURSE DEV FROM THE ASSIGNED SID. PLT FEELS IT IS A COMPUTER OR LNAV PROB AND SUGGESTS NOT TO USE IT ANY MORE.
    Narrative: ZRH DEP. ATC ASSIGNED THE MOROK 1U RNAV DEP. ADEQUATE TIME AT THE GATE TO BRIEF THE SID. AT RWY END, RWY SYMBOL TOUCHED ACFT SYMBOL WHICH ALLOWS FOR USE OF LNAV AFTER TKOF. WHEN WE WERE AIRBORNE A TURN TO THE L WAS INITIATED AT 1.1 DME KLO VOR WITH HEADING SELECT. AFTER INTERCEPTION OF MAGENTA RTE LINE OF THE SID, LNAV WAS ARMED AND THEN ENGAGED. CLB AIRSPD WAS AT 210 KIAS OR LESS. I WAS PNF, AND HAD PROGRESS PAGE #2 DISPLAYED TO CHK XTRACK ERROR. THE INITIAL DEV WAS 3H DEPICTION IS WHAT THE FMC DEPICTS WHEN AIRBORNE ON COURSE. WITH THE COMMAND BARS CTRED AND STILL ON THE LNAV TRACK, WE BOTH NOTICED THAT WE WERE BEING COMMANDED TO FLY AWAY FROM THE KLO 255 DEGS. AT THAT TIME WE CHANGED ROLL MODES TO HEADING SELECT AND MADE A FURTHER CUT TO INTERCEPT THE 255 DEGS. IMMEDIATELY THEREAFTER, ZRH DEP ASKED FOR OUR HEADING AND I SAID WE ARE IN A L TURN TO INTERCEPT THE 255 DEG RADIAL. HE SAID WE WERE OFF COURSE. WE HAD NO MEANS TO MEASURE DEV FROM TRACK. REST OF DEP UNEVENTFUL. BEING AN RNAV DEP WE USED LNAV. HOWEVER, THE GND, THE FMC MAP AND LEGS PAGE SHOW A TRACK FROM RWY 16 TO D163A, KLO163 AT 1 NM TO D360A, KLO 360 DEGS AT 1 NM AND A COURSE OF 255 DEGS TO THE AARAU WAYPOINT. THIS WOULD NEVER WORK, THAT IS A PARALLEL TRACK OR HDG. HOWEVER, WHEN ONE LOOKS AT THE 10-3H, THE SID TRACK SHOWS XING THE 360 DEG RADIAL AT ABOUT 3 DME. IF THIS IS AN RNAV DEP, IT IS POORLY DRAWN IN THE FMC COMPUTER. IF WE ARE TO TURN L AFTER TKOF FROM RWY 16 AND INTERCEPT THE 255 DEG RADIAL AND DISREGARD THE RNAV COURSE, THEN THIS SHOULD BE STATED, THAT IS, DO NOT USE LNAV AT THE START. AND THEN I QUESTION THE PURPOSE OF THIS RNAV DEP. LET'S GO BACK TO THE SIMPLE TURN OVER THE ARPT, KLO VOR. IN SUM: THIS RNAV DEP IS REALLY A MANUAL DEAD-RECKONING SID TO INTERCEPT A VOR RADIAL. THIS ZRH RNAV DEP DOES NOT GIVE ANY GUIDANCE ON HOW WIDE IT MAY OR MAY NOT BE FLOWN. SUGGEST WE WITHDRAW THIS PARTICULAR SID UNTIL THIS MATTER IS CLRED UP. SUPPLEMENTAL INFO FROM ACN 370431: AFTER LEVELING AT ATC ASSIGNED ALT OF 5000 FT AND RESETTING QNH, IT WAS NOTICED ON RAW DATA THAT THE FMC WAS NOT FOLLOWING THE PROPER GND TRACK AS DEPICTED ON THE CHART. HEADING SELECT WAS USED TO OVERRIDE LNAV AND THE RAW DATA DEP WAS RE- INTERCEPTED. DURING THE CORRECTION ATC QUESTIONED OUR HEADING AND ADVISED US THAT OTHER TFC HAD TO DEVIATE.

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  38. Accession Number: 380542
    Synopsis: B767-200 ACFT ON STAR ARR HAD COM PROBS CONTACTING APCH CTLR AND WHEN FINALLY ESTABLISHING COM THE FLC WAS INFORMED THEY WERE OFF COURSE. AFTER CHKING NAV ACCURACY THEY FOUND ALL 3 INERTIAL REF UNITS OUT OF TOLERANCE (60 MI OFF). ATC VECTORED ACFT FOR APCH AND LNDG.
    Narrative: PROCEEDING DIRECT CARTR WHILE DSNDING ON THE ARR TO SLC IN B767-200, FO FLYING WITH AUTOPLT ON, LNAV AND VNAV ENGAGED. JUST FELT FMS WAS NOT GIVING US CORRECT POS FROM CARTR. XCHKED ON FIX PAGE AND MANUAL VOR -- OGD RADIAL. ALL CHKED OK ON MAP. WHEN CALLED APCH TO VERIFY, NO ANSWER. MADE 3 CALLS, STILL NO ANSWER. FINALLY SWITCHED TO TWR AND INSTRUCTED TO RETURN TO FREQ WE WERE ORIGINALLY ON. APCH ANSWERED WE HAD PASSED CARTR BY 20 MI (W). INFORMED APCH FMS HAD BECOME INACCURATE -- CHANGE TYPE ACFT -- NEEDED VECTORS. ON FINAL TO RWY 16R, I EXTENDED RWY ON FMS AND AT TOUCHDOWN WE SHOWED 62 MI FROM RWY. DISCOVERED ALL 3 INERTIAL REF UNITS OVER 1 DEG E OF CORRECT POS. XCHKED GATE POS AT BOSTON (OUR STARTING POINT) -- ITS LATITUDE/LONGITUDE WAS CORRECT. I ALSO CHKED ACFT POS ON MAP AS WE TURNED TO ACTIVE RWY -- SHOWED US ON RWY 22R (BOS). THIS TURNED OUT FINE BECAUSE WE VISUALLY FELT UNCOMFORTABLE. (BY LOOKING AT THE VARIOUS VALLEYS WE THOUGHT CARTR WAS IN.) IF IMC, WOULD HAVE DRIVEN EXTRA 25 MI TO CARTR FAT, DUMB, AND BLIND. STILL DON'T UNDERSTAND WHAT HAPPENED TO APCH CTL ON THE RADIO. MUST HAVE BEEN IN BLIND SPOT? WE TRUST THE MAGIC SO MUCH -- WE HAD NO CLUES. ONE PLT COULD HAVE BEEN IN MANUAL TO VERIFY XING RADIALS FROM OGDEN BUT WHO THOUGHT ALL 3 INERTIAL REF UNITS COULD GET LOST ON LONGITUDE ONLY, LATITUDE WAS CORRECT. NO FMC MESSAGE. IT'S AN EYE OPENER!

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  40. Accession Number: 388280
    Synopsis: RPTED ALTDEV WHEN ACFT DSNDED BELOW ASSIGNED ALT APPARENTLY DUE TO AUTOPLT PROB.
    Narrative: IN CRUISE AT FL310, FO FLYING, AUTOPLT ON, LNAV ON, VNAV ON, FO IS BRIEFING ILS DME RWY 34L APCH TO SLC. WHEN FO NOTICES ACFT DSNDING VERY SLOWLY PASSING THROUGH FL306, FO IMMEDIATELY KICKED OFF AUTOPLT, HAND FLEW ACFT BACK TO FL310. TRIED 'A' AND 'B' AUTOPLTS, NO HELP. ACFT WAS TOO ERRATIC TO FLY IN PITCH SO HE HAND FLEW IT. LATER, DISCOVERED A FLT CTL 'SPD TRIM FAIL.' NO COMMENT WAS MADE TO US ABOUT ALTDEV. REST OF FLT UNEVENTFUL.

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  42. Accession Number: 395870
    Synopsis: A CL65 CREW HAS SOME PROBS WITH THEIR FMS MAKING A DSNDING TURN OVER SPA, SC. THE PIC HAD TO REVERT TO HEADING MODE TO TURN BACK TO THE DESIRED RADIAL. ATC STEPS IN AND GIVES AN ALT RESTR AND A TURN.
    Narrative: WE WERE APCHING SPARTANBURG VOR FROM THE W AT FL310. GND SPD WAS +500 KTS AND WIND FROM NW AT +100 KTS. NAV WAS FMS IN NAV MODE. WE WERE GIVEN A XING RESTR ALSO THAT REQUIRED A RATE OF DSCNT OF +3000 FPM. TURN AND DSCNT WERE STARTED ABOUT THE SAME TIME. OUTBOUND COURSE WAS 035 DEGS (L TURN) WITH NW WINDS AT +100 KTS. SO I EXPECTED A LARGE HEADING CHANGE TO STAY ON TRACK. I WATCHED THE FMS GO THROUGH OUTBOUND COURSE AND TURN TO WHAT I THOUGHT WAS TOO MUCH CORRECTION. THE AIRPLANE WAS IN A 30 DEG BANK TO THE L. I WENT TO HEADING MODE AND SET HEADING TO REINTERCEPT OUTBOUND COURSE (ABOUT 85 DEGS). BY THIS TIME ATC SAID WE HAD A TFC CONFLICT AND MAINTAIN FL280. WE WERE ABOUT 27700 FT. I CANCELED THE AUTOPLT AND FLEW THE AIRPLANE TO FL280 AND BACK ON COURSE. I EXPECTED A LARGE CHANGE IN HEADING TO ACCOMMODATE WINDS AND COURSE CHANGE, AND HAD NO INDICATION OF A MALFUNCTION. THERE ALSO WAS VERY LITTLE TIME TO CHK AND VERIFY FMS INDICATIONS. SUPPLEMENTAL INFO FROM ACN 396189: ATC CALLED AND STOPPED OUR DSCNT AT FL280 AND GAVE US A 085 DEG HDG TO RETURN TO COURSE. WE WERE THEN CLRED TO TRAKS, ON THE FMS NAV MODE, WE WENT TO TRAKS BUT THE FMS DIDN'T MAKE THE TURN AT TRAKS. WE WENT TO HEADING MODE AND MADE THE CORRECTION. THE FMS WORKED PROPERLY THE REST OF THE DAY.

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  44. Accession Number: 396329
    Synopsis: A B767 CREW EXPERIENCES A MAP SHIFT WHILE ATTEMPTING TO ALIGN WITH THE RWY 25R ILS LOC. ACFT HAD BEEN ON THE APCH FOR RWY 24R AND HAD BEEN SHIFTED OVER TO THE S COMPLEX BY APCH CTLR.
    Narrative: THE REMARKS SECTION OF OUR FLT PLAN CONTAINED A WARNING TO WATCH FOR AN FMS MAP SHIFT INBOUND TO LAX. IT SAID SEVERAL ACFT HAD EXPERIENCED MAP SHIFTS DURING THE ARR. WE WERE CLRED DIRECT 'CIVET' INTXN AND WERE EXPECTING THE 'CIVET' ARR TO RWY 25L. THE FMS WAS PROGRAMMED FOR A 'CIVET' ARR AND ILS RWY 25L. ATC THEN CHANGED OUR CLRNC TO THE 'MITTS' ARR, DIRECT 'SNRKL' INTXN, CROSS 'SNRKL' AT OR ABOVE 12000 FT, CLRED ILS RWY 24R. WE RETUNED THE NAVAIDS AND REPROGRAMMED THE FMS FOR A 'MITTS' ARR TO RWY 24R. WE WERE ISSUED TFC TO OUR L SEVERAL TIMES BUT NEVER DID SEE THE TFC. ATC THEN OFFERED, AND WE ACCEPTED RWY 25R. I TUNED THE LOC AND WENT TO A RAW DATA DISPLAY ON MY HSI, WHILE THE CAPT LOOKED FOR THE RWY 25R APCH PLATE AND THEN SELECTED THE ILS RWY 25R IN THE FMS. WE WERE INSTRUCTED TO JOIN THE RWY 25R LOC, CROSS 'MUSIK' INTXN AT OR ABOVE 8000 FT, CLRED ILS RWY 25R. I DON'T RECALL SEEING OUR POS IN RELATION TO THE RAW DATA DISPLAY OF THE LOC BECAUSE I WAS DISTRACTED AT THIS POINT: THE ACFT MADE AN ABRUPT L TURN, AND THEN WE GOT A TCASII RA TO 'REDUCE DSCNT.' I BELIEVE THE ABRUPT L TURN WAS CAUSED BY A MAP SHIFT THAT BECAME APPARENT A BIT LATER. ANYWAY, WE RESPONDED TO THE TCASII WARNING. THEN I SAW THE ARPT VISUALLY AND REALIZED WE WERE WELL S OF THE LOC WHEN I EXPECTED TO BE N OF THE LOC. WE INITIATED A R TURN BACK TOWARD THE LOC IMMEDIATELY, AND INFORMED ATC THAT WE WERE CORRECTING. AT THIS POINT I COULD SEE THAT THE CAPT'S DISPLAY SHOWED US ABOUT 5 MI N OF THE LOC, WHEN IN REALITY WE WERE S OF THE LOC. THE ARR AND RWY CHANGES MADE DETECTING THE MAP SHIFT ALMOST IMPOSSIBLE UNTIL IT WAS TOO LATE. I THINK THE PNF SHOULD MONITOR RAW DATA AT ALL TIMES DURING ARRS TO LAX ARPT. SUPPLEMENTAL INFO FROM ACN 396417: MOMENTS PASSED AS WE SET UP FOR THAT CLRNC. ATC CONTINUED TO CALL WITH TFC, AIRSPD RESTRS, AND FREQ CHANGES, REQUIRING RESPONSES AND INTERRUPTIONS TO OUR FMS SET-UP. WE WERE GIVEN ANOTHER FREQ CHANGE. SOCAL APCH CTL IMMEDIATELY OFFERED US RWY 25R. ALTHOUGH ALMOST REFUSING THE OFFER, IT WAS ACCEPTED FOR THE SHORTER TAXI TIME TO THE GATE. (ALMOST REFUSED DUE TO MULTIPLE CLRNC CHANGES ALREADY AND DIFFICULTY, DUE TO TIME CONSTRAINTS AND UNFAMILIARITY, IN NEW SETUPS FOR EACH CHANGE AND MULTIPLE CALLS FROM ATC INHIBITING OUR CLRNC PROCESSING.) SOCAL APCH THEN CLRED US TO INTERCEPT THE RWY 25R LOC. LOOKING AT MY HSI MAP, I EXPECTED TO HAVE TO TURN L SLIGHTLY TO INTERCEPT THE LOC. THE AUTOPLT ALREADY WAS/HAD BEEN IN A LOW-BANK TURN TO THE L. THIS PUZZLED ME FOR A MOMENT. THE INTERCEPT ANGLE WAS ALREADY TOO GREAT SO I INTERCEDED AND REDUCED THE ANGLE. SOCAL APCH HAD CLRED US FOR THE APCH. ALMOST IMMEDIATELY OUT OF 8000 FT, WE HAD A TCASII ALERT, 'REDUCE DSCNT.' WHEN I LOOKED AT THE TCASII, THE ALERT SOUNDED ONE MORE TIME AS I SAW A TARGET PASS 500 FT, MORE OR LESS UNDER US, ALSO IN A DSCNT. AT THAT TIME A PLT JUMP SEAT RIDER BEHIND ME POINTED OUT BY VISUAL REF TO THE ARPT THAT WE WERE S OF BOTH RWY 25L AND RWY 25R LOCS AND GOING FURTHER S. I IMMEDIATELY WENT TO RAW DATA, MADE A CORRECTION BACK TO THE R TO INTERCEPT RWY 25R LOC AND FURTHER REDUCED OUR RATE OF DSCNT. AUTOPLT LOC WAS ALSO ARMED. WITHIN SECONDS, WE WERE ON THE LOC AND THE REMAINDER OF THE FLT PROGRESSED NORMALLY. NEEDLESS TO SAY, WE SPENT SOME TIME ANALYZING THIS. OUR FIRST REALIZATION WAS THAT WE'D EXPERIENCED A 'MAP SHIFT,' WITHOUT RECOGNIZING IT IMMEDIATELY. UPON REALIZING THAT WE WERE CHASING A PHANTOM LOC TO THE S (L), WE RECOGNIZED THE SHIFT. MINS LATER, AT THE GATE, MAINT CONFIRMED A SHIFT OF AT LEAST 2 1/2 MI. ON REFLECTION, WE MIGHT HAVE SAVED SOME OF THIS IRREGULAR OP HAD WE: 1) ARMED THE AUTOPLT FOR LOC INTERCEPTION IMMEDIATELY AFTER RECEIVING THE CLRNC AND DIALING IN THE LOC FREQ. 2) DOWNLOADED SOME OF THE AUTOMATION RIGHT AWAY AND GONE TO MANUAL AND RAW DATA MODE. 3) REFUSED THE OFFER OF RWY 25R SINCE WE WERE SET UP FOR RWY 24R. NORMALLY, WE DON'T INTERCEPT THE LOC TOO FAR OUT BECAUSE IT'S TOO UNSTABLE AND CAUSES THE ACFT TO WING WALK TOO MUCH. INSTEAD, WE USE THE FMS CALCULATED LOC, AND ARM THE LOC WHEN IN CLOSER. STANDARD PROC ALSO CALLS FOR 1 PLT TO BE ON RAW DATA FOR LOC INTERCEPT. THAT WAS DONE, BUT WE WERE PLAYING CATCH-UP WITH THE CLRNC AND FAILED TO CATCH THE RAW DATA DISCREPANCY RIGHT AWAY. ALL OF THIS HAPPENED IN A VERY SHORT TIME FRAME, COMPRESSED AND COMPLICATED BY AN UNUSUALLY HIGH NUMBER OF CALLS FROM ATC. ALTHOUGH RAW DATA WAS AVAILABLE TO CORRECT US, WE DID NOT SEE IT IN THE FEW SECONDS AVAILABLE BEFORE WE REALIZED IT ANYWAY. THE MAP SHIFT WAS A SERIOUS COMPLICATION. IT HAD ALREADY POINTED THE ACFT TOWARDS THE SW BEFORE WE SAW IT. WITHOUT ALL THE CLRNC CHANGES, THE MAP SHIFT MORE THAN LIKELY WOULD HAVE BEEN CAUGHT MUCH MORE QUICKLY, IF NOT IMMEDIATELY. WITH PAST KNOWN MAP SHIFTS, I WOULD RECOMMEND THAT 1 PLT MONITOR THE ENTIRE ARR AND APCH, AS WE DO IN MEXICO CITY. NEVER LET ATC FURTHER COMPLICATE OR RUSH YOUR ARR/APCH. AND DOWNLOAD TO THE APPROPRIATE LEVEL OF AUTOMATION IMMEDIATELY WHEN NECESSARY. WITH MY 11 YRS EXPERIENCE IN GLASS COCKPITS, I REALLY THOUGHT THAT I WAS MORE IMMUNE TO THIS KIND OF THING HAPPENING TO ME THAN MOST. LET ME TELL YOU. CIRCUMSTANCES CAN CONSPIRE TO TRAP ANY UNSUSPECTING VICTIM.

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  46. Accession Number: 397919
    Synopsis: AN ACR B757 FLC HAS THEIR ACFT TURN OFF COURSE DURING AN ILS APCH TO RWY 25L AT LAX. THE FLC RECOGNIZED THE DEV AND CORRECTED. LATER, THE FLC FOUND THAT THERE HAD BEEN A CHANGE IN THE APCH DIRECTION AND ALTHOUGH THE NEW ILS WAS OPERATING, APPARENTLY SO WAS THE OLD XMITTER.
    Narrative: IN CLOUDS WITH AUTOPLT ENGAGED AND TRACKING RWY 25L LOC IN LNAV. ALL IS WELL, BUT GAATE APCH FIX IS NOT IN FMS, SO FO SELECTS ILS MODE ON EHSI FOR ILS DME. ABOUT 2 NM LATER, ACFT BEGINS A R TURN AWAY FROM LOC (TOWARD OTHER RWYS AND ACFT). AS PF, I SWITCH TO HDG SELECT MODE OF AUTOPLT AND CORRECT BACK. WHILE ON COURSE, MAP SHOWS AN INCREASING TRACK DEV AWAY FROM COURSE. AT FAF (BASED ON DME), THE MAP/FMC SHOWS US DEVIATING 10 DEGS OFF COURSE AND STILL 3 MI TO GO. STOPPED ON GND ON TXWY M BTWN RWYS 25L&R, MAP/FMC SHOWS US 1.3 NM OUT ON FINAL, -3036 FT ON VNAV PATH, AND A GND SPD OF 20 KTS. AT GATE XX, LAST FMS POS IS 3 MINS OFF IN LONGITUDE FROM COMMERCIAL CHART COORDINATES. PER NORMAL OP, FMC FINALLY DROPPED OUT OF NAV MODE AWAITING NEW RTE. ALL OPS NORMAL ON RETURN FLT TO PHX. FOR SOME REASON, THIS ACFT FMS RADIO UPDATED AWAY FROM COURSE AT A CRITICAL POINT IN OUR FLT. THE ONLY 'ALERT' OF THIS MALFUNCTION WAS OUR SITUATIONAL AWARENESS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR WAS FLYING A B757-200 WHEN IT TURNED OFF OF THE ILS COURSE. HE MADE AN ENTRY IN THE MAINT LOG CONCERNING AN FMS ERROR, BUT THE MAINT PERSONNEL WERE UNABLE TO DUPLICATE THE INCIDENT. HIS CHIEF PLT LATER INFORMED HIM, ACCORDING TO THE RPTR, THAT THE LAX CTLRS HAD ADMITTED THAT BOTH THE RWY 25L AND THE RWY 7R ILS XMITTERS WERE OPERATING AT THE SAME TIME AND THEREFORE THE FMS PROBABLY UPDATED BY USING THE DME AND LOC SIGNAL FROM THE NEAREST XMITTER, THAT OF RWY 7R. THE CAPT SAID THAT HIS COMPANY'S STANDARD PRACTICE IS TO HAVE BOTH PLTS SELECT MAP MODE FOR THE APCH. THIS PREVENTS THE FMS FROM UPDATING ITS POS. REQUIRING THE PNF TO TUNE THE ILS FREQ AND TRACK IT IN THE ILS MODE ALLOWS THE FMS TO USE AUTOMATIC TUNING TO VORS IN THE AREA WHILE TRACKING THE ILS'S RAW DATA. THE OTHER NAVAID'S DATA THEN CONTINUOUSLY UPDATES THE FMS'S POS. THE CHIEF PLT, ALLEGEDLY TOLD THE CAPT THAT THE COMPANY'S APCH POLICY WAS UNDER REVIEW.

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  48. Accession Number: 398621
    Synopsis: A B747-400 MAKING AN APCH INTO JFK LOSES THE L FMC WHICH FAILS ALL THE ILS INSTS. THE ACFT EXECUTES A MISSED APCH BECAUSE OF THE LOW WX AND JFK AND DIVERTS TO EWR.
    Narrative: ACR FLT XX APR/XA/98. DURING THE INITIAL APCH PHASE TO RWY 31R AT JFK AT 4000 FT, EXPERIENCED INTERMITTENT FAILURE OF BOTH FMC'S AND SUBSEQUENT INTERMITTENT VHF FAILURE (PARTIAL). AT THIS POINT, WE DISCONTINUED THE APCH, CLBED TO 8000 FT MSL AND HELD APPROX 20 MI NE, SE OF JFK TO RATIFY SIT. UPON HEARING FROM THE CABIN CHIEF PURSER ABOUT AN ODOR OF BURNING WIRES IN THE AFT CABIN, WE DISCONTINUED HOLDING AND PROCEEDED TO EWR FOR AN UNEVENTFUL APCH AND LNDG IN VISUAL CONDITIONS. THE FLC DETERMINED THAT ELECTRICAL EQUIP FAILURE WAS DUE IN PART TO A MALFUNCTION IN THE ELECTRICAL EQUIP COOLING SYS. I DO NOT RECALL THE CAPT DECLARING AN EMER, BUT ATC DID PROVIDE PRIORITY HANDLING FOR OUR APCH AND LNDG AT EWR. MY PRIMARY ROLE DURING THIS INCIDENT WAS IN MAINTAINING CONTACT WITH MAINT TO TRY AND FIND A CAUSE FOR THE ACFT'S PROBS. I ALSO WAS RESPONSIBLE FOR COORDINATING OUR DIVERSION FOR LNDG AT EWR INSTEAD OF JFK. THIS WAS DONE THROUGH COMPANY COMS. I ALSO KEPT THE PAX AWARE OF OUR SIT THROUGHOUT THE ENTIRE EPISODE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT IT IS NOW KNOWN THAT THERE WAS A FAILURE OF THE L FMC. IT IS FELT THAT THE FAILURE WAS INTERMITTENT WHICH WOULD EXPLAIN WHY THE FLC NEVER RECEIVED AN EICAS WARNING. WHEN A FLT ATTENDANT RPTED THE SMELL OF HOT BURNING WIRES ANOTHER RELIEF FLT OFFICER WENT TO THE BACK TO INVESTIGATE, BUT HE COULD NOT DETECT ANY BURNING WIRE ODOR. THE COOLING FAN WAS ALSO OPERATING ON AN INTERMITTENT BASIS AS WAS DETERMINED LATER. WITH THE LOSS OF THE FMC, THEY COULD NOT KEEP THE ILS AVAILABLE FOR THE APCH. SINCE THE FLC COULD VISUALLY IDENT EWR THEY MADE A DECISION TO GO TO THAT VFR ARPT. FLC AND MAINT PERSONNEL DETERMINED TOGETHER THAT BECAUSE THE FMC WAS INTERMITTENT IT WOULD BE REPLACED. HOWEVER, AS THE ACFT WAS FERRIED BACK TO JFK BY ANOTHER FLC, THE FMC FAILED AGAIN. IT WAS FELT THAT A COOLING FAN THAT WAS FAILING SPORADICALLY PLAYED A PART IN THE FMC FAILING BECAUSE OF INADEQUATE COOLING. THAT WAS ANOTHER FAILURE THAT WAS NEVER DISPLAYED ON THE EICAS PANEL. THE ACFT TYPE WAS A B747- 400. THE ACFT MANUFACTURER AND ACR MAINT ARE WORKING ON WHY THE FAILURE WAS NEVER ANNUNCIATED ON THE EICAS SCREEN. SUPPLEMENTAL INFO FROM ACN 398505: THE UPPER EICAS DISPLAYED 'AUTOTHROTTLE DISCONNECT' AND 'FMC MESSAGE.' THE L AND R CDU'S WERE BLINKING 'RESYNCHING' AND THE 'MAP FAIL' AND 'VTK' WARNINGS WERE ON THE NAV DISPLAYS. THE L 'ND' RESTORED ABOUT 30 SECONDS LATER AND I SAID 'I GOT THE MAP BACK.' ONE MIN OR SO LATER, IT FAILED AGAIN WITH THE 'RESYNCHING' MESSAGE ON THE CDU'S. JFK MAINT WAS CONTACTED AND WE WERE GIVEN SOME GUIDANCE THAT POSSIBLY WE HAD A MAJOR ELECTRICAL OVERLOAD AND THEY SUGGESTED TURNING 'OFF' THE UTILITY BUS SWITCHES TO LOWER THE ELECTRICAL LOAD. THIS WAS DONE AND IMMEDIATELY THE UPPER EICAS FILLED WITH MESSAGES ABOUT SYS THAT WERE NOW UNPWRED, AND THE 'AUTOTHROTTLE' AND 'FMS MESSAGES' WERE STILL AT THE TOP OF THE PAGE. WE CONTINUED IN THAT CONFIGN FOR A FEW MORE MINS UNTIL ONE OF THE EICAS MESSAGES CAME UP 'EQUIP COOLING.' THE PNF FO'S REMARKED 'FINALLY THERE'S SOMETHING I HAVE A PROC FOR.' THE L CDU WOULD ACCEPT NOTHING. I MOMENTARILY SELECTED THE 'NAV SELECTOR' TO 'CDU-L' TO TRY TO HARD TUNE THE L ILS AND THE CDU WENT BLANK. ABOUT 4 MI OUT ON FINAL, THE FO'S WERE ABLE TO GET THE ILS ON THE RADIO RAW DATA DISPLAYS AND THE ILS WAS USED FOR GUIDANCE. THE APPROX TIME FROM INITIAL PROB TO LNDG AT EWR WAS ABOUT 25 MINS. THE 'MASTER FMC' WAS NOT TRIED BECAUSE BOTH FMC'S APPEARED TO HAVE PROBS -- BUT NO EICAS MESSAGE EVER SAID 'FMC FAILURE.' THIS WAS ALL AT THE END OF A 12 HR FLT! FATIGUE CERTAINLY DIDN'T HELP! SUPPLEMENTAL INFO FROM ACN 399265: NAV INFO FROM FMC'S NIL TO UNRELIABLE.

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  50. Accession Number: 400760
    Synopsis: A DC10 FLC WAS TOO BUSY TO NOTE THE AUTOPLT DISCONNECT AND THEIR DEV FROM ALT. BRIGHT DAY ON TOP AND NO AURAL WARNING. CREW WAS BUSY COPYING AN ACARS RE-RELEASE.
    Narrative: FLT DURING IFR -- VISUAL ON TOP. AUTOPLT DISCONNECTED WHILE CREW WAS READING AND COPYING THE RE-RELEASE. ALTDEV WAS 600 FT. CONTRIBUTING FACTORS -- VERY BRIGHT GLARE IN COCKPIT AND NO AURAL DISCONNECT WARNING.

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  52. Accession Number: 403254
    Synopsis: A320 ACFT ON SID DEP AND SHORTLY AFTER TKOF FLC HAD TCASII RA DIRECTING A DSCNT WITH TARGET SUPERIMPOSED ON ACFT. FLC FOLLOWED THE RA UNTIL BREAKING OUT OF CLOUDS AT 900 FT AT WHICH TIME GPWS SOUNDED AND FLC SAW TALL BUILDINGS. THEY CONTINUED WITH ATC CLRNC AND THE FALSE WARNING CONTINUED THROUGH MOST OF THE FLT.
    Narrative: UPON DEP FROM LGA RWY 13, WHITESTONE CLB, PASSING APPROX 1000 FT AGL, TCASII TA 'TFC, TFC' SOUNDED. AT THE TIME WE WERE IN IMC CONDITIONS. IMMEDIATELY AFTER THAT RA 'REDUCE VERT SPD' CAME ON WITH TCASII TARGET SUPERIMPOSED ON OUR ACFT SYMBOL. WE BEGAN REDUCING CLB WHEN RA 'DSND, DSND' SOUNDED WITH VERT SPD COMMAND OF GREATER THAN 2000 FPM ANNUNCIATED. TARGET STILL DIRECTLY ON TOP OF US WITH RELATIVE ALT DISPLAYED. WE IMMEDIATELY COMMENCED DSCNT AND EXITED CLOUDS AT 900 FT AGL AT WHICH TIME GPWS WARNING CAME ON SAYING 'TOO LOW, TERRAIN' BY THIS TIME SPD HAD BUILT UP TO 280 KTS. I THEN DECIDED IT WAS BETTER TO TAKE A CHANCE ON HITTING ANOTHER AIRPLANE VERSUS THE SURE THING OF COLLIDING WITH THE GND, AND DIRECTED THE FO TO RESUME CLB AND DEP WHILE I TURNED XPONDER TO TA ONLY. AT THIS TIME ATC GAVE US A NEW HDG AND ALT AND I RPTED THE TCASII RA MANEUVER. ALL THIS TIME EITHER A TA, RA OR GPWS WARNING HAD BEEN GOING ON AND FOR A WHILE 'DSND, DSND' AND 'TOO LOW, TERRAIN' WERE BEING BROADCAST SIMULTANEOUSLY. THE COCKPIT INDEED WAS A CACOPHONY OF BELLS, WHISTLES AND FLASHING LIGHTS. THIS SHOWS THE DANGER OF BLINDLY FOLLOWING TCASII DIRECTIONS. THE PHANTOM TARGET FOLLOWED US ALMOST ALL THE WAY TO OUR DEST AT RELATIVE ALT. IF WE HADN'T POPPED OUT WHEN WE DID AND SEEN BUILDINGS IN FRONT OF US IT COULD HAVE BEEN A MUCH DIFFERENT STORY. WE ARE TAUGHT TO IMMEDIATELY RESPOND TO AN RA AND AT THAT ALT YOU CAN LITERALLY FIND YOURSELF 'BTWN A ROCK AND A HARD PLACE.' CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR CAPT HAD NOT HAD FEEDBACK ON THE CAUSE OF THE FALSE TARGET, BUT WAS PLANNING TO FOLLOW UP. AND, HE SAYS HE WILL CONTACT ASRS IF HE HAS ANY INFO TO PASS ON. RPTR HAD BEEN ON VACATION AND WAS JUST GETTING BACK TO WORK, SO HE WILL TRY. HOWEVER, AS HE SAYS, SINCE THE PROB WENT AWAY ENRTE, MAINT PROBABLY WOULDN'T DO MUCH. RPTR CAPT WAS COUNSELED ABOUT THE SUPPRESSION BUS PROB IN OTHER ACFT AND A SUPERIMPOSED TARGET IS HIGHLY SUSPECT.

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  54. Accession Number: 407782
    Synopsis: A B737-300 FLC GETS AN OFF COURSE CORRECTION FROM PHX DEP CTLR WHEN THEY UNKNOWINGLY EXPERIENCE A MAP SHIFT. RPT CITES AN EQUIP COOLING FAN MALFUNCTION AS A CAUSATIVE FACTOR.
    Narrative: BUCKEYE 2 DEP FROM PHOENIX, RWY 26L. WE CONTACTED PHX DEP CTL AND WERE CLRED TO 15000 FT. AS THE PNF, I BECAME PREOCCUPIED IN THE COCKPIT (HEADS DOWN). I LAST SAW 9 DME FROM THE PHX VOR AND NOTICED THE PF TURNING TOWARDS THE BXK VOR. I CAUTIONED HIM THAT HE WAS TURNING EARLY AND THAT HE SHOULD TURN BACK TO THE L ON THE PROPER HDG OF 240 DEGS UNTIL THE 13 DME FIX. DURING THIS CONVERSATION BTWN OURSELVES, DEP CTL CLRED OUR FLT DIRECT TO THE BXK VOR. WE BOTH MISSED THIS INSTRUCTION. THE PF CORRECTED (AS I COMMANDED) AND AT THE PROPER FIX (13 DME) TURNED THE ACFT TO A HDG OF 280 DEGS. I MANUALLY CHANGED THE NAVIGATIONAL RADIOS TO THE BXK VOR FOR OUR INTERCEPT OF THE 077 DEG RADIAL. BOTH MAP DISPLAYS INDICATED THAT WE WERE N OF THE BXK 077 DEG RADIAL. I INSTRUCTED THE PF TO TURN L TO 240 DEGS TO RE-INTERCEPT THE PROPER RADIAL. THIS PUT OUR ACFT ON A DIRECT HEADING TO THE BXK VOR (AS DISPLAYED ON OUR EFIS DISPLAYS). DEP CTL ASKED WHAT OUR HEADING WAS AND I INFORMED HIM 240 DEGS. I FAILED TO MENTION TO HIM THAT THIS HEADING WAS GETTING US DIRECT TO BXK VOR AS DISPLAYED. THE DEP CTLR INFORMED US THAT WE WERE 9 MI S OF BXK VOR AND WE NEEDED TO TURN R TO RE- INTERCEPT THE AIRWAY (J212) W OF BXK VOR. ENRTE TO OUR DEST WE VERIFIED OUR POS WITH CTR AND MANUALLY OVER VARIOUS NAVAIDS. THERE WERE NO DISCREPANCIES NOTED. UPON LNDG AT SNA I CALLED PHX TRACON AND TALKED TO THE SUPVR ON DUTY. HE EXPLAINED TO ME WHAT THEY INDICATED ON RADAR AND VERIFIED THAT THE NAV FACILITIES WERE OPERATING NORMALLY. I EXPLAINED WHAT WE OBSERVED IN THE COCKPIT AND VERIFIED TO HIM THAT WE HAD THE PROPER NAV FREQS TUNED IN AND THAT I SUSPECTED IRS DRIFT AND SYMBOL GENERATION FAILURE. THE WORKING CTLR KEPT OUR ACFT AND INBOUND TFC ON THE ARLIN ARR SEPARATED THROUGHOUT THIS EVENT. MY ACFT MAINTAINED LAST ASSIGNED ALT OF 15000 FT AND THE INBOUND TFC HAD THEIR ALT AMENDED TO MAINTAIN 16000 FT. NO TFC CONFLICTS OCCURRED. I CONTACTED OUR MAINT SUPVR IN SNA AND EXPLAINED TO HIM OUR EXPERIENCE. I GAVE HIM DATA ON OUR RTE IN REGARDS TO LATITUDE AND LONGITUDES AND THE DIFFERENCES BTWN THE L AND R IRS'S. I ALSO BACKED THIS UP WITH DATA FROM THE POS DIFFERENCE DISPLAY (LOCATED ON THE LOWER R SIDE OF OUR MAP DISPLAY) FROM OVER A RANDOM POS ENRTE AND THE ARR GATE POS. I WAS CONTACTED BY OUR MAINT CTLR THAT NIGHT FOR ANY ADDITIONAL INFO. THE FOLLOWING MORNING, I MET THE OUTBOUND CREW AND GAVE THEM A BRIEFING ON MY EXPERIENCE. THE CAPT HAD EXPLAINED THAT HE HAD EXPERIENCED THIS ONCE BEFORE ON A B757. THIS OUTBOUND CREW DID IN FACT FLY THIS ACFT AND I WAS INFORMED THEY DID NOT HAVE ANY PROBS. ON JUL/SAT/98, THIS ACFT HAD A DISCREPANCY WRITE UP IN REGARDS TO THE EQUIP SUPPLY FAN FLICKERING AND CAUSING THE DISPLAYS TO FADE OUT. MAINT CORRECTIVE ACTION WAS THAT THEY COULD NOT DUPLICATE AND THE ACFT WAS RETURNED TO SVC. THAT EVENING OF JUL/SAT/98, I WAS ON THE JUMP SEAT OF THIS SAME ACFT ENRTE TO LAX. DURING CLBOUT THE SUPPLY FAN WAS FLICKERING AND CAUSING BOTH EFIS DISPLAY UNITS TO FADE OUT. THE CREW CHANGED THE FAN SWITCH TO THE AUX FAN WITH NO CHANGE. IT WASN'T UNTIL THE ACFT GOT TO CRUISE ALT OF 31000 FT DID THE SYS COOL OFF ENOUGH TO EXTINGUISH THE LIGHT. MAINT CTL AND DISPATCH WAS CONTACTED ENRTE AND THE FLT WAS GIVEN CLRNC TO CONTINUE TO LAX. UPON ARR IN LAX, CONTRACT MAINT WAS TO MEET THE ACFT FOR INSPECTION. AT THIS PRINTING, I AM NOT AWARE OF THE FINDINGS.

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  56. Accession Number: 415555
    Synopsis: A B757-200 LOSES AIRSPD SHORTLY AFTER REACHING CRUISE ALT AND HAS TO DSND 2000 FT TO REGAIN PROPER AIRSPD IN ZMP AIRSPACE.
    Narrative: ATC INQUIRED IF WE WERE ABLE TO CLB TO FL410 (FOR TFC REASONS) ON A W TO E TRANSCONTINENTAL FLT. MAX SVC CEILING FOR OUR ACFT DUE TO WT RESTRS WAS FL400, AS A RESULT ATC REQUESTED US TO CRUISE AT FL390 TO ACCOMMODATE ANOTHER ACFT ON A SIMILAR RTE AT FL370. WE ACCEPTED THE CLRNC TO FL390. AN FMC CLB TO FL390 WAS INITIATED AND UPON REACHING FL390 WE PROGRAMMED A SLIGHTLY REDUCED MACH SPD TO MAXIMIZE THE BUFFET BOUNDARY AT THE NEW ALT. AT SOME POINT AFTER LEVELOFF AND STABILIZATION AT THE NEW SPD, AIRSPD BEGAN TO DISSIPATE AT AN EXTREMELY SLOW RATE THAT WENT UNDETECTED BY BOTH CREW MEMBERS. SOMETIME LATER WE FELT A VERY SLIGHT ACFT VIBRATION THAT WE INITIALLY ASSUMED TO BE CAUSED BY AN ENG BEING OUT OF SYNCHRONIZATION. WHEN WE REALIZED THE VIBRATION THAT WE HAD DETECTED WAS ACTUALLY THE ONSET OF LOW SPD BUFFET, WE IMMEDIATELY ADVANCED THE THROTTLES (WHICH WERE ALREADY AT A NEAR CRUISE PWR SETTING) AND INITIATED A SLOW DSCNT IN ORDER TO REGAIN REQUIRED AIRSPD. SIMULTANEOUSLY, I DIRECTED THE FO TO REQUEST A LOWER ALT FROM ATC. THE CTLR ADVISED THAT LOWER WAS NOT AVAILABLE DUE TO TFC AND REQUESTED THE NATURE OF OUR DIFFICULTY. WE ADVISED ATC THAT WE HAD AN AUTOPLT MALFUNCTION AND THAT WE WERE DSNDING IN ORDER TO AVOID AN ACFT UPSET AND WE WOULD ACCEPT A VECTOR OFF COURSE. WE WERE ABLE TO STABILIZE THE SPD OF THE ACFT AT FL382 AND TURNED TO THE CTLR'S OFF COURSE VECTOR HDG TO AVOID CONFLICT WITH THE TFC AT FL370. AFTER SEPARATION WAS ACHIEVED (INSURED) ATC CLRED US TO MAINTAIN FL370. WE DISCOVERED THAT THE AUTOTHROTTLES HAD SOMEHOW DISENGAGED DURING OUR CRUISE AT FL390. THE LAST PWR SETTING BEFORE THE DISENGAGEMENT OF THE AUTOTHROTTLES WAS JUST SLIGHTLY BELOW THE SETTING NECESSARY TO MAINTAIN PROPER AIRSPD. NO EICAS OR OTHER WARNINGS ACTIVATED (NORMALLY MASTER WARNING LIGHTS AND HORN) THAT WOULD ALERT US TO THE AUTOTHROTTLE DISCONNECT. AUTOTHROTTLES WERE RE-ENGAGED AND WORKED NORMALLY THROUGHOUT THE REMAINDER OF THE FLT. THIS FLT WAS CONDUCTED USING INTEGRATED FMC AUTOPLT OPS FROM 1000 FT AGL. THERE WAS NO CHANCE THAT EITHER PLT INADVERTENTLY INTERRUPTED THE PROGRAMMING SEQUENCE AND CAUSED THE AUTOTHROTTLES TO DISENGAGE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THEY NEVER GOT AN EICAS MESSAGE OR AN AURAL CAUTIONARY WARNING THAT THEY HEARD OR SAW WHEN THE AUTOTHROTTLES WERE DISENGAGED. HOWEVER, THE THROTTLE ANNUNCIATION WAS NOT OBSERVED. RPTR COULD NOT RECALL WHEN THAT ANNUNCIATION DISAPPEARED FROM THE ADI SCREEN. RPTR FEELS THE FLC WOULD HAVE HEARD THE WARNING SOUND OF DISCONNECT, BUT CANNOT EXPLAIN HOW THE THROTTLE ANNUNCIATION WOULD HAVE DISAPPEARED WITHOUT THEIR KNOWLEDGE. ACFT HAD BEEN AT CRUISE ALT ABOUT 15 MINS WITH DECAYING AIRSPD WHEN THE BUFFETING BEGAN.
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