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Incidents related to Issue 21 incidents related to this issue.

Issue: controls of automation may be poorly designed (Issue #37)
Description: Automation controls may be designed so they are difficult to access and activate quickly and accurately, or easy to activate inadvertently.

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  2. Accession Number: 74321
    Synopsis: CLEARED TO 6000 AND WHEN SETTING ALT ALERTER INADVERTENTLY SET 5000.
    Narrative: WE WERE CLRD BY HOU APCH TO DESCEND TO 6000'. THE F/O CHANGED THE MODE CONTROL PANEL ALT SETTING TO 6000' (VERIFIED BY ME). WE BECAME DISTRACTED BY TFC CALLOUTS AND HAD NOT NOTICED THAT THE ALT SETTING HAD BEEN MISREAD OR HAD SLIPPED TO 5000'. THE ACFT AUTOMATICALLY LEVELED AT 5000' RESULTING IN A CALL BY APCH TELLING US WE WERE ONLY CLRD TO 6000'. WE DISCOVERED THAT THE ALT SET KNOB COULD BE SLIGHTLY OUT OF DETENT AND LATER BUMPED INTO A DIFFERENT ALT. ALSO, WITH GLARE THE NUMERALS ARE VERY DIFFICULT TO READ. (LEAD CRYSTAL READOUT). THE NUMERICAL SIX ALSO RESEMBLES THE NUMERAL GIVE. SUPPLEMENTAL INFORMATION FROM ACN 74381: REGARDLESS A CONFLICT WAS RECORDED.

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  4. Accession Number: 89189
    Synopsis: ALT OVERSHOT ON DESCENT.
    Narrative: AS WE WERE DSNDING, THE F/O AND I WERE NOT CERTAIN OF THE ALT WE WERE CLRED TO. AT THE SAME MOMENT THE ATC CTLR ASKED US OUR ALT. WE REPLIED THAT WE WERE DSNDING TO 10000' AS CLRED, AND THAT WE WERE PASSING 10600'. HE REPLIED THAT WE WERE CLRED ONLY TO 11000'. (THE ALT ON THE "GLARE SHIELD" PANEL WAS SELECTED TO 10000'). AS WE WERE DSNDING VERY SLOWLY AND ADJUSTING TO 250 KTS AIRSPD, AS I CAN BEST RECALL, OUR DSNT HAD COMMENCED SOMETIME BEFORE. AT THIS TIME WE WERE NOT SURE JUST HOW THE ERROR HAD OCCURRED. SINCE WE WERE NOT "RUSHED" OR OTHERWISE DISTRACTED I HAVE BEEN LOOKING FOR OTHER REASONS FOR THIS ERROR. INHERENT IN THE DESIGN OF THE WDB IS THE ABILITY OF ONLY TWO PLTS TO CONTROL AND SUPERVISE THE OPERATION OF ALL OF THE SYSTEMS OF THE ACFT. MANY CONTROLS ARE MULTI-FACETED SO THAT ALL MAY BE WITHIN ARMS REACH OF THE TWO COCKPIT POSITIONS. THUS, THE ALT SEL (ALT SELECT) KNOB HAS THREE FUNCTIONS: 1). IT IS ROTATED TO SELECT A NEW DISIRED ALT. 2). IT IS PUSHED TO ALTERNATE THE SELECTOR BETWEEN THE "HUNDREDS" AND THE "THOUSANDS" SCALES. 3). IT IS PULLED TO ACTIVATE THE LVL/CH (LEVEL CHANGE) FUNCTION, THEREBY DRIVING THE FLT DIRECTOR AND AUTOPLT, IF SELECTED, TO DIRECT A SELECTED CLB OR DSNT. AS INGENIOUS AS THE DESIGN IS, EXPERIENCE HAS REVEALED A SMALL BUT CRITICAL IMPERFECTION. IT HAPPENS TO BE VERY EASY TO ROTATE THIS KNOB: ONE CAN SELECT A LARGE CHANGE IN ALT WITH A FLICK OF THE WRIST. THE "FRICTION" COUNTERING THE ROTATION IS VERY LIGHT, AND IT IS THEREFORE POSSIBLE TO OVERSHOOT THE INTENDED SELECTION. SINCE THE PLT IS AT THIS MOMENT CONCENTRATING ON SELECTING AN ALT, IT IS MOST LIKELY THAT HE WILL EASILY OBSERVE THE ERROR AND MAKE A CORRECTION. BUT THERE IS ANOTHER AND MORE INSIDIOUS VARIATION TO THE PROB: THE PLT MAY ACTIVATE THE LVL/CH (LEVEL CHANGE) MODE AFTER HE HAS SATISFIED HIMSELF THAT THE CORRECT ALT HAS BEEN SELECTED. BUT AS HE PULLS THE ALT SEL KNOB, IF HE DOES NOT PULL DIRECTLY AWAY FROM THE PANEL, BUT IN A SLIGHTLY TANGENTIAL DIRECTION, HE CAN OFFSET THE ALT SELECTED. WHAT I HAVE OBSERVED ON SEVERAL OCCASIONS IS THAT THE PLT IMPARTS A SLIGHT ROTATIONAL FORCE TO THE KNOB THEREBY CHANGING THE ALT SELECTION BY, USUALLY, ONE THOUSAND FEET! WHAT IS EVEN OF MORE CONCERN TO ME, IS THAT THIS SCENARIO MAY HAVE BEEN IN EFFECT DURING A FLT IN WHICH I WAS IN COMMAND. 10000' WAS SELECTED, BUT THE CTLR HAD CLRED US ONLY TO 11000', AS VERIFIED BY A RECORDING OF THE EVENT. TO SAY THAT IT IS SIMPLE HUMAN ERROR IS UNDERSTANDABLE, BUT IT ALSO MUST BE NOTED THAT IT IS AN ERROR NOT COMMITTED BY THIS AIRMAN IN OVER 14000 HOURS: OVER 30 YEARS OF FLYING. I RECOMMEND DRAWING THE ATTN OF THE MANUFACTURER TO THIS SUBTLE IMPERFECTION FOR A CORRECTION BEFORE OTHER AIRMEN FALL PREY TO IT AS I HAVE. I PROPOSE FURTHER THAT THE CHARACTERISTICS OF THE VHF RADIO FREQ SELECTOR HEADS BE PUT FORTH AS AN EXAMPLE OF WHAT RESISTANT FRICTION COULD BE. SUCH POSITIVE ACTION ON THE PART OF A SELECTOR WOULD BE OF IMMENSE BENEFIT COUNTERING THE PROBS IN THE SITUATION I HAVE JUST DESCRIBED. IF WE HAD BEEN INVOLVED IN THE ONLY KNOWN CASE OF MISSELECTION OF ALT ATTRIBUTABLE TO THIS SCENARIO, I WOULD NOT PRESS THIS CASE BEFORE YOU. A YEAR AGO, I CONSIDERED IT MERELY A PITFALL TO AVOID THAT WAS DUE TO LACK OF FAMILIARITY WITH NEW EQUIPMENT. BUT I HAVE SINCE SEEN SEVERAL INSTANCES OF THIS ERROR BEING GENERATED ON THE LINE BY PLTS OF VARIED EXPERIENCE ON THE WDB. I THEREFORE BELIEVE STRONGLY THAT ATTN BE DRAWN TO THIS PROB AS IT HAS THE POTENTIAL OF VERY SERIOUS REPERCUSSIONS SHOULD IT OCCUR AT A CRITICAL JUNCTURE IN OUR CROWDED AIRWAY SYS.

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  6. Accession Number: 128714
    Synopsis: ACR WDB TURN 90 DEGREES TO THE RIGHT BEFORE THE FLT CREW NOTICED THAT THE TURN WAS SUPPOSED TO BE TO THE LEFT.
    Narrative: WE WERE TOLD TO HOLD AT JUPITER INTXN SE AT 10000'. THE AUTOPLT WAS ENGAGED AND CTLING THE ACFT. UPON ARR AT JUPITER (WE WERE FLYING NBOUND ON A1 TOWARD JUPITER) I ROTATED THE AUTOPLT HDG COMMAND BUG TO THE LEFT TO A HDG OF 156 DEGS FOR DIRECT ENTRY TO THE LEFT-HAND PUBLISHED HOLDING PATTERN AT JUPITER INTXN. SINCE WE WERE HDG 17 DEGS ON A1 TOWARD JUPITER AND I ROTATED THE HDG BUG TO 156 DEGS, THE AUTOPLT TURNED THE ACFT TO THE RIGHT INSTEAD OF TO THE LEFT AS DESIRED. I SHOULD HAVE MOVED IT IN SMALL INCREMENTS TO THE LEFT. WHILE THIS WAS HAPPENING I WAS DSNDING AND SLOWING AND FAILED TO NOTICE THE ACFT WAS TURNING RIGHT INSTEAD OF LEFT. THE CAPT DISCOVERED MY MISTAKE AFTER WE HAD TURNED ABOUT 90 DEGS TO THE RIGHT. WE IMMEDIATELY STARTED A LEFT TURN BACK TO 156 DEGS. BY THE TIME WE GOT TURNED AROUND WE WERE 22 DME FROM NARITA VOR INSTEAD OF THE 32 DME WE WERE SUPPOSED TO BE. ALTHOUGH I BELIEVE THE CAUSE OF THIS INCIDENT TO BE PLT ERROR, I BELIEVE THERE WERE SOME CONTRIBUTING FACTORS. THERE WAS A STUCK MIC ON THE FREQ WE WERE WORKING AND THIS CAUSED A LOT OF CONFUSION AND A DELAY IN RECEIVING HOLDING INSTRUCTIONS. I THINK THERE IS A FLAW IN THE DESIGN OF THE WDB AUTOPLT. IF YOU TURN THE BUG TO THE LEFT, THE ACFT SHOULD TURN TO THE LEFT.

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  8. Accession Number: 140503
    Synopsis: ACR MLG OVERSHOOTS ALT IN CLIMB.
    Narrative: WE WERE OPERATING FLT FROM DFW TO SLC. DURING THE CLB, AFTER PASSING FL310, WE WERE INSTRUCTED TO CHANGE FREQS TO 134.55. ON THE NEW FREQ WE RPTED TO ZFW THAT WE WERE OUT OF FL320, CLBING TO FL330. ZFW ASKED US TO CONFIRM THE ALT THAT WE HAD BEEN CLRED TO. 33000' WAS DISPLAYED IN THE AUTOPLT ALT DISPLAY AND WE TOLD THE CTLR THAT WE WERE CLRED TO FL330L. THE CENTER CTLR ASKED IF WE COULD REACH FL350 IN 2 MINS OR IF WE WOULD RATHER DSND BACK TO FL310. WE TOLD HIM THAT WE COULD REACH FL350 IN 2 MINS AND WE CONTINUED OUR CLB TO FL350. THE CTLR THEN INFORMED US THAT OUR CLRNC HAD BEEN TO FL310. OUR FLT PLAN CALLED FOR AN INITIAL CRUISING ALT OF FL310 AND FL330 WOULD HAVE BEEN THE WRONG ALT FOR THE DIRECTION OF FLT. I DO NOT KNOW THE REASON FOR THE EXCURSION. IT IS POSSIBLE, BUT UNLIKELY, THAT THE PREVIOUS CTLR CLRED US TO FL330. IT IS POSSIBLE THAT WE MIS-SET THE ALT IN THE AUTOPLT ALT WINDOW. THE FGS ON THIS PARTICULAR ACFT IS A NEW, IMPROVED TYPE. ON EARLIER (AND THE MOST COMMON) MODELS, THE ALT KNOB MUST BE PULLED TO ARM THE ALT. ON THIS MODEL THE KNOB ONLY NEEDS TO BE SET. IT IS POSSIBLE THAT ONE OF US INADVERTENTLY BUMPED THE ALT KNOB AND ACCIDENTALLY CHANGED THE ALT SETTING.

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  10. Accession Number: 141226
    Synopsis: USE OF MISSED APCH DISPLAY NOT INCORPORATING RAW DATA INFORMATION AND PUSH PULL KNOB SELECTOR DESIGN CONTRIBUTE TO TRACK DEVIATION IN GLASS COCKPIT MLG.
    Narrative: ACFT WAS COUPLED TO AUTOPLT AND AUTOPLT WAS ARMED FOR THE ILS (8L AT ATLANTA). ACFT INTERCEPTED AND CAPTURED LOCALIZER AT APPROX 15 NM FROM AIRFIELD, ACFT AT 5000'. I IDENTIFIED LOCALIZER. AS PER COMPANY PROC CAPT ROTATED HDG SELECT KNOB TO 340 DEG FOR MISSED APCH HDG, BUT UNKNOWN TO EITHER OF US THIS MULTIFUNCTION KNOB WAS PUSHED IN FAR ENOUGH TO ACTIVATE "HDG HOLD". I DID NOT NOTICE THE FLT MODE ANNUNCIATOR WINDOW CHANGE FROM "LOC TRK" TO "HDG HLD". OF COURSE, THE ADI (FLT DIRECTOR) DISPLAY REMAINED AS BEFORE WITH THE PITCH BAR GIVING ALT HOLD AT 5000' AND THE BANK BAR STILL CENTERED BUT CENTERED BECAUSE WE WERE ON HDG NOT LOCALIZER. OBVIOUSLY WE GRADUALLY STARTED TO DRIFT RIGHT. THE HSI (NAV DISPLAY) WAS SELECTED ON MAP MODE (20 MI SCALE). ON THIS SCALE A SMALL DEVIATION OFF LOCALIZER IS TOO SMALL TO DETECT. I MONITORED THE GLIDE SLOPE (RAW DATA DISPLAY) AND SAW IT DSND THROUGH THE FLT DIRECTOR PITCH BAR. I LOOKED AT THE FMA AND REALIZED WE WERE NO LONGER ARMED FOR THE ILS. I IMMEDIATELY ANNOUNCED TO THE CAPT AND DISCONNECTED THE AUTOPLT TO START DSNT AND SELECTED ARC MODE ON THE NAV DISPLAY. I SAW WE WERE FULL SCALE LOCALIZER DEFLECTION SO I PUT IN ABOUT A 15 DEG CORRECTION TO COURSE. AT THAT MOMENT ATLANTA APCH CALLED TO TELL US WE WERE DRIFTING INTO THE PARALLEL ILS COURSE AND HE TOLD US TO MAINTAIN 4500' UNTIL ESTABLISHED. (HE ALSO GAVE US A HDG TO CORRECT). I LEVELED AT 4700' AND AS I DID THE LOCALIZER CENTERED UP AND THE ILS WAS RESUMED UNEVENTFULLY. HAVING MAP MODE IN HSI INSTEAD OF ARC DOES NOT MAKE A LOCALIZER DEVIATION IMMEDIATELY OBVIOUS. LACK OF CONTINUOUS CROSS-CHECK OF FMA BY PLTS IS A FACTOR. HDG SELECT KNOB DOUBLES AS HDG HOLD BUTTON AND AN IMPERCEPTIBLE EXTRA PUSH IN ON IT ACTIVATES HDG HOLD. TO CORRECT THE PROBLEM: FLY ILS WITH ARC (OR ROSE) IN MAP TO MAKE DEVIATIONS IMMEDIATELY OBVIOUS. ADDITIONALLY, MULTIFUNCTION KNOBS SHOULD NOT BE ACCEPTED ON ACFT. IT IS SIMPLY TOO EASY AT NIGHT WHEN YOU ARE TIRED OR DISTRACTED TO ACTIVATE THE WRONG FUNCTION. (IN THE MLG WE HAVE 3 MULTIFUNCTION KNOBS WHERE DIFFERENT FUNCTIONS ARE ACTIVATED DEPENDING ON HOW FAR IN YOU PUSH THE KNOB. IT CAN BE VERY TRICKY SOMETIMES).

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  12. Accession Number: 148747
    Synopsis: ACR X CLIMBED TO OCCUPIED ALT AND HAD LESS THAN STANDARD SEPARATION FROM MLT Y. PLTDEV. SITUATION. EQUIPMENT DESIGN ALT PRE-SELECT CAN CHANGE WHEN PULLED TO ARM.
    Narrative: ACR X HAD JUST LEVELED OFF AT AN INTERMEDIATE ALT OF FL270, APPROX 15 TO 20 MI E OF ELX VOR, WHEN CHICAGO CTR CALLED TO INFORM US THAT OUR CLRED ALT WAS FL260 AND NOT FL270. WE WERE THEN INSTRUCTED TO DSND BACK TO FL260. ALMOST IMMEDIATELY AFTER LEVELING OFF, WE WERE RECLRED TO CONTINUE OUR CLB TO OUR FINAL CRUISE ALT OF FL310. DURING THE CLB, CHICAGO CTR INFORMED US THAT WE WERE EARLIER INVOLVED IN A POSSIBLE ALT CONFLICT WITH ANOTHER ACFT CRUISING AT FL270. AFTER LNDG AT BDL, WE IMMEDIATELY CALLED OUR COMPANY. IT WAS DETERMINED FROM THE TAPES THAT I (THE PNF) HAD READ BACK FL260. WE HAD INDEED MADE THE MISTAKE, SOMEHOW, OF SETTING THE WRONG ALT. AT THE TIME OF THE INCIDENT, BOTH THE F/O AND MYSELF WERE CERTAIN THAT SOMEONE ELSE HAD MADE THE MISTAKE. WHEN WE WERE TOLD OF THE RESULTS OF THE TAPE READING, WE WERE BOTH STUNNED. OUR COCKPIT DISCIPLINE WAS GOOD AND OUR PROCS WERE STANDARD, BUT I HAD ACCEPTED FL260 AS THE CLRNC AND SET FL270 IN THE ALT PRESELECT WINDOW W/O EITHER OF US CATCHING THE MISTAKE. FORTUNATELY, THE ATC SYS WORKED AS DESIGNED AND A MUCH MORE SERIOUS CONSEQUENCE WAS AVOIDED. WE ALLEGEDLY MISSED MLT Y BY 400' AND 1/2 MI. AFTER MUCH SOUL SEARCHING AND DISCUSSION WITH OTHER MLG PLTS, I BELIEVE I KNOW WHAT HAPPENED. RELYING ON THE ALT PRESELECT READOUT AS A MEMORY TOOL CAN BE A MISTAKE THAT LEADS TO THIS TYPE OF ERROR. DIALING IN FREQ, HDG, ALT, AND ALTIMETER CHANGES WHILE SIMULTANEOUSLY TRYING TO READ THEM BACK, CAN CAUSE A PLT TO RUSH THINGS TOO MUCH. THE MLG ALT PRESELECT KNOB MUST BE PULLED TO ARM THE AUTOPLT/FLT DIRECTOR CAPTURE MODE. WHILE PULLING ON THE KNOB, IF ONE DRAGS A FINGER OR TWISTS IT JUST SLIGHTLY, THE WRONG ALT CAN BE INADVERTENTLY SET. IF THIS WINDOW READOUT IS THEN USED AS THE ONLY RECORDING OF A CLRNC, IT IS UNLIKELY THAT EITHER PLT WILL CATCH THE MISTAKE. SEVERAL OTHER PLTS HAVE HAD THIS HAPPEN BUT CAUGHT IT. WE DIDN'T! IT'S NO EXCUSE, BUT I BELIEVE THIS TO BE A REASON WHICH COULD HAVE LED TO THIS MISHAP. SUPPLEMENTAL INFO FROM ACN 148396. JUST AFTER LEVEL OFF AT FL270, THE CTR QUERRIED US AS TO OUR ALT. THEY HAD IN FACT CLRED US TO FL260. CTR TURNED US AND GAVE US DSNT TO FL260 BUT NOT BEFORE A CONFLICT OCCURRED WITH ANOTHER MLT Y. I WAS CONCENTRATING ON FLYING AND PROBABLY NOT AS ATTENTIVE TO THE RADIO AS I COULD HAVE BEEN. HAD I BEEN ON AUTOPLT, I MAY HAVE HEARD THE CLB CLRNC AND PREVENTED THE INCIDENT. THE ALT PRESELECT ON THE FLS, ONCE SET, BECOMES THE GOSPEL FOR THE ASSIGNED ALT. THE PRESELECT KNOB MUST BE PULLED TO ARM THE ALT. IN SO DOING, IT IS VERY EASY TO TURN THE KNOB ENOUGH TO CAUSE A 1000' ERROR IN THE ALT READOUT. I BELIEVE THIS IS WHAT HAPPENED TODAY. SUPPLEMENTAL INFO FROM ACN 148401. ACR X DEPARTED ORD REQUESTING 330 CHKED ON FREQ AND WAS CLRED TO FL260 FOR HIS TFC. MLT Y, AT FL270. ACR X READ BACK CLBING TO FL260 AND PROCEEDED TO CLB THROUGH FL260 TO FL270. UPON NOTICING THIS, ACR X WAS ASKED IF HE WAS LEVEL AT FL260. ACR X RESPONDED CLBING TO FL260. ACR X WAS DSNDED TO FL260 AND PLACED ON A HDG. PLTS PAYING MOREATTN TO THE FREQ COULD HAVE PREVENTED THIS.

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  14. Accession Number: 190331
    Synopsis: ALT DEV ALT OVERSHOT IN DSCNT.
    Narrative: WHILE CRUISING AT FL330, THE #1 FLT ATTENDANT CAME TO THE COCKPIT. SHE WAS CONCERNED WITH PASSENGERS WHO WERE WORRIED ABOUT CONNECTING FLTS AT ORD BECAUSE WE WERE BEHIND SCHEDULE. I WAS FLYING THE ACFT, BUT WAS INTERESTED IN HOW THE CAPT WOULD HANDLE THIS SITUATION SINCE I'M GETTING CLOSE TO CAPT UPGRADE. WHILE WE WERE DISCUSSING THIS MATTER, ORD ARTCC GAVE US A DSCNT CLRNC TO FL290. THE CAPT ACKNOWLEDGED ON THE RADIO AND I SET AND ARMED 290 IN THE DIGITAL ALT WINDOW. I THEN BEGAN A SLOW (1000 FPM) DSCNT USING THE VERT SPD MODE OF THE AUTOPLT. THE CONVERSATION CONTINUED. PASSING THROUGH FL300, THE CAPT STARTED TO SAY, '1000 FT TO GO', BUT HE NOTICED 280 WAS SET IN THE ALT WINDOW AND THAT IT WAS NOT ARMED. SO HE SAID, '2000 FT TO GO, BUT THE ALT IS NOT ARMED.' I SIMPLY REACHED UP AND ARMED THE ALT WITH 280 SET IN THE WINDOW. MORE CONVERSATION ABOUT THE PASSENGER CONNECTIONS. 'PASSING 290 FOR 280 AND IT'S ARMED' WAS INTERJECTED BY THE CAPT. I WAS SLOWLY CHANGING THE VERT SPD 100 FT AT A TIME FOR A SMOOTH LEVEL OFF, AND PASSING FL284 WAS DSNDING AT 300 FPM. SUDDENLY, IT STRUCK ME THAT FL280 WAS THE WRONG ALT FOR OUR DIRECTION OF FLT. I WAS TRYING TO TRACE THE SEQUENCE OF EVENTS BACKWARD IN MY MIND AND STARTED TO LEVEL OFF THINKING, 'WE SHOULD BE AT FL290', WHEN ATC CALLED AND ASKED OUR ALT. THE CAPT SAID, 'PASSING 283 FOR 280.' ATC REPLIED, 'YOUR ASSIGNED ALT WAS 290, HOWEVER IT'S NOT A PROBLEM AND YOU CAN CONTINUE YOUR DSCNT TO FL270.' THE CAPT ACKNOWLEDGED, 'DSNDING TO 270.' WHEN GIVEN A FREQ CHANGE BY THIS CTLR, THE CAPT ASKED IF THERE WAS ANY PROBLEM CREATED BY OUR ALT DEV. THIS CTLR SAID, 'NO PROBLEM.' AFTER REPLAYING THE ABOVE SCENARIO NUMEROUS TIMES, I'M SURE I NOW KNOW EXACTLY WHAT HAPPENED. I HAD SET AND ARMED FL290 IN THE ALT WINDOW. I WAS TURNED TO MY L WITH MY L ARM BEHIND MY SEAT BACK SO I COULD SEE THE FLT ATTENDANT AS SHE TALKED. I WAS USING HDG SELECT ON THE AUTOPLT TO FLY THE VOR RADIAL INBOUND. 2 OR 3 TIMES DURING THIS DSCNT, I REMEMBER CHANGING HDG A COUPLE DEGS TO MAKE MINOR COURSE CORRECTIONS. ON AT LEAST 1 OCCASION, I REACHED FOR THE HDG KNOB WITH MY R HAND AND I CAN RECALL VERY LIGHTLY BRUSHING SOMETHING AS I RETRACTED IT FROM THE HDG KNOB. I'M SURE THAT I MUST HAVE JUST TICKED THE ALT KNOB AND THAT CAUSED IT TO CHANGE FROM 290 TO 280 AND DISARM. I HAVE BEEN A COCKPIT CREW MEMBER WITH SCHEDULED PASSENGER CARRIERS FOR OVER 17 YRS NOW. PRIOR TO 1991, I HAD FILED ONLY 1 NASA RPT (ON A NEAR MISS). DURING 1991, THIS IS NOW MY THIRD NASA RPT. THESE LAST 3 RPTS HAVE ALL BEEN ON THE MLG AND ALL PERTAIN TO ALT DEVS. I HAVE HEARD THAT THIS MLG IS BY FAR THE WORST OFFENDER CONCERNING ALT EXCURSIONS. BY NO STRETCH OF THE IMAGINATION CAN THIS ALT ALERT/AUTOPLT LEVEL OFF SYS BE CONSIDERED FOOL PROOF. IN FACT, IT IS A VERY MIXED UP BAG OF TRICKS WAITING TO BITE THE UNWARY. IT NEEDS TO BE FIXED, NOW! I CAN ONLY HOPE IT DOESN'T TAKE A MIDAIR COLLISION AND HUNDREDS OFF FATALITIES TO GET A CORRECTION FOR THIS SYS.

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  16. Accession Number: 190331
    Synopsis: ALT DEV ALT OVERSHOT IN DSCNT.
    Narrative: WHILE CRUISING AT FL330, THE #1 FLT ATTENDANT CAME TO THE COCKPIT. SHE WAS CONCERNED WITH PASSENGERS WHO WERE WORRIED ABOUT CONNECTING FLTS AT ORD BECAUSE WE WERE BEHIND SCHEDULE. I WAS FLYING THE ACFT, BUT WAS INTERESTED IN HOW THE CAPT WOULD HANDLE THIS SITUATION SINCE I'M GETTING CLOSE TO CAPT UPGRADE. WHILE WE WERE DISCUSSING THIS MATTER, ORD ARTCC GAVE US A DSCNT CLRNC TO FL290. THE CAPT ACKNOWLEDGED ON THE RADIO AND I SET AND ARMED 290 IN THE DIGITAL ALT WINDOW. I THEN BEGAN A SLOW (1000 FPM) DSCNT USING THE VERT SPD MODE OF THE AUTOPLT. THE CONVERSATION CONTINUED. PASSING THROUGH FL300, THE CAPT STARTED TO SAY, '1000 FT TO GO', BUT HE NOTICED 280 WAS SET IN THE ALT WINDOW AND THAT IT WAS NOT ARMED. SO HE SAID, '2000 FT TO GO, BUT THE ALT IS NOT ARMED.' I SIMPLY REACHED UP AND ARMED THE ALT WITH 280 SET IN THE WINDOW. MORE CONVERSATION ABOUT THE PASSENGER CONNECTIONS. 'PASSING 290 FOR 280 AND IT'S ARMED' WAS INTERJECTED BY THE CAPT. I WAS SLOWLY CHANGING THE VERT SPD 100 FT AT A TIME FOR A SMOOTH LEVEL OFF, AND PASSING FL284 WAS DSNDING AT 300 FPM. SUDDENLY, IT STRUCK ME THAT FL280 WAS THE WRONG ALT FOR OUR DIRECTION OF FLT. I WAS TRYING TO TRACE THE SEQUENCE OF EVENTS BACKWARD IN MY MIND AND STARTED TO LEVEL OFF THINKING, 'WE SHOULD BE AT FL290', WHEN ATC CALLED AND ASKED OUR ALT. THE CAPT SAID, 'PASSING 283 FOR 280.' ATC REPLIED, 'YOUR ASSIGNED ALT WAS 290, HOWEVER IT'S NOT A PROBLEM AND YOU CAN CONTINUE YOUR DSCNT TO FL270.' THE CAPT ACKNOWLEDGED, 'DSNDING TO 270.' WHEN GIVEN A FREQ CHANGE BY THIS CTLR, THE CAPT ASKED IF THERE WAS ANY PROBLEM CREATED BY OUR ALT DEV. THIS CTLR SAID, 'NO PROBLEM.' AFTER REPLAYING THE ABOVE SCENARIO NUMEROUS TIMES, I'M SURE I NOW KNOW EXACTLY WHAT HAPPENED. I HAD SET AND ARMED FL290 IN THE ALT WINDOW. I WAS TURNED TO MY L WITH MY L ARM BEHIND MY SEAT BACK SO I COULD SEE THE FLT ATTENDANT AS SHE TALKED. I WAS USING HDG SELECT ON THE AUTOPLT TO FLY THE VOR RADIAL INBOUND. 2 OR 3 TIMES DURING THIS DSCNT, I REMEMBER CHANGING HDG A COUPLE DEGS TO MAKE MINOR COURSE CORRECTIONS. ON AT LEAST 1 OCCASION, I REACHED FOR THE HDG KNOB WITH MY R HAND AND I CAN RECALL VERY LIGHTLY BRUSHING SOMETHING AS I RETRACTED IT FROM THE HDG KNOB. I'M SURE THAT I MUST HAVE JUST TICKED THE ALT KNOB AND THAT CAUSED IT TO CHANGE FROM 290 TO 280 AND DISARM. I HAVE BEEN A COCKPIT CREW MEMBER WITH SCHEDULED PASSENGER CARRIERS FOR OVER 17 YRS NOW. PRIOR TO 1991, I HAD FILED ONLY 1 NASA RPT (ON A NEAR MISS). DURING 1991, THIS IS NOW MY THIRD NASA RPT. THESE LAST 3 RPTS HAVE ALL BEEN ON THE MLG AND ALL PERTAIN TO ALT DEVS. I HAVE HEARD THAT THIS MLG IS BY FAR THE WORST OFFENDER CONCERNING ALT EXCURSIONS. BY NO STRETCH OF THE IMAGINATION CAN THIS ALT ALERT/AUTOPLT LEVEL OFF SYS BE CONSIDERED FOOL PROOF. IN FACT, IT IS A VERY MIXED UP BAG OF TRICKS WAITING TO BITE THE UNWARY. IT NEEDS TO BE FIXED, NOW! I CAN ONLY HOPE IT DOESN'T TAKE A MIDAIR COLLISION AND HUNDREDS OFF FATALITIES TO GET A CORRECTION FOR THIS SYS.

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  18. Accession Number: 209793
    Synopsis: ADV COCKPIT WDB ON ARR AT GATWICK DSNDS THROUGH 8000 FT CLRED ALT BY 500-600 FT WHEN ALT ALERT SETTING JUMPS TO NEXT VALUE DUE TO NOT BEING COMPLETELY IN ITS DETENT.
    Narrative: WHILE BEING STEPPED DOWN IN HOLDING AT WILLO, WE WERE CLRED TO TURN TO 090 DEG VECTOR, AND TO DSND TO FL80. WX WAS CAVU WITH SEVERAL ACFT IN SIGHT. I WAS FLYING ON AUTOPLT AND SELECTED AND ENGAGED THE HDG AND ALT ON THE FLT CTL UNIT BY PULLING ON THE SELECTOR KNOB. PASSING FL80 I CHKED THE ALT ALERTER AND IT SHOWED FL70. I GOT THAT ,'SOMETHING ISN'T RIGHT' FEELING, AND ASKED THE FO IF WE HAD BEEN CLRED TO FL70, AS THERE WAS QUITE A BIT OF TFC ON THE RADIO. HIS FIRST REACTION WAS TO CHK THE ALERTER, AND I COULD NOW SEE HE WAS UNSURE. BEFORE I COULD ASK FOR VERIFICATION FROM ATC THE CTLR ADVISED WE HAD BEEN CLRED TO FL80. I DISCONNECTED THE AUTOPLT AND CLBED IMMEDIATELY TO FL80. WE DSNDED TO ABOUT 74-75000 FT. WE CONTINUED THE APCH WITH NO FURTHER COMMENT. I BELIEVE A MAJOR CONTRIBUTING FACTOR IS THE OVER SENSITIVITY OF THE ALT ALERT SET KNOB. IT TAKES VERY LITTLE ROTATIONAL FORCE TO CHANGE THE ALT SETTING. SOMETIMES JUST THE PULLING AND RELEASING OF THE KNOB WILL CHANGE THE SETTING. WHICH I THINK HAPPENED IN THIS CASE. MOST CREWS ARE AWARE OF AND WATCH FOR THIS OCCURRENCE. I WAS, I DO AND IT STILL GOT ME. I WOULD RECOMMEND THAT THE ALT ALERTER BE MODIFIED, SO THAT CHANGING THE ALT SETTING WOULD REQUIRE A MORE POSITIVE OR DEFINITE MOVE, (IE, INCREASING THE FRICTION OR A DEFINITE DETENT). AN INST THAT COULD NOT BE CHANGED BY MEARLY PULLING ON THE KNOB TO ENGAGE THE LEVEL CHANGE. OTHER FACTORS, 2 MAN, ALL NIGHT, TRANSOCEANIC, AND THE FACT THAT THE WX WAS SO GOOD. THAT SCAN WAS BOTH IN AND OUT.

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  20. Accession Number: 232991
    Synopsis: CAPT OF ACR LGT ACFT MISTAKENLY SET THE WRONG ALT INTO THE ACFT FMC RESULTING IN AN ALT OVERSHOOT.
    Narrative: CRUISING AT FL200 WITH REQUESTED ALT OF FL230, CTR CLRED US TO FL210. I SELECTED FL210 WHILE NOTING THE NEW ASSIGNED ALT ON THE PRIMARY FLT DISPLAY. I THEN PUSHED THE ALT SELECT KNOB TO ENGAGE VNAV WHILE I MONITORED THE FLT MODE ANNUNCIATOR TO VERIFY ENTERING CLB MODE. A FEW MINS LATER, CTR TOLD US TO MAINTAIN FL210 AND I NOTICED WE WERE LEVEL AT FL220. I DON'T KNOW HOW FL220 GOT IN THE FMS, BUT MUST ASSUME THAT WHEN I PUSHED THE ALT KNOB TO ENTER VNAV, THE ASSIGNED ALT CHANGED 1 DIGIT WHILE I WAS LOOKING OVER AT THE FLT MODE ANNUNCIATOR. WE WERE AT FAIRLY LIGHT GROSS WT AND CLBING FAST WHEN THE FLT ATTENDANT CAME IN TO OFFER COFFEE. I GLANCED AT THE FMA, NOTICED ALT CAPTURE AND TURNED MY ATTN TO THE FLT ATTENDANT. AS I LOOKED BACK, WE WERE IN MANAGED LEVEL FLT. I DIDN'T NOTICE WE WERE 1000 FT HIGH. BECAUSE OF THE MULTIFUNCTIONAL USES OF THIS KNOB (PUSH, PULL, TWIST) FOR VNAV MODES AND LEVEL CHANGES, IT CAN CREATE A TRAP. IF EACH MODE/LEVEL IS VERIFIED IN SEQUENCE IT MAY END UP ERRONEOUS. THE ANSWER WITH THIS KNOB IS TO REVERIFY ALL SELECTIONS AFFECTED BY THIS KNOB AFTER REMOVING YOUR HAND FROM IT.

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  22. Accession Number: 240798
    Synopsis: FLC OF ACR MLG ACFT INADVERTENTLY OVERSHOT DSCNT ALT DUE TO THE ACFT'S AUTOPLT ALT SETTING PROB.
    Narrative: DURING DSCNT TO KLGA ON FLT X, CTLR INSTRUCTED US TO DSND FROM 12000 FT TO 7000 FT WHILE ON THE MILTON 7 ARR. AUTOPLT WAS ON RNAV TRACKING. I SET 7000 FT INTO ALT WINDOW AND CAPT VERIFIED SETTING. PASSING ABOUT 8500 FT WE BEGAN A TURN. I CHKED PROGRESS ON THE UNFAMILIAR ARR WHILE MONITORING DSCNT. CTLR THEN NOTIFIED US TO MAINTAIN 7000 FT. OUR ALT WAS 6500 FT AND BOTH OF US NOTICED 6000 FT NOW IN THE ALT WINDOW. I HAND FLEW THE ACFT BACK TO 7000 FT AND CONTINUED THE ARR. NO TFC CONFLICT. IT APPEARS THAT THE DIGITAL ALT WINDOW WAS SET BTWN THE DETENTS (WHICH ARE 'SOFT' IN THIS EQUIP) AND SLIPPED AFTER BEING SET. THOUGH I WAS MONITORING THE DSCNT, DISTRACTING FACTORS MADE ME FORGET THE ORIGINAL XMISSION AND MADE ME THINK IT WAS THE 6000 FT NOW INDICATED.

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  24. Accession Number: 361141
    Synopsis: INFLT WX ENCOUNTER. RPTR STATES THAT THE RADAR WAS OVERWHELMED BY INTENSE RAIN ACTIVITY AND THEY ENTERED A TSTM WITH RESULTANT LIGHTNING STRIKE PLUS ALTDEV. ACFT DAMAGE AS A RESULT OF TURB AND LIGHTNING.
    Narrative: ACFT WAS ON CRUISE AT FL180 AND GIVEN PLT'S DISCRETION DSCNT TO 11000 FT. UPON PASSING 16000 FT WAS INSTRUCTED TO STOP DSCNT AT 15000 FT. SHORTLY THEREAFTER, ATC CLRED US FOR PLT'S DISCRETION DSCNT TO 11000 FT. AT THIS POINT WE PENETRATED A TSTM CELL (OUR RADAR WAS OVERWHELMED BY THE INTENSE RAIN ACTIVITY AROUND US). I (FO) PUNCHED THE CLB BUTTON BY ACCIDENT ON THE AUTOPLT IN AN ATTEMPT TO BEGIN OUR DISCRETIONARY DSCNT TO 11000 FT. TURB WAS MODERATE TO OCCASIONALLY SEVERE. WE THEN WERE HIT BY LIGHTNING ONLY MOMENTS AFTER I HIT THE CLB MODE (I AM UNSURE AS TO WHICH HAPPENED FIRST, CLB MODE ACTIVATION OR THE LIGHTNING). WE NOTICED THE ALT CLBING THROUGH 16300 FT AND I DISCONNECTED THE AUTOPLT AND IMMEDIATELY DSNDED TO 11000 FT MANUALLY. ATC SAID NOTHING OF THE DEV. WE LOST ALL COM WITH ATC BECAUSE OF SEVERE STATIC INTERFERENCE DUE TO FREQUENT LIGHTNING AND ICING ON THE ANTENNAS. WE LATER DISCOVERED THAT THE ANTENNAE TO COM #2 HAD BEEN COMPLETELY DESTROYED BY THE LIGHTNING. WE WERE OFF ALT A TOTAL OF APPROX 1 MIN WITH AN ADDITIONAL 30 SECONDS (PERHAPS) TO DSND BACK BELOW 11000 FT. CONTRIBUTING FACTORS: ON BOARD RADAR BECAME USELESS EARLY IN FLT. PF UNABLE TO SEE PANEL CLRLY DUE TO TURB AND BRIGHT LIGHTNING. PLTS WERE UNABLE TO NOTICE PITCH-UP ATTITUDE OF INITIAL CLB AS ACFT PITCH, ROLL AND YAW WERE CHANGING CONSTANTLY AND DRAMATICALLY. LOSS OF COM ON ALL RADIOS ALONG WITH ICING AND THE INITIATION OF A VISUAL DAMAGE SEARCH FROM THE LIGHTNING (LOOKING OUT THE WINDOWS) ALL CAUSED THE ALTDEV TO GO UNNOTICED FOR A CLB DURATION OF 1300 FT. I DON'T FEEL ATC EVEN HAD GOOD RADAR CONTACT WITH US DUE TO THE EXTREME WX CONDITIONS. NO CONFLICT WITH OTHER ACFT -- NO ONE ELSE STUPID ENOUGH TO BE ANYWHERE NEAR WHERE WE WERE. UPON LNDG IN TLH, WE DISCOVERED MULTIPLE AREAS OF LIGHTNING DAMAGE TO ANTENNAS AND ACFT SKIN. THIS WAS THE FLT FROM HELL. I SHOULD HAVE BEEN A DENTIST! SENT WITH APOLOGIES FOR POOR HANDWRITING, GRAMMAR AND SENTENCE STRUCTURE.

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  26. Accession Number: 361546
    Synopsis: AN ACR B767 FLC HAS DIFFICULTY WITH THEIR FMCS AND RELATED NAV AND AUTOFLT SYS. THE PROBS WERE FINALLY RESOLVED AND THE SYS ARE RESTORED TO NORMAL OP.
    Narrative: FLT LEFT LHR ON TIME AT XX00Z. INITIALLY ON HDGS/ VECTORS BY LONDON AND SCOTTISH CTL. OCCASIONALLY WHILE CLBING OUT WE WOULD GET MESSAGE ON FMC 'RTE UPLINK READY TO LOAD.' SINCE WE HAD ALREADY DONE THIS ON THE GND AND EVERYTHING LOOKED NORMAL IT WAS JUST BOTHERSOME, BUT QUESTIONABLE WHY THIS FMC (BOTH ACTUALLY) WAS DOING THAT. NEAR GLASGOW WE WERE AT OUR FINAL, FL310 AND THE FO HAD FINISHED DOING ALL THE REQUIRED CHKS BEFORE ENTERING CLASS II AIRSPACE. IRS CHKED FINE, OUR VOR CHK WAS RIGHT ON, POS CHK WAS CORRECT AND OUR MAGNETIC COMPASS, HSI CHK WAS CORRECT. I WAS PF AND HAD ACFT HOOKED UP TO AUTOPLT AND AUTOTHROTTLE. WE WERE ABOUT TO RECEIVE OUR OCEANIC CLRNC WHEN ON THE ADI THE VNAV ANNUNCIATION AND LNAV ANNUNCIATION WENT AMBER WITH A YELLOW LINE THROUGH THEM. SIMULTANEOUSLY A MASTER CAUTION WENT OFF WITH ANNUNCIATION OF AUTOTHROTTLE DISCONNECT AND AUTOPLT DISCONNECT. THE AUTOTHROTTLE DID DISCONNECT, BUT THE ACFT'S AUTOPLT STAYED ENGAGED, BUT WITHOUT ANY GUIDANCE. TRYING TO RE-ENGAGE LNAV AND VNAV WAS UNSUCCESSFUL. WE DESELECTED CTR AUTOPLT AND TRIED THE L AND R AUTOPLT WITH NO SUCCESS. USING HEADING SELECT I WAS ABLE TO MAINTAIN DIRECTIONAL GUIDANCE AND SELECTING 'FLCH' WAS ABLE TO MAINTAIN AIRSPD AND ALT. SINCE THE AUTOPLT WAS WORKING, OBVIOUSLY SOMETHING WITH LNAV AND VNAV WAS NOT FUNCTIONING PROPERLY. WE HAD LOST OUR ACTIVE WAYPOINT, (WE WERE DIRECT 'MATIK' AT TIME) HOWEVER ALL OUR WAYPOINTS WERE STILL DISPLAYED. THE FMC STILL HELD OUR RTE, BUT NO ETA'S WERE ON LEG'S PAGES OR ON PROGRESS PAGE. WE RE-SELECTED 'MATIK' AS OUR ACTIVE WAYPOINT, AND WHILE VERY SLOW THE FMC FINALLY REENGAGED THE RTES AND WE TRIED 'LNAV' AND THE ACFT WAS ONCE AGAIN ON IRS NAV. THE CAPT THEN TOLD ME 'YOU FLY AND TALK, WE'LL WORK ON THE PROB' MEANING THE FO AND HIM. THEY CALLED MAINT AND DISPATCH AND APPARENTLY THEY WERE OF VERY LITTLE HELP. I DID NOT HEAR ANY OF THEIR CONVERSATION EXCEPT THE FO AND CAPT WERE VERY UPSET WITH THEM. DURING THIS TIME I HAD SCOTTISH CONFIRM OUR POS, AND I DID SOME CHKING ON FIX PAGE WITH VORS AND SUCH. ALL THE TIME, THE FMC DISPLAY A RTE, BUT IT WAS NOT ACTIVE, AND ABOUT THIS TIME MAINT HAD US PULL AND RESET CERTAIN CIRCUIT BREAKERS. AFTER THIS THE RTE HAD REMAINED IN THE FMC, BUT IT HAD NOW BECOME 'MOD RTE' WHICH MEANS IT WAS NOT ACTIVE, ALSO THE MESSAGE 'PERF/VNAV UNAVAILABLE' STARTED BEING DISPLAYED. THE FO AND I REALIZED ALMOST IMMEDIATELY THAT THAT MEANT WE'D LOST OUR PERFORMANCE PLATFORM, AND THAT WAS ONE REASON WE DID NOT HAVE ETA'S TO POINTS. I INDEXED THE FMC AND PULLED UP PERFORMANCE PAGE AND SURE ENOUGH ALL OUR PERFORMANCE DATA HAD BEEN DUMPED, PROBABLY DUE TO RESETTING CIRCUIT BREAKERS OF FMC AND OTHER EQUIP. AS SOON AS I ENTERED ALL THE DATA THE FMC IMMEDIATELY CAME UP WITH ALL THE PROPER DATA, ETA'S TO FIX, TIME ENRTE, GROSS WT, ETC. WE ONCE AGAIN DID ALL OUR CHKS FOR ENTERING CLASS II AIRSPACE, AND FELT COMFORTABLE THAT THE PROB WAS FIXED. WE AGREED AND WE WERE ON OUR WAY. DURING THE OCEAN XING WE WERE ALWAYS ON COURSE AND WHILE OVER ICELAND HAD OUR POS VERIFIED WITH REYKEVIC CTL. ON WHY THE FMC DID WHAT IT DID I HAVE SOME THOUGHTS. WHILE UNDER RADAR VECTORS, THE CAPT KEPT SWITCHING FROM HDG SELECT TO LNAV, FOR AS HE SAID 'TO KEEP THE CLOCK UPDATED.' OFTEN WHEN HE DID THIS THE MESSAGE 'NOT ON INTERCEPT HDG' WOULD COME UP. SINCE I WAS HAND FLYING AND KEEPING A HEADING IT MAY HAVE CONFUSED THE FMC ON WHAT IT WAS SUPPOSED TO DO. ALSO I KNOW THE CAPT WAS GOING TO UPLOAD THE WINDS, BUT I WONDER IF HE ACCIDENTALLY HIT 'UP LOAD RTE' INSTEAD AND THAT WAS WHY WE KEPT GETTING 'RTE UPLINK READY TO LOAD' MESSAGE. WE NEVER HAD FMC FAILURE, NOR DID WE GET THAT MESSAGE, THE RTE WAS ALWAYS IN THE FMC, AND MAP DISPLAY WAS GOOD, IT JUST FOR SOME REASON, PROBABLY HUMAN, CAUSED IT TO OVERLOAD AND GO INTO A DEGRADE MODE UNTIL IT HAD ALL THE FACTS. THAT WE WERE ABLE TO RESTORE IT POINTS TO SOME GLITCH, EITHER ELECTRONICALLY OR HUMAN, THAT CAUSED IT TO BEHAVE THE WAY IT DID. AT NO TIME WERE WE IN CLASS II AIRSPACE, AND AT NO TIME DID WE LOSE STANDARD NAV CAPABILITY (VOR, ADF, ILS). CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE INTL RELIEF FO SAID THAT HE SUSPECTED THAT THE CAPT HAD INITIALLY ATTEMPTED TO ENTER UPDATED WINDS BY INADVERTENTLY PUSHING THE 'UPLOAD RTE' BUTTON. THE RPTR SAID THAT LATER IN THE FLT, THE REGULAR FO AND HE TALKED ABOUT THESE EVENTS AND THEY AGREED THAT THE PRIMARY CAUSE OF THE PROB WAS HUMAN ERROR. THE RPTR ALSO SAID THAT ONE OF THE OTHER PROBS WAS THAT THE FMCS WERE BEING OVERLOADED WITH INPUTS AND WERE IN DANGER OF CEASING TO FUNCTION. THIS IS A COMMON PROB AND OR LIMITATION THE RPTR SAID WITH THE B767 AND B757 FMCS. HE SAID THAT YOU JUST CAN'T MOVE TOO FAST WITH YOUR TYPING OR THEY WILL QUIT.

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  28. Accession Number: 369050
    Synopsis: MLG ACFT WITH XING RESTR ALT CLRNC, CAPT INSERTED INTO FMS BUT FAILED TO EXECUTE, REALIZED ACFT WASN'T DSNDING AND TOOK OVER MANUALLY, BUT DIDN'T MAKE RESTR.
    Narrative: ARRIVED AT OUR ASSIGNED ALT OF FL290 AT JAXSN INTXN APPROX 4 MI LATE (AFTER JAXSN INTXN). THE CAPT WAS FLYING AND WHEN HE WAS PROGRAMMING THE FMS FOR THE JAXSN RESTR OF FL290, HE APPARENTLY DID NOT HIT THE 'EXECUTE' BUTTON HARD ENOUGH TO ENTER IT IN THE FMS. I SAW THE RESTR IN THE BOX BUT THE THROTTLES WERE IN THE WAY OF HIS CTL PANEL, SO I DIDN'T SEE THE WHITE EXECUTE LIGHT 'ON.' AS WE APCHED THE FIX, THE ACFT DIDN'T DSND AND I ADVISED THE CAPT. HE TOOK OVER MANUALLY AND USED SPD BRAKES IN AN ATTEMPT TO MEET THE RESTR. NOTHING WAS SAID BY THE CTLRS.

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  30. Accession Number: 376434
    Synopsis: AN ACR B737 FLC MADE SEVERAL ERRORS USING THE AUTOFLT SYS AND TRIGGER AN RA TO WHICH THEY PROPERLY REACT. AFTER ALL OF THIS THEY WERE ABLE TO COMPLETE THE APCH AND LNDG.
    Narrative: I WAS FLYING THE LOC APCH TO RWY 27 AT SAN DIEGO (LINDBERG FIELD). APCH CTL HAD TURNED US BASE LEG AT 4000 FT (180 KTS) THEN GAVE US A HDG OF 240 DEGS MAINTAIN 3800 FT UNTIL ON APCH. CLRED FOR THE LOC APCH RWY 27. I REACHED DOWN AND SWITCHED THE AUTOTUNE TO MANUAL (UNAWARE THE OTHER PLT HAD JUST DONE THAT FOR ME) AND MISTAKENLY INCREASED THE AIRSPD TO 240 KIAS INSTEAD OF THE HEADING BUG. WE WERE CLRED BEHIND ANOTHER B737 WHICH WE HAD IN SIGHT. I IMMEDIATELY DISENGAGED THE AUTOPLT AND AUTOTHROTTLES BECAUSE THE ACFT WAS ACCELERATING AND NOT TURNING TO INTERCEPT FINAL. WHEN I REALIZED MY RADIO WAS NOT TUNED TO THE PROPER FREQ I SAW THAT WE WERE GOING THROUGH FINAL APCH. I MADE AN IMMEDIATE TURN. WE ENDED UP GOING SLIGHTLY THROUGH FINAL. I KEPT THE ACFT I WAS FOLLOWING IN SIGHT AND STARTED A SLOW DSCNT. WE RECEIVED THE RA AND FOLLOWED THE COMMANDS AND ADVISED ATC. WE IMMEDIATELY RE-ESTABLISHED ON THE LOC (AFTER CLR OF CONFLICT) AND THE REST OF THE APCH WAS NORMAL. THE FACTORS FROM MY END WERE THAT I ROTATED THE WRONG KNOB ON THE FMC PANEL (AIRSPD INSTEAD OF HEADING) AND WHEN I THOUGHT I WAS TUNING THE LOC I ACTUALLY PUT THE NAV RADIOS IN AUTOTUNE. EVERYTHING HAPPENED AT THE SAME TIME AND IT TOOK A FEW SECONDS TO ANALYZE WHAT WAS HAPPENING CAUSING ME TO DEVIATE THROUGH THE COURSE AND DSND LOWER THAN THE ASSIGNED 3800 FT.

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  32. Accession Number: 385666
    Synopsis: AN ACR B737 FLC FINDS THAT THE AUTOPLT ENGAGEMENT PADDLES COULD BE ALMOST IN THE 'CMD' POS AND REMAIN THERE AND YET NOT BE ACTUALLY ENGAGED. THE ACFT CLBED ABOVE ITS ASSIGNED ALT AND TURNED OFF ITS COURSE SINCE THE AUTOPLT WAS NOT, IN FACT, ENGAGED.
    Narrative: COPLT WAS PF, I WAS PNF. AS WE WERE CLBING THROUGH FL290 TO THE ASSIGNED FL310, I TURNED OFF THE SEAT BELT SIGN AND PROCEEDED TO PERFORM THE ASSOCIATED PUBLIC ANNOUNCEMENTS. I TOLD THE PNF I WOULD BE 'OFF THE AIR' DURING THIS TIME, DURING MY ANNOUNCEMENT. THE PNF LEVELED THE ACFT AT FL310 AND ENGAGED THE 'B' AUTOPLT. I FINISHED MY ANNOUNCEMENT, TURNED MY VHF-1 VOLUME BACK UP, LOOKED UP AND SAW WE WERE CLBING THROUGH FL314 IN A R TURN (APPROX 20 DEG ANGLE OF BANK). THE PF TOOK CTL AND MADE THE WINGS LEVEL, THEN CORRECTED OUR CLB BY LEVELING OFF AT ABOUT FL317 -- THEN BEGAN A DSCNT BACK TO FL310 WHILE TURNING BACK TO COURSE. THERE WAS INITIAL CONFUSION AS TO WHAT WAS HAPPENING. WE BOTH THOUGHT AT FIRST THAT THE FMC HAD MALFUNCTIONED, OR THAT THE COMPUTER WAS GIVING ERRONEOUS INSTRUCTION TO THE AUTOPLT. HOWEVER, THE AUTOPLT WAS NOT ENGAGED. I DID NOT SEE THE PF ENGAGE THE AUTOPLT, BUT HE SAID HE DID, AND THAT IT PROPERLY ENGAGED AND TRACKED THE LNAV-VNAV FUNCTIONS. WE HAD AN OMC OBSERVING, AND HE CONFIRMED THIS. THE OMC WAS A COMPANY NEW HIRE RECENTLY QUALIFIED IN OUR ACFT AS FO. AS WE DSNDED THROUGH FL313, ZLA QUERIED OUR ALT. I TOLD THEM WE WERE THROUGH FL312, THAT OUR AUTOPLT HAD DISENGAGED, AND WE WERE CORRECTING THE COURSE AS WELL. HE SAID 'NO PROB - - JUST KEEPING YOU HONEST.' WE THEN TRIED TO DIAGNOSE OUR PROB. WE TRIED TO RE-ENGAGE THE 'B' AUTOPLT. THE BUTTON LIT -- THEN WENT DARK. I TRIED 'A' AUTOPLT -- IT DID NOT LIGHT. I TRIED THE 'CWS' MODE TO NO AVAIL. AT THIS POINT, WE REALIZED THAT THERE NEVER WAS AN AUTOPLT DISCONNECT HORN. I ASKED THE OMC TO CHK AND RECHK ALL CIRCUIT BREAKERS. I THEN BECAME PF -- AND ASKED THE COPLT TO REVIEW OUR FLT MANUAL. ALL CIRCUIT BREAKERS WERE IN, THERE WAS NO FLT MANUAL GUIDANCE ON THIS PROB. THE FO THEN NOTICED THE AUTOPLT DISENGAGE BAR WAS SLIGHTLY DOWNWARD. HE PUSHED IT BACK UP. I ENGAGED THE 'B' AUTOPLT AND IT WORKED NORMALLY. THE BAR WAS DOWN JUST SLIGHTLY, NOT ENOUGH TO PROMINENTLY REVEAL THE YELLOW AREA BEHIND IT, OR ILLUMINATE THAT AREA, AS IT DOES WHEN FULLY DISENGAGED. THIS WAS OUR SECOND LEG IN THIS PLANE, AND IT WORKED FINE TO THIS POINT. NO OTHER TFC WAS VISIBLE OR APPEARED ON TCASII. THE FLT CONTINUED NORMALLY, AND NORMALLY FOR THE NEXT 3 LEGS WE FLEW IT. HOWEVER, WE DID HAVE QUESTIONS ABOUT THIS OCCURRENCE: 1) WHY THERE WAS NO AUTOPLT DISCONNECT WARNING HORN. BOTH THE PF AND OMC BELIEVED THE AUTOPLT DID ENGAGE, WHICH SHOULD HAVE PRODUCED THE HORN FOR A DISENGAGEMENT. 2) WE HEARD NO ALT WARNING HORN THROUGH FL313, AS WE SHOULD HAVE. IT MAY HAVE SOUNDED, BUT NOBODY RECALLED IT. 3) HOW DID THE AUTOPLT DISENGAGE BAR GET TO THE POS IT WAS IN. HOW LONG WAS IT LIKE THAT? BECAUSE OF THESE QUESTIONS, WE TESTED THESE SYS ON THIS LEG. THEY ALL WORKED NORMALLY. THE AUTOPLT HORN AND ALT WARNING HORN BOTH SOUNDED IN CASES THEY SHOULD HAVE. AS A PRECAUTION, I RPTED THE PROB TO OUR COMPANY MAINT FOR THEIR REVIEW OF THESE SYS. THE AUTOPLT DISCONNECT BAR WAS NOT FULLY DOWN -- IN A DISCONNECT POS. ON A FLT THE FOLLOWING DAY, I DISCOVERED (IN ANOTHER PLANE) THAT THE 'B' AUTOPLT ENGAGE BUTTON WILL ILLUMINATE FOR A BRIEF TIME (1 SECOND) AND THEN EXTINGUISH WITH NO HORN OR 'COMMAND' ANNUNCIATION. THE 'A' WILL STAY DARK IF PUSHED. I CONCLUDE THAT SINCE WE GOT NO HORN, AND THE PLANE WAS NOT TRIMMED FOR LEVEL FLT, THE AUTOPLT DID NOT ENGAGE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR WAS FLYING A B737-300 AT THE TIME AND SINCE HIS DISCOVERY HE HAS BEEN ABLE TO DUPLICATE THE ALMOST-ENGAGING OF THE AUTOPLT ON SEVERAL B737S. HE SAID THAT SINCE THIS EVENT HE ALWAYS CHKS THE ENGAGE PADDLES DURING HIS PREFLT PROC AND IF HE CAN HE DEMONSTRATES THE PHENOMENON TO HIS FO. HE STATED THAT HE WAS NEVER TRAINED TO COMPLETELY SEAT THE PADDLE IN THE 'CMD' (COMMAND) POS DURING HIS INITIAL TRAINING.

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  34. Accession Number: 403917
    Synopsis: ALT EXCURSION DURING HIGH ALT CRUISE BY FLC OF AN MD11.
    Narrative: I WAS ACTING AS PNF WHILE RECEIVING MY IOE ON THE MD11. THE CHK CAPT WAS FLYING IN THE R SEAT AND WAS THE PF. AFTER DEPARTING CVG FOR EUROPE, WE WERE AT CRUISE ALT OF 33000 FT MSL NEAR SYRACUSE, NY. THE WX WAS DETERIORATING RAPIDLY WITH MULTIPLE TSTMS, EXTREME TURB, STRONG WINDS, AND ACCORDING TO THE CTR, TORNADIC ACTIVITY. IT WAS NECESSARY TO MAKE MANY LATERAL DEVS TO AVOID THE WX, AND WE WERE BOTH CONCENTRATING ON THE WX RADAR WHILE BEING GIVEN SEVERAL CHANGES TO OUR CLRNC BY ZNY. I WAS VERY BUSY TALKING ON THE RADIO AND ATTEMPTING TO CHK OUR RTE ON THE CHARTS AND MAPS. CTR CALLED AND ASKED OUR ALT, AT WHICH POINT WE BOTH REALIZED THAT THE AIRPLANE (WHICH WAS ON AUTOPLT AT ALL TIMES) WAS LEVEL AT 32000 FT. THE PF IMMEDIATELY CLBED BACK TO 33000 FT. THERE WAS NEVER AN ALT WARNING FROM THE AUTOPLT OR ALTIMETER SYS, AND NEITHER OF US CAN EXPLAIN HOW THE ALT CHANGED. IT IS POSSIBLE THAT IN ALL THE CONFUSION TAKING PLACE, THAT THE PF TURNED THE ALT CTL KNOB INSTEAD OF THE HEADING KNOB TO ATTEMPT A WX DEV. THE 2 KNOBS ARE NEXT TO EACH OTHER AND ARE ALMOST IDENTICAL ON THIS AIRPLANE. THE CTLR SAID THAT THERE WAS NO CONFLICT AND 'NO PROB.'

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  36. Accession Number: 407350
    Synopsis: B747 CREW ENTERS WARNING AREA WITHOUT CLRNC IN ZOA AIRSPACE.
    Narrative: HAVING BEEN OFF FOR OVER 50 DAYS AND HAVING ONLY USED THE LITTON-92 FOR NAV 4 TIMES IN THE PAST I ARRIVED EARLY AND WITH THE FO COMPLETED A THOROUGH PREFLT LOADING AND RECHK OF THE WAYPOINTS IN THE NEW LITTON-92 INERTIAL NAV SYS. TKOF WAS AT XX25Z AND WAS ASSIGNED THE MOLEN TWO (MOLEN2.MOLEN) DEP. THE FO CONTACTED BAY DEP CTL AND AFTER WESLA INTXN I TRANSITIONED TO THE SFO 287 DEG RADIAL (V199) OUT TO MOLEN INTXN. WE WERE HANDED OFF TO ZOA. JUST AS I WAS TUNING THE 156 DEG RADIAL OF ENI WE WERE THEN CLRED DIRECT TO KENNT INTXN. I SWITCHED ON THE AUTOPLT AND PRESSED THE DIR KEY ON THE LITTON-92 THEN TYPED THE FIRST LETTER OF THE WAYPOINT. THE CDU DISPLAYED KENNT ON LINE 4 (HERE IS MY ERROR), I THEN PRESSED ENT AND WAS ASKED TO CONFIRM 'K' N 48 DEG 38.46 E 21 DEG 14.00 SLAVIC. SO I REPEATED THE PROCESS WITH THE SAME RESULTS, DURING THIS TIME ZOA CALLED AND ASKED IF WE WERE PROCEEDING TO KENNT. NOW I HAD JUST SPENT ABOUT 40 MINS GOING THROUGH EVERY WAYPOINT ON OUR RTE. I ANSWERED THAT I WAS GETTING SOME WAYPOINT IN YUGOSLAVIA. I THEN BEGAN TYPING IN KENNT ON THE DIRECT PAGE, WHICH IS COMPLICATED BY THE FACT THAT ALL THE KEYS ON THE LITTON-92 HAVE AT LEAST TWO AND SOME THREE DIFFERENT FUNCTIONS. AT THIS TIME ZOA CALLED SAYING THAT WE WERE GOING TO ENTER A WARNING AREA AND TO TURN TO A HDG OF 010 DEGS. I IMMEDIATELY TURNED THE ACFT. AFTER BEING HANDED OFF TO THE HIGH ALT SECTOR I ASKED THE CTLR IF WE HAD ENTERED THE WARNING AREA HE RESPONDED NO WE HAD NOT. AFTER ABOUT 45 MINS WE RECEIVED A SELCAL FROM SAN FRANCISCO COMMERCIAL RADIO ASKING THAT WE CALL ZOA. I USED THE SATELLITE PHONE ON THE ACARS AND ASKED CHICAGO DISPATCH TO PATCH US THROUGH. I WAS CONNECTED WITH A SUPVR WHO INFORMED ME THAT HE DIDN'T HAVE ANY DETAILS AND ASKED THAT I CALL BACK WHEN I ARRIVED AT MY DEST. I INFORMED HIM THAT I WOULD NOT BE LNDG UNTIL LATE. THE SUPVR THEN ASKED THAT I CALL BACK IN 1 HR AND HE WOULD HAVE THE DETAILS FOR ME. I CALLED BACK AS REQUESTED AND THE SUPVR INFORMED THAT WE HAD GONE 5 MI INTO W-260. I ASKED IF THERE HAD BEEN ANY TFC CONFLICTS CAUSED BY THIS AND WAS TOLD THAT THERE WAS NO CONFLICTING TFC.

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  38. Accession Number: 416150
    Synopsis: AN F100 EXITS THE BOUNDARIES OF THE PUBLISHED HOLDING PATTERN 40 MI W OF FWA. CTLR GIVES THE CREW A 'WAKE UP' CALL.
    Narrative: ASSIGNED TO HOLD AT FWA. ENTERED HOLD AND ESTABLISHED. WE WERE WORKING ON CALCULATING ALTERNATES, FUEL, AND TIME REMAINING, WHEN ATC CALLED AND SAID WE WERE 40 MI W OF THE HOLD. WE WERE ASSIGNED A HDG BACK TO FWA AND RE- ENTERED THE HOLD. LOOKING BACK, WE DISCOVERED WE HAD INADVERTENTLY GOTTEN INTO A HDG MODE WHILE WE WERE DOING OUR CALCULATIONS. THE ONLY EXPLANATION WE COULD COME UP WITH FOR THIS DEV WAS THAT ONE OF US HAD BRUSHED AGAINST THE HDG KNOB OF THE AUTOPLT WHICH THEN PUT US INTO A HDG MODE. BECAUSE WE WERE DEEPLY INVOLVED IN OUR FUEL CALCULATIONS, WE FAILED TO NOTICE THAT THE ACFT WAS PROCEEDING OUT OF THE HOLD. WE WENT BACK TO THE HOLD AND THE FLT CONTINUED WITH A NORMAL LNDG AT ORD.

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  40. Accession Number: 416600
    Synopsis: FLC OF AN MDT DSNDED BELOW ASSIGNED XING ALT DUE THE FO TURNING THE ALT PRESELECT KNOB INSTEAD OF THE DESIRED AIRSPD SETTING KNOB OF THE FLT GUIDANCE SYS. THE FO NOTICED HIS MISTAKE AND CORRECTED BACK TO ASSIGNED AT ONCE.
    Narrative: WE HAD A CLRNC TO CROSS TARNE AT 11000 FT AND 250 KTS. THE FO WAS FLYING AND HAD 11000 FT SET IN THE ALT PRESELECT. I WAS LOOKING AT THE ARR CHART AND THE APCH PLATE AS WE NEARED 11000 FT. ON THIS ACFT, THE ALT SELECT KNOB AND THE AIRSPD SELECT KNOB LOOK AND FEEL SIMILAR. IT WAS DARK IN THE COCKPIT. AS WE APCHED 11000 FT, THE FO THOUGHT HE HAD THE AIRSPD KNOB AND WAS TRYING TO SELECT 250 KTS, BUT WAS ACTUALLY TURNING THE ALT KNOB. THE ALT PRESELECT KNOB WAS INADVERTENTLY SET TO AN ALT BELOW 11000 FT, SO WE DSNDED THROUGH 11000 FT. I LOOKED UP AS WE PASSED 11000 FT AND THE FO CAUGHT IT AT THE SAME TIME ALSO. HE IMMEDIATELY CORRECTED, HOWEVER, WE DSNDED TO 10500 FT BEFORE WE GOT THE DSCNT STOPPED. WE HAD BEEN HANDED OFF BY CTR JUST PRIOR TO THIS, AND CHKED IN WITH APCH AFTER CORRECTING THE ALT. NOTHING WAS SAID. I'LL TRY TO KEEP MY HEAD UP AS WE APCH ASSIGNED ALTS, AND WE'LL BOTH BE MORE CAREFUL IN PROGRAMMING THE AUTOMATION.

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  42. Accession Number: 418060
    Synopsis: A B737-800 PROCEEDS TO SSM INSTEAD OF FLYING TOWARDS BUF ON J95 LIKE THE FLT PLAN SAYS TO DO.
    Narrative: ROUTING ON PDC FOR FLT EWR-SEA SHOWED EWR 6 DEP TO GAYEL, J95 BUF, SSM. I, AS FO, CHKED THE RTE TWICE IN THE FMC AND IT WAS THE SAME AS THE PDC. AFTER DEP, WE FLEW THE RTE ON J95 TO CFB AND THE ACFT PROCEEDED DIRECT TO SSM OMITTING BUF. ABOUT 20 MI OUT OF CFB ZOB ASKED US OUR ROUTING. WE NOTICED THE DISCREPANCY AND TOLD HIM WE WOULD PROCEED TO BUF, WHICH WE DID. THE ONLY THING THAT WE THOUGHT COULD HAVE HAPPENED SINCE NEITHER OF US DELETED BUF IN THE FMC IS THAT WE INADVERTENTLY DOWNLOADED A SECOND FLT PLAN INTO THE FMC AFTER I CHKED THE FIRST DOWNLOADED FLT PLAN AND THE POSSIBLY SECOND DOWNLOADED FLT PLAN HAD CFB DIRECT SSM.
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