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Incidents related to Issue 4 incidents related to this issue.

Issue: automation may be too complex (Issue #40)
Description: Automation may be too complex in that it may consist of many interrelated components and may operate under many different modes. This makes automation difficult for pilots to understand and use safely.

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  2. Accession Number: 69981
    Synopsis: WDB HAS TWO ALT BUSTS, AN AIRSPEED EXCURSION AND A HEADING EXCURSION WITHIN FIVE MINUTES.
    Narrative: WE WERE FLYING A WDB WITH FULL FMS EFIS CAPABILITY. DURING A FIVE MINUTE PERIOD WE FAILED TO LEVEL OFF AT AN ASSIGNED ALTITUDE TWICE, INADVERTENTLY SLOWED TO STICK SHAKER, AND MISSED A HDG ROLLOUT BY ALMOST 60 DEGREES. UNBELIEVABLE. I THINK THE CAPTAIN WAS MORE AMAZED THAN I WAS, AND PERHAPS DWELLING ON EACH PREVIOUS EVENT CAUSED A PREOCCUPATION THAT CAUSED THE NEXT. INOPERATIVE COMPONENTS (AUTOTHROTTLES HERE) MAY HAVE BEEN A FACTOR, BUT NOT AN EXCUSE. AS FOR MY PART, ALL OF THIS COMES FROM ONE THING. I WASN'T WATCHING THE CAPTAIN. UNFORTUNATELY, THE FACT IS THAT I OFTEN DON'T. THESE 2-M COCKPITS HAVE BECOME SO COMPLEX THAT REDUCING THE WORKLOAD MEANS 4 OR 5 SEPARATE FUNCTIONS TO GET THE AIRPLANE TURNED TO AN OUTER MARKER. PERHAPS WE NEED MORE TRAINING, OR AT LEAST AN INOP COMPONENTS TRAINING. BUT MOST OF ALL, OUR SYSTEM OF CROSSCHECKS WILL WORK IF A STRICT DISCIPLINE IS FOLLOWED, ESPECIALLY WHEN ONE THING GOES WRONG, OTHERS WILL FOLLOW.

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  4. Accession Number: 77914
    Synopsis: ALT OVERSHOT ON CLIMBOUT WHEN DESCENT CLRNC WITH ALT RESTRICTION GIVEN BEFORE REACHING ASSIGNED ALT AND FMC REPROGRAMMED.
    Narrative: WE HAD RECEIVED A CLRNC TO CLB TO 16000', DIR TO THE SRP VORTAC ON THE 23 MIN FLT FROM TUS TO PHX. SOMEWHERE BTWN 11000' AND 15000' (SLIGHTLY LESS THAN 1 MIN'S TIME) WE WERE CLRD TO CROSS 35 SE OF SRP AT OR BELOW 14000', 250 KTS, MAINTAIN 10000'. AS IS STANDARD PRACTICE AT OUR COMPANY, I SET THE NEW CLRNC LIMIT ALT (10000') IN THE ALT SELECTOR OF THE AUTOPLT/FLT DIRECTOR SYSTEM MODE CTL PANEL, MENTALLY ASSURING MYSELF THAT THE AUTOPLT WOULD LEVEL THE ACFT AT 16000' SINCE THAT WAS THE CRS ALT PROGRAMMED IN THE FLT MANAGEMENT COMPUTER (FMC). I REACHED INTO MY FLT BAG TO PULL OUT A BINDER TO STOW MY TUCSON PLATES, AND WAS JUST OPENING IT WHEN THE ABQ CENTER CTLR CALLED, "PHX ALTIMETER 29.84." I RESET THE ALTIMETER AND NOTED THAT THE INDICATED ALT WAS NOW 16400' AND CLBING RAPIDLY. I DISCONNECTED THE AUTOPLT AND MANUALLY LEVELED AT 16000'. THE MAX INDICATED ALT WAS 16700'. COMMON PRACTICES CAN LEAD TO CRITICAL ERRORS UNDER SITUATIONS ONLY SLIGHTLY DIFFERENT FROM THE NORM. NORMALLY, WE DON'T RECEIVE DES CLRNCS BEFORE REACHING THE ASSIGNED CRS ALT. NORMALLY, WE SET THE ALT SELECTOR OR ALERTER TO THE NEW CLRNC LIMIT ALT AS SOON AS WE RECEIVE IT. I DID THIS AUTOMATICALLY W/O CONSIDERING THAT IT MIGHT BE AN INVALID RESPONSE. WE'RE PSYCHOLOGICALLY PROGRAMMED TO EXPECT THINGS TO HAPPEN WITH A MACHINE BASED ON OUR EXPERIENCE WITH WHAT USUALLY HAPPENS. WITH THIS AIRPLANE'S EFIS DURING A CLB OR DES IN THE VNAV MODE, THE AIRPLANE WILL LEVEL OFF AT THE CRS ALT PROGRAMMED IN THE FMC EVEN IF THE ALT SELECTOR IS SET AT A HIGHER (DURING CLB) OR LOWER (DURING DES) ALT. EX: FMC CRS ALT FL330, CLRD TO FL370, ALT SELECTOR SET TO 370, AUTOPLT LEVELS THE AIRPLANE AT FL330. HAPPENS ALL THE TIME, SO I KNEW THE AUTOPLT WOULD LEVEL THE ACFT AT 16000'. WRONG! WHAT I DID, IN FACT, WAS TELL IT TO STOP AT AN ALT I WASN'T ON THE WAY TO. THE AUTOPLT THEN REVERTED TO THE CWS PITCH MODE, IN WHICH THE AIRPLANE KEEPS ON GOING IN THE LAST DIRECTION IT WAS POINTED, UNTIL THE PLT POINTS IT SOMEWHERE ELSE WITH THE YOKE. THERE IS NO AURAL WARNING WHEN THIS HAPPENS, THE AUTOPLT HASN'T DISCONNECTED, IT'S JUST HLDG A PITCH ATTITUDE. THERE'S A SMALL YELLOW CWS PITCH WARNING ON THE EADI, BUT IT HAS TO BE LOOKED AT TO BE SEEN (MUCH LIKE TFC AND ALTIMETERS). I ALSO KNEW I'D HAVE TIME TO STOW MY DEP PLATES BEFORE APCHING 16000', AS THE AUTOPLT STARTS A SMOOTH LEVEL OFF AS A FUNCTION OF RATE OF CLB AND WOULD BE REDUCING IT'S RATE OUT OF ABOUT 13000'. WRONG AGAIN! SINCE IT DEFAULTED TO CWS PITCH AND I DIDN'T NOTICE IT, WE WERE STILL CLBING AT 4 TO 6000 FPM. NO TIME FOR ANY INATTN OR DISTR. SO WHERE WAS THE NFP WHO WOULD NORMALLY BE CROSSCHECKING ALT AND MAKING APPROPRIATE CALLOUTS? THE SAME PLACE HE ALWAYS IS DURING MOST OF THE TIME SPENT ABV 10000' ON THIS RUN: DEEP IN THE MIDDLE OF COPYING ATIS AND MAKING REQUIRED FLT-FOLLOWING RADIO CALLS TO THE COMPANY. IT'S COMMON KNOWLEDGE THAT THE PF HAS LITTLE BACKUP ON A SHORT FLT LIKE THIS, BECAUSE THERE IS SO MUCH RADIO WORK TO DO. ALL THE MORE REASON FOR THE PF TO DO NOTHING BUT FLY (OR, THESE DAYS, MONITOR). SOMEWHERE IN ABQ CTR THERE WAS AN ALERT CTLR WHO TACTFULLY BROUGHT MY ATTN BACK WHERE IT SHOULD HAVE BEEN IN THE FIRST PLACE. MY HAT IS OFF TO HER! THE NEW TECHNOLOGY MACHINERY (FMC, EFIS, ETC) IS MARVELOUS, BUT IT SUCKERS US INTO COMPLACENCY. IN THE OLDER SERIES AUTOPLT, THE CWS MODE WAS THE NORM, RATHER THAT THE EXCEPTION. THIS WAS FINE, AS YOU KNEW YOU WERE IN IT. IN MY EXPERIENCE, THERE'S A MUCH HIGHER INCIDENCE OF ALT/SPD/ROUTE BUSTS IN THE FMC-EQUIPPED ACFT, LARGELY (I THINK) BECAUSE THE SYSTEM IS SO COMPLEX THAT THERE ARE MANY OPPORTUNITIES FOR FAULTY PROGRAMMING. SUGGESTIONS: ALT AWARENESS! ALT ALERTERS ARE WONDERFUL, BUT WE'VE BECOME TOO DEPENDENT ON THEM. LET'S ALL TAKE A HARD LOOK AT OUR PROCS FOR THEIR USE AND BE SURE THEY'RE VALID FOR THE INTENDED RESULT. CONTINUALLY EMPHASIZE THE IMPORTANCE OF DEVOTING YOUR FULL ATTN TO MONITORING THE FLT WHENEVER THE OTHER CREWMEMBERS ARE INVOLVED WITH OTHER DUTIES. TRY TO MINIMIZE DISTRS DURING CLBS/DES, NOT JUST BELOW 10000'. ALWAYS FOLLOW UP ANY CHANGES IN AUTOPLT/FLT DIRECTOR MODE WITH A CHK OF THE MODE ANNUNCIATOR. IN NEW TECHNOLOGY ACFT, THIS MEANS EVERY TIME YOU PUSH A BUTTON. FOR R & D: IF WE MUST HAVE AN AURAL WARNING FOR AN AUTOPLT DISCONNECT, IS IT ANY LESS DANGEROUS TO HAVE IT REVERT TO A CWS MODE W/O THE PLT BEING AWARE? THIS IS A VERY COMMON OCCURRENCE. A CANCELLABLE AURAL WARNING AFTER, SAY, 3 SECS OF CWS WOULD DO THE TRICK. PERHAPS IF THE MACHINE CAN LEAD US ASTRAY, IT SHOULD WARN US. IS IT ACCEPTED PRACTICE FOR ATC TO GIVE DES CLRNCS PRIOR TO REACHING THE ASSIGNED CRS ALT? THIS COULD LEAD TO VARIOUS ERRORS AND CONFUSION.

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  6. Accession Number: 126918
    Synopsis: COMMUTER FLT CREW CLIMBED THROUGH ASSIGNED ALT.
    Narrative: MY COPLT WAS FLYING FROM CLEVELAND HOPKINS TO COLUMBUS, (PORT COLUMBUS) OH. SCHEDULED FLT TIME IS APPROX 25 MIN. MY COPLT HAS ONLY BEEN ON THE LINE IN THIS ACFT FOR A MONTH, AND COMES FROM A BACKGROUND OF HELICOPTER AVIATION. IN THE 20 SOME ODD MINS BETWEEN ARPTS (NOT JUST THESE 2, BUT MOST ALL OF OUR CITY PAIRS) WE GET AN OVER-ABUNDANCE OF VECTORS AND ALT CHANGES, ALT CHANGES ASSOCIATED WITH CROSSING RESTRICTIONS, AND AIRSPEED OR CONFIGURATION CHANGES. WE WERE CLEARED TO 12,000' MSL WITH AUTOPLT ENGAGED. ALT SELECT WAS PROPERLY DIALED TO 12,000' MSL. BETWEEN OUR CHECKLISTS DEP CALLS FOR THE DEP STATION, ATIS FOR THE ARR, AND OUR IN RANGE CALL TO THE ARR STATION, IT GETS PRETTY BUSY TO DO NON FLYING AND FLYING DUTIES BOTH. I DO NOT PLACE THE BLAME ON MY F/O SQUARELY AS IF HE WAS THE "BAD GUY". YES HE WAS THE FLYING PLT, YES HE IS KNOWLEDGEABLE ON THE ACFT. BUT HE IS NEW TO THE ACFT AND BLINDLY HAD PLACED HIS TRUST ON THE AUTOPLT. HE DID NOT NOTICE THE SUBTLE AND QUIET WAY THE AUTOPLT HAD NOT CAPTURED THE ALT FOR LEVEL OFF. ON MY SCAN I CAUGHT THE ERROR AT 12,300'. WITH THE ROUND OUT, WE GOT TO 12,400' MSL AT WHICH TIME THE CTLR (BEING A GOOD, SHARP CTLR) WAS CALLING FOR US TO VERIFY ASSIGNED ALT. THERE ARE MANY FACTORS THAT CONTRIBUTE TO THIS SITUATION. ONE IS SCHEDULING. TO FLY PER THE FLT AND DUTY REGS OF 121 IS ABSURD. WE WERE "LEGALLY" SCHEDULED TO FLY A 2-DAY TRIP. A FULL 7.5 HRS OF FLYING WITHOUT BREAKS (15-20 MIN TURNS). LONG DAY! ON THIS PARTICULAR RUN, NO BREAKFAST IS AVAILABLE, NO LUNCH EITHER! EITHER RESTAURANTS ARE NOT OPEN OR TOO FAR AWAY! ANOTHER CONTRIBUTING FACTOR IS THE ACFT. THERE IS SO MUCH "HIGH TECHNOLOGY" TO THIS COCKPIT, THAT A LOT OF PLTS ARE SIMPLY OVERWHELMED BY THE EFIS FOR THEIR FIRST 500 OR SO HRS IN THE COCKPIT. THERE ARE MANY OTHER FACTORS, BUT THIS LAST I'LL WRITE ABOUT IS OUR ATC SYSTEM. THE ATC SYSTEM IS TOO SATURATED. WE SMALL AIRPLANE DRIVERS (ANYTHING SMALLER THAN A DC9) HAVE BECOME THE SYSTEM DAMPERS. ONCE WE GET WITHIN 200 MI OF OUR DESTINATION, WE ARE WORKED TO THE MAX TO FILL IN FOR A FAILING ATC SYSTEM. ON OUR AVERAGE 35 MIN FLTS, WE ARE GETTING UPWARDS OF 40 ACFT CONFIGURATION CHANGES. SOMETIMES WE WILL GET EITHER A SPEED CHANGE OR ALT CHANGE BEFORE WE HAVE ACCOMPLISHED THE ORIGINAL ASSIGNMENT.

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  8. Accession Number: 380906
    Synopsis: ACR MLG FLC FAILS TO MAKE AN ALT XING RESTR. FO, PF, IMPROPERLY PROGRAMMED THE FMC IN THE DSCNT PAGE, USING THE WRONG INTXN. PIC, PNF, WAS USING THE WRONG VOR DME FOR DISTANCE INFO.
    Narrative: (STRUK ARR HOU, HOBBY.) CLRED TO CROSS MARIT AT 10000 FT. 10000 FT RESTR PLACED IN WRONG LINE (WRONG INTXN) -- STRUK. INITIAL DSCNT WAS BEGUN AT AN APPROPRIATE DISTANCE, BUT PNF SWITCHED VOR TO NEXT NAV AID, LOST BACK-UP CHK FOR ALT XING. PF GOT BEHIND ACFT. CTR AND APCH NOTIFIED ASAP AS TO DEV AND VOLUNTEERED TO TURN IF NEEDED. NO COMMENTS MADE BY EITHER CTR OR APCH. ACFT CROSSED MARIT INTXN ABOUT 2500 FT HIGH. HI-TECH EQUIP -- SYS OVERLOAD ON LOW-TECH USER. MUCH OF OUR NEW TECHNOLOGY ACTUALLY GETS IN THE WAY OF GOOD SOLID AVIATING. SUPPLEMENTAL INFO FROM ACN 380988: CTR CTLR ASKED IF WE WOULD MAKE 'MARIT AT TEN.' PNF INITIALLY RESPONDED AFFIRMATIVE AS WE DOUBLE CHKED OUR PROGRESS. I DISCOVERED I HAD ENTERED XING RESTR (10000 FT/250 KTS) IN FMC AT STRUK INTXN VERSUS MARIT. PF (ME) WAS USING LNAV/DSCNT PAGE. PNF HAD SWITCHED VOR TO HOBBY VERSUS TNV AND LOST AWARENESS OF XING PROGRESS. 13TH HR OF LONG DAY CONTRIBUTED. INADEQUATE XCHK BY CREW.
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