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Incidents related to Issue 8 incidents related to this issue.

Issue: pilots may lack confidence in automation (Issue #46)
Description: Pilots may lack confidence in automation due to their experience (or lack thereof) with it. This may result in a failure to use automation when it should be used.

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  2. Accession Number: 62983
    Synopsis: ALT OVERSHOT ON DESCENT.
    Narrative: I WAS FLYING THE ACFT IN IMC CONDITIONS ON THE AUTOPLT. CHICAGO APCH GAVE US A DESCENT FROM 8000 TO 7000'. I SET 7000 IN THE ALT SELECT WINDOW, ARMED THE LEVEL OFF MODE, ROTATED THE PITCH KNOB TO APPROXIMATELY 800 FPM RATE OF DESCENT. I THEN BEGAN TO QUICKLY REVIEW MY APCH PLATE. I SAW WE WERE APCHING 7000' AND EXPECTED THE AUTOPLT TO LEVEL THE ACFT. AT 6750' THE ACFT HAD NOT LEVELLED. I RELEASED THE AUTOPLT WITH THE YOKE DISCONNECT, ARRESTED THE DESCENT AT 6700' AND IMMEDIATELY BEGAN TO MANUALLY FLY THE ACFT BACK TO 7000'. CHICAGO APCH THEN ASKED US IF WE WERE MAINTAINING 7000 AND STATED THAT THE ALTIMETER WAS 29.65. WE ACKNOWLEDGED, AS WE MAINTAINED THE 7000'. THIS IS THE SECOND TIME THIS HAS HAPPENED TO ME IN A SHORT TIME. I AM BEGINNING TO DISTRUST THE ALT ARM MODE OF THE AUTOPLT TO THE POINT WHERE I'D RATHER FLY MOST APCHES MANUALLY! I HAVE ASKED THE CAPT IF I APPEARED TO BE OPERATING THE AUTOPLT IMPROPERLY. HE COULD NOT IDENTIFY ANY ERRORS ON MY PART. HE ASKED ME IF I COULD RECALL TOUCHING THE PITCH WHEEL TO ADJUST THE RATE OF DESCENT NEAR THE LEVEL OFF POINT, PERHAPS DISARMING THE LEVEL OFF MODE. I COULD NOT RECALL DOING SO. SUPPLEMENTAL INFO FROM ACN 62766. I WAS TUNING THE ADF FOR THE APCH AND CAUGHT THE DEVIATION JUST AS WE WERE PASSING THROUGH 7000'.

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  4. Accession Number: 86759
    Synopsis: ADVANCED TECHNOLOGY LGT OVERSHOT ALT IN AUTOMATIC MODE.
    Narrative: THIS ACFT LGT IS EQUIPPED WITH THE LATEST AND GREATEST (ALMOST) FLT GUIDANCE/AUTOPLT SYSTEMS AVAILABLE. FORTUNATELY I DON'T BELIEVE ANYTHING IS FOOLPROOF. WE HAD BEEN CLEARED FROM 310 TO 350 WHICH WE SET INTO THE ALT WINDOW. THE AUTOPLT WAS ALREADY HOOKED UP SO THE COMMAND TO CLIMB WAS MADE AFTER THE ALT OF 350 WAS SET INTO THE WINDOW. NORMAL (BY OUR REQUIRED PROCEDURES) ALT CALLOUTS WERE MADE. AT APPROX 34800' WE BOTH REALIZED THAT PROPER ANNUNCIATION "ALT CAP" WAS NOT BEING DISPLAYED SOON ENOUGH FOR OUR RATE OF CLIMB. THE CAPT QUICKLY DISCONNECTED THE AUTOPLT AND AUTOTHROTTLES AND LEVELED THE ACFT. WE OVERSHOT 350 BY ABOUT 200-300' AT THE VERY MOST THANKS TO ALL COCKPIT MEMBERS' VIGILANCE. WE HAD A JUMP SEATER WHO ALSO SAW THE PROBLEM DEVELOP. THIS ACFT AND ITS ELECTRONIC WONDERMENT IS A FINE MACHINE AND IT IS ABSOLUTELY UNDER NO CIRCUMSTANCES SUPPOSED TO VIOLATE ALT SET IN THE WINDOW DURING THIS TYPE OF FLT CONDITION. (CRUISE CLIMB OR DESCENT NOT ON AN ILS) THIS ACFT CONTINUES TO EXHIBIT BEWILDERING ELECTRONIC IDIOSYNCRASIES SUCH AS FALSE MALFUNCTION MESSAGES OF MANY VARIETIES. THIS ALT PROBLEM TURNS OUT TO BE MORE COMMON THAN I THOUGHT AT LEAST THREE OTHER PLTS HAVE HAD IT HAPPEN TO AN ALT ORAL TONE PRIOR TO THE SELECTED ALT BEING REACHED NOT AFTER YOU'VE BROKEN THROUGH BY APPROX 300'! A MAINTENANCE WRITEUP WAS MADE. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING INFORMATION: SINCE SENDING REPORT, RPTR HAS TALKED TO AT LEAST 10 OTHER PLTS AND ALL HAVE HAD ALT BUSTS. IN THIS INCIDENT THE FMC WAS IN THE FLC, FLT LEVEL CHANGE, MODE BUT ALT BUSTS ARE ALSO HAPPENING WITH THE FMC IN THE V-NAV, VERTICAL NAVIGATION, MODE. THE NEW ALT WAS IN BOTH THE ALT SELECT ON THE MODE CTL PANEL AND HAD BEEN ENTERED IN THE FMC AND ALT ARM WAS ANNUCIATED BUT THE SYSTEM DID NOT CHANGE TO ALT CAPTURE. RPTR HAD ALSO DISCUSSED PROBLEM WITH INSTRUCTOR PLT AND COMPANY IS AWARE OF THE PROBLEM. THE PROBLEM APPEARS TO HAVE SURFACED IN THE LAST YEAR AND ONE HALF AS THE ACFT GET OLDER AS IT WAS NOT A PROBLEM IN FIRST COUPLE YEARS OF OPERATION. RPTR WONDERS IF HEAT AND AGE ARE CAUSING BREAKDOWN IN THE SYSTEM OR SOFTWARE AS THEY ARE GETTING MORE SPURIOUS MESSAGES POSSIBLY FROM THE MULTIPLEXING WIRING SYSTEM. TO DATE MANUFACTURER HAS FAILED TO ACKNOWLEDGE PROBLEM WITH SYSTEM. SYSTEM'S FORMER PERFORMANCE HAS CAUSED FLT CREWS TO RELAX VIGILANCE BUT CONFIDENCE BASE IS NOW BEING ERODED AND MORE ARE HANDFLYING IN CLIMB AND DESCENT TO KEEP ATTN ON SYSTEM. RPTR ALSO FEELS STRONGLY THAT AURAL WARNING SHOULD BE RETURNED TO ALT ALERT SYSTEM 300' BEFORE ALT AS ON OLDER ACFT.

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  6. Accession Number: 122911
    Synopsis: ACR MLG ALT DEVIATION OVERSHOT DURING DESCENT USING 'ADVANCED FLT GUIDANCE SYSTEM.'
    Narrative: DSNDING TO CROSS 30 DME S OF BNA AT AND MAINTAIN 11000'. ACFT ON AUTOPLT WITH ALT CAPTURE ARMED. I FLEW THROUGH ALT ANYWAY. ACFT BOTTOMED OUT AT 10500' AFTER AUTOPLT DISENGAGED. THIS TYPE MLG IS NOTORIOUS FOR ALT BUSTS BECAUSE IT HAS AN "ADVANCED FLT GUIDANCE SYS," INCORPORATING AUTOMATIC ALT CAPTURE. THIS SYS WORKS JUST WELL ENOUGH TO TRAP YOU. OLDER MLGS W/O THIS SYS WERE NOT NOTED FOR THIS PROB. WHAT'S WRONG HERE? A MISGUIDED DESIRE TO RELY ON POORLY DESIGNED AUTOMATION REDUCES SAFETY MARGINS.

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  8. Accession Number: 201651
    Synopsis: ALTDEV ALT UNDERSHOT XING RESTRICTION NOT MET.
    Narrative: FLT DTW-LGA: CLE CTR CLRED US FROM 410 TO CROSS ETG AT OR BELOW 370 TO MAINTAIN 330. CAPT LEG TO FLY MY LEG TO PROGRAM FMC. WE WERE W OF ETG ON J-146. WHEN CTR ISSUED CLRNC AND WHILE I PROGRAMMED THE FMC, CAPT WAS LECTURING ON HOW TO REALLY FLY THE ACFT TO SAVE GAS. I REPEATED THE CLRNC TO HIM AND NOTED THE FMC HAD CALCULATED A TOP OF DSCNT POINT. THE CAPT WAS FLYING WITH THE AUTOPLT IN AUTO HOLD AND SPD INTERVENE. THIS IS FINE, HOWEVER, PF MUST REMEMBER TO DSND AT THE APPROPRIATE TIME. THE CAPT WAS SO INVOLVED WITH HIS LECTURE, AND I DISTRACTED BY THIS LECTURE, WE MISSED THE TOP OF DSCNT POINT FAR ENOUGH TO ONLY BE ABLE TO CROSS ETG AT 40000 DSNDING. A 3000 FT ERROR. I ADVISED CLE CTR THAT WE ARE DOING OUR BEST TO MEET THE XING ALT. THERE WAS NO TA. CAPT DID TELL ME THAT HE DOES NOT LIKE THIS AUTOMATIC COCKPIT STUFF. PERHAPS PLTS WHO ARE THAT UNCOMFORTABLE WITH NEW GENERATION ACFT SHOULD STAY WITH STEAM GAUGES, OR TRAIN MORE TO BUILD THE CONFIDENCE IN THE FMC AND AUTOPLT FLT DIRECTOR SYS TO ACT AS A THIRD PLT IN THESE ACFT. AND THE REST OF US CANNOT ALLOW OURSELVES TO BECOME SO DISTRACTED BY CONVERSATION THAT WE MISS XING RESTRICTIONS, HDGS, SPD LIMITS ETC.

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  10. Accession Number: 225086
    Synopsis: FLC OF ACR MLG ACFT EXPERIENCED A MULTI MASTER WARNING OF AN ENG PROBLEM RIGHT AFTER TKOF AND RETURNED TO LAND.
    Narrative: ON DEP FROM 27R AT PHL PASSING 2000 FT RECEIVED MULTIPLE WARNINGS/ALERTS FROM MFDU (MULTI-FUNCTION DISPLAY) RMFDU INOP. TGT OVERLIMIT #2 ENG, N1 OVERSPD #2 ENG, LIGHT ON START LEVER #2. MASTER WARNING TRIPLE CHIME ALERT. THE PRIMARY MFDU DISPLAYING ENG PARAMETERS WERE IN LIMITS AT ALL TIMES (WOULD CHANGE COLOR ON TAPE DISPLAY IF OUT OF LIMITS). I ALSO DISENGAGED AUTOTHROTTLES AND PULLED ENG #2 TO IDLE TO SEE IF THIS WOULD CHANGE ANYTHING AND IT DID NOT. THE WARNINGS/ALERTS DISPLAY WAS CONTINUOUSLY INTERMITTENT WHITE/RED (WHITE BEING -- CONDITION NO LONGER EXISTS). I REQUESTED A RETURN TO FIELD FROM DEP AND WE MADE AN UNEVENTFUL LNDG AND SECURED ENG AFTER CLRING RWY. I NEVER SHUT DOWN #2 ENG AS I FELT THIS WAS A WARNING COMPUTER FAULT NOT AN ACTUAL EXCEEDANCE. NO EMER WAS DECLARED. ONE PROBLEM WITH THIS SITUATION WAS A TRIPLE CHIME ALERT (HIGHEST ALERT CONDITION) WHICH COULD NOT BE SELECTED WITHOUT SHUTTING DOWN THE ENG. I DID HAVE TO SECURE THE MASTER AUDIO WARNING (SECURING ALL AUDIO ALERTS) IN ORDER TO SILENCE THE ALERT. I BELIEVE THAT THIS WAS A DESIGN FLAW IN THE ACFT. YOU SHOULD BE ABLE TO SECURE ANY ALERT AUDIO BY PRESSING ON THE MASTER WARNING LIGHT WHICH WOULD CONTINUE TO FLASH RED. THE AUDIO WAS VERY DISTRACTING.

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  12. Accession Number: 366583
    Synopsis: B767 ON NORTH ATLANTIC RTE AT FL350 WITH NEW MINIMUM ALT SEPARATION GOT A TCASII TA ON ANOTHER B767 AT FL340 ON SAME RTE. RPTR LEARNS FROM CONTACT WITH OTHER ACFT THAT THEY ALSO HAVE TA AND ARE FLYING AT MACH PT 80. RPTR REQUESTS AND RECEIVES APPROVAL FOR MACH PT 81. ADVISORIES STOPPED WHEN RPTR'S ACFT GOT AHEAD OF THE OTHER ACFT. RPTED THAT THE ADVISORIES LASTED FOR ABOUT 30 MINS. RPTR STATED THE OTHER ACFT WAS GOING TO OR ALREADY HAD TURNED OFF THE TCASII TO KEEP FROM GETTING THE CONSTANT ADVISORIES.
    Narrative: NEW MINIMUM ALT SEPARATION ON NORTH ATLANTIC RTES AND TCASII ROUTING: STEAM OYSTR 55N 050W 57N 040W 58N 030W 57N 020W 56N 010W MAC. FL350 MACH .80 B767-300. APPROX 12 MINS PRIOR TO STEAM, OBSERVED ANOTHER ACFT APCHING STEAM FROM A DIFFERENT ANGLE (10 DEGS OR SO), BELOW OUR ALT. APPROX 10 MINS PRIOR TO STEAM, RECEIVED VERBAL 'TFC' AND YELLOW TCASII TA. CHKED OUR ALT AT FL350. TCASII HAD TFC AT FL340. TALKED TO OTHER ACFT (ANOTHER B767) AND FOUND HE HAD SAME ROUTING AND ASSIGNED MACH .80. ALSO, HE TOO WAS RECEIVING TCASII TA. AFTER APPROX 15 MINS OF CONTINUOUS YELLOW TA AND OCCASIONAL VERBAL 'TFC,' REQUESTED AND RECEIVED CLRNC TO MAKE XING AT MACH .81. ONCE WE GOT AHEAD OF OTHER B767, THE TCASII TA VERBAL AND YELLOW ADVISORIES STOPPED. TOTAL TIME OF CONTINUOUS TCASII TA YELLOW WAS APPROX 30 MINS. WHILE TALKING TO OTHER ACFT, HE INDICATED THAT HE WAS GOING TO OR ALREADY HAD TURNED OFF HIS TCASII TO KEEP FROM GETTING CONSTANT ADVISORIES. A POTENTIAL PROB EXISTS: SOMEBODY IS GOING TO TURN OFF THIS SAFETY EQUIP AND JEOPARDIZE HIS AND OTHER ACFT. ALSO, HAS ANYONE SERIOUSLY THOUGHT ABOUT WHAT HAPPENS WHEN SOMEONE GETS AN RA? THE POTENTIAL EXISTS FOR A LOT OF ACFT TO BE SCATTERED THROUGHOUT A LOT OF ALTS OUT THERE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR INDICATED A RPT TO THE UNION AND TO THE COMPANY ABOUT THE TCASII TA'S. RPTR STATED HE HAD HEARD THAT THERE WILL BE SOFTWARE CHANGE NEXT YR TO TAKE CARE OF THE PROB. RPTR SAID HE WAS SCARED THAT PLTS MIGHT TURN OFF THEIR TCASII AND INDICATED THIS COULD BE MORE OF A PROB FOR ACFT AVOIDANCE. RPTR HAS NOT HAD THE PROB RECUR BUT HAS TALKED TO OTHERS THAT HAVE.

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  14. Accession Number: 387512
    Synopsis: FLC OF B757 HAS TCASII RA AND DSNDS ONLY TO FIND THEMSELVES HEAD ON WITH TFC AT ANOTHER ARPT. A CLB RA IS RECEIVED AND THEY CLB.
    Narrative: ON VECTORS TO LAX N COMPLEX (RWY 24) MY B757 WAS ON AUTOFLT, FLAPS 20 DEGS, SPD 160 KTS, 2500 FT MSL, JUST STARTING R BASE TURN WHEN TCASII GAVE SUDDEN RA TO 'DSND NOW.' AUTOFLT WAS DISCONNECTED IMMEDIATELY AND DSCNT BEGUN WITH GUIDANCE FROM VSI. ONCE CLR OF CONFLICT (ALT LOSS 400 FT) WE RECEIVED AN IMMEDIATE CLB RESOLUTION DUE TO NOW BEING HEAD-ON WITH TFC ON APCH TO ANOTHER LAX AREA ARPT. (WE BELIEVE THE OTHER ACFT WAS INBOUND TO SMO ARPT.) MANUAL THRUST WAS APPLIED ALONG WITH A CLB TO CLR THIS CLB RESOLUTION. APCH WAS CONTINUED WITH A CLOSE-IN ILS RWY CHANGE TO A SUCCESSFUL LNDG AT LAX. BOTTOM LINE: A FALSE TCASII RESOLUTION PUT OUR ACFT INTO A REAL TFC CONFLICT AND RESOLUTION. THIS IS THE SECOND FALSE RESOLUTION I HAVE EXPERIENCED IN OUR B757 ACFT IN 8 MONTHS TIME.

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  16. Accession Number: 404517
    Synopsis: AN ACR DH8 FLC HAD VISUAL CONTACT ON A DC9 THAT PASSED OVER THEM, BUT THEIR TCASII EQUIP ISSUED AN 'RA' THAT REQUIRED A CLB. THE MAINT PERSONNEL FOUND NO PROBLEM WITH THE TCASII EQUIP.
    Narrative: ATC INFORMED US THAT A JET HAD US IN SIGHT AT OUR 5 O'CLOCK POS AND WOULD CONTINUE CLB, WE GOT AN RA WITH A CLB COMMAND OF 1500 FT. FURTHER IT GAVE A CLB, XING CLB COMMAND OF 1500 FT AS WE ACQUIRED A VISUAL ON THE DC9 500 FT ABOVE US. I LEVELED OFF AT 9500 FT TO AVOID A COLLISION, THEN DSNDED BACK TO 9000 FT. HAD I CONTINUED THE CLB ACCORDING TO THE TCASII WE WOULD HAVE HIT THE DC9. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR WAS FLYING A DEHAVILLAND DASH 8- 300 AND WAS FAIRLY HEAVY AT THE TIME. HE SAID THAT HE STARTED TO PULL UP, BUT SAW THE DC9 AND STOPPED. HE HAD ALREADY ADVISED THE CTLR THAT HE WAS REACTING TO AN RA. HE THEN TOLD THE CTLR THAT THEY WERE GOING TO HOLD ALT. THE TCASII ADVISORY PEAKED AT 2000 FT CLB AND HELD THIS FOR A FEW MOMENTS EVEN THOUGH THE DC9 WAS ABOVE THEM. HE ENTERED THIS IN THE MAINT LOG. THIS ANALYST ASKED IF THE DC9 HAD BEEN DSNDING OVER THEM PRIOR TO HIS SIGHTING AND HE SAID THAT HE DID NOT KNOW. HE DID CHK WITH MAINT PERSONNEL SEVERAL DAYS LATER AND FOUND THAT THE TCASII DID PASS ALL OF THE MAINT CHKS AT THE COMPANY AND AT THE CONTRACT SERVICE FACILITY. THE RPTR ALLEGED THAT HIS COMPANY'S TRAINING ON THE TCASII IS INADEQUATE AND THAT HE DOES NOT TRUST THE EQUIP.
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