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Incidents related to Issue 6 incidents related to this issue.

Issue: monitoring requirements may be excessive (Issue #5)
Description: Pilots are required to monitor automation for long periods of time, a task for which they are perceptually and cognitively ill-suited, and monitoring errors may be likely.

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  2. Accession Number: 50466
    Synopsis: ACR WDB ALT EXCURSION WHILE DESCENDING USING FMS.
    Narrative: ATC CLRD FLT TO 310. F/O SET UP FMS/AUTO FLT TO DSND TO 310. ACFT BEGAN DSNT. CREW CHECKED CHARTS. ATC REQUESTED FLT ALT. CREW THEN NOTICED ACFT CLBING RAPIDLY AT FL360. F/O IMMED RETARDED POWER, DISCONNECTED AUTOPLT/THROTTLES AND DESCENDED TO 310. NO ALT ALERTING FUNCTIONS ACTIVATED. UNABLE TO DETERMINE WHY ACFT SUDDENLY CLBED AFTER BEGINNING DSNT ON VNAV. CONCLUSION: SPURIOUS AUTOFLT ALT EXCURSION. RECOMMENDATION: PLT FLYING SHOULD MONITOR AUTO FLT FUNCTION CLOSELY AS CANNOT DEPEND ON FMS/AUTO FLT RELIABILITY. IMPROVE CHECKING AND RELIABILITY OF AUTO FLT AND ALERTING SYSTEMS. SUPPLEMENTAL INFO FROM ACN NO. 50692: IT WAS SUBSEQUENTLY DISCOVERED THAT A PORTION OF THE ALT ALERT SYSTEM WAS INOPERATIVE.

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  4. 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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  6. Accession Number: 148853
    Synopsis: ACR MLG ALT DEVIATION UNDERSHOT ALT CROSSING RESTRICTION.
    Narrative: ON AN ENRTE DSNT INTO DAYTON OUR CLRNC WAS DIRECT RID VOR, DIRECT DAYTON WITH A DSNT TO 11000'. THE CTLR GAVE US A NEW CLRNC TO CROSS 10 MI W OF RID AT 10000'. THE CAPT, BEING LESS EXPERIENCED IN USING THE FLT MGMNT COMPUTER THAN I, WANTED ME TO SHOW HIM HOW TO PROGRAM THE DSNT FOR NEW RESTRICTIONS. WE PUT THE RESTRICTION IN THE MAGIC BOX AND FOR SOME REASON, ALMOST CERTAINLY SOMETHING WE DID IMPROPERLY, THE MACHINE WANTED TO MAKE THE RESTRICTION 10 MI E OF RID. BY THE TIME WE CAUGHT THE ERROR IN THE MIDST OF DOING CHKLISTS AND THE USUAL COCKPIT DUTIES WE WERE TOO LATE TO MAKE THE RESTRICTION. NOTHING WAS SAID AND THERE WAS NO CONFLICT. THERE IS NO QUESTION THAT THIS MISTAKE WAS OUR FAULT BUT IT BRINGS UP A POINT. THESE WHIZ BANG COMPUTERS AND FLT MGMNT SYS ARE GREAT, BUT YOU NOT ONLY HAVE TO WATCH THEM LIKE A HAWK, THEY ARE A ERROR WAINTING TO SPRING. FLT MGMNT SYS AS THEY ARE CURRENTLY DESIGNED DO THE MOST AND ARE EASIEST TO USE WHEN YOU NEED THEM LEAST; AT CRUISE. THE CLOSER YOU ARE TO THE GND, THAT IS ON TKOF OR APCH, THE MORE DEMANDING OF ATTN THEY ARE. REPROGRAMMING FOR CONSTANTLY CHANGING CLRNS, WHICH HAPPENS MOST IN THE TKOF OR APCH PHASES DISTRACTS ATTN FROM OUTSIDE AND INSIDE VIGILANCE AS WELL AS STEPS UP SITUATIONS WHERE MISTAKES ARE LIKELY TO OCCUR AS THE WORKLOAD INCREASES. TO BE SURE, THE PLTS ARE ALWAYS RESPONSIBLE FOR MAKING WHATEVER RESTRICTIONS THERE ARE, NOT THE COMPUTERS. IF WE'RE GOING TO HAVE THESE SOPHISTICATED AND REALLY WONDERFUL MACHINES IN THE COCKPITS DESIGN EFFORT SHOULD BE PUT INTO MAKING THEM MORE USEFUL AND LESS PRONE TO INDUCING ERRORS IN THE TKOF AND APCH PHASES.

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  8. Accession Number: 164116
    Synopsis: CLOSE PROX ACR-MLG MDT EAST OFSNA.
    Narrative: ON TKOF FROM SNA RWY 01L, COASTDEP CTL CALLED TFC AT 2 O'CLOCK. WE DID NOT ACKNOWLEDGED TFC,HOWEVER THE CONFLICTING TFC (AN MDT) RPTED OVER ACFT IN SIGHTAND WAS INSTRUCTED BY COAST APCH TO MAINTAIN VIS SEP. WE WERE AT3000' MSL ON AN 010 DEG HDG. COAST THEN GAVE US A VECTOR TO 180DEGS, CLB AND MAINTAIN 9000' MSL. OUR ACFT WAS CLBING AT APPROX5000 FPM. AT 8000' MSL OUR MLG PASSED WITHIN 50' (ESTIMATED) OFTHE ACFT. THE MDT PASSED RIGHT TO LEFT ON A HDG OF 140 DEGS. ANEAR MISS WAS RPTED TO COAST APCH. I BELIEVE THE EXCESSIVE CLBRATE OF THE MLG RESTRICTED THE ABILITY FOR THE AIR CREW TOVISUALLY ACQUIRE TFC AND MAKE THE APPROPRIATE AVOIDANCEMANEUVER. ALSO, THE ACFT WAS UTILIZING THE FMC AND AUTOPLT,WHICH ALSO INCREASES TASK LOADING IN THE TERMINAL ENVIRONMENT,ESPECIALLY WHEN ASSOCIATED WITH SUCH EXTREME RATES OF CLB. THEINCIDENT WAS PROPERLY RPTED TO BOTH COMPANY AND FAA PERSONNEL.ADDITIONALLY, WHEN THE FMC IS FLYING THE ACFT UNDER THEEXCESSIVE RATE OF CLB, PLTS HAVE A TENDENCY TO DEVOTE THEMAJORITY OF THEIR ATTN TO MONITORING THE FMC VS TFC AVOIDANCE.

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  10. Accession Number: 218507
    Synopsis: ALTDEV ALT EXCURSION.
    Narrative: ACFT WAS DSNDING TO CROSS PVD AT 14000 FT TO ENTER HOLD. BECAUSE ANTI-ICE SYS WAS TURNED ON IN DSCNT THE AUTO THROTLES HAD ADVANCED PWR AND ACFT WAS NOT HOLDING ASSIGNED AIRSPD. DISCONNECTED A/T'S AND WAS CONCERNED WITH PROPER AIRSPD AND PWR FOR ANTI-ICE. I DID NOT NOTICE IMMEDIATELY THAT ACFT ON AUTOPLT HAD DSNDED BELOW 14000 BY 300 FT. WHEN I REALIZED WE WERE OFF ALT, I IMMEDIATELY DISCONNECTED AUTOPLT AND CLBED 300 FT TO PROPER ALT. ATC ASKED IF WE WERE AT 14000 FT. I REALLY DON'T KNOW WHY THE AUTOPLT DID NOT ENGAGE 'ALT HOLD.' I AM NOW ON THE ACFT AND WAS SOMEWHAT DISTRACTED BY THE PWR PROBLEM/AIRSPD PROBLEM. JUST AS I NOTICED OUR ALT EXCURSION THE ALT ALERTER ON THE ACFT SOUNDED. EVEN THOUGH THIS ACFT HAS A GLASS COCKPIT AND FULL AUTOMATION, I HAVE LEARNED FROM THIS EXPERIENCE THAT EVEN WITH ALL THE MAGIC YOU DON'T DROP YOUR VIGILANCE FOR 1 SECOND. WE FLEW THE ACFT 1 MORE LEG AND FOUND THE ALT CAPTURE FUNCTION WORKED PROPERLY, SO IT MAY HAVE BEEN OPERATOR ERROR ON MY PART BUT AT THIS POINT I JUST CAN'T SAY FOR SURE. I WILL CONTINUE TO REVIEW THE OCCURRENCE AND MY TECHNIQUES AND OF COURSE WATCH THE AUTOFLT SYS MUCH MORE CAREFULLY IN THE FUTURE.

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  12. 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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