FDAI logo   ::  Site Map  ::   
Home  |  About This Website  |  Contact Us
About This Website » ASRS Incident Report Analysis » Incidents related to Issue

Incidents related to Issue 4 incidents related to this issue.

Issue: data entry errors on keyboards may occur (Issue #71)
Description: Keyboard alphanumeric data entry may be prone to errors, which may adversely affect safety.

  1.  
  2. Accession Number: 175779
    Synopsis: ACR MLG TRACK HEADING DEVIATION AT START OF STAR TO DEN ALSO ALT DEVIATION UNDERSHOT CROSSING RESTRICTION.
    Narrative: INCIDENT OCCURRED AT START OF DSNT ON TAG NE STARR LEADING TO KEANN ARR GATE 50 DENVER. AFTER XING SMITY INTXN WE WERE CLRED TO DSND AT PLTS DISCRETION TO CROSS KEANN INTXN AT 17000' MSL, SPD OUR CHOICE. PROGRAMMING ERROR OF FMS RESULTED IN OFF COURSE TRACK AND BEING TOO HIGH, TOO CLOSE TO INTENDED INTXN TO MEET XING RESTRICTION W/O OFF COURSE VECTOR. FACTORS INVOLVED: A VERY COMPENTENT F/O WHO WAS FLYING THE PLANE, DISTR CAUSED BY CABIN CREW MEMBER WHO WAS IN CONFLICT WITH OTHER F/A'S, LACK OF WX AND TFC (SAT AFTERNOON), A PROGRAMMING ERROR BY F/O, MY FAILURE TO X-CHK INPUT OR TRACK DURING CRITICAL PHASE OF FLT. F/A ENTREE TO DENVER ATIS. USING ATIS DATA, F/O PROGRAMMED THE APCH AND LNDG. HE APPARENTLY HIT WRONG STARR FROM KEY NEGATING FLT PLAN RTING AND SUBSTITUTING IOC INTXN FOR KEANN INTXN. I ALTERED MY NORMAL COCKPIT DISCIPLINE TO HANDLE A PRECEIVED PROB AND DELAYED OTHER NONFLT RELATED DUTIES (COMPANY CALLS, ETC) UNTIL A MORE CRITICAL PHASE, JUST PRIOR TO DSNT. ATC NOTED THE TRACK ERROR AFTER SMITY AND INQUIRED. I IMMEDIATELY SAW THE PROB AND CORRECTED BUT TOO LATE TO MEET XING RESTRICTION W/O CTR VECTOR. CONCLUSIONS: DON'T ALLOW DISTS TO INTERFERE WITH NORMAL COCKPIT PROCS AND DISCIPLINE. ALWAYS X-CHK FMS PROGRAMMING AND NAV PROGRESS NO MATTER WHO IS FLYING OR HOW TRUSTED THEY ARE. DEMAND BOTH FROM MYSELF AND MY F/O'S THAT TRACK AND DISTANCE BE MONITORED AND COMPARED WITH FLT PLAN TO HELP CATCH ERRORS. I WAS IN PROGRESS OF READING CHKLIST WHEN ASKED BY ATC WHAT OUR HDG WAS, AS THEY OFTEN DO FOR PARALLEL VECTORS OF ACFT. IF HE HAD SAID THAT WE APPEARD TO BE DIVERGING FROM FLT PLAN RTE ON HIS INITIAL CALL, MY RESPONSE WOULD HAVE BEEN MORE TIMELY AND MAY NOT HAVE REQUIRED VECTOR TO MEET XING RESTRICTION.

  3.  
  4. Accession Number: 360920
    Synopsis: FLC OF AN LGT FAILED TO FOLLOW THEIR SID FLT PLAN RTE BY MISPROGRAMMING THEIR FMC RESULTING IN ATC INTERVENTION AND VECTORS TO GET ON COURSE.
    Narrative: CLBING OUT OF MIA TO MCO, ZMA CLRED US TO BAIRN INTXN, GOOFY ARR AT MCO. PNF TYPED BARIN INTO FMC. UNDER HIGH WORKLOAD (ALT CHANGES, BUSY ATC COM) WE ENGAGED LNAV WITHOUT VERIFYING RTE. WE CAUGHT MISTAKE IN LESS THAN 20 SECONDS ABOUT THE SAME TIME ATC NOTICED US SLIGHTLY R OF COURSE. ATC PROVIDED VECTOR TO BAIRN. WE SHOULD HAVE SELECTED BAIRN FROM DEP/ARR PAGE RATHER THAN TYPE IT IN FREE-HAND. ALWAYS VERIFY BEFORE EXECUTING.

  5.  
  6. Accession Number: 375594
    Synopsis: AN ACR DC10 WAS CLRED DIRECT TO YQD AND THE CAPT PUT THE WRONG COORDINATES IN THE INS CAUSING HIS ACFT TO BE CONSIDERABLY OFF COURSE. AN ACR B747-400 WAS ON A DIRECT RTE TO YYE AND AT WRONG ALT FOR DIRECTION OF FLT. THE ACFT BOTH RECEIVED A TCASII RA AND THE ARTCC RADAR CTLR SAW THE POTENTIAL CONFLICT ABOUT THE SAME TIME. THE ACFT BOTH FOLLOWED THEIR TCASII ADVISORIES, BUT LEGAL SEPARATION WAS LOST.
    Narrative: APPROX 50 MI W OF FT MCMURRY (YMM) WE WERE CLRED DIRECT THE PAS (YQD). I LOADED THE COORDINATES IN INS AND WE PROCEEDED DIRECT. A COUPLE OF MINS LATER, WE SAW AN ACFT AT 9 O'CLOCK AND HAD AN ALT ALERT ON TCASII TO CLB. WE CLBED AND A B747-400 PASSED BELOW AND AFT OF US. EDMONTON CTR ASKED US IF WE WERE DIVERTING FOR WX AND WE TOLD HIM WE WERE CLRED DIRECT YQD. WE CHKED THE COORDINATES FOR YQD AND REALIZED WE HAD INSERTED N3558.4 RATHER THAN N5358.4. WE IMMEDIATELY CORRECTED THE INS AND WENT DIRECT YQD. WE WERE UNDER RADAR CTL WITH EDMONTON CTR. SUPPLEMENTAL INFO FROM ACN 375738: THE CAPT LOADED THE LATITUDE/LONGITUDE COORDINATES FOR YQD IN THE INS BUT I FAILED TO CHK THEM. IF I HAD CHKED THE COORDINATES PER SOP THIS INCIDENT WOULD NOT HAVE HAPPENED. SUPPLEMENTAL INFO FROM ACN 375740: I WAS NOT IN THE COCKPIT DURING THE ABOVE EVENT AS I WAS PREPARING THE 3 CREW MEALS. BY THE TIME THAT I RETURNED TO THE COCKPIT THE CAPT WAS TALKING TO CTR ABOUT OUR HDG. SUPPLEMENTAL INFO FROM ACN 375745: WE REQUESTED FL330 AND EDMONTON CTR RESPONDED THAT IT WAS AVAILABLE ONLY WITH A RERTE FROM OUR PRESENT POS (VICINITY OF BEJAW INTXN) DIRECT TO FT NELSON DIRECT TO WHITEHORSE TO EXPECT FL350 PRIOR TO WHITEHORSE DUE TO CONFLICTING TFC. WE ACCEPTED THE RERTE AND CLBED TO FL330. APPROX 130 MI ESE OF HIGH LEVEL AT FL330, WE RECEIVED A TCASII TA. WE HAD BEEN ON ALERT FOR THE TFC AS IT WAS DISPLAYED ON OUR NAV DISPLAY INDICATING OUR SAME ALT FOR SOME TIME. WE IMMEDIATELY PICKED THE DC10 UP VISUALLY AND MY INITIAL REACTION WAS THAT IT WAS DIVERGING AWAY FROM US. WE WERE ABOVE AN OVCST WITH NO VISIBLE CONTRAILS. APPROX 10-15 SECONDS AFTER SPOTTING THE ACFT, WE RECEIVED A DSND NOW COMMAND. I DISCONNECTED THE AUTOPLT AND BEGAN A SLOW DSCNT AS WE STILL HAD THE ACFT IN SIGHT VISUALLY. HE PASSED IN FRONT OF US FROM R TO L INTERNALLY AT A DISTANCE OF 2 - 2 1/2 MI WITH A VERT SEPARATION ESTIMATED AT 1000 FT. CTR SHORTLY THEREAFTER APOLOGIZED STATING WE SHOULD HAVE CLRED THIS TFC BY 40 MI. A CONTRIBUTING FACTOR MIGHT HAVE BEEN MY DECISION TO REQUEST AND TAKE A WRONG WAY ALT. HOWEVER, THIS WAS A RADAR ENVIRONMENT. IN RETROSPECT, OBTAINING AS MUCH INFO AS POSSIBLE ON POTENTIALLY CONFLICTING TFC WOULD BE THE PRUDENT AVENUE. I'M CERTAINLY CONVINCED THAT TCASII PLAYED A MAJOR ROLE IN HELPING PREVENT A POSSIBLE MIDAIR TODAY.

  7.  
  8. Accession Number: 410460
    Synopsis: A B777 FLC DOES NOT CATCH THE ERRONEOUS FMC ENTRY RELATIVE TO THEIR RERTE OVER CANADA AND EXPERIENCE A HDG TRACK POS DEV. CTLR CATCHES MISTAKE AND DSNDS ACFT FOR OPPOSING TFC.
    Narrative: ON FLT FROM LHR TO SFO, APCHING N64 W60, RECEIVED RERTE FROM MONTREAL, AS FOLLOWS: N6330 W67, N60 W80, N5530 W90, YWE, AS FILED. I INCORRECTLY ENTERED N5330 W90 VICE N5530 W90 IN THE FMC. FO CHKED RTE BUT DID NOT CATCH ERROR, NOR DID I. SHORTLY THEREAFTER, I WENT ON REST BREAK. THE RERTE WAS PASSED TO DISPATCH (CORRECTLY) BUT NEW FLT PLAN NOT RECEIVED IN COCKPIT UNTIL AFTER 80W SO CREW WAS UNABLE TO CHK ROUTING AGAINST PAPER PLAN. PLOTTING CHART IS NOT REQUIRED OVER CANADA, SO THAT XCHK WAS GONE. 2 POS RPTS WERE MADE (67W AND 80W), BUT ATC DID NOT CATCH ERROR. AT 83W WINNIPEG CALLED TO VERIFY NEXT WAYPOINT. ERROR WAS CAUGHT AT THAT TIME AND FLT WAS CLRED TO DSND TO FL330 FROM FL350 AND CLRED DIRECT WINNIPEG. AFTER SEVERAL MINS FLT WAS CLRED BACK TO FL350. DEV FROM COURSE WAS APPROX 30 NM. PERHAPS RESUMPTION OF POS PLOTTING OVER CANADA WOULD HELP PREVENT ANOTHER OCCURRENCE OF THIS KIND. SUPPLEMENTAL INFO FROM ACN 410444: 2 POS RPTS WERE MADE PRIOR WITH INCORRECT WAYPOINT GIVEN, AND NONE CAUGHT ERROR. FLYING FO HAD COME BACK FROM BREAK PRIOR TO 080W AND CAPT WENT BACK FOR HIS BREAK AT THAT TIME. THE FLYING FO DID NOT CATCH ERROR EITHER. THIS KEYBOARD ENTRY ERROR WHICH CAUSED THE NAV DEV WAS NOT RECOGNIZED BY 3 PLTS AND 3 CTLRS (THROUGH POS RPTS). WE FOLLOWED ALL PROCS CORRECTLY BUT DIDN'T HAVE A NEW FLT PLAN FROM DISPATCH FOR THE FINAL AND MOST ESSENTIAL VERIFICATION. SUPPLEMENTAL INFO FROM ACN 410452: THE CAPT TOOK HIS REST BREAK PRIOR TO W80, I TOOK HIS SEAT AND THE FLYING FO TOOK R SEAT. WE BRIEFED THE RERTE BUT DIDN'T HAVE THE HARD COPY FROM DISPATCH YET FOR HER TO CHK IT. I TOLD THEM THE INCORRECTLY ENTERED WAYPOINT OF N5330 W090. THEY TOLD US TO DSND FROM FL350 TO FL330 (WE SAW TFC AHEAD APPROX 40 NM AT FL350). (ORIGINAL FLT PLAN RTE: N64 W060 DIRECT KAGLY DIRECT TEFFO N544B YWG.) WE DID QUERY DISPATCH AS TO WHY IT WAS TAKING SO LONG TO GET NEW FLT PLAN. THEY ANSWERED OVER ACARS SAYING THEY HAD TO ENTER IT IN THE COMPUTER AND IT WOULD BE A WHILE.
Flight Deck Automation Issues Website  
© 1997-2013 Research Integrations, Inc.