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Incidents related to Issue 6 incidents related to this issue.

Issue: cross checking may be difficult (Issue #72)
Description: It may be difficult for one pilot to monitor what another is doing with automation, possibly reducing awareness of pilot intentions and cross checking for errors.

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  2. Accession Number: 363303
    Synopsis: ACR MLG CLRED TO HOLD CON VOR L TURNS FL370. CAPT WAS ON #2 VHF WITH DISPATCH REGARDING PLAN OF OP. WHEN BACK IN THE COCKPIT HE SET UP THE HOLD PER CHART WITH A R TURN. FO HAD FAILED TO ADVISE OF THE L PATTERN. CTLR QUESTIONED THE DIRECTION OF TURN AFTER 1 CIRCUIT. NO CONFLICT AND THE FLT DIVERTED TO ALTERNATE.
    Narrative: CLRED TO HOLD AT CON NW ON 300 DEG RADIAL, L TURNS, 2O MI LEGS, FL370. FO COPIED HOLDING INSTRUCTIONS AS I WAS TALKING TO DISPATCH ABOUT THE WX AT PWM (WHICH WAS NOW BELOW MINIMUMS) AND OUR POSSIBLE DIVERSION TO BGR, WHICH WE EVENTUALLY DID. UPON RETURNING TO MY PF DUTIES, WAS TOLD OF OUR INSTRUCTIONS BY ATC BUT HE NEGLECTED TO MENTION L TURNS INSTEAD OF THE PUBLISHED HOLDING PATTERN WHICH WAS R TURNS. I ENTERED THE HOLD AND AFTER 1 COMPLETE PATTERN, ATC ASKED US IF WE WERE IN THE HOLD OVER CON L TURNS. WE REPLIED THAT WE WERE HOLDING AS PUBLISHED, IE, R TURNS AND THEN THE FO TOLD ME IT WAS L TURNS AS HE HAD WRITTEN DOWN BUT FAILED TO TELL ME THAT IT WAS L TURNS. THERE WAS NO CONFLICT. WE APOLOGIZED, AND REQUESTED AND RECEIVED A CLRNC TO BGR. ATC STATED THAT THERE WASN'T A PROB AND WE LANDED AT OUR ALTERNATE. THIS WAS CAUSED BY A VERY HVY WORKLOAD AS ALL THE SURROUNDING ARPTS WERE GOING BELOW MINIMUMS OR WERE CLOSED FOR SNOW REMOVAL. IN THE FUTURE I WILL ASK MORE POINTED AND DIRECT QUESTIONS AS I RE-ENTER THE LOOP. THIS WAS ALSO THE FIRST DAY (THIRD LEG) I HAD FLOWN WITH THIS FO AND I WAS OVERCONFIDENT IN HIS ABILITIES. I NEED TO BE MORE VIGILANT! SUPPLEMENTAL INFO FROM ACN 363490: THE CAPT SAID HE WAS BACK SO I TOLD HIM THE HOLDING INSTRUCTIONS. HE PROCEEDED TO BUILD THE HOLD IN THE FMC. UPON ME REVIEWING THE ENTRY IN THE FMC I NOTICED HE HAD ENTERED THE WRONG INBOUND HDG. HOWEVER, I DID NOT NOTICE THAT THE TURNS THAT CAME UP ON THE FMC WERE R. AS WE ENTERED THE HOLD THE CAPT WAS BACK ON #2 RADIO WITH COMPANY. WE DID NOT REALIZE OUR MISTAKE UNTIL ZBW ASKED US WHAT WE WERE DOING.

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  4. 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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  6. Accession Number: 386010
    Synopsis: MD11 ACFT ON SID, PNF, CAPT CHANGED FMS TO HDG WITHOUT INFORMING THE RPTR FO, PF. CONSEQUENTLY, RPTR THOUGHT THE FMS WOULD CAPTURE THE AIRWAY RADIAL, BUT IN HDG SELECT THEY FLEW THROUGH THE RADIAL. FOREIGN CTLR ISSUED HDG AND ALT CLRNC.
    Narrative: ON SID, TURN WAS COMMENCED TO INTERCEPT R263. UPON REACHING INTERCEPT ANGLE, THE FMS WAS CHANGED TO HDG BY PNF AND NOT NOTIFYING PF. AFTER GOING THROUGH RADIAL, I ASKED PNF WHAT WAS OCCURRING. HE DIDN'T KNOW (OR REMEMBER) UNTIL DISCUSSED. AFTER A CORRECTION WAS FLOWN, LONDON CTL ISSUED US A HDG AND ALT.

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  8. Accession Number: 386746
    Synopsis: AN ACR B737 FLC DSNDS BELOW THEIR XING ALT WHEN THE CAPT SELECTS THE WRONG AUTOFLT SYS MODE AND SETS THE ALT ALERTER SELECTOR BELOW THEIR XING ALT.
    Narrative: ZLA CLRED ACFT TO BANDS INTXN WITH MULTIPLE SHORT DSCNTS OF 1000 FT - 2000 FT. CAPT USED VERT SPD MODE TO ACCOMPLISH TASK. DURING TRANSITION TO SOCAL APCH, CLRNC ABOVE WAS RECEIVED. THIS WAS TO BE AN FMC FUNCTION. WE WERE ANTICIPATING A VISUAL APCH, SHORTCUTTING THE ARR. INSTEAD OF RE-ENGAGING VNAV, FIRST THE CAPT SET 2200 FT IN ALT WINDOW -- THAT WOULD HAVE BEEN OK, BUT VNAV HAS TO BE ENGAGED TO READ FMC ALTS. VERT SPD LET THE ACFT DSND BELOW (BANDS, 7000 FT). DUTIES OF CREW MEMBERS WERE DIVIDED. CAPT WITH VISUAL, FO WITH ARR, STAR AND APCH CHKLIST ITEMS. OTHER DISTRS: ATIS ONLY RECEIVES CLOSE IN AS DOES COMPANY FREQ. THE ABILITY TO BACK EACH OTHER UP WAS NOT THERE 'AS USUAL' -- XCHKS OF EACH OTHER NOT DONE DUE TO DIVISION OF DUTIES. ALSO TOO DISTR BY RA WHILE WITH ZLA BY KING AIR PASSING 500 FT OVER US. SUPPLEMENTAL INFO FROM ACN 386755: CLRNC: TO KAYOH, CROSS KAYOH AT 7000 FT, 190 KTS. THEN CLRED TO DSND EASTSIDE 2 ARR, TRANSITION TO RWY 19R. ACFT B737 FMC EFIS. DURING TRANSITION TO SOCAL APCH, CLRNC ABOVE WAS RECEIVED. THIS WAS TO BE AN FMC FUNCTION. WE WERE ANTICIPATING A VISUAL APCH, SHORTCUTTING THE ARR. INSTEAD OF RE-ENGAGING VNAV FIRST, THE CAPT SET 2200 FT IN ALT WINDOW. THAT WOULD HAVE BEEN OK, BUT VNAV HAS TO BE ENGAGED TO READ FMC ALTS. LET THE ACFT DSND BELOW (KAYOH INTXN 7000 FT).

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  10. Accession Number: 392704
    Synopsis: B777B DEPARTS LAX, CA, WITH THE FMS NOT PROGRAMMED. DURING CLBOUT IT SUFFERS LOSS OF SEPARATION BECAUSE THE FLC IS BUSY TRYING TO PROGRAM THE FMS PROPERLY. FLC IS DISTRACTED WITH PERSONAL PROBS.
    Narrative: THIS IS A CLASSIC CASE OF HOW TO HAVE AN ACCIDENT WITH THE GLASS COCKPIT. I WAS THE REGULAR PLT, BUT FLYING AS RELIEF. THE COPLT WAS FLYING, LAX TO LHR FLT ON JAN/SAT/98. THE CAPT WAS UNDER STRESS. HE JUST COMMITTED HIS CLOSE RELATIVE TO A MENTAL INSTITUTION. HE STATED HE THOUGHT SOMETHING WAS WRONG WITH HIS HEART. HE TOLD ME TO KEEP AN EYE ON THE COPLT BECAUSE ON PREVIOUS TRIPS HE WOULD LOSE HIS SIT AWARENESS. THERE WAS A LOT OF CONFUSION ON COCKPIT SETUP. TWO MECHS HAD TO CLR TWO STATUS MESSAGES. THE FUELER WAS HAVING TROUBLE BALANCING THE FUEL. THEN THE DATA MODE DEFAULTED TO THE #2 RADIO. BUT FINALLY WE GOT GOING. WE DEPARTED ON THE LOOP DEP OUT OF LAX. THE COPLT MISSED THE L TURN AT 2 MI AND HAD TO BE DIRECTED TO TURN BY THE CAPT. AT THIS POINT THE CAPT REALIZED THAT THE DEP WAS NOT INSTALLED. HE PUT IN LAX AND HIT (NAV) AND ASKED THE COPLT TO FLY THE SID WHILE HE TRIED TO FIGURE OUT WHAT WAS WRONG WITH THE COMPUTER. THE COPLT FLEW STRAIGHT TO THE VOR AND THEN KEPT GOING STRAIGHT. I TOLD HIM HE HAD TO TURN R. HE ASKED IF HE COULD PUT ON THE AUTOPLT, THE CAPT SAID NO, JUST FLY THE PLANE. HE TURNED BACK R AND THEN TURNED OUTBOUND. AT THIS POINT ZLA TOLD US TO CLB TO FL260 AND TFC AT 3 O'CLOCK POS. THE NEXT THING WE GOT WAS TCASII 'DSND NOW.' WE SAW THE OTHER ACFT PASS IN FRONT. THE COPLT DID NOT REACT TO THE TCASII RA AND HAD TO BE TOLD BY BOTH OF US TO DSND. IT APPEARED ZLA WAS NEVER AWARE OF THE CONFLICT. THE PROB WAS THAT THE CAPT INSTALLED LAX AS DEST INSTEAD OF LHR. AS A RESULT, THE PREVIOUS FLT'S INBOUND ARR WAS STILL SHOWING TO LAX. THIS IS WHAT THE COPLT THOUGHT WAS THE OUTBOUND COURSE. THIS PUT HIM S OF THE OUTBOUND RADIAL AND CAUSED THE TFC CONFLICT. WHY ZLA DID NOT CATCH IT IS BEYOND ME. LESSONS: 1) THE PLT WHO INSTALLS INFO INTO THE COMPUTER, MUST HAVE EACH PAGE CHKED BY THE OTHER PLT. 2) THE PF SHOULD ALWAYS BACK UP WITH RAW DATA. 3) DO NOT DO COMPUTER WORK THAT'S COMPLICATED BELOW 18000 FT. 4) IF YOU ARE STRESSED OUT AND NOT FEELING WELL, GO ON SICK LEAVE.

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  12. Accession Number: 395382
    Synopsis: MD80S ACFT BEING VECTORED FOR APCH WITH ACFT MANEUVERING, RPTR CAPT THOUGHT THE AUTOPLT HAD CAPTURED AND WOULD HOLD ALT, BUT IT DIDN'T AND ACFT LOST 300 FT WHILE IN TURN.
    Narrative: CAPT, PF, FO, PNF, OBSERVED FMA SWITCH FROM IAS TO ALT CAPTURE. WE WERE THEN GIVEN A 30 DEG HDG CHANGE EXECUTED AT 25 DEG BANK. I LOOKED DOWN AT APCH CHART FOR ILS FREQ AND HEARD ALT WARNING. ALT WAS NOW 6700 FT. AUTOPLT DID NOT EXECUTE ALT HOLD. AUTOPLT WAS DISCONNECTED AND ACFT FLOWN BACK TO 7000 FT. NO CONFLICT WITH OTHER ACFT OBSERVED OR MENTIONED BY US OR ATC. SUPPLEMENTAL INFO FROM ACN 395700: ON AUTOPLT THE CAPT SELECTED HEADING AND THE ACFT ROLLED INTO 30 DEGS OF BANK AS ALT CAPTURE WAS ANNUNCIATED ON THE FMA. AS COPLT PNF MY JOB IS TO BACK UP THE PF, BUT IN THIS CASE TO BACK UP ACTUAL ALT I HAVE TO GO XCOCKPIT DUE TO AFL ALTS ON THE FO'S ALTIMETER.
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