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Incidents related to Issue 8 incidents related to this issue.

Issue: both pilots' attention simultaneously diverted by programming (Issue #75)
Description: Both pilots may become involved in programming duties simultaneously, possibly diverting the attention of both pilots from safety-critical tasks.

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  2. Accession Number: 62470
    Synopsis: FLT OVERSHOT HOLDING FIX.
    Narrative: IN DESCENT FOR HOLDING 40 MILES WEST BNA VOR LEFT HAND TURN, ASKED FOR HOLDING SPEEDS. GOT INVOLVED (BOTH PLTS) WORKING PMS COMPUTER TO OBTAIN EPR SETTINGS FOR HOLDING (I SHOULDN'T HAVE). ACFT PASSED HOLD FIX 4 MILES (36 DME W BNA) WHEN HOLDING TURN (STANDARD RATE) INITIATED. NO CONFLICT.

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  4. Accession Number: 63592
    Synopsis: WHILE REPROGRAMMING THE AUTOPLT FMS, FLT CREW ALLOWED MLG TO GET BEHIND DESCENT PROFILE AND MISSED AN ALT CROSSING RESTRICTION.
    Narrative: WHILE FLYING THE 24/25 PROFILE DESCENT INTO LAX, THE 15M TO 21M' ALT WINDOW WAS MISSED. THE F/O WAS NEW TO THE ACFT AND WAS FLYING THIS LEG. THE ACFT BEING FLOWN WAS ONE OF THE FEW IN THE FLEET EQUIPPED WITH A PMS. THIS FLT WAS THE F/O'S FIRST EXPERIENCE USING THE PMS. THE PMS DID NOT PROGRAM THE TOP OF DESCENT POINT CORRECTLY. INSTEAD OF DISENGAGING THE PMS AND MAKING MANUAL INPUTS TO THE AUTOPLT, I ATTEMPTED TO ASSIST THE F/O IN REPROGRAMMING THE PMS TO A CORRECT DESCENT PROFILE. WE ALSO RECEIVED AN AIRSPEED RESTRICTION THAT HAD TO BE PROGRAMMED IN. AT ANY RATE, THE BOTTOM LINE IS THAT DURING THE TIME WHILE MY ATTN WAS FOCUSED ON HELPING MY F/O WITH A SYSTEM HE WAS UNFAMILIAR WITH (AND USING FOR THE FIRST TIME), I NEGLECTED TO REALIZE THAT WE WERE TOO HIGH AT THE FILLMORE VOR. THE TIME NEEDED TO UPDATE THE PMS WAS INSUFFICIENT WITH REGARD TO THE EXPERIENCE LEVEL OF THE F/O, AND IT TOOK ME MUCH LONGER THAN I REALIZED AT THE TIME TO ASSIST IN MANUALLY UPDATING THE SYSTEM. JUST PAST FILLMORE VOR, LAX CENTER ASKED FOR OUR ALT, WHICH WAS 22400. THE PMS WAS THEN DISREGARDED, MANUAL INPUTS TO THE AUTOPLT WERE MADE AND A STEEP DESCENT WAS MADE TO MAKE THE BAYST 10M' RESTRICTION (WHICH WAS CLOSE). THE ALT WAS MISSED BECAUSE ATTN WAS DIVERTED TO REPROGRAM AN AUTOMATIC FLT SYSTEM THAT DID NOT FUNCTION PROPERLY. THE DIVERSION OF ATTN WAS EXCESSIVE PARTIALLY BECAUSE OF THE INEXPERIENCE OF THE F/O WITH THE PMS AND PARTIALLY BECAUSE THE CAPT DID NOT REALIZE HOW LONG IT WAS TAKING TO ASSIST IN THE REPROGRAMMING. AWARENESS OF THE MANY POTENTIAL CIRCUMSTANCES THAT MAY CAUSE DISTRACTIONS FROM THE PRIMARY FLYING DUTIES SHOULD PREVENT ANY RECURRENCES OF SIMILAR SITUATIONS.

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  6. Accession Number: 146839
    Synopsis: ACR MLG ALT DEVIATION ALT UNDERSHOT. ALT CROSSING RESTRICTION NOT MET.
    Narrative: FLT 5/90, CLT-SFO, DSNDING INTO SFO WBND TO MOD VOR. BEING VECTORED AND ASSIGNED 250 KIAS, GIVEN LOCKE ARR TO SFO, WE FOUND THAT THE LOCKE ARR IS NOT IN OUR RNAV/FMC DATA BASE. WHILE BLDG THE ARR INTO FMC (WITH F/O READING DATA AND CAPT INPUTTING FMC) FOUND ACFT NO LONGER IN AUTOTHROTTLE SPD MODE, AND AIRSPD UP TO 290 KIAS. BEGAN REDUCING BACK TO 250 KTS AS CTLR ASKED ABOUT OUR SPD. CONTINUED DSNT W OF MODESTO IN FMC VNAV MODE WITH CLRNC TO CROSS LOCKE INTXN AT 10000'. CTLR ASKED US DURING DSNT IF WE WOULD MAKE THE RESTRICTION; F/O AFFIRMED WE WOULD. A MINUTE OR SO LATER I TOLD F/O TO TUNE IN SCAGGS ISLE VORTAC AND VERIFY OUR POS. WE FOUND WE WERE AT LOCKE, NOT THE 10-12 MI SE SHOWN BY FMC. CTLR THEN TOLD US WE WERE AT LOCKE. OUR ALT WAS APPROX 14000'. I ACKNOWLEDGED OUR ERROR ON THE RADIO AND EXTENDED THE SPD BRAKES, HURRYING DOWN TO 10000'. AFTER STABILIZED AT 10000', I HAD THE F/O CHK THE POS WE HAD PUT INTO THE FMC FOR LOCKE. WE FOUND THAT HE HAD GIVEN ME THE DISTANCE FROM UPEND TO LOCKE, RATHER THAN THE MILEAGE OF LOCKE FROM SCAGGS ISLE VORTAC. RECOMMENDATIONS: AIRLINE SHOULD PROVIDE COMPLETE DATA BASE IN RNAV (FMC). WHEN NECESSARY TO BUILD DATE, ONE PLT BUILDS INTO FMC WHILE OTHER MONITORS ACFT. SECOND PLT THEN VERIFIED VALIDITY OF NEW DATA BY CHKING LAT/LONG COORDINATES BEFORE DATA IS ACTIVATED. USE VORTAC BACKUP AS SOON AS ALT RESTRICTIONS ARE ISSUED. SUPPLEMENTAL INFO FROM ACN 146837: COCKPIT WORKLOAD WX, SB AM, WALKUP CALL TO START THIS TRIP.

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  8. Accession Number: 243598
    Synopsis: CREW PUT WRONG FLT NUMBER IN ACARS AND THEREFORE RECEIVED WRONG ATC CLRNC ON PRE-DEP CLRNC.
    Narrative: ON PREFLT OF ACARS UNIT COPLT INITIALIZED ACARS WITH INCORRECT FLT NUMBER. CLRNC OBTAINED THROUGH PRE-DEP CLRNC SYS WITH MESSAGE FROM PRE-DEP CLRNC ALT AND SQUAWK ENTERED IN APPROPRIATE BOXES. FMC PROGRAMMED. FLT DEPARTED BWI. DEP CTL INDICATED WE HAD WRONG NUMBER IN XPONDER. CAPT REMEMBERED SPECIFICALLY PUTTING IN XPONDER CODE FROM PRE-DEP CLRNC MESSAGE. UPON FURTHER INVESTIGATION, IT WAS DETERMINED THAT WRONG CLRNC WAS OBTAINED THROUGH PRE-DEP CLRNC. FORTUNATELY, IN BWI DEPARTING RWY 28, ALL DEPS CLB TO 4000 FT ON HDGS ASSIGNED BY TWR. A READBACK OF CORRECT RTING WAS OBTAINED FROM ATC AND FLT CONTINUED TO DEST. NO DEVS FROM FLT PLAN OR CLRNC FROM GND, TWR, DEP CTL OR CTR WERE MADE. PROB AROSE BECAUSE BOTH CREW MEMBERS SHARED DATA INPUT TO ALL 'BOXES,' INSTEAD OF 1 CREW MEMBER INPUTTING DATA AND THE OTHER XCHKING ALL INFO. ALSO CONTRIBUTING TO THIS ERROR WAS THE FAILURE OF 1 AND/OR BOTH CREW MEMBERS TO CHK, DOUBLE CHK, OR EVEN TRIPLE CHK ALL DATA INPUTS. AS FAR AS CONDUCT OF FLT IS CONCERNED, WE KNEW WHAT WE WERE SUPPOSED TO DO, WHERE WE WERE GOING, AND HOW TO GET THERE, HOWEVER, THE PREFLT CLRNC WE OBTAINED FROM PRE-DEP CLRNC HAPPENED NOT TO BE THE CORRECT ONE FOR OUR DEST.

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  10. Accession Number: 245915
    Synopsis: ALTDEV ALT OVERSHOT IN NON ADHERENCE TO ATC CLRNC.
    Narrative: WE DEPARTED DFW ON A WORTH 5 DEP -- TUCUMCARI TRANSITION WITH AN ASSIGNED ALT OF 10000 FT. THE CAPT WAS HAND FLYING THE ACFT. ON CLBOUT, DEP ASSIGNED US A WESTERLY HDG AND ADVISED THAT, DUE TO WX, WE WERE TO BE ASSIGNED TO INTERCEPT THE DFW 262 DEG RADIAL OUTBOUND WITH FURTHER CLRNC TO COME FROM ZFW. AS PNF, I ATTEMPTED TO ENTER THE NEW ROUTING INTO THE FMC USING MY FMC CTL DISPLAY UNIT (CDU). MEANWHILE, THE CAPT (UNKNOWN TO ME, HEAD DOWN FEVERISHLY WORKING ON MY CDU) SELECTED MANUAL VOR TUNING ON 117.0 AND WAS READY TO USE THE SINGLE POINTER (SELECTED TO VOR) AND RDMI TO COMPLETE THE INTERCEPT. I INFORMED THE CAPT OF MY DIFFICULTIES, HE DIVERTED HIS ATTN TO HIS CDU TO SEE WHAT I HAD DONE. ABOUT THEN, WE PASSED THROUGH 10000 FT. I THINK THE ALT ALERT LIGHT AND CAUTION SIGNALS ACTIVATED. THE CAPT PROMPTLY RETURNED THE ACFT TO 1000 FT. THE CTLR CALLED US AND STARTED TO ASK A QUESTION, BUT THEN STOPPED. END OF OCCURRENCE. FACTORS -- THIS WAS MY SECOND FLT AS PNF IN ACFT TYPE. ALL OF MY PREVIOUS FLYING WAS IN NON ADVANCED COCKPIT TYPE ACFT. MY INEXPERIENCE LED ME TO ATTEMPT TO GENERATE A COMPUTER SOLUTION FOR A SIMPLE MANUAL VOR PROB. THE CAPT (WITH 20 PLUS YRS AS CAPT BUT ONLY 100 HRS IN ACFT TYPE) ALLOWED ME TO DISTRACT HIM AT AN INOPPORTUNE MOMENT. ATTEMPTING TO REDUCE THE WORKLOAD THROUGH AUTOMATION CREATED A MORE DEMANDING SIT, DISTRACTING US FROM THE BASICS OF FLYING. RECOMMENDATION -- INTERNAL ACFT ALT ALERTS SHOULD BE SET TO ALERT FLCS FOR CORRECTIVE ACTION BEFORE ALTDEV REACHES SAFETY LIMITS/ FAA ALERT PARAMETERS. THIS WOULD PROVIDE FOR EARLIER CORRECT FLC RESPONSE WHEN THEY ARE MOMENTARILY DISTRACTED BY ANY OF A MYRIAD OF POSSIBLE SITS. SUPPLEMENTAL INFO FROM ACN 245833: 2 NEW 'GUYS' TRYING TO KEEP UP WITH THE COMPUTER -- I REVERTED TO A MANUAL INTERCEPT.

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  12. Accession Number: 359641
    Synopsis: AN ACR B737-400 CREW ADMITS TO AN ALTDEV ALT OVERSHOT ON CLBOUT.
    Narrative: WE DEPARTED RWY 30L AT SJC. OUR CLRNC WAS VIA THE SJC 8 DEP, WHICH CALLS FOR A R TURN TO 110 DEGS TO JOIN THE OAK R-121. THE DEP REQUIRES THE TURN TO COMMENCE AT SJC 1.8 DME TO STAY WITHIN 4.0 DME AND A LEVEL OFF AT 5000 FT. WE WERE NAVING USING FMS. WORKLOAD WAS HIGH FOR BOTH PLTS, AND THE FMS DID NOT APPEAR TO BE INTERCEPTING THE COURSE. NEITHER PLT NOTICED THE ALT PASSING 5000 FT. AT 5300 FT, THE ALT ALERTER SOUNDED AND IMMEDIATELY DEP CTL CLRED US TO 6000 FT. NO MENTION OF THE DEV WAS MADE BY ATC. THE MAJOR CAUSE OF THIS DEV WAS WHEN BOTH PLTS WERE DISTRACTED BY A MINOR FMS PROB DURING A BUSY DEP. THE PF SHOULD HAVE IGNORED THE FMS AND SWITCHED TO RAW DATA NAV.

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  14. Accession Number: 374100
    Synopsis: CAPT OF AN SF340 MISTAKENLY TAXIED ONTO A RWY WHEN HE FAILED TO FOLLOW TAXI INSTRUCTIONS DURING TAXI OUT FOR TKOF.
    Narrative: CLRED TO TAXI TXWY KK TO FOLLOW ACR MD80 DIRECT TXWY B TO RWY 22R. TAXIING OUT TXWY KK, GND INSTRUCTED US TO TURN L ON TXWY A, TAKE TXWY J AND THEN TURN L ON TXWY B. RUNNING THE TAXI CHKLIST, FO HAD HIS HEAD DOWN SETTING UP THE MGMNT FLT DIRECTOR (IN SF340) FOR SPDS AS I BRIEFED BY LEADING V SPDS AND TORQUE SETTINGS (CHKLIST REQUIRES CAPT TO BRIEF WHILE TAXIING) REQUIRING MY HEAD TO BE INSIDE AND DOWN ALSO. I MISSED THE L TURN ON TXWY B AND BEGAN TO TURN L ONTO RWY 4L. I WAS ACROSS THE HOLD SHORT LINE AND COMMITTED PRIOR TO OBSERVING MY ERROR. ALTHOUGH THE CHKLIST REQUIREMENT IS QUESTIONABLE, I'VE FOLLOWED IT THOUSANDS OF TIMES WITHOUT ERROR. A FEW SECONDS OF DISTR BY BOTH PLTS SET US UP FOR THIS ERROR. GND THEN CLRED US ON RWY 4L TO L TURN ONTO TXWY H, R ON TXWY B TO CONTINUE TO RWY 22R. ALTHOUGH THERE WERE NO ACFT ON RWY 22R/4L, THE POTENTIAL FOR PROBS WAS OBVIOUS.

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  16. Accession Number: 402840
    Synopsis: FLC OF A B737-500 OVERSHOT ASSIGNED HOLDING FIX DURING ENRTE DSCNT DUE TO DISTR OF PROGRAMMING THE FMC FOR THE FIX. ATC WAS NOTIFIED OF THE MISTAKE AND THE CREW RETURNED TO THE FIX IMMEDIATELY.
    Narrative: FO WAS PF, SAT-IAH. DURING THIS LEG, CTR GAVE US A HOLD 70 MI OUT OF R234, IAH WHILE WERE ON THE GLAND 7 STAR. WE WERE APPROX 13 MI FROM THIS POINT (NOT A CHARTED FIX) WHEN WE RECEIVED THE HOLD. I SET RAW DATA ON MY SIDE AND PROCEEDED TO ASSIST THE FO IN SETTING UP A HOLD ON THE FMC. I WAS ENGROSSED IN HELPING THIS SETUP (AND ATTEMPTING TO KEEP FO'S FINGERS FROM PUNCHING THE WRONG BUTTONS) THAT I FLEW PAST THE HOLDING POINT. I NOTIFIED ATC AND QUICKLY RETURNED TO THE FIX. WE EXECUTED THE HOLD VIA THE NOW SET UP FMC, FOLLOWING IT WITH RAW DATA TO ENSURE ACCURACY. FO WAS UNABLE TO ACCOMPLISH SOME IMPORTANT TASKS RELATING TO FMC WORK ON THE B737-500. MY ERROR WAS IN ATTEMPTING TO 'TEACH' THIS FO, RATHER THAN SIMPLY PAYING ATTN TO THE RAW DATA AND 'FLYING THE AIRPLANE.'
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