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Incidents related to Issue 26 incidents related to this issue.

Issue: automation may adversely affect pilot workload (Issue #79)
Description: Automation may increase overall pilot workload, or increase pilot workload at high workload times and reduce pilot workload at low workload times, possibly resulting in excess workload and/or boredom.

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  2. Accession Number: 51254
    Synopsis:
    Narrative: WE WERE CLEARED BY ATC TO CROSS ALKID INTERSECTION AT 11000'. DFW APCH CTL CALLED OUT TFC AT 10000', 12 O'CLOCK, AT ABOUT 5 MILES. BOTH F/O AND I WERE LOOKING OUTSIDE FOR TFC AT LEVEL OFF AT 11000. I OBSERVED ACFT TO CONTINUE DESCENT TO 10800' AS AUTO PILOT WITH ALT ARMED DID NOT LEVEL OFF. I DISCONNECTED A/P AT 10800' AND PROMPTLY CLIMBED BACK TO 11000'. ALL ALTIMETERS WERE PROPERLY SET ON 29.87 ALT SETTING. AT NO TIME DID OUR ACFT COME NEAR THE TFC NOR DID WE DESCEND BELOW 10800'. THE AUTOMATIC FEATURES OF THE ADV MLG ACTUALLY CAUSE A GREATER WORK LOAD FOR THE PLTS TO SET THE GADGETS, TRY TO OBSERVE IF THEY WORK, AND CAUSE COMPLACENCY IN RELYING ON THEM. THEN THEY FREQUENTLY DO NOT WORK JUST AT THE TIME THEY ARE CRITICALLY NEEDED.

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  4. Accession Number: 62081
    Synopsis: MLG WAS GIVEN A LAST MINUTE CLRNC TO DESCEND AND GIVEN AN ALT CROSSING RESTRICTION. THEY UNDERSHOT THE RESTRICTION BY 300'.
    Narrative: WHILE CRUISING AT FL330, ENROUTE FROM DFW TO MCO, JAX CTR GAVE US A "SHORT NOTICE" DESCENT TO CROSS CTY VOR AT FL270. IN ORDER TO GET THE DESCENT STARTED QUICKLY AND SMOOTHLY, I SWITCHED FROM PMS (PERF MGT SYS-DELCO) TO AUTOPLT--VERT SPD MODE AND ESTABLISHED A RATE OF DESCENT TO ARRIVE AT FL270 A COUPLE OF MILES BEFORE CTY. BECAUSE WE WERE BUSY WITH ATC PLANNING OUR ARRIVAL, ATIS, FLT ATTENDANTS, AND, BECAUSE I WANTED TO LEVEL OFF AT AN OPTIMUM CRUISE SPEED WITH THE LEAST AMOUNT OF FUSS, I SWITCHED BACK TO PMS DESCENT MODE AT FL283. WHILE CHECKING ON OTHER THINGS, I FAILED TO NOTICE THE PMS HAD LEVELED OFF AT ABOUT FL277 TO MAKE ITS OWN SPEED ADJUSTMENTS. BY THE TIME I CORRECTED FOR THIS, WE HAD CROSSED CTY ABOUT 300' HIGH. BECAUSE OF THE LATE NOTICE AND OTHER DISTRACTIONS, I DID NOT HAVE TIME TO PROGRAM THE PMS FOR THE CROSSING ALT. IN ANY CASE, THE PMS SHOULD HAVE CONTINUED THE ESTABLISHED DESCENT, WHICH WOULD HAVE MADE THE CROSSING. OVER THE YEARS, I'VE LEARNED THAT AUTOMATED SYSTEMS OF VARIOUS SORTS ARE A NICE HELP CRUISING ALONG IN A MORE RELAXED ATMOSPHERE, HOWEVER, FREQUENTLY THEY CAN BE A HINDERANCE WHEN THE WORKLOAD IS HIGH, BECAUSE OF THE EXTRA STEPS REQUIRED TO MANAGE IT ALL. IE, PROGRAMMING, CHECKING AND DOUBLE-CHECKING RESULTED. I DON'T USUALLY RELY COMPLETELY ON THESE AIDS AND I CERTAINLY WOULDN'T RECOMMEND IT. HOWEVER IN THIS CASE, I DID NOT FOLLOW MY OWN ADVICE. IT'S IMPORTANT TO REMEMBER THESE DAYS THAT WE ARE STILL PILOTS--NOT JUST SYSTEMS MANAGERS!

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  6. Accession Number: 108752
    Synopsis: ACR WDB ALT OVERSHOT DURING DESCENT IN TURBULENT CONDITIONS.
    Narrative: DSNT FROM FL200 TO 12000', USING FMC NAV AND AUTOPLT. APPROX 15000' ENTERED TOPS, ENCOUNTERED MODERATE TO SEVERE TURB, HEAVY RAIN. ALMOST SIMULTANEOUSLY ATC CLRED TO CROSS 40 SW LRP, AT 12000'. LRP NOT AVAILABLE IMMEDIATELY DUE NOT AUTO SELECT ON VOR, OFF SCREEN ON CRT. CAPT (PNF) SCRAMBLED TO FIND THE ARWY CHART TO GET THE VOR FREQ WHILE I GOT ENG ANTI-ICE AND IGNITION TURNED ON. THEN CAPT BEGAN ADJUSTING RADAR TO FIND OUT WHY WE WERE GETTING HEAVY RAIN AND TURB. WHEN DME FINALLY LOCKED ON LRP, IT READ 31 NM (SW OF LRP). I DEPLOYED SPOILERS AND TURNED OFF AUTO THRUST. RAIN AND TURB WORSENED IN DSNT. AS WE APCHED 12000', I OBSERVED AIRSPD DECREASING. NOT IMMEDIATELY REALIZING, DUE TO CONCERN ABOUT THE EXTREME TURB, THAT THE AUTOPLT WAS LEVELING THE ACFT AT 12000' W/O AUTO THRUST AVAILABLE, I DISCONNECTED THE AUTOPLT. THE ACFT WAS TRIMMED NOSE DOWN AND CONTINUED DSNT BELOW 12000'. THE CAPT RECOGNIZED THE PROB IMMEDIATELY AND CALLED OUT, "ALT." FLEW THE ACFT BACK TO 12000' AND RE-ENGAGED AUTOPLT. MINIMUM ALT APPROX 11800'. CONTRIBUTING FACTORS: PROFICIENCY--I AM JUNIOR ON WDB X, HAVE BEEN MOSTLY ASSIGNED FOR LAST 6 MONTHS AS RELIEF PLT (CRUISE ONLY) OR WITH RESTRICTED CAPT. CONSEQUENTLY, FLEW 1 LEG IN OCT, 2 IN NOV, 1 IN DEC, NONE IN JAN, 1 IN FEB, NONE IN MAR. THIS WAS ONLY MY SIXTH LEG IN 6 MONTHS. CREW SHORTAGE--I AM IN THE MIDDLE OF WDB Y TRANSITION TRNING (COMPLETED FAA ORAL 3/29. RELEASED FROM TRNING DUE BACKED UP SIMULATOR SCHEDULE). DUE TO CREW SHORTAGE, SENT OUT ON WDB X TRIP DURING WDB Y TRANS TRNING. ATC PROC--ASSIGNMENT OF A CROSSING RESTRICTION ONLY 10 NM FROM THE CROSSING FIX, USING A NAVAID WHICH IS BEHIND AN ACFT USING FMC EQUIP, IMPOSED AN EXCESSIVE WORKLOAD ON THE CREW WITH TOO LITTLE TIME TO SET IT UP. FATIGUE--I WAS EXTREMELY FATIGUED AFTER BEING UNABLE TO SLEEP IN THE HOTEL IN PARIS. HOTEL IS NOISY DURING THE DAY WHEN CREW IS SLEEPY, STUFFY AT NIGHT. COMPANY REFUSES OT CHANGE HOTEL. (I DO NOT SMOKE OR DRINK ALCOHOL.) RECOMMENDATIONS: THE ISSUE OF PROFICIENCY OF RELIEF PLTS ON LONG RANGE FLTS SHOULD BE ADDRESSED. CAPT'S IN THE WDB X OPERATION ON OUR AIRLINE DO NOT FEEL OBLIGATED TO GIVE LEGS TO THE RELIEF PLT. ONCE HAVING INITIATED TRANSITION TRNING ON NEW EQUIP, A PLT SHOULD NOT BE REQUIRED TO OPERATE A PREVIOUSLY QUALIFIED EQUIP TYPE W/O AT LEAST ONE SIMULATOR REFRESHER PERIOD. CONSTANT CREW SHORTAGES ARE DESTROYING PLT PERSONAL LIVES. I AM BEGINNING TO BELIEVE THAT SCHEDULED AIRLINE PLT STAFFING LEVELS NEED TO BE ADDRESSED BY THE FAR'S. THIS IS A COMPLEX SUBJECT, BUT OUR PLT GROUP IS EXPERIENCING INTENSE TURMOIL OVER THE EFFECTS OF CREW SHORTAGES. ATC SHOULD AVOID SHORT RANGE CROSSING RESTRICTIONS. CTLRS SHOULD BE TRAINED ON OPERATIONAL CHARACTERISTICS OF FMC ACFT (EG, NAVAIDS BEHIND THE ACFT ARE NOT READILY ACCESSIBLE). PLT WORKING AGREEMENTS DO NOT PROVIDE ADEQUATE LEVERAGE TO ENSURE THAT PLTS ARE GIVEN SUITABLE HOTEL ACCOMMODATIONS. UNSUITABLE HOTELS ARE SECOND ONLY TO CREW SHORTAGES AS THE MAJOR PROB IN FLT OPS ON OUR AIRLINE. HOTELS ARE CHANGED CONSTANTLY TO REDUCE COSTS, AND MANY PLT ARE COMPLAINING ABOUT FATIGUE DUE TO INADEQUATE REST ON LAYOVERS.

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  8. Accession Number: 132299
    Synopsis: TRACK DEVIATION.
    Narrative: WE HAD JUST DEPARTED DCA IN AN MLG. AFTER FOLLOWING THE NE NOISE ABATEMENT PROCS AND SEVERAL VECTORS, WE WERE DIRECTED RNAV DIRECT DAILY INTXN ON COURSE. AFTER PASSING DAILY WE NOTED THAT THE FMS WAS TUNING ONLY 2 STATIONS INSTEAD OF THE USUAL 4 OR 5. THE FMS THEN WENT INTO DEAD-RECKONING. WE PULLED OUT OUR MAPS AND STARTED TUNING THE VOR'S AND CORRECTING THE COURSE. FMS HAD BEEN INDICATING ABOUT A 70 KT CROSSWIND, WHEN IN FACT WE HAD 140 KTS. CENTER ADVISED WE WERE 8 MI LEFT OF COURSE AND VECTORED US FOR CORRECTION. WE ADVISED THEM OF OUR SITUATION AND LATER RPTED THE RNAV CAPABILITY INOP. WE COULD PREVENT SUCH AN INCIDENT IF WE BACKED UP THE FMS WITH MANUAL SYSTEMS; HOWEVER, THAT WOULD DEFEAT THE WHOLE CONCEPT OF 2-M CREWS WITH HIGH-TECH COMPUTERS ASSUMING PART OF THE WORKLOAD. ON A FLT SUCH AS THIS, THE ONLY THING COMPUTERS DO FOR PLTS IS DOUBLE THE WORKLOAD.

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  10. 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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  12. 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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  14. Accession Number: 167993
    Synopsis: ACR FLC MAKES WRONG RWY APCH AT LAX.
    Narrative: PASSING ARNES ON COVET 2 PROFILE DSNT WE BOTH (2 MAN CREW) THOUGHT WE WERE CLRED AFTER PASSING FUELR FOR THE 25L ILS APCH WITH A SIDESTEP TO RWY 24R. APCH LATER ASKED IF WE HAD THE ARPT AND WE RPTED WE DID AND WE BOTH THOUGHT WE WERE CLRED FOR A VIS TO RWY 24R. WE SWITCHED THE ILS TO 24R AND TURNED IN THAT DIRECTION. ALT WAS 4000' AND DSNDING, THEN APCH TOLD US TO TURN 20 DEG L AND THAT WE HAD TFC Y TO OUR R. HE APPARENTLY WAS TURNING INTO RWY 24R. APCH SAID OUR ORIGINAL CLRNC WAS FOR RWY 25R NOT FOR RWY 24R. THE REST OF THE APCH AND LNDG WAS NORMAL ON RWY 25R. APPARENTLY WE MISHEARD THE CLRNC. CONTRIBUTING FACTORS. TUNING IN A RWY AND BEING FORCED TO CHANGE TO ANOTHER RWY WHILE TRYING TO MAKE ALT RESTRICTIONS ETC. ALSO FLYING AN AUTOMATED, GLASS COCKPIT ACFT IN A HIGH DENSITY AREA INCREASES THE PLT WORKLOAD TO THE LIMIT, WHEN HAVING TO CHANGE RWYS ON FINAL, FORCING YOU TO REPROGRAM THE COMPUTER, RETUNE THE NAV RADIOS AND CHANGE UHF FREQ AND CHANGE CHARTS. IT BECOMES VERY EASY TO MISUNDERSTAND CLRNCS. ALSO NO ONE HAD TIME TO LOOK FOR OTHER TFC.

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  16. Accession Number: 358711
    Synopsis: MD80 WAS DSNDING AND AS THEY APCHED FL270, THE CAPT WAS REPROGRAMMING THE FMS WHICH CANCELED THE ALT CAPTURE AND THE RATE OF DSCNT INCREASED. ACFT DSNDED TO FL269 AND TRIGGERED A TCASII RA ON A DC10, OPPOSITE DIRECTION TFC, AT FL260.
    Narrative: ZDC CLRED US TO FL270. DURING DSCNT PF PROGRAMMED THE FMS TO DSND AT 250 KIAS AND 1500 FPM. JUST PRIOR TO LEVELING AT FL270, THE PF NOTED THAT THE IAS WAS 260 KIAS WHILE DSCNT RATE WAS 400 FPM WITH THROTTLES ADVANCING. AT THAT TIME THE PF BEGAN TO REPROGRAM THE FMS WHICH CANCELED THE ALT CAPTURE FUNCTION OF THE AUTOPLT. WHILE 'HEADS DOWN' AND TASK SATURATED WITH THE FMS THE ACFT INCREASED ITS RATE OF DSCNT AND DSNDED THROUGH FL270. AT THAT TIME THE PNF TOOK CTL OF THE ACFT AND BEGAN A CLB BACK TO FL270. AT ABOUT THE SAME TIME A DC10 (?) TRIGGERED AN RA ON THE TCASII. ACR Y TFC WAS OPPOSITE DIRECTION AT FL260. THE ACR Y FLT RPTED A NEAR MISS TO THE CTR CTLR. THE CTLR QUERIED OUR FLT LEVEL TO WHICH WE RPTED FL270 WHICH WAS WHERE WE WERE AT. WE BELIEVE THAT THE INCREASING DSCNT RATE IN COMBINATION WITH THE 1000 FT CLRNC TRIGGERED AN RA. WE BELIEVE THE MISS DISTANCE WAS AT LEAST 900 FT VERT.

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  18. 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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  20. Accession Number: 360828
    Synopsis: ALTDEV ALT UNDERSHOOT. AUTOPLT AUTOCAPTURE REVERTED TO VERT SPD MODE.
    Narrative: ATC CLRED FLT TO 12000 FT AT CROWE, THEN SUBSEQUENTLY LIMITED THAT TO 21000 FT WHILE ISSUING A VECTOR N. ACFT HAD BEEN SPED UP, SLOWED DOWN AND GIVEN NORMAL SPD PRIOR TO THIS, CAUSING THE AUTOMATION TO BE A HINDRANCE TO OPS AND TRIPPING TO VERT SPD. ACFT DID NOT AUTO LEVEL AT 21000 FT -- NOTED BY PLTS AT 20600 FT. WHILE CORRECTING, ATC ADVISED A STEP DSCNT CLRNC TO 20000 FT, THEN 16000 FT, AND FINALLY 12000 FT, 10000 FT, AND VISUAL APCH. NO TFC CONFLICT NOTED. FACTORS: CONSTANT PROGRAMMING CHANGES TO THE FMC, BACKSIDE CLOCK OPS, DISTRACTIONS OF IN RANGE CALLS AND ATC CHANGES TO SPD AND ALT RESTRS THAT INCREASED COCKPIT WORKLOAD IN THE DSCNT PHASE.

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  22. Accession Number: 360911
    Synopsis: AN ACR CAPT RPTS THAT THE AUTOFLT SYS ON THE MD88 HAS SOME 'ERRATIC AND POTENTIALLY HAZARDOUS' CHARACTERISTICS ASSOCIATED WITH THE VNAV AND AUTOTHROTTLE FUNCTIONS. THE RPTR ALSO COMPLAINS ABOUT A NAV PROGRAM IN THE FMC.
    Narrative: THE VNAV CAPTURE FUNCTION OF AUTOPLT IS POTENTIALLY HAZARDOUS DURING CONDITIONS OF HIGH ACFT CLB PERFORMANCE (IE, LIGHT GROSS WT AND/OR LOW TEMP). IT IS NOT UNCOMMON FOR THE AUTOTHROTTLES TO PULL BACK PWR BELOW CLEAN SPD WHILE IN A TURN, AT 3000 FT MSL WITH LEVEL OFF AT 6000 FT MSL. EVEN CLBING AT 250 KTS PASSING THROUGH 10000 FT ENRTE TO 12000 FT IT IS NOT UNCOMMON FOR THE AUTOTHROTTLES TO PULL BACK PWR AND THEN JAM IT ON AGAIN TO ACCELERATE. THIS ERRATIC NATURE OF THE AUTOTHROTTLES REQUIRES THE PLT'S FULL ATTN, OR WILL BE MISSED WHILE PERFORMING OTHER FLT DUTIES AND RESULT IN AIRSPD FALLING BELOW SAFE LEVELS. THE INCLUSION OF THE 6000 FT INITIAL CLB ALT IN THE FMS FOR THE REDSS ONE DEP INHIBITS VNAV WHEN, WHILE ON VECTORS, WE ARE GIVEN CLRNC TO A HIGHER ALT. PLEASE REMOVE THIS RESTR FROM THE FMS DATA BANK FOR THE DEP. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THIS RPTR SAID THAT SINCE HE HAS STARTED OPERATING THIS ACFT IN LINE OPS HE HAS DISCOVERED THAT IT DOES NOT ALWAYS SMOOTHLY AND CORRECTLY CAPTURE THE SELECTED ALT. THE MD88 AUTOTHROTTLES WILL START REDUCING THRUST WELL BEFORE THEY SHOULD AS THE ACFT APCHS ITS ALT HE SAID. ALSO HE COMPLAINED THAT IN SOME EXTREME CASES THE AUTOTHROTTLES WOULD ALLOW THE AIRSPD TO DECREASE TO A CRITICAL LEVEL IF HE WERE NOT WATCHFUL. HE ALSO COMPLAINED THAT IF THE LEVEL OFF ALT WAS AROUND 10000 FT OR SLIGHTLY ABOVE, THE AUTOTHROTTLES WOULD REDUCE AS THE ALT WAS CAPTURED AND THEN GO BACK TO FULL PWR AFTER LEVELING AT OR PASSING 10000 FT. LASTLY, THE RPTR COMPLAINED ABOUT A RECENT CHANGE IN THE SOFTWARE THAT WAS ANTICIPATING A NORMAL CLRNC THAT IS OFTEN GIVEN ON A DEP. HOWEVER, THE ALT RESTR IS NOT ALWAYS GIVEN YET, WITH THE SOFTWARE CHANGE, THE FMC ALWAYS TRIES TO MEET THE RESTR.

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  24. Accession Number: 363470
    Synopsis: LGT ACFT OVERSHOT ASSIGNED ALT ON CLB BY 300 FT AND RETURNED BACK IMMEDIATELY. FLC RPTR'S STATE THAT, BECAUSE THE COURSE WAS NOT DISPLAYED AND FMC PROGRAMMING REQUIRED THEIR ATTN, IT CONTRIBUTED TO A HIGH WORKLOAD AND DISTR FROM ALT.
    Narrative: DEPARTED IAH, WE WERE ISSUED A CLB TO 15000 FT, CLRNC WAS RADAR VECTORS TO FIRST FIX. ABOUT 30 MI W, WE WERE CLRED ON COURSE AND A FREQ CHANGE. DUE TO THE FACT THAT THE COURSE PRIOR TO THE FIX WAS NOT DISPLAYED, THIS CREATED TOO MUCH OF A WORKLOAD WITH THE EFIS/COCKPIT LOAD. WE HAD ALTDEV OF 300 FT HIGH AND CORRECTED BACK TO 15000 FT IMMEDIATELY.

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  26. Accession Number: 363986
    Synopsis: FLC OF A300 MAKING A GAR DUE TO TFC ON THE RWY IS ASSIGNED 2000 FT. BECAUSE OF NOT USING TOGA PWR FLC IS DISTR AND CLBS ABOVE ASSIGNED ALT.
    Narrative: LOCATION: SJU. THE CAPT WAS FLYING A VISUAL STRAIGHT-IN APCH TO SJU RWY 8. THE WX WAS CAVOK BUT THERE WAS HVY INBOUND TFC DUE TO UNSCHEDULED CLOSURE OF RWY 10. THE APCH WAS HAND FLOWN WITH THE ILS RWY 8 TUNED AND THE FLT DIRECTOR IN LAND. AT ABOUT 1000 FT, THE CAPT DISENGAGED THE AUTOTHROTTLES. WE WERE SPACED VERY TIGHTLY BEHIND LIGHT ACFT TFC ON A R BASE. TWR INSTRUCTED S-TURNS TO INCREASE SPACING AND ASKED THE LIGHT ACFT TO LAND LONG AND TAKE THE HIGH SPD, BUT IT DIDN'T WORK AND AT ABOUT 500 FT, THEY TOLD US TO GAR. THE CAPT MANUALLY PUSHED UP THE PWR, CALLED FOR FLAPS AND THEN GEAR AS WE CLBED OUT TO 2000 FT AS INSTRUCTED BY THE TWR. HOWEVER, HE DID NOT USE THE TOGA LEVERS AND, AS A RESULT, THE FMA REMAINED IN APCH MODE. AT ABOUT 1000 FT IN THE CLB, I TOLD HIM HE HAD TO TOGA TO GET THE FMA TO DO WHAT HE WANTED AND HE INDICATED HE DIDN'T WANT TO HAVE THE PWR GO UP THAT HIGH. DURING ATTEMPTS TO GET THE FMA TO DISENGAGE FROM THE APCH MODE IN A STEADY CLB, WE BOTH NOTICED WE WERE GOING THROUGH 2000 FT. THE CAPT HAD BEGUN A TURN AS INSTRUCTED BY TWR, AND REALIZING THE ALT TREND, HE LOWERED THE NOSE AND DSNDED BACK TO 2000 FT. AT THE TOP OF CLB I THINK WE REACHED 2500 FT. WE BOTH SHUT OUR FLT DIRECTORS OFF AND GOT BACK TO BASIC FLYING. TWR DID NOT COMMENT ON THE DEV AND WE SUBSEQUENTLY COMPLETED A NORMAL APCH AND LNDG. SUPPLEMENTAL INFO FROM ACN 364350: MADE A MISTAKE AND LEARNED FROM THIS EPISODE AND HOPE IT WILL PREVENT OTHER INCIDENTS.

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  28. Accession Number: 367361
    Synopsis: B757 ON BEARR 2 STAR SLC CLRED TO HOLD AT BYI AS PUBLISHED, VERY CLOSE TO THE VOR. FO, PF, ON IOE FLT AND WAS RUSHED IN SETTING UP THE HOLD. IN ERROR HE PROGRAMMED A L TURN VERSUS R TURN AT BYI. IN CHKING THE CHART HE MISREAD BEARR HOLDING PATTERN FOR BYI. ONE TURN IN THE PATTERN AT BYI AND THEN CLRED STAR. NO COMMENT FROM CTLR.
    Narrative: FLT CLRED TO SLC VIA BEARR 2 ARR, BYI TRANSITION AT FL370. APPROX 20 NM W OF BYI, CLRNC RECEIVED TO CROSS POINT 35 MI SE OF BYI AT FL310. THE FO WAS PF AND WAS ON HIS B757 OPERATING EXPERIENCE FLTS. I AM A B757 LINE CHK AIRMAN. WHILE HE WAS PROGRAMMING THE FMC FOR DSCNT, CTR CALLED AND SAID, 'APCH CTL HAS STOPPED ACCEPTING ARRS, MAINTAIN FL370 AND HOLD AT BYI AS PUBLISHED ON THE BEARR 2 ARR, LEG LENGTH OUR OPTION, NO IDEA HOW LONG HOLD WILL BE BUT EFC AC30Z.' AT THIS TIME WE WERE RAPIDLY ACHING BYI, THE HOLDING FIX. FO QUICKLY REPROGRAMMED FMC FOR HOLD AT FL370 AND SLOWED ACFT RAPIDLY TO HOLDING SPD. HE MISREAD THE PUBLISHED DIRECTION OF HOLD, SEEING THE NON STANDARD PATTERN IN THE CTR OF THE CHART AT BEARR INTXN. I FAILED TO CATCH THE ERROR. WE MADE ONE L-HAND PATTERN, WHICH SHOULD HAVE BEEN R-HAND, BEFORE BEING CLRED OUT OF HOLDING TO CONTINUE ON THE ARR. NO COMMENT FROM ATC REGARDING OUR ERROR. JUST TOO MUCH TO DO IN TOO LITTLE TIME, COMPOUNDED BY TURB AND LACK OF EXPERIENCE ON ONE PLT'S PART. IT SEEMS IMPOSSIBLE TO ANTICIPATE EVERYTHING. SUPPLEMENTAL INFO FROM ACN 367360: THE CLOSE PROX OF THE 2 HOLDING PATTERNS MAY HAVE CONTRIBUTED TO FOCUSING ON THE BEARR HOLDING PATTERN.

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  30. Accession Number: 371460
    Synopsis: ACR LGT WAS TOO HIGH ON THE APCH DURING STAR ARR INTO LAX AFTER A RWY CHANGE WAS MADE. ACFT WENT AROUND FOR ANOTHER APCH. INITIAL CONFUSION OCCURRED OVER WHICH RWY WAS ASSIGNED AND THE FAILURE TO SET THE ALT WINDOW FOR DSCNT.
    Narrative: DSNDING INTO LAX ON THE (STAR) CIVET ONE ARR, JUST PRIOR TO 'BREMR' INTXN, APCH CTL CHANGED OUR RWY TO RWY 25R. HOWEVER, THERE WAS SOME CONFUSION IN COCKPIT AS EACH PLT 'HEARD' A DIFFERENT RWY. THE DISTR RESULTED IN OUR FAILURE TO CROSS 'ARNES' INTXN AT 10000-11000 FT PER THE STAR. FURTHER, WE GOT SO FAR BEHIND ON THE APCH THAT WE ELECTED TO DISCONTINUE THE APCH AT THE OM. WE WERE THEN VECTORED TO AN APCH AND LNDG ON RWY 24R. LAX CONTINUES TO BE A DIFFICULT ARPT TO OPERATE INTO. THERE ARE 4 RWYS WITH SIMILAR SOUNDING NAMES, SO IT IS EASY TO SAY ONE RWY AND THINK ANOTHER. ONCE AGAIN THOUGH, THE OLD ADAGE ABOUT 'SOMEONE MUST FLY THE AIRPLANE' HAS BEEN PROVEN WISE. THE COPLT, WHO WAS FLYING, GOT DISTRACTED WITH ME AND FAILED TO FLY THE AIRPLANE TO THE REQUIRED XING ALT. ALSO, THE ADDED BUSY WORK OF THE GLASS COCKPIT CONTRIBUTED TO OUR INABILITY TO COMPLETE THE APCH AND LNDG. SUPPLEMENTAL INFO FROM ACN 371434: APCHING BREMR WE WERE GIVEN A RWY CHANGE TO RWY 25R. THE PNF THOUGHT THAT THE RWY THAT WE HAD BEEN GIVEN WAS RWY 24R. THERE WAS A ZLA CTLR WHO WAS ON THE JUMP SEAT, WE ASK WHAT HE HAD HEARD. HE INDICATED HE HEARD RWY 25R. THERE IS 7 MI BTWN BREMR AND ARNES AND AT A SPD OF 210 KTS TAKES APPROX 2 MINS. THE CAPT WAS THE FIRST TO NOTICE THAT WE HAD NOT RESET OUR ALT WINDOW TO 10000 FT AFTER XING BREMR TO MEET THE BELOW 11000 FT ABOVE 10000 FT FOR ARNES. WE CONTINUED THE APCH BUT WERE HIGH AND MADE A GAR AND LANDED RWY 24R. I PERSONALLY BLAME MYSELF FOR BECOMING DISTRACTED AND NOT MONITORING THE FLT PATH OF THE ACFT. ALTHOUGH A RWY CHANGE APPEARS TO BE A SIMPLE PROC, THIS PHASE OF THE APCH IS BUSY ENOUGH WITHOUT ADDING A NEW SET OF PROBS. SET PRIORITIES AND HAVE THE SELF DISCIPLINE TO MAINTAIN THOSE PRIORITIES. POSSIBLY USING SCENARIOS SIMILAR TO THE ONE WE EXPERIENCE, IN TRAINING WOULD HELP TEACH SOME OF THESE POINTS.

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  32. Accession Number: 387010
    Synopsis: B747-400 ACFT ON OCEANIC RTE ENCOUNTERED AREA OF SEVERE WX AND HAD TO DIVERT AROUND WX. FLC HAD SOME DIFFICULTY PROGRAMMING THE FMC PROPERLY FOR OFFSET PLUS HIGH WORKLOAD. FLC FORGOT TO PLOT POS AND GIVE POS RPT. BOTH PLTS IN COCKPIT WERE FO'S AND THE CAPT WAS ON BREAK SLEEPING. FLT WAS FANS FLT.
    Narrative: I WAS A RELIEF PLT AND HAD JUST ASSUMED MY SHIFT AFTER BEING ON BREAK. DISPATCH SENT US A MESSAGE VIA ACARS RECOMMENDING A REROUTE TO THE W OF CLRED CUS VIA 10 DEGS S 160 DEGS W TO AVOID CUMULO NIMBUS ACTIVITY ASSOCIATED WITH TROPICAL CYCLONE 'OSEA.' THE CAPT (JUST BEFORE LEAVING THE COCKPIT FOR HIS BREAK) SAID, THAT 'SHE (THE DISPATCHER) WAS OVERLY HELPFUL AND THAT MOST OF THE WX WAS BEHIND US AND WE SHOULD HAVE SMOOTH SAILING.' HE COULD NOT HAVE BEEN MORE WRONG. GOING BY WHAT THE CAPT SAID, I HAD THE OTHER (NON-FLYING) FO TELL DISPATCH THAT OUR CURRENT FLT PLAN LOOKED OK. WITHIN 15 MINS OF THAT, AN INTENSE, 100 NM WIDE RETURN STARTED TO GROW ON OUR RADAR 200 MI AHEAD. I TRIED TO CONVINCE THE OTHER FO THAT WE SHOULD ASK FOR 10 DEGS S 160 DEGS W REROUTE AS RECOMMENDED. HE THOUGHT IT WAS TOO FAR OFF COURSE AND SUGGESTED THAT IT LOOKED BETTER TO THE E. I AGREED TO THAT AND WE ASKED TO DEVIATE 40 NM L OF CUS. AS SOON AS WE STARTED L (S) THE LINE WE WERE TRYING TO GO AROUND APPEARED TO GROW ON OUR CRT. I HAD HIM ASK FOR 70 NM AND SOON FOR 99 NM (THE MOST THE SOFTWARE WILL ALLOW, THIS WAS A 'FANS' RTE). DURING THIS DEV IT GOT INCREASINGLY TURBULENT TO ALMOST CONTINUOUS MODERATE. THE OTHER FO WAS INVOLVED IN FANS COMS AS I WAS FLYING THE ACFT AND WE FORGOT TO GIVE A POS RPT AT 11 DEGS S AND 155 DEGS W. WE ALSO DIDN'T DO A PLOT WHILE DEVIATING. AS WE CLRED THE END OF THE CUMULO NIMBUS LINE AND ASKED FOR DIRECT TO 14 DEGS S 153 DEGS W, OR TO CONTINUE OUR L OFFSET FOR A WHILE LONGER, TAHITI RESPONDED 'UNABLE.' WE INQUIRED AS TO WHICH WAS UNABLE, THE DIRECT OR THE OFFSET, THE NEXT CTR, AUCKLAND ASKED FOR OUR POS WE WERE ABEAM 13 DEGS 27 MINS S 157 DEGS W (OUR FIR CHK POINT). SO WE GAVE AN ESTIMATE TO THAT POINT, AND AUCKLAND CLRED US TO GO DIRECT TO THE SUCCEEDING POINT, S 27 DEGS W 170 DEGS. DURING THIS DEV THE WORKLOAD SEEMED HIGH TO ME, BECAUSE THE OTHER FO (NON-FLYING) WAS HAVING SOME DIFFICULTY WITH THE FMC AND RESPONDING TO ATC. ON THE FMC WE MADE THE MISTAKE OF NOT 'EXECUTING' THE 99L OFFSET (JUST USING THE DOTTED LINE) AND THAT AFFECTED HIS ABILITY TO USE THE 'POS RPT' SCREEN TO RESPOND TO ATC QUICKLY. I THOUGHT ABOUT AWAKENING THE CAPT WHEN I REALIZED WE HAD MISSED A POS RPT AND A PLOT, BUT IT LOOKED LIKE SINCE WE WERE GIVING THE PRESENT POS TO AKL, THIS SIT WAS SOLVED. IN HINDSIGHT, I SHOULD HAVE ADVOCATED MORE STRONGLY TO FOLLOW DISPATCH'S RECOMMENDATION FOR A REROUTE REQUEST. I ALSO SHOULD HAVE BEEN MADE AWARE OF HOW THE OTHER FO WAS KEEPING UP ON THE POS RPT AND PLOTTING CHART.

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  34. Accession Number: 388404
    Synopsis: FLC OF A320 COMPLAINS OF ROUTING ON SHORT FLT WHICH REQUIRES REPROGRAMMING THE FMS. THEY FLEW MANUALLY INSTEAD OF REPROGRAMMING.
    Narrative: FIRST OF ALL, YOU CAN PROBABLY JUST FILE THIS WHOLE RPT UNDER 'COMPLAINING/BITCHING PLT.' I RECEIVED A CLRNC FROM SAN-LAX THIS MONTH WHICH I FOUND TO BE VERY CONFUSING AND NOT USER (PLT) FRIENDLY AT ALL. I WAS CAPT ON FLT FROM SAN-LAX ON DEC/XX/97, FLYING AN AIRBUS A320. DUE TO WX AND WINDS, WE WERE DEPARTING TO THE E AT SAN AND LNDG TO THE E AT LAX. (THESE 2 ITEMS ALONE SHOULD PROBABLY BE AN EMER PROC!) OUR FIRST CLRNC FOR TKOF TO THE W WAS CANCELED AND WE BACK-TAXIED FOR TKOF ON RWY 9 AT SAN. OUR NEW CLRNC WAS '...CLRED VIA THE LNSAY DEP TO INTERCEPT THE SLI 148 DEG RADIAL, TO THE VTU 114 DEG RADIAL, TO V8, TO TANDY...SQUAWK, ALTIMETER....' FOR ONLY A 26 MIN FLT (107 MI) I THOUGHT THIS WAS AN EXCESSIVE AMOUNT OF RADIAL INTERCEPTS AND TURNS. THE A320 (AS MOST ROMEO EQUIPPED ACFT) CAN EASILY LOAD WAYPOINTS INTO THE FMS, BUT NOT USER FRIENDLY WITH A CLRNC SUCH AS THIS. I ASKED TO 'GO DIRECT FROM HARBR (ON SLI 148 DEG RADIAL) TO TANDY' BUT WAS DENIED. THIS 'DIRECT' ROUTING WOULD HAVE PARALLELED THE ORIGINAL CLRNC BY APPROX 3 MI. RATHER THAN TAKING AN EXCESSIVE AMOUNT OF TIME TRYING TO LOAD THIS FLT PLAN, WE FLEW IT MANUALLY WITHOUT USE OF THE FMS. THE WX WAS MARGINAL (ALWAYS IS WHEN YOU HAVE OTHER PROBS!) AND OUR MEANS OF FLYING WAS SAFE, BUT VERY BUSY (CONFUSING?) FOR SUCH A VERY SHORT FLT. I ALSO HEARD NO OTHER ACFT ON THE FREQ UNTIL HANDED OFF TO LAX APCH CTL, SO TFC WAS NOT A FACTOR. THIS FLT OF 26 MINS REQUIRED US TO USE THE FOLLOWING CHARTS/MAPS TO PROPERLY IDENT ALL THE POINTS AND ROUTING: LNSAY 1, LO-ALT CHART 5/6, OCEAN 1, AND LAX APCH ILS RWY 7R. HERE COMES MY MAIN BEEF! (FINALLY) -- MOST OF THE WAYPOINTS SHOWN ON ANY OF THESE PAGES ARE NOT SHOWN ON ANY OTHERS! I HAVE NO IDEA WHY THERE HAS TO BE SO MANY DIFFERENT WAYPOINTS FOR ALL THE SIDS, VICTOR RTS, AND ARRS IN THIS AREA. FAA DEFINITELY NEEDS TO BE ABLE TO COORDINATE A BETTER ROUTING, ESPECIALLY WHEN WORKING ROMEO EQUIPPED ACFT. THERE WAS A LOT OF MEDIA PRESS GIVEN TO THE WORKLOAD OF THE ACR FLT AT CALI AND THE CONFUSION OF THE AIRCREW USING A GLASS COCKPIT. I DON'T THINK PLTS ARE GETTING LAZIER (ALREADY ARE) OR NOT AS COMPETENT AS THE 'I REMEMBER WHEN' DAYS, BUT FLYING 'GLASS' DOES REQUIRE A DIFFERENT MINDSET. IT WOULD BE MUCH SAFER IF FAA REALIZED THIS FACT AND TOOK MEASURES TO UPDATE THE SYS OR ELIMINATE SOME OF THE REASONS FOR CONFUSION AND EXCESSIVE WORKLOAD THAT IS NOT REQUIRED.

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  36. Accession Number: 396150
    Synopsis: AN ACR B767 FLC WAS VECTORED OFF OF THE STAR RTE THEN GIVEN AN ASSIGNED SPD THEN GIVEN A CLRNC DIRECT TO A NAVAID THAT WAS ON THE STAR RTE. THE FLC INTERCEPTED THE STAR RTE AND FOLLOWED THE CTLR'S INSTRUCTIONS TO DSND, BUT WERE UNSURE IF THEY SHOULD MEET ALL OF THE STAR RESTRS. THE CTLR EXPECTED THEM TO DO SO, APPARENTLY.
    Narrative: WE WERE CLRED DIRECT TO BORGER, BOWIE THREE ARR DFW EXPECT TO LAND N RWY 36L. PRIOR TO PASSING BGD, TURNED TO S HEADING DUE TFC AND DSNDED TO FL330, THEN CONTINUED TO FL240. ATC TOLD US TO MAINTAIN 320 KTS FOR TFC SPACING. THEN TOLD TO SLOW 280 KTS FOR SPACING AND CLRED DIRECT TO BOWIE. (FO AND I CANNOT REMEMBER IF ATC TOLD US TO RESUME STAR.) WE CONTINUED THE STAR MAINTAINING LAST ASSIGNED IAS OF 280 KTS. WE WERE GIVEN CROSS KAGLE AT 12000 FT, WITH NO MENTION OF SPD. THEN GIVEN AN ASSIGNED HEADING OF 130 DEGS AFTER PASSING SILER, DIFFERENT FROM THE EXPECTED 170 DEGS ON STAR, A CLUE OF POSSIBLE RWY CHANGE FROM THAT ON ATIS. AGAIN NO MENTION OF SPD. AS WE PASSED SILER, WE WERE GIVEN IMMEDIATE R TURN AND TOLD WE DID NOT FOLLOW STAR SPDS. (WE THOUGHT WE WERE ON POSITIVE CTL FROM ATC AND ON AN ASSIGNED IAS OF 280 KTS.) WE WERE GIVEN 210 KTS. ATC ASKED IF WE SAW B727 AT 11 O'CLOCK POS. I ANSWERED YES, AND ATC TOLD US TO FOLLOW HIM. WE ACKNOWLEDGED. I DO NOT KNOW IF OUR SPACING WITH B727 WAS TOO CLOSE FOR ATC RULES, (DID NOT LOOK CLOSE TO US). WE DID NOT GET TCASII, TOOK NO EVASIVE ACTION, ATC DID NOT SAY WE HAVE REDUCED SEPARATION. SOLUTION: DO NOT ASSUME: IF ATC PULLS YOU OFF OF STAR, MUST RE-ESTABLISH THAT YOU ARE BACK ON STAR. POSITIVELY, WE AS PLTS MUST NOT ASSUME ANYTHING AND QUESTION ATC IF TO RESUME STAR ALT AND SPDS. CONTRIBUTING FACTORS: DFW HAS SO MUCH TFC THAT CTLRS TALK MUCH TOO FAST. CAPT DISTRACTED ON COMPANY RADIO, ATIS GAVE EXPECT RWY. ATC CHANGED RWYS 3 TIMES RWYS 36L, 35C, THEN LANDED ON RWY 35R. MAX WORKLOAD ON GLASS/FMS COCKPITS. FROM NOW ON, WILL QUESTION ATC IF ONCE OFF STAR, TO RESUME STAR ALT AND SPDS.

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  38. Accession Number: 404370
    Synopsis: FLC OF A B757 OVERSHOT ASSIGNED DEP ALT SOON AFTER TKOF ON A SID DEP DUE TO CLRNC CHANGE AND THE AUTOTHROTTLES STILL ON TKOF SETTING AND NOT REDUCED TO CLB PWR. THEREFORE, IT TOOK MORE TIME TO LEVEL OFF ACFT.
    Narrative: WHILE CLEANING UP, ACCELERATING, AND CLBING, FULL PWR. DEP GAVE A TURN FROM 060 DEGS TO 280 DEGS. WENT FROM TAILWIND TO 40 KT HEADWIND INTO THE SUN. THROTTLES WERE IDLE (AUTOTHROTTLE DISCONNECT) TO LEVEL OFF AT 2500 FT. ACFT CONTINUED UP TO 2800 FT BEFORE DSNDING MOMENTUM TOOK OVER. SOLUTION: TOO LOW LEVELOFF ALT, CHANGING FREQS, ACFT CONFIGN, TURNING, TURB, WINDSHEAR, ETC. DUE TO EARLY CAPTURE OF ALT DUE TO HIGH RATE OF CLB, AUTOTHROTTLES WENT TO THROTTLE HOLD (TKOF PWR) BECAUSE CLB THRUST WASN'T SELECTED YET. NECESSITATING AUTOTHROTTLE DISCONNECT, PULLED TO IDLE. SUPPLEMENTAL INFO FROM ACN 404600: THIS WAS CAUSED BY MOMENTARY WORKLOAD SATURATION DUE TO ATC CLRNC CHANGE AND A PECULIAR FUNCTION OF THE AFDS DURING A LOW ALT LEVELOFF AT A HIGH RATE OF CLB. SOLUTION -- ALLOW SID TO BE FLOWN AS DEPICTED, OR AT LEAST, EDUCATE ATC CTLRS TO GIVE TIME FOR THE ACFT TO BE PROPERLY CONFIGURED BEFORE MAKING CHANGES TO THE CLRNC.

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  40. Accession Number: 408901
    Synopsis: AN A320 DSNDS ON THE LAX CIVET ARR AND DSNDS BELOW AN ASSIGNED ALT BECAUSE OF MGMNT OF THE AUTOFLT SYS.
    Narrative: THE FLT WAS PART OF AN OE TRIP FOR A PLT NEW TO THE A320. WE HAD BEEN CLRED FOR THE PARADISE 2 ARR TO LAX AND WERE SWITCHED TO THE CIVET 1 ABOUT 50 MI FROM THE ARPT. DUE TO A LATE DSCNT CLRNC CAUSED BY TFC CONGESTION AND WX DEVS WE WERE ABOVE THE FMGC COMPUTED VERT PATH WHEN CLRED TO DSND VIA THE ARR. IT WAS NECESSARY TO USE OPEN DSCNT MODE AND SPD BRAKES TO RETURN TO THE VERT PATH. JUST PRIOR TO LEVELING AT 10000 FT WE WERE GIVEN AN AIRSPD RESTR TO 210 KTS AND THE OE STUDENT PULLED THE FCU ALT KNOB (I WAS UNAWARE THAT HE HAD) AND PUT THE AIRPLANE BACK TO OPEN DSCNT MODE. BECAUSE THE LOWEST ALT ON THE CIVET 1 IS 8000 FT, IT IMMEDIATELY PUT THE AIRPLANE IN IDLE/OPEN DSCNT CAUSING US TO BEGIN DSNDING PRIOR TO THE RESTR ON THE ARR. TO RETURN IMMEDIATELY TO THE ASSIGNED ALT IT WAS NECESSARY TO DISCONNECT THE AUTOPLT AND AUTOTHROTTLES SINCE THE FMGC WOULD HAVE COMMANDED A MUCH MORE GRADUAL RETURN TO ALT. THE ARRS TO LAX FROM THE E ARE BUSY ONES AND THERE ARE MANY SHORT NOTICE ALTERATIONS TO RTES, RWYS AND SPDS THAT CAN BE DIFFICULT TO KEEP UP WITH IN AN AUTOMATED AIRPLANE. THE CIVET 1 AND THE ILS TO RWY 25L HAVE TOO MANY ALT RESTRS THAT MUST BE MANUALLY COMPLIED WITH. IT WOULD BE MUCH BETTER IF THE ILS GS COULD BE USED OUT TO ARNES INTXN RATHER THAN THE COMBINATION OF THE CIVET 1 AND THE ILS RWY 25L.

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  42. Accession Number: 411189
    Synopsis: A TAXIING ACR MLG PASSES OVER THE HOLD SHORT LINE FOR RWY 8 AT ABQ. THE ACFT WAS AT TXWY A3 AND THE FO CLAIMS THAT THERE IS AN ARPT PROB WITH THE ILLUSION OF THE TXWYS AT C, A1, A2 AND A3 BEING SIMPLY EXITS FROM THE RAMP AND NOT ACCESS TXWYS TO THE RWY. SAYS THERE SHOULD BE WARNING SIGNS REGARDING A POSSIBLE RWY INCURSION IN THIS AREA.
    Narrative: DURING TAXI FOR TKOF, CAPT TAXIED PAST HOLD SHORT LINE APPROX 10-12 FT. CALLED TWR AND TOLD THEM WE WERE READY FOR TKOF. NO TFC CONFLICTS. TWR CLRED US ONTO RWY AND SUBSEQUENT TKOF WAS UNEVENTFUL. PROB AROSE DUE TO 2 MAN COCKPIT (ADVANCED FMS) AND SHORT TAXI, ALONG WITH THE FACT THAT TXWY A IS PART ON SAME CONCRETE AS TERMINAL RAMP. FO WAS BUSY READYING COCKPIT FOR DEP AND READING CHKLIST. ARPT LAYOUT IS VERY CONFUSING. THERE IS NO BOUNDARY BTWN THE TERMINAL RAMP AND TXWY A. INCURSION OCCURRED AT TXWY A3. THE PERCEPTION IS THAT TXWYS C, A3, A2, AND A1 ARE EXITS FROM RAMP, NOT ONTO RWY 8/26 AT ABQ. THERE NEEDS TO BE A PHYSICAL BARRIER OR BETTER SIGNS DEMARKING TXWY A AND THE TERMINAL RAMP. AT THE VERY LEAST, SOME WARNING SIGNS AT TXWYS A1, A2, A3, AND C WARNING OF DANGER OF POSSIBLE RWY INCURSION DUE TO POOR DESIGN OF ARPT. PROCS SHOULD BE STUDIED FOR HIGHER WORKLOAD COCKPITS IN 2 MAN CREWS. MAYBE A PROC THAT REQUIRES THE ACFT TO BE STOPPED WHILE TAXIING WHEN DATA IS ENTERED IN FMS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: FO ADMITS TO BEING BUSY WITH THE CHKLIST DURING THE TAXI OUT. HE STATED THAT THE HOLD LINES WERE VISIBLE BUT FELT THAT THE ILLUSION THAT ONE EXPERIENCES ABOUT THE RAMP VERSUS THE RWY WAS CAUSAL. THE ACCESS TXWYS ARE VERY SHORT AND THE PERCEPTION IS THAT THOSE TXWYS ARE EXITS TO A PARALLEL TXWY WHICH, IN REALITY, IS RWY 8. HE DOESN'T KNOW IF THE CAPT FILED A COMPANY RPT OR NOT.

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  44. Accession Number: 411580
    Synopsis: CAPT OF A SAAB 340A (SF34-L) OVERSHOT ASSIGNED ALT AFTER TKOF DUE TO DISTR OF HAND FLYING THE ACFT AND LACK OF SLEEP. DEP CTLR INTERVENED AND ALERTED HIM AT 300 FT ABOVE ASSIGNED. THE FO WAS BUSY WITH AFTER TKOF CHKLIST.
    Narrative: DURING THE CLB AFTER TKOF I CLBED BEYOND OUR INITIAL ALT ASSIGNMENT BY APPROX 300 FT. OUR ASSIGNED ALT WAS 2500 FT MSL. I WAS HAND FLYING WITHOUT THE FLT DIRECTOR OR AUTOPLT. WHEN THE ROCKFORD DEP CTLR VERIFIED OUR INDICATED ALT AND POS AFTER THE INITIAL CALL FROM THE FO THE ALT ERROR WAS NOTICED. I IMMEDIATELY STARTED A DSCNT BACK TO THE ASSIGNED ALT. DURING THE DSCNT WE WERE THEN CLRED TO 7000 FT MSL. I THEN BEGAN TO CLB AGAIN TO THE NEW ALT ASSIGNMENT. THERE WERE NO OTHER ACFT INVOLVED. CONTRIBUTING FACTORS AND HUMAN PERFORMANCE CONSIDERATIONS: I WAS PRIMARILY FOCUSED ON THE AIRSPD, ATTITUDE AND CLB RATE. I WAS NOT AS VIGILANT OF THE ACFT'S ALT AS AT MOST OF THE ARPTS THE INITIAL CLB ALT IS ABOVE 4000 FT MSL. I WAS TOO CONDITIONED TO THIS. THE FO WAS BUSY WITH THE AFTER TKOF CHKLIST AND DID NOT NOTICE THE ALT EXCURSION. IT DOESN'T TAKE US MUCH TIME TO GET TO 2500 FT. THE FLT WAS THE SECOND HALF OF A CONTINUOUS DUTY OVERNIGHT. WE ONLY HAD 4 HRS OF REST SINCE ARRIVING IN ROCKFORD AFTER XA00. THE FO AND FLT ATTENDANT BOTH SLEPT ON THE VAN RIDE FROM THE HOTEL TO THE ARPT. I WAS FORMULATING OPTIONS FOR AVOIDING THE LINE OF WX WE WOULD HAVE TO CROSS TO GET TO OUR DEST. I HAD AVERAGED ONLY 5 HRS OF SLEEP THIS MONTH DURING THE TRIPS. I WAS UNABLE TO GET CAUGHT UP ON REST DURING THE DAYTIME BTWN TRIPS. CONCLUSION: I NEED TO USE THE SYS THAT ARE AVAILABLE TO ME LIKE THE FLT DIRECTOR AND AUTOPLT. ESPECIALLY WHEN I AM SLEEP DEPRIVED AND FATIGUED. I TYPICALLY DID NOT USE THEM UNTIL CRUISE FLT. THIS IS DUE TO THE FACT THAT IT WOULD GET PRETTY BORING WATCHING THE AIRPLANE DO THE FLYING. I CAN DO WITHOUT THE ADRENALINE SHOT OF AN ALT EXCURSION HOWEVER. WHENEVER I AM AT AN ARPT WITH A LOWER THAN NORMAL INITIAL CLB RESTR I MUST BRIEF THIS WITH THE FO SO THAT WE CAN BOTH BE VIGILANT OF IT. PERHAPS THE CHKLIST CAN BE DELAYED UNTIL A BIT LATER WITHOUT COMPROMISING SAFETY.

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  46. Accession Number: 412670
    Synopsis: A DSNDING B737-300 FAILS TO CROSS THE DALAS INTXN AT THE REQUIRED ALT OF 12000 FT. CAPT THOUGHT IT WAS A 13000 FT ALT ASSIGNMENT, THE FO PF THOUGHT 12000 FT.
    Narrative: WE WERE FLYING THE ROME 2 ARR PROC TO ATL. RECEIVED A CLRNC TO CROSS ERLIN AT 13000 FT. LATER WERE GIVEN A CLRNC DIRECT TO DALAS (11 MI BEYOND ERLIN). THIS CLRNC DID NOT ALLOW US TO CROSS ERLIN SO WE WERE GIVEN 12 MI W OF DALAS AT 13000 FT. SO WE COULD MAKE THIS RESTR, I WAS TRYING TO PROGRAM A FIX FOR THE RESTR WHEN I NOTICED THE FO HAD DIALED 12000 FT INSTEAD OF 13000 FT. WE WENT TO 12500 FT THEN BACK TO 13000 FT. MY FO REMEMBERS THE RESTR TO BE 12000 FT. I REMEMBER 13000 FT. THE CTLRS WERE VERY BUSY, WE WERE VERY BUSY AS WELL. COULDN'T GET A WORD IN TO CONFIRM THE ALT. WE WERE THEN XFERRED TO APCH AND RECEIVED A NEW CLRNC TO 10000 FT. WE DIDN'T SAY ANYTHING, THE CTLRS DIDN'T SAY ANYTHING. THEY WERE PROBABLY TOO BUSY TO NOTICE. THIS IS A CLASSIC EXAMPLE OF AUTOMATION- DISTR DEVELOPING INTO A POSSIBLE BUSTED ALT. I DO INDEED BELIEVE AUTOMATED COCKPIT, AT LEAST NAV, IS GREAT. BECAUSE WE HAD AN AUTO-COCKPIT, THE CTLR KNEW THIS AND GAVE US DIRECT, WHICH SHORTENED OUR RTE A LITTLE BUT PUT OUR ABILITY TO MAKE THE RESTR IN DOUBT. WE WERE BUILDING THE NEW FIX TO CHK IF WE WERE GOING TO MAKE THE RESTR WHEN CONFUSION DEVELOPED AND THINGS WENT 'SOUTH' FROM THERE. SUPPLEMENTAL INFO FROM ACN 411964: OUR FMC WAS PROGRAMMED TO LATERALLY NAV THE ROME 2 ARR PROFILE AS WELL AS THE VERT PROFILE TO COMPLY WITH THE ERLIN RESTR OF 13000 FT AT 250 KTS AS DICTATED ON THE PLATE FOR A PLANNED LNDG TO THE E. AT 40 NM FROM THE RMG VOR, WE WERE CLRED DIRECT TO DALAS INTXN AND INSTRUCTED TO CROSS 10 NM W OF DALAS AT 12000 FT. AT THE TIME OF THIS CLRNC, WE WERE LEVEL AT FL240. AS MY CAPT BEGAN TO REPROGRAM OUR FMC, I ENTERED 12000 FT IN THE ALT WINDOW OF OUR MCP AND BEFORE I STARTED MY DSCNT, I REQUESTED THAT THE PNF/CAPT VISUALLY CONFIRM MY ALT ENTRY. TO MY RECOLLECTION, HE CONFIRMED THE 12000 FT ENTRY. WHILE MY CAPT WAS BUSY WITH THE FMC, I BEGAN A RAPID VERT SPD CTLED DSCNT TO CROSS 10 MI W OF DALAS AT 12000 FT. ATC FURTHER COMPLICATED OUR SIT BY ISSUING A SPD REDUCTION TO 250 KTS. AFTER ASSESSING OUR SIT, I DETERMINED WE COULD MEET THIS RESTR, PROVIDED THE SPD BRAKE WAS DEPLOYED AND AN IMMEDIATE 3000-4000 FPM DSCNT RATE WAS INITIATED. PASSING THROUGH 13000 FT AND 14 NM W OF DALAS INTXN, MY CAPT SUDDENLY TOOK CTL OF THE ACFT AND LEVELED OFF AT 13000 FT, AS OPPOSED TO OUR ASSIGNED ALT OF 12000 FT. DUE TO THE FACT THAT IT WAS VMC, AND MY SITUATIONAL AWARENESS CONFIRMED THAT NO OTHER ACFT WERE IN OUR VICINITY, I ELECTED NOT TO OVERRIDE MY CAPT'S ACTIONS. CONTRIBUTING FACTORS: BOTH PLTS RELATIVELY INEXPERIENCED IN ATL AIRSPACE, HVY NAV AND COM WORKLOAD, CAPT'S CONFUSION BTWN PAST AND CURRENT CLRNC, PNF DISTR BY LAST MIN AUTOMATION WORKLOAD, END RESULT BEING AN ASSIGNED ALT DISAGREEMENT BTWN THE PF AND PNF.

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  48. Accession Number: 414290
    Synopsis: PLT OF BE20 LINED UP WITH THE WRONG RWY DURING AN ILS APCH DUE TO USING AN OUTDATED CHART. HE, THE TWR CTLR AND THE CREW OF A B737 WAITING TKOF, NOTICED HIS MISTAKE IN TIME FOR A SIDESTEP TO THE ASSIGNED PARALLEL RWY.
    Narrative: DSNDING INTO ONT ON THE ZIGGY 3 ARR, WE WERE GIVEN RADAR VECTORS FOR THE ILS RWY 26L ONT. WE INTERCEPTED THE ILS RWY 26L LOC AND PROCEEDED INBOUND ON THE ILS. I WAS VERY BUSY RUNNING CHKLISTS AND DOUBLECHKING THAT I HAD THE EFIS SET UP CORRECTLY, AS THIS WAS MY THIRD FLT AND FIRST ILS IN THIS NEW AIRPLANE. ON SHORT FINAL, TWR CLRED A FLT FOR TKOF ON RWY 26R. I LOOKED UP TO VERIFY I WAS ON THE CORRECT RWY AND TO SEE THE B737. WHEN I DID THIS, I REALIZED I WAS LINED UP FOR RWY 26R INSTEAD OF RWY 26L. AT THIS POINT, ON SHORT FINAL, I STILL HAD PLENTY OF ROOM TO SIDESTEP TO RWY 26L AND LAND. THE TWR CTLR AND B737 CREW REALIZED I WAS LINED UP FOR RWY 26R AT ABOUT THE SAME TIME I DID AND THERE WAS NO CONFLICT BTWN AIRPLANES. AFTER LNDG, I VERIFIED THAT I HAD INDEED HAD THE ILS RWY 26L APCH PLATE OUT AND THE LOC FREQ OF 109.7 IN THE NAV RADIO. AFTER DISCUSSING THIS WITH THE TWR, I LEARNED THAT THE FREQ FOR THE ILS RWY 26L HAD BEEN CHANGED TO 111.35 SOMETIME IN THE PRECEDING 6 MONTHS AND THAT I HAD USED AN OUT-OF-DATE APCH PLATE. THIS PROB CAME ABOUT BECAUSE I WAS IN A NEW AIRPLANE EQUIPPED WITH EFIS AND FMS THAT I WAS JUST BECOMING FAMILIAR WITH. I SPENT TOO MUCH TIME CHKING TO MAKE SURE I HAD THE EFIS SET UP CORRECTLY AND NEGLECTED TO IDENT THE LOC. AFTER LNDG, I FOUND THAT WHEN I HAD REVISED MY APCH PLATES I HAD NOT REMOVED THE OLD ONE AND JUST INSERTED THE NEW ONES BEHIND THEM. BECAUSE THE 3 OF US INVOLVED (MYSELF, THE TWR CTLR AND THE B737 CREW) WERE AWARE OF WHAT WAS HAPPENING AROUND US, SAFETY WAS NEVER COMPROMISED DURING THIS EVENT, BUT I HAVE LEARNED THAT LITTLE THINGS, SUCH AS CURRENT APCH PLATES OR IDENT A FREQ, CAN KEEP THINGS FROM GETTING TO THAT POINT IN A HIGH WORKLOAD ENVIRONMENT.

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  50. Accession Number: 415429
    Synopsis: LGT ACR ACFT IS CLRED FROM ONE STAR TO ANOTHER, THEN WITHIN 10 MI OF LNDG, IS AGAIN RECLRED FOR ANOTHER APCH, LNDG ON A PARALLEL RWY. PLT CONCERNED WITH INCREASED COCKPIT WORKLOAD CAUSED BY RWY CHANGES AND THE ACCOMPANYING AUTOMATION INPUTS.
    Narrative: ENRTE FROM EWR TO LAX, ZLA CHANGED ENRTE CLRNC 'AFTER PGS VORTAC, J128 TO LAX.' SET UP IN CDU, THE CLRNC CHANGED BACK TO 'DIRECT CIVET, CIVET ARR.' PRIOR TO CIVET, RECLRED FOR 'MITTS ARR, CLRED DIRECT SNRKL INTXN, SNRKL AT OR ABOVE 12000 FT.' HAD TO TYPE IN SNRKL TO CDU, AS IT DID NOT COME UP WHEN SELECTING MITTS ARR, ALSO HAD TO PUT IN ALT RESTR AT SNRKL. NOT SURE IF THEY CLRED US TO DSND VIA THE MITTS ARR (15 MI FROM MITTS) AND FINALLY GOT CONFIRMATION TO DSND VIA ARR 3 MI FROM MITTS AND WE HAD TO USE SPD BRAKES AND VERT SPD MODE TO GET DOWN IN TIME. CLRED INITIALLY FOR ILS RWY 24R, SET IN CDU AND ILS FREQS. FO HAD BEEN ADVISED TO HAVE APCH PLATE READY FOR RWY 24L. REBRIEFED ILS FOR RWY 24R VERSUS RWY 25L, THE INITIAL RWY FOR THE ORIGINAL CIVET ARR. ABOUT 6 MI FROM LAX, APCH ASKED IF WE HAD THE FIELD IN SIGHT. WE REPLIED 'AFFIRMATIVE' AND HE RECLRED US FOR THE 'VISUAL APCH TO RWY 24L (VERSUS RWY 24R) AND TO CONTACT LAX TWR.' WHEN FO SET IN TWR FREQ, HE SET 135.9 VERSUS 133.9 AND DID NOT CALL THEM ASAP. AS THE CAPT HAD ASKED FOR THE ILS FREQ TO BE SET IN FOR RWY 24L, FO COULD NOT CHANGE THE ILS FREQ IN THE HEAD, AS 'APCH' MODE HAD ALREADY BEEN SELECTED FOR RWY 24R. FO RESET RWY 24L IN CDU AND WAS THEN ABLE TO DIAL IN ILS FREQ FOR RWY 24L. CAPT WAS HAND FLYING AFTER THE CLRNC WAS CHANGED FROM RWY 24R TO RWY 24L, USING RAW DATA ON ADI AND HSI. AFTER FO RETUNED ILS TO RWY 24L, NEITHER PLT HAD FLT DIRECTOR DATA. CAPT CONTINUED TO HAND FLY THE APCH UNDER VISUAL CONDITIONS, AND AT 700-800 FT AGL, WE SPOTTED AN ACFT ON RWY 24L. THE FO ASKED THE CAPT IF WE WERE CLRED TO LAND AND THE CAPT REPLIED AFFIRMATIVE (HEARING CLRED FOR THE APCH, AND SWITCH TO TWR, AND WITH ALL OF THE OTHER DISTRS, FOCUSED ON THE APCH AND THOUGHT WE HAD BEEN CLRED TO LAND). ON THE LNDG ROLL, WE COMMENTED ON HOW QUIET IT WAS, AND AFTER CLRING THE RWY AND SWITCHING TO GND CTL, THE FO NOTICED 135.9 HAD BEEN SET VERSUS 133.9. GND GAVE US TAXI INSTRUCTIONS TO THE GATE WITH NO COMMENTS. WE CALLED THE TWR SUPVR TO CLR UP THE SIT. HIS REACTION TO THE STATEMENT WAS THAT IT WAS A COORD PROB BTWN TRACON AND THE TWR, ADDING THAT HE DID NOT CONTACT US UNTIL 2 NM FROM THE RWY, AS IF HE WAS UNAWARE THAT WE WERE NOT ON FREQ. WE DID NOT ADMIT TO HIM THAT WE HAD NOT HEARD THE LNDG CLRNC, AND HE MADE NO FURTHER COMMENTS ON THE MATTER. WE BRIEFLY DISCUSSED WHY LAX ALWAYS SEEMS TO GIVE MULTIPLE APCH AND RWY CHANGES, AND HE ANSWERED THAT THEY LAND ACFT ON THE INSIDE RWYS -- OCCASIONALLY, TO HELP OUT WITH SPACING OF ACFT FOR APCH CTL. 2 EXPERIENCED CREW MEMBERS LANDED WITHOUT A CLRNC FROM THE TWR DUE TO ALL OF THE WORKLOAD AND DISTRS LISTED ABOVE. AUTOMATION IS GOOD ONLY TO A POINT. WHEN IT BECOMES CUMBERSOME, THEN RAW DATA AND BASIC AVIATION SKILLS TAKE PREFERENCE. RECOMMENDATIONS: KEEP APCH AND RWY CHANGES TO A MINIMUM. ENSURE AT 1000 FT AGL (500 FT AGL MINIMUM) THAT LNDG CLRNC HAS BEEN RECEIVED. IT MIGHT NOT BE A BAD IDEA TO PUT IT ON THE LNDG CHKLIST, AS BASIC AS THAT MAY SEEM (IN THIS CASE IT MAY HAVE HELPED). AVOID CDU CHANGES AT LOW ALTS THAT COULD PROVE TO BE DISTRACTING.

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  52. Accession Number: 416490
    Synopsis: A B737-300 FLC COMPLAINS OF THE DESIGN FEATURES OF THE OPALE 4 ARR STAR CHART. THEY SUFFERED A HDG TRACK POS DEV ON APCH TO YYC.
    Narrative: INBOUND TO CYYC FROM SFO OUR CLRNC SINCE TKOF HAD BEEN 'OPALE DIRECT YYC.' WE LISTENED TO THE ATIS AT ABOUT 10 MINS PRIOR TO START OF DSCNT AND THEY WERE USING RWY 34. ABOUT 10 NM PRIOR TO OPALE, EDMONTON CTR CLRED US FOR THE 'OPALE 4 ARR.' WE TRIED TO LOAD THE ARR FROM THE FMC DATABASE, BUT FOUND IT WAS NOT AVAILABLE. WE BOTH REACHED FOR OUR CHARTS AND THE FO BEGAN READING THE ARR FIXES AND I TYPED THEM INTO THE FMC WITHOUT ERROR. HE TOLD ME THE PLATE SAID NOT TO EXPECT LOWER THAN 10000 FT UNTIL E OF MOGOT. I DID NOT BACK UP HIS REVIEW OF THE CHART MYSELF, ALTHOUGH I GLANCED AT THE ARR FIXES. I WAS THEN DISTR FOR SEVERAL MINS BY TURB, ICING AND PREPARING FOR THE APCH. WHEN WE GOT TO MOGOT, HE DID NOT TURN THE ACFT AND I LOOKED AT THE AERO PAGE AND SAW 100 DEG HDG OFF OF MOGOT AND TOLD HIM TO TURN TO 100 DEGS. A FEW SECONDS LATER, CALGARY APCH CALLED US TO TELL US WE WERE FLYING THE ARR FOR RWY 28! LIKE MANY INCIDENTS, THERE WAS A STRING OF EVENTS THAT LED TO THE NAV DEV. THE MAIN ISSUE IS THE CHARTING CHART MAKER USES FOR THE ARRS TO CYYC. I BELIEVE CHART MAKER SHOULD PRINT IN LARGE BOLD TYPE 'RWY 10' ABOVE 'ALBRO,' 'RWY 34' ABOVE 'HANSI,' AND 'RWY 16/RWY 28' ABOVE 'MOGOT' TO BETTER ALERT THE PLT TO THE DIFFERENT RWY TRANSITIONS! ALSO, THE PRACTICE OF PLACING NOTES VERTLY (IE, RWY 34/16 NOTES) ON A PAGE WHEN EVERYTHING ELSE IS L TO R HORIZLY ORIENTED DOES NOT CATCH YOUR EYE WHEN YOU ARE HURRIED! AS PLTS, WE DON'T READ THE TEXT DESCRIPTIONS WHEN WE ARE HURRIED! ALSO CONTRIBUTING, WE HAD FAR MINIMUM REST AFTER A TOUGH DAY PREVIOUSLY AND WE WERE NOT PHYSIOLOGICALLY AT A PEAK. THE FO WAS NEW TO OUR AIRLINE. AND ATC SHOULD HAVE GIVEN US THE CLRNC MORE THAN 1 MIN BEFORE THEY EXPECTED US TO FLY IT! ALSO CONTRIBUTING: THE FACT THAT THE ARR WAS NOT IN THE FMC DATABASE WHICH GREATLY INCREASED OUR WORKLOAD.
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