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 3 incidents related to this issue.

Issue: behavior of automation may not be apparent (Issue #83)
Description: The behavior of automation devices -- what they are doing now and what they will do in the future based upon pilot input or other factors -- may not be apparent to pilots, possibly resulting in reduced pilot awareness of automation behavior and goals.

  1.  
  2. Accession Number: 123923
    Synopsis: HEADING AND TRACK DEVIATION OVER THE NAT SYSTEM. ASSOCIATED SPEED DEVIATION. LESS THAN STANDARD SEPARATION OCCURRED WITH ANOTHER ACFT.
    Narrative: FLT WAS PROCEEDING EBND TO EUROPE FROM THE USA ON NORTH ATLANTIC TRACK "V" THE MOST NORTHERN TRACK PUBLISHED THIS DAY UPON REACHING A FIX LOCATED AT 58 DEG 000 N 02 DEG 000 W. THE ACFT (AUTOPLT COUPLED TO INS) EXECUTED A 10 DEG BANK LEFT TURN, WHICH WAS UNDETECTED INITIALLY BY EITHER PLT. THE ACFT DEVIATED 6.6 MI FROM THE TRACK PRIOR TO THE CREW DISCOVERING THE ERROR. CORRECTIVE ACTION WAS INITIATED BY THE CAPT TO RETURN THE ACFT TO CENTERLINE, BY IMMEDIATELY TURNING RIGHT TO ESTABLISH AN INTERCEPT HDG. THE TURN, BECAUSE OF AN 85 KT CROSSWIND FROM THE S IN FURTHER EXCURSION FROM CENTERLINE TO A MAX DISTANCE OF 16 MI, ONCE ESTABLISHED ON A PROPER INTERCEPT ANOTHER ACFT WAS OBSERVED IN LEVEL FLT AT THE 4 O'CLOCK POSITION AT THE SAME ALT. THE CREW DEDUCED THAT THIS ACFT WAS ASSIGNED THE SLOT IMMEDIATELY TO THEIR REAR AND THAT ALONG TRACK SEPARATION WAS REDUCED. THE CAPT ELECTED TO FLY A 10 MI OFFSET FROM THE ASSIGNED TRACK IN ORDER TO INSURE SAFE SEPARATION. ONCE PROCEEDING ON A PARALLEL TRACK SPEED ALSO WAS INCREASED IN AN EFFORT TO REGAIN ALONG TRACK SEPARATION. THE OBSERVED ACFT ALSO INCREASED SPEED AND MAINTAIN A 3 O'CLOCK POSITION. AT THIS POINT FLT REDUCED SPEED IN ORDER TO KEEP THE OTHER ACFT IN SIGHT. SIMULTANEOUSLY WITH THE ABOVE DESCRIBED MANEUVERING, FLT MADE NUMEROUS ATTEMPTS TO CONTACT THE CONTROLLING AGENCY TO REQUEST A LOWER ALT. ONCE CONTACT WITH SHANWICK OCEANIC AND SCOTTISH CTL WAS MADE, THEY WERE ADVISED OF THE INCURRED DELAY AND CLRNC TO A LOWER ALT WAS RECEIVED. THE FLT CONTINUED NORMALLY UNDER RADAR CONTACT TO FINAL DESTINATION. THE CAUSE OF THIS NAVIGATION EXCURSION MAY BE ATTRIBUTED TO A COMPOUNDING OF MINOR ERRORS. THE NEXT FIX AFTER 58 N 20 W WAS 57 N 10 W. THE FIRST ERROR OCCURRED IN SPITE OF ACCOMPLISHING THE STANDARD COORDINATE CHECK, WHEN THE WEST COORDINATE AS 100 DEG 000 WEST VICE 010 DEG 000 WEST. THIS ERROR RESULTED IN THE ACFT ATTEMPTING TO REVERSE COURSE AT STATION PASSAGE. THE SECOND MINOR ERROR INVOLVED A F/A ENTERING THE COCKPIT SOLICITING BREAKFAST ORDERS AT THE CRITICAL TIME NEAR STATION PASSAGE. THE COURSE AND DISTANCE CHECK WOULD HAVE REVEALED A PROBLEM WITHOUT THE DISTRACTION.

  3.  
  4. Accession Number: 385322
    Synopsis: AN A320 ACFT ON VECTORS FOR ILS APCH. FLC HAS DIFFICULTY GETTING ACFT OUT OF 'MANAGED' MODE AND ACFT TURNS OPPOSITE DIRECTION FROM HDG DESIRED. FLC WAS ABLE TO CORRECT THE PROB. LOW TIME CAPT MAY HAVE CONTRIBUTED TO LACK OF UNDERSTANDING MANAGED VERSUS MANUAL MODES.
    Narrative: WE WERE BEING VECTORED WITH THE AUTOPLT ENGAGED FOR AN ILS APCH TO RWY 21R AT DTW. ON BASE LEG, TURNING R TO FINAL, WE WERE GIVEN HDG 120 DEGS AND WHILE TURNING TO THAT HDG, GIVEN HDG 160 DEGS TO INTERCEPT THE LOC. I SELECTED HDG 160 DEGS AND PUSHED THE 'LOC' PUSH BUTTON TO ARM THE FMGC FOR THE INTERCEPT. THE FLT DIRECTOR THEN IMMEDIATELY COMMANDED A L TURN AND THE AUTOPLT FOLLOWED IT. AFTER A SLIGHT 'REACTION TIME' DELAY WHILE I WENT THROUGH THE GLASS COCKPIT TROUBLESHOOTING SEQUENCE (WHAT'S IT DONE? WHY'S IT DOING THAT? HOW DO I MAKE IT STOP?), I PULLED THE HDG KNOB AND TURNED IT TO THE R, WHICH SHOULD HAVE CAUSED THE GUIDANCE SYS TO EXIT WHATEVER MODE IT HAD GONE INTO AND TURN TO THE SELECTED HDG. THIS DID NOT WORK, HOWEVER, AND THE ACFT CONTINUED IN THE L TURN. I THEN DISENGAGED THE AUTOPLT, DISREGARDED THE FLT DIRECTOR AND TURNED THE ACFT BACK TO THE R. THIS ALL TOOK PLACE IN JUST A FEW SECONDS, BUT IT WAS ENOUGH TO CAUSE AN OVERSHOOT ON WHAT WAS ALREADY A TIGHT INTERCEPT. ALSO, BECAUSE OF THE COMPRESSED SEQUENCE OF EVENTS, I DID NOT OBSERVE THE ANNUNCIATIONS ON THE FMA PANEL AND DON'T KNOW WHAT MODE THE FLT GUIDANCE SYS WENT INTO THAT CAUSED THE L TURN. WHEN WE GOT THINGS SORTED OUT WITH THE CTLR AND WERE ON AN INTERCEPT HDG FROM THE OTHER SIDE OF THE LOC, THE FLT DIRECTOR CONTINUED TO COMMAND A L TURN, IN SPITE OF REPEATED ATTEMPTS BY THE FO TO SELECT A HDG TO THE R. THE SELECTED HDG SHOWED IN THE WINDOW BUT THE 'MANAGED NAV' DOT WOULD NOT GO OUT. WE ARMED FOR THE APCH BY PUSHING THE 'APPR' PUSH BUTTON AND THE FLT DIRECTOR THEN SUCCESSFULLY CAPTURED THE LOC AND SEEMED TO RETURN TO NORMAL OP. AFTER LNDG WE WROTE UP THE FLT GUIDANCE SYS, BUT AS I WRITE THIS, I AM AT A LOSS TO EXPLAIN WHAT HAPPENED. THE L TURN SHOULD NOT HAVE BEEN COMMANDED, AND THE MANAGED NAV MODE SHOULD HAVE BEEN DISENGAGED BY SELECTING A HDG TO THE R. THE HDG SELECTED WAS ONLY ABOUT 40 DEGS OR 50 DEGS R OF THE PRESENT HDG, SO IT WAS NOT A CASE OF SELECTING A HDG CHANGE OF OVER 180 DEGS AND HAVING THE ACFT TURN THE SHORTEST DIRECTION. WITH ONLY 100 HRS IN THE ACFT, I DO NOT CONSIDER MYSELF AN AUTH, SO I AM GOING TO BRING THIS SIT UP TO THE 'EXPERTS.'

  5.  
  6. Accession Number: 402411
    Synopsis: CAPT OF DC10 FAILED TO FOLLOW THE FLT PLAN RTE DUE TO INADVERTENTLY MISPROGRAMMED FMC NAV DATABASE. AFTER THE FLC NOTED THEIR ERROR THEY WERE GIVEN A VECTOR TO BACK ON COURSE.
    Narrative: ENRTE WBOUND ON J80 WE WERE FILED J80 GLD DIRECT TO JNC THEN VIA J80 OAL . ALTHOUGH THE RTE WAS ENTERED INTO THE GPS PROPERLY ON THE RTE PAGE OF THE GPS, I CLOSED UP A DISCONTINUITY ON THE LEGS PAGE AND THE DIRECT ROUTING WAS INADVERTENTLY REMOVED AND WE FLEW THE INITIAL PORTION OF J80. DURING OUR NAV CHK WITH THE VORS BTWN GLD AND JNC WE DISCOVERED THE PROB. I THEN ASKED FOR DIRECT JNC AND ATC APPROVED MY REQUEST. THIS CAN BE AN INSIDIOUS TRAP BECAUSE WE CHKED THE LEG PAGE WITH THE FLT PLAN AS WELL AS THE PROGRESS PAGE DISTANCE AND THE 2 POINTS WERE BOTH CHKED ON THE GND AS OK.
Flight Deck Automation Issues Website  
© 1997-2013 Research Integrations, Inc.