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Incidents related to Issue 18 incidents related to this issue.

Issue: crew coordination problems may occur (Issue #84)
Description: The use of automation may adversely affect crew coordination, possibly leading to unsafe conditions.

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  2. Accession Number: 54493
    Synopsis: FAILED TO HOLD SHORT OF ACTIVE RWY PER TAXI INSTRUCTIONS.
    Narrative: ON DEP BOSTON THE RWY WAS INITIALLY 27. IT WAS CHANGED TO 9 AND THEN TO 15. DURING TAXI CLRNC AFTER PUSHBACK THE RWY WAS CHANGED TO 4R AND THE ENSUING CLRNC CALLED FOR HOLDING SHORT OF 4L. IN AN EFFORT TO REPROGRAM THE COMPUTER AND CALL FOR THE TKOF DATA FOR 4R I DID NOT PROVIDE THE CAPT WITH BACK UP SUPPORT REGARDING RWY 4L HOLD SHORT. WE TAXIED CLEAR OF 4L AND BELOW THE GLIDE PATH OF A LNDG LIGHT TWIN ACFT. I WAS ALERTED TO THE ERROR VIA A RADIO CALL FROM GROUND. THE LNDG ACFT DID NOT POSE A SAFETY PROBLEM AND NEITHER ACFT NEEDED TO TAKE EVASIVE ACTION. WE DID EXPEDITE THE TAXI AFTER THE CALL FROM GROUND. MY ROLE AS A COPLT WOULD HAVE PROVIDED THE PROPER BACK UP TO THE CAPT HAD I NOT BEEN PREOCCUPIED WITH THE COMPUTER AND GAINING THE NEW TKOF DATA. PRIORITIZING MY DUTIES IN A TWO MAN COCKPIT IS AN ONGOING NECESSITY.

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  4. Accession Number: 125745
    Synopsis: TRACK DEVIATION.
    Narrative: PRIOR TO APCH OR DOWNWIND, DISCUSSION TOOK PLACE AS TO HOW THIS APCH MIGHT BE FLOWN ON COMPUTER DATA AND HOW TO BUILD THIS APCH. I CONCLUDED IT COULD NOT BE DONE. I CHOSE NOT TO OCCUPY MY HAND FLYING WITH DISTRACTIONS AS WE HAD BEGUN DSNT OUT OF 10,000'. WHILE MANEUVERING TO A DOWNWIND, IFR, THE CAPT WAS BUSY AT THE FMC AND WE HAD LOTS OF TIME, IN ADDITION TO AN OCCASIONAL RADIO CALL AND MONITORING MY FLYING. WE WERE GIVEN A TURN TO A RIGHT BASE AND WERE RECEIVING VECTORS TO THE FINAL APCH COURSE WITH A CLRNC TO INTERCEPT THE LOCALIZER AND FLY THE LDA APCH. THE CAPT COMMENTED THAT HE "HAD THE APCH ON THE COMPUTER". I SWITCHED TO "MAP" FOR A LOOK (RAW DATA IN VIEW IN FD DISPLAY, BOTH LOC AND GS). IT LOOKED GOOD, BUT I HAD NO TIME TO CHECK IT. I FAILED TO SEE THE ANGLE TO THE RWY WAS WRONG, HE HAD A STRAIGHT IN FINAL. I FAILED TO NOTE THE LOC DISPLAY MOVING SLOWLY FROM LEFT TO RIGHT AS WE FLEW THROUGH THE LOC. (APCH MODE OF FD WAS ARMED AND CAPTURED WITH AN APPROPRIATE LATERAL COMMAND.) WHEN I NOTICED THE FULL DEFLECTION RIGHT AND THE APCH COURSE ON THE MAP WAY TO THE LEFT, I COMMENTED THAT "SOMETHING IS WRONG". THE CTLR QUERIED US IF WE HAD THE LOC OK AND REITERATED THE FREQ WHICH WE BOTH IMMEDIATELY CHECKED. CTLR STATED HE "HAD US LEFT OF COURSE AND TO TURN RIGHT TO A NEW INTERCEPT HDG OF 170?" THE CAPT HAD INDICATED TO ATC "WE HAD A DISCREPANCY, AND TO KEEP US ADVISED OF OUR PROGRESS". I COMMENTED THAT THE RAW DATA AGREED WITH THE CTLR BUT THE HDG WOULD NEVER TAKE US ON AN INTERCEPT WITH THE MAP COURSE. THE CTLR WAS VERY HELPFUL AND SAID WE "WERE IN GOOD SHAPE AND APCHING THE LOC". THE CAPT WAS LOST IN THE PROBLEM SO I REACHED DOWN AND PUT MY DISPLAY BACK ON FULL-UP COMPASS ROSE ILS MODE. I CONCURRED WITH THE CTLR AND CONCLUDED THE CAPT'S APCH HAD LED ME ASTRAY AND THAT I WAS STAYING ON RAW DATA. THIS LEG I WAS 100% RAW DATA AND WENT TO THE "COMPUTER MAP" FOR A LOOK AT THE ABSOLUTE WRONG TIME. THE CAPT WAS CONFUSED AT THIS POINT AND I WAS NOW BACK ON THE APCH WITH RAW DATA, I COULD NOT GET HIM TO ABANDON THE COMPUTER. I CALLED OUT GLIDE SLOPE MOVING, INTERCEPT, AND GLIDE SLOPE HIGH AS I STATED I WOULD NOT DSND BELOW 3000' UNLESS HE WAS SURE OF WHERE WE WERE ALSO. HE CONCURRED. THE CAPT RECOGNIZING MY CALLS QUICKLY GOT ON RAW DATA AND COMMANDED ME TO DSND WHICH I DID AT ABOUT 1200 FPM. WE PROCEEDED AND I STATED THAT IF WE DID NOT BREAK OUT VISUALLY OR CAPTURE THE GLIDE SLOPE AT A COMFORTABLE ALT FOR MANEUVERING, I WOULD EXECUTE A GO AROUND. CAPT AGREED. WE BROKE OUT ABOUT 900' ON THE LOC AS WE CAUGHT THE GLIDE SLOPE AND WERE IN A COMFORTABLE POSITION FOR THE TURN TO FINAL WITH A SAFE UNEVENTFUL AND SMOOTH LNDG.

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  6. Accession Number: 358110
    Synopsis: BOTH PLTS INPUT INFO TO THE AUTOPLT AND ONE CANCELLED THE OTHER RESULTING IN CLBING ABOVE ASSIGNED ALT.
    Narrative: IN CRUISE FLT AT 16000 FT WE WERE GIVEN A REVISED ALTIMETER SETTING WHICH CAUSED A SIGNIFICANT CHANGE IN INDICATED ALT. WE WERE ALSO GIVEN A DSCNT CLRNC IN THE FORM OF A XING RESTR. THE PF COMMANDED HIS FLT DIRECTOR TO 'CLB' IN AN EFFORT TO CORRECT THE INDICATED ALT CHANGE CAUSED BY THE NEW ALTIMETER SETTING. THE AUTOPLT FOLLOWED THIS COMMAND, HOWEVER, THE PNF HAD SET THE ALT GIVEN IN THE DSCNT CLRNC IN THE ALT PRE-SELECTOR. THIS ACTION REMOVED THE ALT REF FOR THE AUTOPLT 'CLB' FUNCTION. CONCURRENT TO THESE EVENTS, BOTH PLTS BECAME DISTR DISCUSSING A PLAN TO DEVIATE AROUND PRECIP BEING DEPICTED BY RADAR. DUE TO THE IMPROPER AUTOPLT INPUT THE AIRPLANE DEVIATED VERTLY (CLBED ABOVE) FROM THE ASSIGNED ALT. UPON NOTICING THE DEV WE DISCONNECTED THE AUTOPLT AND MANUALLY FLEW THE AIRPLANE BACK TO THE CORRECT ALT. AFTER THE SIT WAS CORRECT WE QUERIED THE CTLR, RPTING OUR DEV AND ASKING IF THIS HAD CAUSED ANY PROB. HE REPLIED IT DID NOT. BETTER COCKPIT COMS AND DIVISION OF TASKS, WITH REGARD TO THE RADAR DISTR, WOULD HAVE PREVENTED THIS EVENT.

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  8. 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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  10. Accession Number: 386340
    Synopsis: AN ACR DC9 FLC DSND BELOW THE GS INTERCEPT ALT WHILE STILL OUTSIDE OF THE OM. THE AUTOPLT SYS HAD DEFAULTED TO THE VERT SPD MODE WHEN IT WAS ACTIVATED AND ARMED FOR INTERCEPT WHILE BELOW THE GS AND THE CAPT DID NOT RECOGNIZE THIS.
    Narrative: WE HAD JUST RECEIVED APCH CLRNC AND HAD JOINED THE LOC OUTSIDE THE OM. WE HAD NOT YET INTERCEPTED THE GS AND WERE ABOVE THE MINIMUM GS INTERCEPT ALT. THE CAPT (PF) BEGAN A DSCNT TO MINIMUM GS INTERCEPT ALT (AT LEAST I THOUGHT). AS WE APCHED THE ALT, THE CAPT DID NOT APPEAR TO BE LEVELING OFF. I ANNOUNCED THAT I WAS NOT RECEIVING GS INDICATIONS ON MY HSI AND ADI. HE IMMEDIATELY COMMANDED A GAR. WE WERE REVECTORED FOR THE APCH AND LANDED WITHOUT FURTHER INCIDENT. I BELIEVE PART OF THE CONFUSION ON THE CAPT'S PART WAS THAT HE WAS HAND FLYING WHEN WE INITIATED OUR DSCNT TOWARD GS INTERCEPT ALT. DURING THIS, HE ASKED ME TO ENGAGE THE AUTOPLT AND ARM THE ILS CAPTURE. BECAUSE HE WAS BENEATH THE GS AT THE TIME, THE AUTOPLT WOULD REMAIN IN VERT SPD MODE UNTIL GS CAPTURE. APPARENTLY HE MUST HAVE THOUGHT THE AUTOPLT CAPTURED. BETTER COMS AND CHOICE OF WORDS ON MY PART MAY HAVE PREVENTED THE GAR.

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  12. Accession Number: 398066
    Synopsis: FLC OF A CANADAIR REGIONAL JET CL65 FAILED TO TURN AND INTERCEPT THE AIRWAY AS CLRED, CAUSING A POTENTIAL CONFLICT WITH ANOTHER ACR JET AND ATC INTERVENTION TO VECTOR THEM BACK ON COURSE.
    Narrative: TAKING OFF IAD ARPT. APPROX TIME XA31. WE GOT VECTORS TO JOIN J149. THE CTLRS CHANGED OUR VECTORS 3 TIMES TO JOIN J149 -- HDG 300 DEGS TO JOIN, THEN 310 DEGS TO JOIN, AND FINALLY 330 DEGS TO JOIN. WE WERE CLBING THROUGH 6000-7000 FT WHEN WE GOT OUR LAST VECTOR. I TURNED THE HDG BUG TO 330 DEGS (WE WERE ON AUTOPLT) WITH INTENTIONS OF PRESSING THE NAV BUTTON TO CAPTURE THE RADIAL. WHEN WE ROLLED OUT ON THE 330 DEG HDG, MY ATTN GOT DIVERTED TO SOMETHING ELSE, SO I NEVER PRESSED THE NAV BUTTON. WITHIN APPROX 30-40 SECONDS, WE HAD GONE THROUGH THE RADIAL, J149, THAT WE WERE SUPPOSED TO CAPTURE. NEITHER THE CAPT NOR I SAW THIS. THEN THE DEP CTLR FOR IAD CAME ON AND ALERTED US THAT WE HAD GONE THROUGH THE AIRWAY AND TOLD US TO TURN TO A 260 DEG HDG TO REJOIN AND TO INCREASE OUR RATE OF CLB. JUST THEN, THE CTLR TOLD AN ACR Y JET TO INCREASE THEIR DSCNT. NO MENTION WAS MADE THAT THE 2 AIRPLANES WERE GETTING CLOSE. THE CTLR JUST SAID TO TAKE THESE ACTIONS. WE DID GET AN AMBER TA ALERT AND OUR TCASII DID SHOW THE ACR Y JET WITHIN 4-5-6 MI OF US. WE HAD TO GO OFF AUTOPLT TO TURN ENOUGH (INCREASE BANK), SO WE COULD BETTER AVOID ANYTHING MORE SERIOUS FROM HAPPENING. NOTHING MORE WAS SAID AND WE WERE SWITCHED TO THE NEXT CTLR. THE BIG THING THAT CONTRIBUTED TO THIS SIT WAS THE CREW'S ATTN BEING DIVERTED AWAY FROM THE FLYING AT HAND AND NOT CHKING EACH OTHER'S ACTIONS -- ESPECIALLY IN A BUSY CLASS B AREA. BTWN THE CTLR ALERTING US, TCASII, AND OUR QUICK CORRECTIVE ACTIONS HELPED MAKE THIS EVENT NOTHING MAJOR. MAYBE RELYING ON THE AUTOPLT TOO MUCH ALSO MIGHT HAVE BEEN A CONTRIBUTING FACTOR.

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  14. Accession Number: 400360
    Synopsis: FO OF AN AIRBUS A320, EA32, EXCEEDED SPD LIMITATION BELOW 10000 FT DURING DSCNT ARR DUE TO MISPROGRAMMING THE FMS MODE CTLING THE DECELERATION OF THE AIRSPD. THE MISTAKE WAS NOTICED JUST PRIOR TO LEVELING OFF AT THE ASSIGNED 9000 FT.
    Narrative: WHILE SERVING AS PF/SIC I FAILED TO DECELERATE TO 250 KIAS BELOW 10000 FT MSL. IT IS CUSTOMARY TO UTILIZE THE A320'S MANAGED VERT NAV FUNCTION WHILE IN THE APCH ENVIRONMENT. IN THIS CIRCUMSTANCE I LEFT VERT NAV AND SELECTED THE IAS/OPEN DSCNT MODE IN ORDER TO COMPLY WITH AN ATC REQUEST TO 'KEEP YOUR SPD UP.' NOT ONLY IS VERT GUIDANCE SACRIFICED IN SELECTED SPD/OPEN DSCNT MODE, SO IS AUTOMATIC DECELERATION TO 250 KIAS. WE WERE INFORMED BY ATC TO EXPECT A RWY OTHER THAN THE ONE WE HAD PLANNED AND PROGRAMMED IN THE FMS. AS THE ACFT APCHED 10000 FT WITH CLRNC TO 9000 FT THE PNF/PIC MADE APPROPRIATE FMS CHANGES FOR THE NEW RWY AND I TOOK OUT THE CHARTED IAP IN ANTICIPATION OF A 'REBRIEF.' DESPITE MAKING THE STANDARD 'ONE TO GO' AND 'TWO TO GO' ALT AWARENESS CALLOUTS, I WAS DISTRACTED AND DID NOT NOTICE THE ACFT WAS STILL OPERATING AT 335 KIAS AS WE PASSED 10000 FT. I RECOGNIZED THE EXCESSIVE SPD PRIOR TO REACHING 9000 FT AND INITIATED A DECELERATION TO 250 KIAS. APPROX 1 1/2 MINS ELAPSED WHILE THE ACFT WAS BELOW 10000 FT AND ABOVE 250 KIAS. THIS IS A TEXTBOOK EXAMPLE HOW IMPORTANT IT IS TO CLOSELY MONITOR ADVANCED TECHNOLOGY ACFT, AND NOT TO BECOME TOO RELIANT ON THE FUNCTIONS THAT NORMALLY EASE PLT WORKLOAD. IT IS ALSO A LESSON IN DIVISION OF COCKPIT DUTIES -- BASIC CRM DICTATES 1 PLT REMAIN FOCUSED AT ALL TIMES ON FLYING THE AIRPLANE. WHILE I BELIEVE I WAS ALWAYS COGNIZANT OF ACFT POS AND ALT, I LOST TRACK OF AN IMPORTANT SITUATIONAL AWARENESS ELEMENT.

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  16. Accession Number: 401142
    Synopsis: AN ACR B757 FLC EXPERIENCES A MAP SHIFT THAT WAS APPARENTLY CAUSED WHEN THE IRS SYS WERE NOT ALLOWED TO UPDATE THEMSELVES DUE TO FLC MISOP OF THE NAV RADIOS.
    Narrative: ON THE PDZ2 ARR IN THE VICINITY OF THE ARNES INTXN WE EXPERIENCED A MAP SHIFT ON THE FO'S FMC. CAPT WAS IN EXPANDED ILS AND THE FO WAS IN AUTO MODE. FO SWITCHED TO MANUAL MODE AND DEV TO ASSIGNED CLRNC OCCURRED. CALLED DISPATCH DESK IMMEDIATELY AFTER ARR AND TOLD DISPATCHER OF THE ABOVE. CAPT WAS TUNED TO LAX RWY 25L LOC. NO REF ON THE FO'S RECEIVER AT TIME OF SHIFT.

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  18. Accession Number: 403612
    Synopsis: FLC OF A CL65 WITH HIGH MINIMUMS CAPT EXECUTED A MISSED APCH. CAPT CONCENTRATED ON COM WITH NO ASSIST TO FO FLYING. THEY HAD DIFFICULTY SETTING UP FOR ENTRY TO THE HOLD, CONFIGURING THE ACFT, AND THEY OVERSPEED THE ACFT FOR FLAP SETTING. ON SECOND TRY A RWY CHANGE CREATED MORE COCKPIT CONFUSION BUT APCH AND LNDG ACCOMPLISHED.
    Narrative: THE CAPT HAD JUST MOVED FROM THE L SEAT OF THE EMB120 TO THE L SEAT OF THE CL65 AND HAD ACCUMULATED APPROX 12 HRS SINCE FINISHING IOE. HE WAS A HIGH MINIMUMS CAPT AND LATER TOLD ME THAT IN 9 YRS OF FLYING THE LINE HE HAD ONLY ONCE BEFORE HAD TO PERFORM AN ACTUAL MISSED APCH PROC. THE WX AT OUR DEST WAS RIGHT AT THE CAPT'S HIGH MINIMUMS. SO WE MADE SURE TO DISCUSS NOT ONLY THE PUBLISHED MISSED APCH PROC, BUT ALSO THE STANDARD CALLS TO BE USED THROUGHOUT THE APCH AND SUBSEQUENT MISSED APCH, IF REQUIRED. AT THE BOTTOM OF THE APCH, THE CAPT CALLED 'MINIMUMS' AND I SAW ONLY CLOUDS/FOG. SO I CALLED 'GO MISSED, SET THRUST, FLAPS 8 DEGS.' HE COMPLIED AND THEN IMMEDIATELY TRIED TO CALL TWR TO NOTIFY THEM OF OUR MISSED APCH. TWR DID NOT ANSWER THE FIRST CALL, NOR THE SUBSEQUENT 3. UNFORTUNATELY, WHILE THE CAPT WAS MAKING REPEATED CALLS TO THE TWR, THE SUBSEQUENT STANDARD CALLS OF 'POSITIVE RATE' AND '1000 FT' WERE OMITTED. NONETHELESS, I CALLED FOR 'GEAR UP' WHEN I SAW THE POSITIVE RATE. AND ABOUT THAT TIME, I NEEDED TO SET UP THE MISSED APCH NAVAIDS IN ORDER TO INTERCEPT THE PROPER OUTBOUND CLB RADIAL. AS I REACHED DOWN TO SET THE RADIO, THE OVERSPD CLACKER SOUNDED BRIEFLY BECAUSE I HAD REACHED THE FLAPS 8 DEG LIMIT SPD OF 230 KTS. IN A WAY, THIS MAY HAVE BEEN A BLESSING BECAUSE WHEN THE CAPT OMITTED THE '1000 FT' CALL, I DID NOT ORDER THE FLAPS TO 0 DEGS. AS A RESULT, THE CLACKER AT 230 KTS PROMPTED MY ATTN BACK FROM THE NAV RADIOS TO THE AIRSPD WHICH I REDUCED TO 200 KTS TO COMPLY WITH THE 200 KT SPD LIMIT NEAR THE CLASS C PRIMARY ARPT. AT THIS POINT, I TOLD THE CAPT (WHO WAS STILL ON THE RADIO TRYING TO CALL THE TWR) 'I NEED SOME HELP HERE.' SIMULTANEOUSLY, I LEVELED OFF AND SLOWED WHILE BANKING AGGRESSIVELY TO INTERCEPT THE OUTBOUND RADIAL TOWARD THE HOLD. FINALLY, TWR RETURNED OUR CALL AND AFTER SOME DISCUSSION ISSUED US A HOLD ON THE SAME LOC (RWY 18L) AS THE APCH WE HAD JUST ATTEMPTED TO SO WE COULD WAIT FOR THE WX TO IMPROVE. WE PROGRAMMED THE HOLD AT THE RWY 18L FAF (FRAZE) INTO THE FMS AND ENGAGED THE AUTOPLT, BUT BECAUSE OF OUR NAV SETUP, THE FMS/AUTOPLT FLEW DUTIFULLY INBOUND ON THE LOC TO FRAZE BUT DID NOT ENTER THE HOLD AT FRAZE. I WAS MONITORING CLOSELY, SO I SIMPLY USED HDG MODE TO STEER US INTO THE HOLD. HOWEVER, DURING THIS DISTR, WE DID NOT CALL ENTERING THE HOLD. FURTHERMORE, NO EFC TIME HAD BEEN ISSUED. SHORTLY THEREAFTER, ATC ISSUED VECTORS TAKING US OUT OF THE HOLD AND WBOUND TO 'GET US OUT OF THE WAY.' THEN ATC ASKED IF WE WANTED TO TRY 'THE APCH' AGAIN. THE CAPT SAID YES AND ATC BEGAN TO ISSUE VECTORS AROUND TO A NE HDG. AT THIS POINT, I ASKED THE CAPT TO PROCEED THROUGH THE CHKLISTS FROM CLB ALL THE WAY THROUGH THE APCH CHKLIST JUST TO MAKE SURE WE HADN'T MISSED ANYTHING. WHEN WE REACHED THE 'APCH BRIEFING' ITEM, I REBRIEFED THE ILS TO RWY 18L INCLUDING THE STANDARD CALLOUTS AND THE PUBLISHED MISSED APCH PROC. I THEN ASKED THE CAPT IF HE WOULD TRY TO ASK TWR FOR ALTERNATE MISSED APCH INSTRUCTIONS JUST IN CASE THE CONDITIONS HAD NOT IMPROVED. HE DENIED MY REQUEST. THEN ATC ISSUED A VECTOR TO JOIN THE ILS RWY 18R LOC. THE CAPT DID NOT CATCH THIS CHANGE OF ASSIGNED APCHS, BUT I WAS PRETTY SURE ATC SAID 'RIGHT.' SO I QUICKLY ASKED THE CAPT TO VERIFY THE APCH ASSIGNED. WE TRIED BUT THE FREQ WAS SATURATED AND I HONESTLY DID NOT KNOW WHAT TO DO. THIS WAS THE FIRST TIME ATC SAID ANYTHING ABOUT THE ILS TO THE R SIDE. AS WE PASSED THROUGH THE ILS RWY 18R LOC, ATC VERY GRUFFLY TOLD US TO FLY 'HDG TO REINTERCEPT ILS RWY 18R LOC.' ONCE ESTABLISHED, WE COMPLETED THE APCH TO MINIMUMS (HIGH MINIMUMS). LIFE WOULD HAVE BEEN A BIT EASIER IF THE CAPT, AFTER AN INITIAL TRY OR 2, HAD CHOSEN TO CONCENTRATE MORE ON AVIATE AND NAV RATHER THAN FIXATING ON COMMUNICATE. AND I WISH ATC HAD GIVEN US A HEADS UP ON THE CHANGE IN OUR APCH ASSIGNMENT. IN RETROSPECT, GIVEN OUR POS ON THE W SIDE OF THE ARPT, I PROBABLY SHOULD HAVE SUSPECTED A CHANGE TO RWY 18R.

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  20. Accession Number: 406350
    Synopsis: ACR FO APPARENTLY NOT ABLE TO GET PIC'S FOCUS TO THE ACTIVITY AT HAND. PIC UNABLE TO MEET ALT XING RESTRS, BEING PROMPTED BY THE FO TO COMPLETE COCKPIT RESPONSIBILITIES. FO BELIEVES WHAT HAPPENED IS FURTHER JUSTIFICATION FOR CRM REGS.
    Narrative: DSNDING INTO TORONTO, ONTARIO, ENRTE FROM CHARLOTTE, NC, WE WERE CLRED LATE FOR THE PROFILE DSCNT RWY 6 INTO TORONTO. DUE TO THE LATE CLRNC WE WERE STILL PRETTY HIGH FL240 OR HIGHER. WE ACCEPTED THE CLRNC AND STARTED COMING DOWN. WHEN CALCULATING OUR RATE OF DSCNT WE NEEDED TO MEET THE XING RESTR, I STARTED TO REALIZE THAT WE PROBABLY WOULD NOT MAKE THIS. I ASKED THE CAPT IF HE WANTED TO LET TORONTO KNOW THAT WE PROBABLY WOULD NOT MAKE THE RESTR (BTWN 10000-11000 FT AND 250 KTS). THE CAPT RESPONDED BY PLACING THE ACFT IN A 5500 FPM DSCNT WITH PWR AT IDLE AND FLT SPOILERS AT FULL EXTENSION. I ASKED THE CAPT AGAIN WITH 8 MI TO GO IF HE WANTED RELIEF FROM THE XING RESTR AND HE SAID 'NO.' WE CROSSED LINNG INTXN AT 12000 FT. THEN WE WERE VECTORED FOR THE ILS RWY 6R APCH INTO TORONTO. THE CAPT DID NOT PLACE THE LOC INTO HIS NAV TUNER. I CALLED 'LOC ALIVE' AND 'WE'RE THROUGH THE LOC' AND REALIZED HE DID NOT HAVE THE CORRECT FREQ IN HIS NAV TUNER. I TUNED IN THE CORRECT FREQ. THE CAPT WAS USING THE AUTOPLT TO FLY. THE CAPT WENT FULL SCALE ON THE LOC AGAIN. THE CAPT STARTED COMING BACK AND WAS ABOUT TO GO THROUGH THE LOC AGAIN WHEN I SAID, 'DO YOU HAVE THE RWY IN SIGHT, WE'RE ABOUT TO GO THROUGH THE LOC AGAIN.' HE COMMENTED BY SAYING, 'WELL, I'M TRYING TO USE THIS DAMNED AUTOPLT.' I STATED, 'WELL TURN IT OFF.' WE LANDED WITHOUT INCIDENT. I'M SURE THE TORONTO CTLRS WERE WONDERING WHAT WAS GOING ON. THE BOTTOM LINE IS THIS CAPT WAS WAY BEHIND THE ACFT. THE CAPT WAS NOT WILLING TO LISTEN TO HIS FO OR THE CTLR. I FEEL CRM MUST BECOME MANDATORY FOR COMMUTER AIRLINE CREWS. WE'RE IN GENERAL YOUNGER, MORE INEXPERIENCED CREWS FLYING TODAY'S MOST RECENTLY MADE JETS. WE NEED APPROVED CRM PROGRAMS.

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  22. Accession Number: 410600
    Synopsis: ACR FLC DO NOT CORRECT PIC EFIS NAV GAUGE WITH WRONG HDG AND FO DOES NOT CHALLENGE INPUT INDICATION, CHANGES HIS AND FLT TRACKS INCORRECT NAVAID RADIAL. ERROR IDENTED BY PIC AND ACFT QUICKLY RETURNS TO CORRECT DEP RADIAL. NO ATC INTERVENTION. PIC QUESTIONS FO AND BOTH ACKNOWLEDGE NECESSITY FOR COMPLETING COCKPIT PROC.
    Narrative: FO PF. I AM PNF. MONITORING CLB AS NORMAL, RTE APPEARS NORMAL, THEN I REALIZE WE ARE ESTABLISHED ON WRONG AIRWAY. WE SHOULD BE ON 130 DEG RADIAL BAL, INSTEAD ARE ESTABLISHED ON 101 DEG RADIAL BAL. I QUESTION FO, HE RESPONDS THAT MY (CAPT'S) EFIS AND NAV ARE SET UP ON THE 101 DEG RADIAL, SO HE JUST ASSUMED IT WAS THE CORRECT RADIAL AND AIRWAY. I EXPLAINED THAT THE 101 DEG RADIAL WAS FROM THE LAST LEG OF MRB, V44 101 DEG RADIAL. I HAD NOT YET SET UP AN ADVANCED COURSE. I ASKED IF HE HAD NOT RECEIVED AN AMENDED RTE SINCE WE ARE OFTEN CLRED TO ENO FROM OVER BAL AS A SHORT CUT. HE RESPONDED NO, JUST SET HIS NAV TO MINE. I EXPLAINED, HE BETTER KNOW WHERE HE IS GOING AND CLRED, WHICH HE ACKNOWLEDGED AGREEABLE TO BE CORRECT. ATC MADE NO ISSUE OF THIS ERROR, PROBABLY THINKING A PREVIOUS CTLR ISSUED THIS CLRNC. NO OTHER TFC INVOLVED. ATC SHORTLY THEREAFTER CLRED US THIS SHORT CUT TO ENO. A LESSON TO THE FO, BUT MORE OF A LESSON TO ME, CAN'T DROP THE GUARD AN INSTANT -- CONSTANT VIGILANCE -- NO ASSUMPTIONS. 'A GOOD WAY TO FLY INTO A MOUNTAIN.'

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  24. Accession Number: 411610
    Synopsis: CAPT OF AN ACR ATTEMPTED TO INTERCEPT THE WRONG LOC COURSE. DUE TO NOT REPROGRAMMING THE FMS TO THE NEWLY ASSIGNED LOC THE ACFT TRIED TO INTERCEPT LOC FOR RWY 26R VERSUS RWY 27L. APCH CTLR INTERVENED AND GAVE ANOTHER HEADING TO INTERCEPT THE NEW RWY LOC ASSIGNMENT.
    Narrative: TALKING TO FINAL CTLR, HE TOLD US TO EXPECT RWY 26R, I WAS AT 250 KTS DSNDING FROM 10000 FT TO 6000 FT, TOLD TO TURN TO HDG 220 DEGS AND SLOW TO 210 KTS. WE WERE 2-3 MI FROM FINAL APCH COURSE. WHEN WE WERE TOLD WE WERE GOING TO RWY 27L, DSND TO 2800 FT, THE FO STARTED TO SET UP FMS FOR ME TO VERIFY AND PUT THE LOC ON HIS SIDE. I PUT THE LOC COURSE ON MY SIDE BUT DID NOT BRING THE FREQ OVER ON MY PANEL AND PROGRAM THE FLT DIRECTOR TO CAPTURE THE LOC. THE AUTOPLT TRIED TO CAPTURE RWY 26R LOC. AT THE SPD WE WERE GOING THE ACFT WENT THROUGH THE LOC SO THAT IT WAS R OF COURSE. THE CTLR SAW THIS AND MADE IT PLAIN THAT WE WERE TRYING TO CAPTURE THE WRONG LOC AND TO TURN MORE L FOR RWY 27L. IF WE DID NOT SEE THE ACFT FOR RWY 26R WE WOULD HAVE TO STOP DSCNT. WE SAW THE ACFT. NO CONFLICT. INTERCEPTED LOC RWY 27L, LNDG WITH NO PROBS. THIS WAS THE LAST DAY OF A 5 DAY LINE. 1ST DAY 14 HRS, WITH AN 8 HR OVERNIGHT. 8 HRS NEXT DAY. DAY 3, XA30 SHOW FOR AN 11 HR DAY WITH A LOT OF WX, TURNED INTO A 13 HR DAY. 4TH DAY, 9 HRS WITH A 9 HR 30 MIN OVERNIGHT. THIS WAS 5TH DAY, 2 HRS 20 MIN FLT -- 770 MI. WE WERE GIVEN DIFFERENT RWY, WHEN CLOSE IN, WHEN THE WORKLOAD WAS VERY HIGH AND A SIMPLE MISTAKE OF NOT HITTING MY SIDE HARD ENOUGH OR FORGETTING TO BRING IT OVER TO THE ACTIVE SIDE. WE ARE TRAINED TO 'IDENT' EVERYTHING, BUT DID NOT GET A CHANCE TO DO ALL THREE BEFORE WE WENT THROUGH RWY 26R LOC.

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  26. Accession Number: 412260
    Synopsis: G3 FLC CONDUCTING GPS APCH TO MMU ARPT DID NOT IMMEDIATELY DSND FROM 4000 FT TO 2000 FT AND NEEDED TO BE PROMPTED BY THE CTLR BECAUSE OF OPPOSITE DIRECTION TFC.
    Narrative: ON IFR FLT PLAN FROM ISP TO MMU, ACFT AT 4000 FT PROCEEDING DIRECT TO SAX VOR (APPROX 260 DEG HDG) AT 200 KIAS. FINAL CTLR ISSUED A TURN TO HDG 240 DEGS, DSND TO 2000 FT, CLRED GPS RWY 23 APCH. THE PF TURNED THE ACFT TO 240 DEGS AND BEGAN SETTING UP THE FMS FOR THE GPS APCH. THE PNF DIALED IN 2000 FT IN THE ALT SELECT WINDOW AND ASKED THE PF WHAT HDG THE CTLR HAD ASSIGNED. THE PNF THEN READ BACK THE CLRNC. THE ACFT REMAINED AT 4000 FT BECAUSE THE PF DID NOT HEAR OR ACKNOWLEDGE THE ALT CHANGE. AFTER ABOUT 60 SECONDS, THE CTLR CAME BACK AND REISSUED A DSCNT TO 2000 FT STATING THERE WAS AN ACR AT OUR 12 O'CLOCK POS AND 5 MI. THE PF IMMEDIATELY DSNDED THE ACFT TO THE CORRECT ALT, THE REST OF THE FLT WAS UNEVENTFUL. THIS EVENT OCCURRED BECAUSE: 1) THIS PF DID NOT HEAR THE ALT CHANGE BECAUSE HE WAS PROGRAMMING THE FMS. 2) THE PNF DID NOT CONFIRM WITH THE PF THAT A DSCNT WAS GIVEN. 3) A REQUESTED WX GRAPHIC BECAME AVAILABLE ON THE FMS SCREEN AT THE SAME TIME AS THE CLRNC WAS ISSUED AND DISTR BOTH CREW MEMBERS. PREVENTING THE SAME PROB FROM HAPPENING AGAIN: 1) THE PF DEVOTE MOST OF HIS ATTN ON FLYING THE ACFT AND FOLLOWING ATC INSTRUCTIONS. 2) THE PNF INSURE THE PF FOLLOWS ATC INSTRUCTIONS.

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  28. Accession Number: 412360
    Synopsis: EMB145 CREW DSNDED BELOW CLRED ALT UNTIL THE GPWS ACTIVATED.
    Narrative: DURING VECTOR FOR ILS APCH, VOR AND ILS EQUIP WERE BEING USED AS PRIMARY FLT INSTS AND FMS WAS BEING USED AS BACKUP DISPLAYED ON THE MULTI-FUNCTION DISPLAY. THE CAPT (MYSELF) WAS FLYING THE ACFT. DURING INITIAL CONTACT I THOUGHT THE CTLR SAID TO EXPECT THE ILS TO RWY 28L. THE FO HEARD TO EXPECT RWY 28R CORRECTLY. WE EACH PROGRAMMED OUR FMS EQUIP ACCORDINGLY. WHEN I DISCOVERED WE WERE GOING TO RWY 28R, I ASKED THE FO TO SET MY FMS TO THE PROPER APCH AND I SET MY VHF RADIOS TO THE PROPER FREQ. WE WERE DSNDING TO 3000 FT AT THE TIME. WE WERE GIVEN FURTHER DSCNT TO 2500 FT, BUT THE ALT PRESELECT WAS NOT SET PROPERLY AND WE DSNDED TO 2000 FT, AT WHICH TIME OUR ACFT GPWS TOLD US WE WERE TOO LOW, GEAR NOT DOWN, 1000 FT AGL. I ASKED ATC WHAT ALT I SHOULD BE AT. HE CLBED US TO 3000 FT AND WE FINISHED THE APCH WITHOUT INCIDENT. THIS PROB I THINK WAS DUE TO SPENDING TIME PROGRAMMING THE FMS, WHICH WAS NOT NEEDED TO START WITH, AND NOT FOLLOWING PROPER PROCS FOR SETTING THE ALT PRESELECT AND CONFIRMING BTWN THE 2 PLTS.

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  30. Accession Number: 412570
    Synopsis: B737. FO INCORRECTLY PROGRAMMED FMC.
    Narrative: ATC INDICATED CLRNC LIMIT WAS CLUCK INTXN, DUE TO DEPARTING TFC AT SITKA, WHICH I EXPLAINED TO THE COPLT, TO WHOM I WAS GIVING IOE. HE APPARENTLY THOUGHT HE HEARD ATC SAY 'CLRED DIRECT CLUCK' VERSUS 'CLRED TO CLUCK.' HE PUT DIRECT CLUCK IN THE FMC WITHOUT SAYING ANYTHING AND I MISSED THE CHANGE. A SHORT TIME LATER (5 MINS) ATC INFORMED US WE WERE ON THE WRONG AIRWAY WHICH HAPPENED TO COINCIDE WITH OUR DIRECT ROUTING. NO CONFLICT WITH OTHER TFC, BUT IT TOOK A WHILE TO SORT OUT THE MISTAKE SINCE I WAS QUITE SURE THE CORRECT ROUTING WAS IN THE BOX AND COULDN'T FIGURE OUT WHY A WAYPOINT (LYRIC) HAD DISAPPEARED. THROW IN A SHORT LEG, JNU-SIT, BAD WX, TURB, APCH TO MINIMUMS, NEW COPLT, AND THE POTENTIAL FOR CONFUSION RAPIDLY INCREASES. LESSONS LEARNED: 1) CLRED TO A FIX DOESN'T NECESSARILY MEAN CLRED DIRECT. 2) VERBALIZE AND XCHK EACH OTHER WHEN MAKING CHANGES TO THE BOX (FMC). 3) WHEN IN DOUBT -- ASK.

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  32. 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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  34. Accession Number: 413720
    Synopsis: MD88 CREW DEVIATES FROM CLRED COURSE IN ZOB AIRSPACE.
    Narrative: ON CLBOUT FROM PITTSBURGH, I WAS GIVEN A HDG TO INTERCEPT THE AGC 221 DEG RADIAL TO BURGS INTXN, THEN AS FILED. ANTICIPATING THIS CLRNC, I HAD LOADED IT INTO THE FMS. WHEN CLRED TO INTERCEPT, I WAS HAND FLYING THE ACFT, SO I HAD THE CAPT SELECT THE INTERCEPT IN THE FMS. I WAS WATCHING THE FMS XTRACK TO SEE THE INTERCEPT. AS WE GOT CLOSE TO THE INTERCEPT ON THE MAP DISPLAY, I SWITCHED TO ARC ON MY DISPLAY TO XCHK THE RADIAL FROM AGC (WHICH I HAD TUNED IN). I IMMEDIATELY NOTICED WE WERE PAST THE RADIAL AND CONFIRMED IT ON MY RMI. I TURNED TO PARALLEL COURSE AND ASKED THE CAPT ABOUT THE FMS. WE WERE ON THE 212 DEG RADIAL WHEN INDIANAPOLIS ASKED ABOUT OUR CLRNC. WE TOLD HIM WE WERE CORRECTING BACK TO THE 221 DEG RADIAL. HE SAID JUST TO PROCEED TO HVQ VOR (CHARLESTON) AND THEN AS FILED. AFTER DISCUSSING THIS WITH THE CAPT, WE FIGURED HE MUST HAVE RELOADED THE FMS INCORRECTLY WHEN WE RECEIVED THE CLRNC. I DID NOT REALIZE HE HAD CHANGED WHAT I HAD LOADED. I SHOULD HAVE CHKED THE FMS MORE CLOSELY AND MONITORED MY RMI MORE CLOSELY.

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  36. Accession Number: 414360
    Synopsis: A B757-200 FLC DOES NOT MAKE THEIR XING ALT. ATC ASSIGNS A NEW XING POINT AFTER THE FLC DEV IS NOTED.
    Narrative: WE WERE PROCEEDING DIRECT TO THE SLC VOR FROM THE W AND ATC ASSIGNED A XING RESTR TO CROSS 40 MI W OF THE VOR AT 17000 FT. I WAS THE PNF AND, THEREFORE, TALKING ON THE RADIO. I RESPONDED BACK TO ATC WHAT I HEARD -- THAT WAS 17000 FT AT 40 MI W OF THE VOR. SHORTLY AFTER THIS, ATC CALLED AND ASSIGNED AN AIRSPD OF 250 KIAS AT THIS SAME POS. I READ BACK THE ENTIRE CLRNC TO ATC ('CROSS 40 MI W OF VOR AT 17000 FT AT 250 KIAS'). I RECALL THE CAPT READING THE CLRNC OUT LOUD AS HE BEGAN TO PROGRAM THE FMS. I BELIEVE THAT ATC WAS ALSO TALKING TO ANOTHER ACFT AND WITH ALL THE CHATTER, I DIDN'T HEAR VERBATIM WHAT THE CAPT HAD SAID. HE HAD UNDERSTOOD OUR CLRNC FOR 17000 FT, 250 KIAS TO BE AT THE 20 DME FIX, NOT THE 40 MI FIX. THIS ALL CAME TO LIGHT AS WE WERE DSNDING THROUGH APPROX FL190 AND ATC CALLED AND SAID WE 'HAD MISSED THE 40 MI FIX, AND COULD WE MAKE IT BY 20.' I RESPONDED 'YES.' AT THIS POINT I LOOKED AT THE FMS LEGS PAGE AND SAW THAT THE CAPT HAD A 20 MI FIX FOR THE ALT/AIRSPD RESTR. A JUMP SEAT RIDER ALSO UNDERSTOOD THE ASSIGNED FIX TO BE THE 20 DME FIX, NOT THE 40. BASICALLY, I HEARD '40,' ATC ASSIGNED '40,' AND THE CAPT AND JUMP SEAT HEARD '20.' ATC HAD EARLIER SAID THAT MY XMISSIONS WERE KIND OF BROKEN AND WEAK. BUT EVEN WITH THAT THE CAPT AND OBSERVER UNDERSTOOD ATC TO HAVE SAID 20 DME. IT IS A BIT CONFUSING, BUT I BELIEVE THAT SITUATIONAL AWARENESS WAS BROKEN IN THAT I DIDN'T LOOK AT THE LEGS PAGE TO VERIFY WHAT THE CAPT HAD ENTERED CONCERNING OUR XING RESTR. I ALSO FOUND SOME DIRT IN THE MIKE ON MY BOOM MIKE. AFTER I CLEANED THE DIRT OUT THE NEXT LEG, MY MIKE WAS LOUD AND CLR. HAD MY EARLIER XMISSION TO ATC REGARDS THE XING AND AIRSPD RESTR BEEN LOUD AND CLR, THE CAPT MAY HAVE HEARD MY READBACK OF '40 DME' AND THE SIT WOULD NOT HAVE HAPPENED. THERE HAD ALSO BEEN SOME CONVERSATION IN THE COCKPIT WITH THE JUMP SEAT RIDER WHILE IN CRUISE. THIS MAY ALSO HAVE ADDED INTO THE EQUATION OF REDUCED SITUATIONAL AWARENESS.
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