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Incidents related to Issue 5 incidents related to this issue.

Issue: insufficient information may be displayed (Issue #99)
Description: Important information that could be displayed by automation is not displayed, thereby limiting the ability of pilots to make safe decisions and actions.

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  2. Accession Number: 66260
    Synopsis: ACR WDB ALT DEVIATION OVERSHOT DURING CLIMBOUT FROM MIA.
    Narrative: ON DEPARTURE CAPT WAS TOLD TO CLIMB TO 7000'. COPLT WAS LOOKING OUT FOR TRAFFIC (2 MAN CREW). ALT ALERT WENT OFF AT 7300' MSL. CAPT IMMEDIATELY LEVELED OFF PEAKING OUT AT 7600'. HE THEN DESCENDED BACK TO 7000'. SEVERAL FACTORS WERE INVOLVED: 1) ACFT WAS A WDB -- AUTOTHROTTLE SYSTEM WAS INOPERATIVE PRIOR TO DEPARTURE SO CAPT ELECTED TO HAND FLY ACFT TO MAINTAIN SPEED CONTROL BETTER BELOW 10000'. CAPT WAS PREOCCUPIED BY AN UNUSUAL SYSTEM MALFUNCTION. -- (AUTOTHROTTLES INOP) 2) TRAFFIC WAS CALLED ON CLIMBOUT AND COPLT FAILED TO MAKE A CALL PASSING 6000' FOR 7000' PER COMPANY POLICY. (COPLT DISTRACTED BY VFR LOOKOUT IN HIGH DENSITY ACFT AREA. 3) SILENT COCKPIT THEORY ON ADVANCED JETS HAS ALT ALERT LITE TURN ON 900' PRIOR TO ASSIGNED ALT BUT NO AURAL TONE IS GIVEN. ONLY AURAL TONE IS WHEN ACFT DEVIATES PLUS OR MINUS 300' FROM ALT -- BY THEN IT'S TOO LATE TO CORRECT. AURAL TONE WOULD BE HELPFUL AT 900' PRIOR TO ASSIGNED ALT AND WARNING PLUS OR MINUS 150' WHEN DEVIATION OCCURS. EVEN IF BOTH CREWMEMBERS ARE LOOKING FOR TRAFFIC AURAL TONE WILL ASSIST IN ALERTING CREW. CERTAIN FUNCTIONS OF AUTOPLT ARE AFFECTED BY AUTOTHROTTLES. THIS WAS NOT A CONTRIBUTING FACTOR BUT 2 OF 3 AUTOPLTS WERE NOT FULL SYSTEMS CAPABLE DUE TO PLACARDED AUTOTHROTTLES. SUP INFO FROM ACN 66261. PREOCCUPATION WITH NON-USE OF AUTOMATIC FEATURES (HAND FLOWN CLIMBOUT). 4) CERTAIN FUNCTIONS OF AUTOPLT ARE AFFECTED BY AUTOTHROTTLES. THIS WAS NOT A CONTRIBUTING FACTOR BUT 2 OF 3 AUTOPLTS WERE NOT FULL SYSTEMS CAPABLE DUE TO PLACARDED AUTOTHROTTLES. SUPPLEMENTAL INFO FROM ACN 66261. PREOCCUPATION WITH NON-USE OF AUTOMATIC FEATURES (HAND FLOWN CLIMBOUT). PREOCCUPATION WITH PREVIOUS DISTRACTING FACTORS. POSSIBLE OVERLOAD FROM INFORMATIONAL INPUTS. PREVENTION OF DEVIATIONS COULD POSSIBLY BE ACCOMPLISHED BY UTILIZATION OF AUTOMATIC FEATURES AND EQUIPMENT ESPECIALLY DURING HIGH WORKLOAD PERIODS.

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  4. Accession Number: 372128
    Synopsis: THE FLC OF AN ACR B757 EXPERIENCED A MAP SHIFT DURING AN APCH TO LGA. THE ATCT LCL CTLR DIRECTED THE FLC TO GAR AND THEY SUCCESSFULLY COMPLETED A RAW DATA APCH LATER. THE EFIS MAP DISPLAY WAS 2 PT 5 NM OFF TO THE W AFTER THE FLT WAS IN THE GATE. THE RPTR ADMITTED THAT THEY WERE NOT MONITORING THE RAW DATA DURING THEIR INITIAL APCH.
    Narrative: CLRED THE LGA VOR/DME-G RWY 22 TURNED ON 4 MI OUTSIDE FAF. NOTICED A SLIGHT MOVEMENT ON HSI MAP, WHICH WE HAD ENTERED THE VOR APCH IN EARLIER. FLYING THE LNAV COURSE ON THE HSI, NO ASSOCIATED MESSAGES FROM EICAS OR FMS, NO FLAGS ON ANY INSTS. WHEN WE FINALLY SAW RWY 22 WE WERE 2 MI N AND APCH CTL DIRECTED A MISSED APCH TO 3000 FT AND VECTORED FOR ANOTHER APCH VOR DME-G TO RWY 22, WHICH WAS UNEVENTFUL. AFTER LNDG, THE HSI MAP HAD DRIFTED 2.5 MI AWAY FROM THE ACTUAL RWY. THIS WAS A VERY INSIDIOUS EVENT DURING THE BUSY TIME OF APCH AT THE FAF. SOME NOTIFICATION OF OUR PRIMARY NAV BEING BOLDLY DISPLAYED WHEN IT IS OUT OF TOLERANCE, WOULD BE HELPFUL IN PREVENTING THIS PROB IN THE FUTURE. SUPPLEMENTAL INFO FROM ACN 372125: IN THE BASE TURN FROM NORMAL DSCNT, AND SUDDEN 2 1/2 MI MAP SHIFT OCCURRED IN FMS, WITH NO ASSOCIATED MESSAGES/FLAGS. COMPUTER/AUTOPLT FLEW APPROX 2 MI L OF RWY, AND LGA TWR DIRECTED MISSED APCH, HDOF TO TRACON. WE RE-FLEW SAME APCH ON RAW DATA. AFTER LNDG, MAP WAS SHIFTED 2 1/2 MI W. THIS IS INSIDIOUS, PARTICULARLY WHEN IT OCCURS DURING A BUSY PERIOD, AS TRANSITIONING TO FINAL. CALLBACK CONVERSATION WITH RPTR ACN #372128 REVEALED THE FOLLOWING INFO: THE RPTR SAID THAT HE WAS FLYING A B757-200 EQUIPPED WITH HONEYWELL FMCS WHEN THE MAP SHIFT OCCURRED. HE SAID THAT THIS WAS THE FIRST MAP SHIFT THAT HE HAS EXPERIENCED IN THE SEVERAL YRS THAT HE HAS FLOWN THE ACFT. HE DID HAVE THE RAW DATA TUNED, BUT NOT DISPLAYED AND HE ADMITTED THAT THE FO AS THE PNF SHOULD HAVE HAD THE ILS DISPLAYED ON HIS HSI IN ACCORDANCE WITH COMPANY PROC. AFTER LNDG THE EFIS MAP WAS IN ERROR BY 2 1/2 NM TO THE W. HE ENTERED THE PROB IN THE LOGBOOK AND FURTHER DISCUSSED IT WITH MAINT TECHNICIANS. THEY COULD NOT PINPOINT THE CAUSE OF THE ERROR SO MAINT PERSONNEL CHANGED THE FMCS AND SOME RELATED EQUIP. THE RPTR TALKED TO HIS CHIEF PLT ABOUT THE PROB ALSO. HE HAS NOT BEEN TOLD OF THE CAUSE AS YET. HE HAS DECIDED TO CAREFULLY BACK UP HIS APCH DISPLAYS WITH RAW DATA IN THE FUTURE, HE SAID. HE SAID THAT THIS EPISODE WAS DEEPLY DISTURBING TO HIM AND HIS FO.

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  6. Accession Number: 398020
    Synopsis: AN EMB-145 FLC OVERSHOT THEIR ALT WHEN THEY WERE UNAWARE THAT THE AUTOPLT HAD DISCONNECTED AND FAILED TO LEVEL THE ACFT AT 14000 FT. THE AUTOPLT DESIGN WAS CRITICIZED FOR NOT HAVING A WARNING SYS ALERT WHEN DISCONNECT OCCURS OVER 2500 FT AGL. BOTH PLTS WERE FILLING OUT CUSTOMS FORMS IN DSCNT.
    Narrative: WE WERE FLYING FROM HALIFAX, NOVA SCOTIA (YHZ), TO NEWARK (EWR) ON A STAR AND GIVEN A DSCNT CLRNC TO 14000 FT. I'M NOT SURE TODAY IF THIS WAS THE ALT ATC GAVE US, BUT IT WAS AN EVEN MIDDLE-TEEN ALT AND I WAS SURE OF THE ALT ON THE DAY OF THIS INCIDENT -- THAT WAS NOT THE ISSUE. WHILE DSNDING ROUTINELY, IT WAS THE FO'S LEG AND I WAS FILLING OUT OUR CREW DECLARATION CUSTOMS FORM. I NOTICED THAT MY FO WAS ALSO FILLING OUT HER CUSTOMS FORM, SO I WOULD OCCASIONALLY LOOK UP TO MONITOR OUR FLT SIT. THE AUTOPLT WAS ON AND DSNDING INITIALLY, BUT HAD SOMEHOW DISENGAGED WITHOUT US KNOWING WHY. THE AUTOPLT AURAL WARNING ANNOUNCING DISENGAGEMENT ONLY OCCURS BELOW 2500 FT AGL AND NOT AT ANY OTHER ALTS ABOVE THAT. I HAVE ALREADY EXPERIENCED SEVERAL UNANNOUNCED AND UNKNOWN DISENGAGEMENTS OF THE AUTOPLT DURING CLBS, CRUISE, AND DSCNTS AND CAUGHT THEM DURING NORMAL MONITORING OF THE AUTOPLT WHILE IT WAS FLYING. BECAUSE OUR DSCNT WAS SHALLOW AND BECAUSE WE WERE BOTH FILLING OUT OUR CUSTOMS FORMS, NO ONE NOTICED WE HAD DSNDED THROUGH OUR ASSIGNED ALT UNTIL WE WERE 500 FT BELOW IT. MY FO CORRECTED PROMPTLY AND NO TFC WAS ON TCASII. BEING A SATURDAY, IT WAS A LIGHT TFC DAY ON THE ATC FREQ. ZBW DIDN'T MENTION THE ALTDEV. I STILL DON'T KNOW WHY THE AUTOPLT DISENGAGED. I'M CONCERNED THAT THIS PRIMUS 1000 DOES NOT ANNOUNCE DISENGAGEMENT ABOVE 2500 FT. I HAVE TALKED TO SEVERAL CREW MEMBERS WHO HAVE EXPERIENCED SIMILAR UNEXPLAINED DISENGAGEMENTS. IN THE FUTURE, I WILL PAY CLOSER ATTN TO MONITORING THE AUTOPLT SO THAT A DEV DOES NOT OCCUR IN THE FUTURE AS A RESULT OF AN UNEXPLAINED AND UNANNOUNCED DISENGAGEMENT AND SUPERVISE MY FO'S MORE CLOSELY DURING AUTOFLT. A SIMPLE CHANGE IN THE PRIMUS 1000 SOFTWARE WOULD PROBABLY SOLVE THIS ANNOUNCEMENT PROB. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR INDICATED THAT HE HAS HAD ANOTHER DISCONNECT INCIDENT SINCE HIS INITIAL RPT ON THE EMB145 AUTOPLT PROB. THE COMPANY HAS BEEN INFORMED OF THE INADEQUATE WARNING SYS AND HE IS INTENDING TO INFORM HIS AIRLINE UNION SAFETY COMMITTEE. THE ONLY WARNING THAT THE CREW RECEIVES FROM AN AUTOPLT DISCONNECT INFLT ABOVE 2500 FT IS WHEN THE LITTLE LIGHT GOES OUT IN THE CORNER QUADRANT OF THE AUTOPLT 'PUSH TO ENGAGE' BUTTON. ONE MUST BE VERY ALERT TO THIS LIGHT BEING LIT AND IT IS DIFFICULT AT BEST TO NOTE ANY CHANGE IN THE STATUS OF THE AUTOPLT.

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  8. Accession Number: 398304
    Synopsis: A B767 IN CRUISE DISCOVERED AN UNWANTED FUEL XFER CAUSED BY THE XFEED VALVE LEFT OPEN. NO FUEL CONFIGN WARNING FROM EICAS DUE TO CTR TANK BALLAST REQUIREMENT.
    Narrative: 42 MINS INTO FLT AT FIRST FUEL CHKPOINT, I NOTICED A FUEL IMBAL OF 5600 LBS. THE LIMITATION FOR A B767 WITH THAT FUEL LOAD WAS 2100 LBS. WE DISCOVERED THE XFEED VALVE OPEN. IT WAS OPENED BY A MECH AT ZZZ WHO WAS XFERRING FUEL AND FORGOT TO CLOSE IT. IT IS VERY EASY TO OVERLOOK IT ON THE BEFORE START CHKLIST AND WE DID. NORMALLY A FUEL CONFIGN EICAS MESSAGE WOULD HAVE ALERTED US AT ABOUT 2000 LBS. BUT DUE TO NEW REQUIREMENT TO CARRY CTR TANK BALLAST FUEL THAT EICAS MESSAGE WAS ALREADY INDICATED. IT MASKED A SERIOUS DEVELOPING IMBAL. I WILL BE MORE VIGILANT REGARDING FUEL WHENEVER CARRYING BALLAST FUEL. REGAINING BALANCED FUEL BY XFEED TOOK 30 MINS.

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  10. Accession Number: 398621
    Synopsis: A B747-400 MAKING AN APCH INTO JFK LOSES THE L FMC WHICH FAILS ALL THE ILS INSTS. THE ACFT EXECUTES A MISSED APCH BECAUSE OF THE LOW WX AND JFK AND DIVERTS TO EWR.
    Narrative: ACR FLT XX APR/XA/98. DURING THE INITIAL APCH PHASE TO RWY 31R AT JFK AT 4000 FT, EXPERIENCED INTERMITTENT FAILURE OF BOTH FMC'S AND SUBSEQUENT INTERMITTENT VHF FAILURE (PARTIAL). AT THIS POINT, WE DISCONTINUED THE APCH, CLBED TO 8000 FT MSL AND HELD APPROX 20 MI NE, SE OF JFK TO RATIFY SIT. UPON HEARING FROM THE CABIN CHIEF PURSER ABOUT AN ODOR OF BURNING WIRES IN THE AFT CABIN, WE DISCONTINUED HOLDING AND PROCEEDED TO EWR FOR AN UNEVENTFUL APCH AND LNDG IN VISUAL CONDITIONS. THE FLC DETERMINED THAT ELECTRICAL EQUIP FAILURE WAS DUE IN PART TO A MALFUNCTION IN THE ELECTRICAL EQUIP COOLING SYS. I DO NOT RECALL THE CAPT DECLARING AN EMER, BUT ATC DID PROVIDE PRIORITY HANDLING FOR OUR APCH AND LNDG AT EWR. MY PRIMARY ROLE DURING THIS INCIDENT WAS IN MAINTAINING CONTACT WITH MAINT TO TRY AND FIND A CAUSE FOR THE ACFT'S PROBS. I ALSO WAS RESPONSIBLE FOR COORDINATING OUR DIVERSION FOR LNDG AT EWR INSTEAD OF JFK. THIS WAS DONE THROUGH COMPANY COMS. I ALSO KEPT THE PAX AWARE OF OUR SIT THROUGHOUT THE ENTIRE EPISODE. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT IT IS NOW KNOWN THAT THERE WAS A FAILURE OF THE L FMC. IT IS FELT THAT THE FAILURE WAS INTERMITTENT WHICH WOULD EXPLAIN WHY THE FLC NEVER RECEIVED AN EICAS WARNING. WHEN A FLT ATTENDANT RPTED THE SMELL OF HOT BURNING WIRES ANOTHER RELIEF FLT OFFICER WENT TO THE BACK TO INVESTIGATE, BUT HE COULD NOT DETECT ANY BURNING WIRE ODOR. THE COOLING FAN WAS ALSO OPERATING ON AN INTERMITTENT BASIS AS WAS DETERMINED LATER. WITH THE LOSS OF THE FMC, THEY COULD NOT KEEP THE ILS AVAILABLE FOR THE APCH. SINCE THE FLC COULD VISUALLY IDENT EWR THEY MADE A DECISION TO GO TO THAT VFR ARPT. FLC AND MAINT PERSONNEL DETERMINED TOGETHER THAT BECAUSE THE FMC WAS INTERMITTENT IT WOULD BE REPLACED. HOWEVER, AS THE ACFT WAS FERRIED BACK TO JFK BY ANOTHER FLC, THE FMC FAILED AGAIN. IT WAS FELT THAT A COOLING FAN THAT WAS FAILING SPORADICALLY PLAYED A PART IN THE FMC FAILING BECAUSE OF INADEQUATE COOLING. THAT WAS ANOTHER FAILURE THAT WAS NEVER DISPLAYED ON THE EICAS PANEL. THE ACFT TYPE WAS A B747- 400. THE ACFT MANUFACTURER AND ACR MAINT ARE WORKING ON WHY THE FAILURE WAS NEVER ANNUNCIATED ON THE EICAS SCREEN. SUPPLEMENTAL INFO FROM ACN 398505: THE UPPER EICAS DISPLAYED 'AUTOTHROTTLE DISCONNECT' AND 'FMC MESSAGE.' THE L AND R CDU'S WERE BLINKING 'RESYNCHING' AND THE 'MAP FAIL' AND 'VTK' WARNINGS WERE ON THE NAV DISPLAYS. THE L 'ND' RESTORED ABOUT 30 SECONDS LATER AND I SAID 'I GOT THE MAP BACK.' ONE MIN OR SO LATER, IT FAILED AGAIN WITH THE 'RESYNCHING' MESSAGE ON THE CDU'S. JFK MAINT WAS CONTACTED AND WE WERE GIVEN SOME GUIDANCE THAT POSSIBLY WE HAD A MAJOR ELECTRICAL OVERLOAD AND THEY SUGGESTED TURNING 'OFF' THE UTILITY BUS SWITCHES TO LOWER THE ELECTRICAL LOAD. THIS WAS DONE AND IMMEDIATELY THE UPPER EICAS FILLED WITH MESSAGES ABOUT SYS THAT WERE NOW UNPWRED, AND THE 'AUTOTHROTTLE' AND 'FMS MESSAGES' WERE STILL AT THE TOP OF THE PAGE. WE CONTINUED IN THAT CONFIGN FOR A FEW MORE MINS UNTIL ONE OF THE EICAS MESSAGES CAME UP 'EQUIP COOLING.' THE PNF FO'S REMARKED 'FINALLY THERE'S SOMETHING I HAVE A PROC FOR.' THE L CDU WOULD ACCEPT NOTHING. I MOMENTARILY SELECTED THE 'NAV SELECTOR' TO 'CDU-L' TO TRY TO HARD TUNE THE L ILS AND THE CDU WENT BLANK. ABOUT 4 MI OUT ON FINAL, THE FO'S WERE ABLE TO GET THE ILS ON THE RADIO RAW DATA DISPLAYS AND THE ILS WAS USED FOR GUIDANCE. THE APPROX TIME FROM INITIAL PROB TO LNDG AT EWR WAS ABOUT 25 MINS. THE 'MASTER FMC' WAS NOT TRIED BECAUSE BOTH FMC'S APPEARED TO HAVE PROBS -- BUT NO EICAS MESSAGE EVER SAID 'FMC FAILURE.' THIS WAS ALL AT THE END OF A 12 HR FLT! FATIGUE CERTAINLY DIDN'T HELP! SUPPLEMENTAL INFO FROM ACN 399265: NAV INFO FROM FMC'S NIL TO UNRELIABLE.
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