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Attributes | |
ACN | 110413 |
Time | |
Date | 198905 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : lax |
State Reference | CA |
Altitude | msl bound lower : 13000 msl bound upper : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : lax tower : tys |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | cruise other cruise other descent other |
Route In Use | arrival other arrival star : star |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : cfi pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 15 flight time total : 6200 flight time type : 15 |
ASRS Report | 110413 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot non adherence : published procedure non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
This was my first trip on this aircraft west/O training people aboard. This is still a brand new aircraft and none of us pilots have had much exposure or experience flying in it. We were on the civet profile descent to runway 25L at lax. Our crossing restriction was 14000' to civet. We misinterpreted our instruments and began descent to 10000', believing we were inside civet. At about 13000' the lax approach controller told us that we started down early and needed to maintain 14000' until civet. We immediately climbed to 14400', the assigned altitude to civet. After rechking our instrument we realized that our DME reading was based on fueler intersection instead of the lax localizer DME. I feel this was an easy mistake to make considering our very limited exposure to this aircraft. I find the glass cockpit a very difficult system to master and a frightfully easy way to make critical mistakes--at least when the pilot is new to it. The problem occurred when both of us mistook the DME for fueler intersection displayed on the navigation display for the lax DME, a smaller font image on the primary flight display. The fix for this problem, I believe, is more training for the crews. Chkouts have become extremely costly forcing airlines to make them in the shortest time possible, which is understandable. However, I think more training would help pilots with this extremely complex new flight system. Callback conversation with reporter revealed the following: reporter cites that this was first trip west/O a check airman on board. Also states that this flight crew was very low on combined experience as the captain had only 30 hours of experience. That is counting the 25 hours obtained on IOE time. Reporter also states that the 15 hours he had as operating experience was 3 takeoff's and landing's and the rest of the time was logged from the jump seat. Reporter feels that this is too little exposure to the real world of operating a $125,000,000 aircraft and that he was overworked in the arrival and got confused as the captain started the descent prematurely. He was of no assistance in preventing the deviation. This event occurred in spite of 3 yrs and 9 yrs operating time on standard 747's for first officer and captain. It could be suggested that if at all possible, 2 low time pilots should not mixed together as a flight crew. The coordinated crew concept suffers from the composite low experience level and exposes the aircraft, crew and passenger to an unnecessarily high risk of incident, deviation or accident. The economics as practiced in this low training hours approach cannot be justified considering the possible results from a mix of unfortunate circumstances being thrown to a set of low in type pilots in an ever changing and ever increasingly complex environment. Providing the best in hands on experience and training should be the goal and it is considered, from a historical viewpoint, that first officer's should obtain their operating experience in the seat that they would normally function and therefore be of more assistance to the PIC. Jump seat riding should not be considered for operating experience in this complex aircraft. Callback conversation #2 with reporter revealed the following: the primary flight display (pfd) was on 'ilax' showing ILS/DME distance from 25L at lax. Navigation display (nd) showed mileage to waypoint in stored route. Reporter could not explain why mistake was made when all the waypoints were in the stored route of the FMC. The FMC system automatic selects the required radio for navigation display with, in this case, the 25L 'ilax' ILS/DME being selected. The ILS/DME, according to reporter would not be automatic-selected automatically until about 30 DME out unless 'forced' through selection and activation of certain push buttons near the screen. The 'time' attached to civet waypoint was not considered in the election for descent. The 'bottom line' in the assessment of this event is training and the amount of technical expertise that is introduced to the student in that training atmosphere. There is a level of certainty in the future of the 'glass cockpit' and its portrayal of valuable, usable data. This however comes about through repeated use and experience. Initial training that disallows hands on use in the 'formative hours' can only be previewing another altitude deviation or misinterp that may have more serious considerations. The potential for error in a low time flight crew must be re-emphasized as an evaluation is made of further comments from reporter. On this aircraft there is no ACARS system thus requiring the PNF, in addition to his other duties to contact the company with landing ETA and gate information. Add to this, on a 'civet STAR,' the fact that lax airport constantly uses the task inducing procedure of runway switching to facilitate aircraft departures. Consider the additional workload to re-program the FMC by getting into the pages of the CDU and selecting the newly assigned runway/ILS for approach. Proper crew coordination would then dictate another task induced approach plate review.
Original NASA ASRS Text
Title: ALT DEVIATION ON STAR ARR BY NEW TYPE WDB ACFT.
Narrative: THIS WAS MY FIRST TRIP ON THIS ACFT W/O TRNING PEOPLE ABOARD. THIS IS STILL A BRAND NEW ACFT AND NONE OF US PLTS HAVE HAD MUCH EXPOSURE OR EXPERIENCE FLYING IN IT. WE WERE ON THE CIVET PROFILE DSCNT TO RWY 25L AT LAX. OUR XING RESTRICTION WAS 14000' TO CIVET. WE MISINTERPRETED OUR INSTRUMENTS AND BEGAN DSCNT TO 10000', BELIEVING WE WERE INSIDE CIVET. AT ABOUT 13000' THE LAX APCH CTLR TOLD US THAT WE STARTED DOWN EARLY AND NEEDED TO MAINTAIN 14000' UNTIL CIVET. WE IMMEDIATELY CLBED TO 14400', THE ASSIGNED ALT TO CIVET. AFTER RECHKING OUR INSTRUMENT WE REALIZED THAT OUR DME READING WAS BASED ON FUELER INTXN INSTEAD OF THE LAX LOC DME. I FEEL THIS WAS AN EASY MISTAKE TO MAKE CONSIDERING OUR VERY LIMITED EXPOSURE TO THIS ACFT. I FIND THE GLASS COCKPIT A VERY DIFFICULT SYS TO MASTER AND A FRIGHTFULLY EASY WAY TO MAKE CRITICAL MISTAKES--AT LEAST WHEN THE PLT IS NEW TO IT. THE PROB OCCURRED WHEN BOTH OF US MISTOOK THE DME FOR FUELER INTXN DISPLAYED ON THE NAV DISPLAY FOR THE LAX DME, A SMALLER FONT IMAGE ON THE PRIMARY FLT DISPLAY. THE FIX FOR THIS PROB, I BELIEVE, IS MORE TRNING FOR THE CREWS. CHKOUTS HAVE BECOME EXTREMELY COSTLY FORCING AIRLINES TO MAKE THEM IN THE SHORTEST TIME POSSIBLE, WHICH IS UNDERSTANDABLE. HOWEVER, I THINK MORE TRNING WOULD HELP PLTS WITH THIS EXTREMELY COMPLEX NEW FLT SYS. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING: RPTR CITES THAT THIS WAS FIRST TRIP W/O A CHK AIRMAN ON BOARD. ALSO STATES THAT THIS FLT CREW WAS VERY LOW ON COMBINED EXPERIENCE AS THE CAPT HAD ONLY 30 HRS OF EXPERIENCE. THAT IS COUNTING THE 25 HRS OBTAINED ON IOE TIME. RPTR ALSO STATES THAT THE 15 HRS HE HAD AS OPERATING EXPERIENCE WAS 3 TKOF'S AND LNDG'S AND THE REST OF THE TIME WAS LOGGED FROM THE JUMP SEAT. RPTR FEELS THAT THIS IS TOO LITTLE EXPOSURE TO THE REAL WORLD OF OPERATING A $125,000,000 ACFT AND THAT HE WAS OVERWORKED IN THE ARR AND GOT CONFUSED AS THE CAPT STARTED THE DSCNT PREMATURELY. HE WAS OF NO ASSISTANCE IN PREVENTING THE DEVIATION. THIS EVENT OCCURRED IN SPITE OF 3 YRS AND 9 YRS OPERATING TIME ON STANDARD 747'S FOR F/O AND CAPT. IT COULD BE SUGGESTED THAT IF AT ALL POSSIBLE, 2 LOW TIME PLTS SHOULD NOT MIXED TOGETHER AS A FLT CREW. THE COORDINATED CREW CONCEPT SUFFERS FROM THE COMPOSITE LOW EXPERIENCE LEVEL AND EXPOSES THE ACFT, CREW AND PAX TO AN UNNECESSARILY HIGH RISK OF INCIDENT, DEVIATION OR ACCIDENT. THE ECONOMICS AS PRACTICED IN THIS LOW TRNING HRS APCH CANNOT BE JUSTIFIED CONSIDERING THE POSSIBLE RESULTS FROM A MIX OF UNFORTUNATE CIRCUMSTANCES BEING THROWN TO A SET OF LOW IN TYPE PLTS IN AN EVER CHANGING AND EVER INCREASINGLY COMPLEX ENVIRONMENT. PROVIDING THE BEST IN HANDS ON EXPERIENCE AND TRNING SHOULD BE THE GOAL AND IT IS CONSIDERED, FROM A HISTORICAL VIEWPOINT, THAT F/O'S SHOULD OBTAIN THEIR OPERATING EXPERIENCE IN THE SEAT THAT THEY WOULD NORMALLY FUNCTION AND THEREFORE BE OF MORE ASSISTANCE TO THE PIC. JUMP SEAT RIDING SHOULD NOT BE CONSIDERED FOR OPERATING EXPERIENCE IN THIS COMPLEX ACFT. CALLBACK CONVERSATION #2 WITH RPTR REVEALED THE FOLLOWING: THE PRIMARY FLT DISPLAY (PFD) WAS ON 'ILAX' SHOWING ILS/DME DISTANCE FROM 25L AT LAX. NAV DISPLAY (ND) SHOWED MILEAGE TO WAYPOINT IN STORED ROUTE. RPTR COULD NOT EXPLAIN WHY MISTAKE WAS MADE WHEN ALL THE WAYPOINTS WERE IN THE STORED ROUTE OF THE FMC. THE FMC SYS AUTO SELECTS THE REQUIRED RADIO FOR NAV DISPLAY WITH, IN THIS CASE, THE 25L 'ILAX' ILS/DME BEING SELECTED. THE ILS/DME, ACCORDING TO RPTR WOULD NOT BE AUTO-SELECTED AUTOMATICALLY UNTIL ABOUT 30 DME OUT UNLESS 'FORCED' THROUGH SELECTION AND ACTIVATION OF CERTAIN PUSH BUTTONS NEAR THE SCREEN. THE 'TIME' ATTACHED TO CIVET WAYPOINT WAS NOT CONSIDERED IN THE ELECTION FOR DSCNT. THE 'BOTTOM LINE' IN THE ASSESSMENT OF THIS EVENT IS TRNING AND THE AMOUNT OF TECHNICAL EXPERTISE THAT IS INTRODUCED TO THE STUDENT IN THAT TRNING ATMOSPHERE. THERE IS A LEVEL OF CERTAINTY IN THE FUTURE OF THE 'GLASS COCKPIT' AND ITS PORTRAYAL OF VALUABLE, USABLE DATA. THIS HOWEVER COMES ABOUT THROUGH REPEATED USE AND EXPERIENCE. INITIAL TRNING THAT DISALLOWS HANDS ON USE IN THE 'FORMATIVE HRS' CAN ONLY BE PREVIEWING ANOTHER ALT DEVIATION OR MISINTERP THAT MAY HAVE MORE SERIOUS CONSIDERATIONS. THE POTENTIAL FOR ERROR IN A LOW TIME FLT CREW MUST BE RE-EMPHASIZED AS AN EVALUATION IS MADE OF FURTHER COMMENTS FROM RPTR. ON THIS ACFT THERE IS NO ACARS SYS THUS REQUIRING THE PNF, IN ADDITION TO HIS OTHER DUTIES TO CONTACT THE COMPANY WITH LNDG ETA AND GATE INFO. ADD TO THIS, ON A 'CIVET STAR,' THE FACT THAT LAX ARPT CONSTANTLY USES THE TASK INDUCING PROC OF RWY SWITCHING TO FACILITATE ACFT DEPS. CONSIDER THE ADDITIONAL WORKLOAD TO RE-PROGRAM THE FMC BY GETTING INTO THE PAGES OF THE CDU AND SELECTING THE NEWLY ASSIGNED RWY/ILS FOR APCH. PROPER CREW COORD WOULD THEN DICTATE ANOTHER TASK INDUCED APCH PLATE REVIEW.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.