37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 121616 |
Time | |
Date | 198908 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : lax |
State Reference | CA |
Altitude | msl bound lower : 24000 msl bound upper : 24000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | descent other |
Route In Use | arrival : profile descent arrival other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time total : 20000 flight time type : 75 |
ASRS Report | 121616 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : cfi pilot : atp pilot : commercial |
Experience | flight time last 90 days : 150 flight time total : 15500 flight time type : 300 |
ASRS Report | 121194 |
Events | |
Anomaly | non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During civit profile descent to lax air carrier flight, xx received several speed, altitude and heading changes. Flight xx was given a heading change, and descend to 160. I understood the 160 phraseology to be heading 160, ATC questioned our heading, then issued another heading and took us out of the profile. They reinserted us back into the profile. We proceeded to lax and landed as cleared. Supplemental information from acn 121194: reasons: controllers talking too rapidly, plus frequency congestion making clarification impossible. Aircraft design: heading knob and speed knob are identical and are positioned close together. It is not uncommon to turn the wrong knob, particularly in a dark cockpit, and especially if numbers are the same (eg, heading 250, speed 250). Knobs and number drums are physically identical and positioned side by side.
Original NASA ASRS Text
Title: TRACK AND HEADING DEVIATION.
Narrative: DURING CIVIT PROFILE DSCNT TO LAX ACR FLT, XX RECEIVED SEVERAL SPEED, ALT AND HDG CHANGES. FLT XX WAS GIVEN A HDG CHANGE, AND DSND TO 160. I UNDERSTOOD THE 160 PHRASEOLOGY TO BE HDG 160, ATC QUESTIONED OUR HDG, THEN ISSUED ANOTHER HDG AND TOOK US OUT OF THE PROFILE. THEY REINSERTED US BACK INTO THE PROFILE. WE PROCEEDED TO LAX AND LANDED AS CLRED. SUPPLEMENTAL INFORMATION FROM ACN 121194: REASONS: CTLRS TALKING TOO RAPIDLY, PLUS FREQ CONGESTION MAKING CLARIFICATION IMPOSSIBLE. ACFT DESIGN: HDG KNOB AND SPEED KNOB ARE IDENTICAL AND ARE POSITIONED CLOSE TOGETHER. IT IS NOT UNCOMMON TO TURN THE WRONG KNOB, PARTICULARLY IN A DARK COCKPIT, AND ESPECIALLY IF NUMBERS ARE THE SAME (EG, HDG 250, SPEED 250). KNOBS AND NUMBER DRUMS ARE PHYSICALLY IDENTICAL AND POSITIONED SIDE BY SIDE.
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.