37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 136593 |
Time | |
Date | 199002 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | msl bound lower : 10000 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | descent other |
Route In Use | arrival other arrival star : star enroute airway : zoa |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 14000 |
ASRS Report | 136593 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot non adherence : clearance other anomaly other |
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:
I am an instructor/check pilot on the widebody transport a and widebody transport B. I've been flying/teaching 'glass cockpit' for 7 yrs and have always taught my students not to let the 'magic' of the glass cockpit overwhelm them. I was flying for proficiency and not scheduled to do any IOE or training. However, due to the newness of the widebody transport a you always do wind-up during training. We departed hkg and at the time of the incident had been airborne approximately 12 hours. The first officer was flying and SOP calls for the pilot not flying (PNF) to enter the CDU information. However, this was only the 2ND trip for this first officer and he wanted to program the VNAV descent. I took the aircraft back and he programmed the CDU and erroneously programmed 1100' vs the 11,000' I told him to expect at 20 northwest of sfo. He was having difficulty. I was working with him when ATC called and cleared us for the STAR, descend and maintain 10,000' cross 20 northwest of sfo at 10,000' -- or so I thought! As I recall I think I read back 10, however, I might have just said 'wilco' -- something I teach never to do. 12 hours of flying, working with a student, attention diverted, etc. I asked the first officer to put that crossing restriction in the CDU. He was unable. The CDU will only accept modification to the next active waypoint and the next one. This restriction was based on the 3RD waypoint, so I was attempting to explain to the first officer how to modify that restriction. The first officer misprogrammed the CDU putting in 1000' vs 10,000' and I showed him how to fix that. The descent was normal, smooth, etc, down to 10,000'. Shortly after level off at 10,000', center called and asked us our altitude. A very sinking feeling fell in as I looked down on my chart and saw in my own writing that we always cross this fix at 11,000', even though the chart says to expect to cross. I told the center that I had read back 10T and he said no problem, however, I was only cleared to 11,000'. Callback conversation with reporter revealed the following: reporter states that cockpit workload was dramatically increased by the inability of the first officer to correct an error in CDU operation. Reporter is an experienced instructor and feels that he should not have allowed this distraction to occur. Flight crew fatigue definitely a factor.
Original NASA ASRS Text
Title: ALT DEVIATION. OVERSHOOT IN DESCENT. CROSSING RESTRICTION NOT MET.
Narrative: I AM AN INSTRUCTOR/CHECK PLT ON THE WDB A AND WDB B. I'VE BEEN FLYING/TEACHING 'GLASS COCKPIT' FOR 7 YRS AND HAVE ALWAYS TAUGHT MY STUDENTS NOT TO LET THE 'MAGIC' OF THE GLASS COCKPIT OVERWHELM THEM. I WAS FLYING FOR PROFICIENCY AND NOT SCHEDULED TO DO ANY IOE OR TRAINING. HOWEVER, DUE TO THE NEWNESS OF THE WDB A YOU ALWAYS DO WIND-UP DURING TRAINING. WE DEPARTED HKG AND AT THE TIME OF THE INCIDENT HAD BEEN AIRBORNE APPROX 12 HRS. THE F/O WAS FLYING AND SOP CALLS FOR THE PLT NOT FLYING (PNF) TO ENTER THE CDU INFO. HOWEVER, THIS WAS ONLY THE 2ND TRIP FOR THIS F/O AND HE WANTED TO PROGRAM THE VNAV DSCNT. I TOOK THE ACFT BACK AND HE PROGRAMMED THE CDU AND ERRONEOUSLY PROGRAMMED 1100' VS THE 11,000' I TOLD HIM TO EXPECT AT 20 NW OF SFO. HE WAS HAVING DIFFICULTY. I WAS WORKING WITH HIM WHEN ATC CALLED AND CLRED US FOR THE STAR, DSND AND MAINTAIN 10,000' CROSS 20 NW OF SFO AT 10,000' -- OR SO I THOUGHT! AS I RECALL I THINK I READ BACK 10, HOWEVER, I MIGHT HAVE JUST SAID 'WILCO' -- SOMETHING I TEACH NEVER TO DO. 12 HRS OF FLYING, WORKING WITH A STUDENT, ATTN DIVERTED, ETC. I ASKED THE F/O TO PUT THAT XING RESTRICTION IN THE CDU. HE WAS UNABLE. THE CDU WILL ONLY ACCEPT MODIFICATION TO THE NEXT ACTIVE WAYPOINT AND THE NEXT ONE. THIS RESTRICTION WAS BASED ON THE 3RD WAYPOINT, SO I WAS ATTEMPTING TO EXPLAIN TO THE F/O HOW TO MODIFY THAT RESTRICTION. THE F/O MISPROGRAMMED THE CDU PUTTING IN 1000' VS 10,000' AND I SHOWED HIM HOW TO FIX THAT. THE DSCNT WAS NORMAL, SMOOTH, ETC, DOWN TO 10,000'. SHORTLY AFTER LEVEL OFF AT 10,000', CENTER CALLED AND ASKED US OUR ALT. A VERY SINKING FEELING FELL IN AS I LOOKED DOWN ON MY CHART AND SAW IN MY OWN WRITING THAT WE ALWAYS CROSS THIS FIX AT 11,000', EVEN THOUGH THE CHART SAYS TO EXPECT TO CROSS. I TOLD THE CENTER THAT I HAD READ BACK 10T AND HE SAID NO PROBLEM, HOWEVER, I WAS ONLY CLRED TO 11,000'. CALLBACK CONVERSATION WITH REPORTER REVEALED THE FOLLOWING: REPORTER STATES THAT COCKPIT WORKLOAD WAS DRAMATICALLY INCREASED BY THE INABILITY OF THE F/O TO CORRECT AN ERROR IN CDU OPERATION. REPORTER IS AN EXPERIENCED INSTRUCTOR AND FEELS THAT HE SHOULD NOT HAVE ALLOWED THIS DISTR TO OCCUR. FLT CREW FATIGUE DEFINITELY A FACTOR.
Data retrieved from NASA's ASRS site as of July 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.