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|
Attributes | |
ACN | 143012 |
Time | |
Date | 199004 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : oak |
State Reference | CA |
Altitude | msl bound lower : 12000 msl bound upper : 16000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zoa |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, 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 last 90 days : 180 flight time total : 14000 flight time type : 600 |
ASRS Report | 143012 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 178 flight time total : 8465 flight time type : 242 |
ASRS Report | 143018 |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : published procedure non adherence : clearance |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance none taken : unable |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After passing bsr VOR cleared to hold at anjee intersection as published. Used flight management computer (FMC) to enter holding at anjee by use of holding page. After 1 1/2 turns in holding ZOA cleared us to fly heading 170 degree. Heading was selected on mode control panel (MCP). I believe the altitude deviation chain of events started at this point, because 'exit holding' was not entered and executed at this time on FMC holding page. The next clearance was to fly heading 360 degree to intercept oak 151 degree right cleared for runway 28 profile descent, maintain 210 KTS. At this time we referred back to FMC to enter direct intercept to anjee intersection. But because 'exit holding' on holding page had been bypassed FMC had dropped anjee. PF had set 10000' on MCP when cleared for the profile and at this time V navigation started descending, however, we were not to anjee yet (at or above 16000'). Stopped descent at 15800', climbed back to 16000'. Reinserted anjee on FMC and 16000' on legs page, this was done just as we passed over anjee. Reengaged V navigation, automatic throttles went forward as FMC was looking for 290 KTS because 210 KTS wasn't entered on cruise or descent page. PF then selected speed on MCP and bugged down to 210 KTS. Now with V navigation off descent was not started in time to cross skunk at 12000', 210 KTS. Approaching skunk asked ZOA for altitude relief at skunk and ATC replied do the best you can. We crossed skunk above 12000' problem would not have occurred if the FMC had not been used until profile was established after skunk as FMC requires a lot of input during transitions.
Original NASA ASRS Text
Title: ALT DEVIATION. OVERSHOOT ON DESCENT. ALT CROSSING RESTRICTION NOT MADE.
Narrative: AFTER PASSING BSR VOR CLRED TO HOLD AT ANJEE INTXN AS PUBLISHED. USED FLT MGMNT COMPUTER (FMC) TO ENTER HOLDING AT ANJEE BY USE OF HOLDING PAGE. AFTER 1 1/2 TURNS IN HOLDING ZOA CLRED US TO FLY HDG 170 DEG. HDG WAS SELECTED ON MODE CTL PANEL (MCP). I BELIEVE THE ALT DEV CHAIN OF EVENTS STARTED AT THIS POINT, BECAUSE 'EXIT HOLDING' WAS NOT ENTERED AND EXECUTED AT THIS TIME ON FMC HOLDING PAGE. THE NEXT CLRNC WAS TO FLY HDG 360 DEG TO INTERCEPT OAK 151 DEG R CLRED FOR RWY 28 PROFILE DSNT, MAINTAIN 210 KTS. AT THIS TIME WE REFERRED BACK TO FMC TO ENTER DIRECT INTERCEPT TO ANJEE INTXN. BUT BECAUSE 'EXIT HOLDING' ON HOLDING PAGE HAD BEEN BYPASSED FMC HAD DROPPED ANJEE. PF HAD SET 10000' ON MCP WHEN CLRED FOR THE PROFILE AND AT THIS TIME V NAV STARTED DSNDING, HOWEVER, WE WERE NOT TO ANJEE YET (AT OR ABOVE 16000'). STOPPED DSNT AT 15800', CLBED BACK TO 16000'. REINSERTED ANJEE ON FMC AND 16000' ON LEGS PAGE, THIS WAS DONE JUST AS WE PASSED OVER ANJEE. REENGAGED V NAV, AUTO THROTTLES WENT FORWARD AS FMC WAS LOOKING FOR 290 KTS BECAUSE 210 KTS WASN'T ENTERED ON CRUISE OR DSNT PAGE. PF THEN SELECTED SPD ON MCP AND BUGGED DOWN TO 210 KTS. NOW WITH V NAV OFF DSNT WAS NOT STARTED IN TIME TO CROSS SKUNK AT 12000', 210 KTS. APCHING SKUNK ASKED ZOA FOR ALT RELIEF AT SKUNK AND ATC REPLIED DO THE BEST YOU CAN. WE CROSSED SKUNK ABOVE 12000' PROB WOULD NOT HAVE OCCURRED IF THE FMC HAD NOT BEEN USED UNTIL PROFILE WAS ESTABLISHED AFTER SKUNK AS FMC REQUIRES A LOT OF INPUT DURING TRANSITIONS.
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.