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|
Attributes | |
ACN | 145076 |
Time | |
Date | 199005 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : crl |
State Reference | MI |
Altitude | msl bound lower : 11650 msl bound upper : 12000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other descent other |
Route In Use | enroute : direct enroute : on vectors enroute airway : v98 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 11500 flight time type : 1100 |
ASRS Report | 145076 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : private pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 3000 flight time type : 1000 |
ASRS Report | 146039 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance other spatial deviation |
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 |
Narrative:
In cruise at FL190 and northbound on V98 (dqn 359 degree right/80 NM) ZOB cleared us on an intercept heading for V98 east of pions intersection. Also at this time we were cleared to descend and cross mizar intersection at 12000'. We forgot the descent checklist as we made our turn and began the descent (note: altimeter at dtw 29.47). We noticed a disagreement between the FMS display and the course indicator on the HSI. About 10 NM southwest of mizar, while attempting to verify which course display was correct, we were given holding instructions at mizar (as published/12000'). We leveled at 12000' and were asked by ATC to verify our altitude. We checked our altimeters still set at 29.92. After resetting our altimeters to 29.47 we climbed to 12000' (we were actually at 11650'). As we leveled off, we began a right turn in holding as shown on the FMS. ATC informed us that holding 'as published' meant left turns (we had neglected to enter left turns into the FMS during our confusion). Holding was then terminated by ATC and we were vectored to dtw. Distraction and confusion over the conflicting course displays were factors leading to a missed descent checklist. This snowballed, along with my neglecting to properly program the FMS for published left turns in holding as depicted on the low altitude chart which I had just checked for course verification. A more heads up attitude and avoidance of tendencies to lock in on a single problem would help to stop future incidents of this nature.
Original NASA ASRS Text
Title: ACR MLG ALT DEVIATION OVERSHOT DURING DESCENT, THEN ENTERED HOLDING PATTERN THE WRONG DIRECTION.
Narrative: IN CRUISE AT FL190 AND NBOUND ON V98 (DQN 359 DEG R/80 NM) ZOB CLRED US ON AN INTERCEPT HDG FOR V98 E OF PIONS INTXN. ALSO AT THIS TIME WE WERE CLRED TO DSND AND CROSS MIZAR INTXN AT 12000'. WE FORGOT THE DSNT CHKLIST AS WE MADE OUR TURN AND BEGAN THE DSNT (NOTE: ALTIMETER AT DTW 29.47). WE NOTICED A DISAGREEMENT BTWN THE FMS DISPLAY AND THE COURSE INDICATOR ON THE HSI. ABOUT 10 NM SW OF MIZAR, WHILE ATTEMPTING TO VERIFY WHICH COURSE DISPLAY WAS CORRECT, WE WERE GIVEN HOLDING INSTRUCTIONS AT MIZAR (AS PUBLISHED/12000'). WE LEVELED AT 12000' AND WERE ASKED BY ATC TO VERIFY OUR ALT. WE CHKED OUR ALTIMETERS STILL SET AT 29.92. AFTER RESETTING OUR ALTIMETERS TO 29.47 WE CLBED TO 12000' (WE WERE ACTUALLY AT 11650'). AS WE LEVELED OFF, WE BEGAN A RIGHT TURN IN HOLDING AS SHOWN ON THE FMS. ATC INFORMED US THAT HOLDING 'AS PUBLISHED' MEANT LEFT TURNS (WE HAD NEGLECTED TO ENTER LEFT TURNS INTO THE FMS DURING OUR CONFUSION). HOLDING WAS THEN TERMINATED BY ATC AND WE WERE VECTORED TO DTW. DISTR AND CONFUSION OVER THE CONFLICTING COURSE DISPLAYS WERE FACTORS LEADING TO A MISSED DSNT CHKLIST. THIS SNOWBALLED, ALONG WITH MY NEGLECTING TO PROPERLY PROGRAM THE FMS FOR PUBLISHED LEFT TURNS IN HOLDING AS DEPICTED ON THE LOW ALT CHART WHICH I HAD JUST CHKED FOR COURSE VERIFICATION. A MORE HEADS UP ATTITUDE AND AVOIDANCE OF TENDENCIES TO LOCK IN ON A SINGLE PROB WOULD HELP TO STOP FUTURE INCIDENTS OF THIS NATURE.
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.