37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 193405 |
Time | |
Date | 199111 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : vhp airport : ind |
State Reference | IN |
Altitude | msl bound lower : 11000 msl bound upper : 18000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : ord |
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 | enroute airway : zid enroute 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 : 150 flight time total : 8000 flight time type : 850 |
ASRS Report | 193405 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 220 flight time total : 9000 flight time type : 1500 |
ASRS Report | 193572 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot 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:
Flight from lax-ind. Approaching indianapolis on RNAV with clearance to descend to 240 with crossing restriction. During descent copilot disconnected autoplt because of a stabilizer out of trim light and manually leveled at 240. I went off frequency to get ATIS. When I returned, first officer had reengaged autoplt and stated center had cleared us to 'cross 35 from indianapolis at 11000.' he then programmed the FMC for the crossing restriction using down trk fix mode from ind. Shortly thereafter, during the descent, we noticed the DME to the crossing fix was moving from 35 to 34, so first officer reprogrammed it again. Center inquired if we were going to make the crossing restriction. The FMC showed us well within parameters on both descent and legs pages, so I asked the center how far he showed us from the crossing fix. He stated he showed us '35 mi from the indianapolis VOR.' we were passing 18000 ft at that time, and I stated we could not make it, and we were tracking to kind (as cleared) vice vhp. He stated that he had cleared us to cross from vhp, and to drop the restriction. The aircraft then began an uncommanded left turn, during which the controller issued a correction to make a right 270 degree turn. After we landed, we realized that 2 things occurred. We were given a VORTAC crossing not colocated with our assigned destination, and the first officer had inadvertently placed the down trk fix behind, rather than in front of, an interim fix (kelly), causing an approximately 12-15 mi error, and also the uncommand turn as the FMC attempted to return to crossing fix after kelly. This was clearly a case of pilot overload for the first officer, with no backup from me at a time when it was needed. The first officer did not hear the clearance to 'indianapolis VOR', and since vhp was not on our flight plan, had no reason to assume a crossing restriction would be issued from it. I was not on frequency to back him up. When I did get back, we became absorbed in programming/reprogramming FMC, which was programmed incorrectly, while doing arrival checklist, discussing the stabilizer trim light, and discussing the approach. In retrospect, the prudent action would have been for the PNF (me) to go to a manual backup mode, and allow the PF to handle the FMC chores (autoplt engaged). 2 heads buried in the FMC was not better than 1, particularly when 1 (mine) was not in the loop when clearance issued. If vortacs are not colocated, don't issue crossing restrictions from them unless they are part of the navigation process. Better still, change the names.
Original NASA ASRS Text
Title: ACR MLG ALTDEV UNDERSHOT ALT XING RESTRICTION.
Narrative: FLT FROM LAX-IND. APCHING INDIANAPOLIS ON RNAV WITH CLRNC TO DSND TO 240 WITH XING RESTRICTION. DURING DSCNT COPLT DISCONNECTED AUTOPLT BECAUSE OF A STABILIZER OUT OF TRIM LIGHT AND MANUALLY LEVELED AT 240. I WENT OFF FREQ TO GET ATIS. WHEN I RETURNED, FO HAD REENGAGED AUTOPLT AND STATED CENTER HAD CLRED US TO 'CROSS 35 FROM INDIANAPOLIS AT 11000.' HE THEN PROGRAMMED THE FMC FOR THE XING RESTRICTION USING DOWN TRK FIX MODE FROM IND. SHORTLY THEREAFTER, DURING THE DSCNT, WE NOTICED THE DME TO THE XING FIX WAS MOVING FROM 35 TO 34, SO FO REPROGRAMMED IT AGAIN. CENTER INQUIRED IF WE WERE GOING TO MAKE THE XING RESTRICTION. THE FMC SHOWED US WELL WITHIN PARAMETERS ON BOTH DSCNT AND LEGS PAGES, SO I ASKED THE CENTER HOW FAR HE SHOWED US FROM THE XING FIX. HE STATED HE SHOWED US '35 MI FROM THE INDIANAPOLIS VOR.' WE WERE PASSING 18000 FT AT THAT TIME, AND I STATED WE COULD NOT MAKE IT, AND WE WERE TRACKING TO KIND (AS CLRED) VICE VHP. HE STATED THAT HE HAD CLRED US TO CROSS FROM VHP, AND TO DROP THE RESTRICTION. THE ACFT THEN BEGAN AN UNCOMMANDED L TURN, DURING WHICH THE CTLR ISSUED A CORRECTION TO MAKE A R 270 DEG TURN. AFTER WE LANDED, WE REALIZED THAT 2 THINGS OCCURRED. WE WERE GIVEN A VORTAC XING NOT COLOCATED WITH OUR ASSIGNED DEST, AND THE FO HAD INADVERTENTLY PLACED THE DOWN TRK FIX BEHIND, RATHER THAN IN FRONT OF, AN INTERIM FIX (KELLY), CAUSING AN APPROX 12-15 MI ERROR, AND ALSO THE UNCOMMAND TURN AS THE FMC ATTEMPTED TO RETURN TO XING FIX AFTER KELLY. THIS WAS CLRLY A CASE OF PLT OVERLOAD FOR THE FO, WITH NO BACKUP FROM ME AT A TIME WHEN IT WAS NEEDED. THE FO DID NOT HEAR THE CLRNC TO 'INDIANAPOLIS VOR', AND SINCE VHP WAS NOT ON OUR FLT PLAN, HAD NO REASON TO ASSUME A XING RESTRICTION WOULD BE ISSUED FROM IT. I WAS NOT ON FREQ TO BACK HIM UP. WHEN I DID GET BACK, WE BECAME ABSORBED IN PROGRAMMING/REPROGRAMMING FMC, WHICH WAS PROGRAMMED INCORRECTLY, WHILE DOING ARR CHKLIST, DISCUSSING THE STABILIZER TRIM LIGHT, AND DISCUSSING THE APCH. IN RETROSPECT, THE PRUDENT ACTION WOULD HAVE BEEN FOR THE PNF (ME) TO GO TO A MANUAL BACKUP MODE, AND ALLOW THE PF TO HANDLE THE FMC CHORES (AUTOPLT ENGAGED). 2 HEADS BURIED IN THE FMC WAS NOT BETTER THAN 1, PARTICULARLY WHEN 1 (MINE) WAS NOT IN THE LOOP WHEN CLRNC ISSUED. IF VORTACS ARE NOT COLOCATED, DON'T ISSUE XING RESTRICTIONS FROM THEM UNLESS THEY ARE PART OF THE NAV PROCESS. BETTER STILL, CHANGE THE NAMES.
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.