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|
Attributes | |
ACN | 201659 |
Time | |
Date | 199202 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : fwa |
State Reference | IN |
Altitude | msl bound lower : 31000 msl bound upper : 31000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zau tower : cvg |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | cruise 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 : 120 flight time total : 4000 flight time type : 475 |
ASRS Report | 201659 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : clearance non adherence : far other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were clrd for the oxi 2 arrival, fwa transition to ord, first officer flying the airplane. After passing fwa, both master caution lights on our medium large transport came on and remained lit until they were reset. The overhead annunciation panel was washed out by bright sunlight, making it difficult to find illuminated system malfunction lights. The first officer and I both strained to see if any annunciator light was lit, and to find evidence of any other aircraft malfunction. No system abnormality or other malfunction was found. (The aircraft logbook had several related entries which had been addressed by placarding one of the overhead annunciator lights. The 'flashing' of the master caution lights was not directly addressed by maintenance action). After concluding that the steady illumination of the caution lights was a nuisance warning, I began to consider how I would write the logbook entry to ensure that this problem would be repaired. The first officer had become involved in assessing the problem and then in joining me in my deliberations about the logbook entry. Although we had tuned the oxi 095 degree radial for the turn at spann intersection, we failed to turn because of our distraction. At fwa 40 DME I noticed our divergence and had the first officer turn to heading 230. To intercept the course (oxi 275 degree inbound). Next, we received an ACARS message to call center on a new frequency as soon as possible. The first officer and I do not believe that we missed a radio call, even though we were distraction and were off course. We called the new frequency and received a new clearance. I believe that my failure to monitor the first officer's navigation while I investigated possible aircraft abnormalities was the most important consideration in this occurrence. Also, I should have instructed him to focus solely on flying and navigation while I researched the problem. Secondary factors: repeated failure of maintenance to remedy a serious pilot distraction even though MEL requirements were arguably met. Crew fatigue and 'last flight of the trip' complacency. Relative inexperience of captain. And first officer in these crew conditions.
Original NASA ASRS Text
Title: HDG TRACK DEV.
Narrative: WE WERE CLRD FOR THE OXI 2 ARR, FWA TRANSITION TO ORD, FO FLYING THE AIRPLANE. AFTER PASSING FWA, BOTH MASTER CAUTION LIGHTS ON OUR MLG CAME ON AND REMAINED LIT UNTIL THEY WERE RESET. THE OVERHEAD ANNUNCIATION PANEL WAS WASHED OUT BY BRIGHT SUNLIGHT, MAKING IT DIFFICULT TO FIND ILLUMINATED SYS MALFUNCTION LIGHTS. THE FO AND I BOTH STRAINED TO SEE IF ANY ANNUNCIATOR LIGHT WAS LIT, AND TO FIND EVIDENCE OF ANY OTHER ACFT MALFUNCTION. NO SYS ABNORMALITY OR OTHER MALFUNCTION WAS FOUND. (THE ACFT LOGBOOK HAD SEVERAL RELATED ENTRIES WHICH HAD BEEN ADDRESSED BY PLACARDING ONE OF THE OVERHEAD ANNUNCIATOR LIGHTS. THE 'FLASHING' OF THE MASTER CAUTION LIGHTS WAS NOT DIRECTLY ADDRESSED BY MAINT ACTION). AFTER CONCLUDING THAT THE STEADY ILLUMINATION OF THE CAUTION LIGHTS WAS A NUISANCE WARNING, I BEGAN TO CONSIDER HOW I WOULD WRITE THE LOGBOOK ENTRY TO ENSURE THAT THIS PROBLEM WOULD BE REPAIRED. THE FO HAD BECOME INVOLVED IN ASSESSING THE PROBLEM AND THEN IN JOINING ME IN MY DELIBERATIONS ABOUT THE LOGBOOK ENTRY. ALTHOUGH WE HAD TUNED THE OXI 095 DEG RADIAL FOR THE TURN AT SPANN INTXN, WE FAILED TO TURN BECAUSE OF OUR DISTR. AT FWA 40 DME I NOTICED OUR DIVERGENCE AND HAD THE FO TURN TO HDG 230. TO INTERCEPT THE COURSE (OXI 275 DEG INBOUND). NEXT, WE RECEIVED AN ACARS MESSAGE TO CALL CTR ON A NEW FREQ ASAP. THE FO AND I DO NOT BELIEVE THAT WE MISSED A RADIO CALL, EVEN THOUGH WE WERE DISTR AND WERE OFF COURSE. WE CALLED THE NEW FREQ AND RECEIVED A NEW CLRNC. I BELIEVE THAT MY FAILURE TO MONITOR THE FO'S NAV WHILE I INVESTIGATED POSSIBLE ACFT ABNORMALITIES WAS THE MOST IMPORTANT CONSIDERATION IN THIS OCCURRENCE. ALSO, I SHOULD HAVE INSTRUCTED HIM TO FOCUS SOLELY ON FLYING AND NAV WHILE I RESEARCHED THE PROBLEM. SECONDARY FACTORS: REPEATED FAILURE OF MAINT TO REMEDY A SERIOUS PLT DISTR EVEN THOUGH MEL REQUIREMENTS WERE ARGUABLY MET. CREW FATIGUE AND 'LAST FLT OF THE TRIP' COMPLACENCY. RELATIVE INEXPERIENCE OF CAPT. AND FO IN THESE CREW CONDITIONS.
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.