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|
Attributes | |
ACN | 223697 |
Time | |
Date | 199210 |
Day | Fri |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | atc facility : czqx |
State Reference | NF |
Altitude | msl bound lower : 31000 msl bound upper : 31000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : czqx tracon : bur |
Operator | common carrier : air carrier |
Make Model Name | Heavy Transport, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Route In Use | enroute : atlantic enroute : other oceanic enroute other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer observation : company check pilot oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 130 flight time total : 12500 flight time type : 5800 |
ASRS Report | 223697 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain instruction : trainee |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : clearance other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : became reoriented flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Aircraft was discovered off course to the north. A turn south was made. Shortly thereafter, I checked the 'cross-track' on #2 INS and found it to be 20 mi left. I would estimate total off course error was 25-030 mi. Intending course at the time was wbound from 57 degree north 30 degree west to 55 degree north 40 degree west. Autoplt was discovered to have defaulted from 'navigation' mode to 'heading' mode. Heading bug was set approximately 30 degree right of intended course. Aircraft was plotted on course at a position of approximately 56 degree 40 min north 32 degree 00 west about 10 mins prior to incident. Autoplt will default from 'navigation' to 'heading' during a course transfer on EFIS course/heading panel, but this function wasn't accomplished, so I have no idea how autoplt got to heading mode. Normal procedure calls for one INS to remain in 'course' page for a readout of track error (distance from track centerline) I was conducting IOE training at the time and going over various functions of both INS units; catalogs, data pages, etc, so neither INS was in course page. On analog type aircraft HSI needle would be full scale deflection before being 10 mi off course. On EFIS presentation in 'map' mode and 600 mi scale 20 mi off course is hardly noticeable. My flight director was showing a command to turn left, but this is not unusual when the opposite side INS is controling the autoplt. An analog aircraft if the autoplt defaults from 'auxiliary navigation' (INS controling autoplt) it goes to 'turn nob' -- which maintains current heading. On EFIS aircraft a default goes to 'heading' which, depending on bug setting, can cause a rapid departure from intended course, as happened to us. I believe increasing crew awareness to the fact that an 'off-course' situation will not be displayed in the same dramatic fashion on EFIS aircraft as on analog type displays is important. I also believe crews transitioning to EFIS equipment should be aware of the importance of scanning ADI navigation mode displays which show what is controling the autoplt. My own inexperience on EFIS aircraft (approximately 100 hours) contributed to this incident.
Original NASA ASRS Text
Title: HDG TRACK DEV IN AN OVERWATER OP DEVELOPS INTO A GROSS NAV ERROR. POS DEV.
Narrative: ACFT WAS DISCOVERED OFF COURSE TO THE N. A TURN S WAS MADE. SHORTLY THEREAFTER, I CHKED THE 'CROSS-TRACK' ON #2 INS AND FOUND IT TO BE 20 MI L. I WOULD ESTIMATE TOTAL OFF COURSE ERROR WAS 25-030 MI. INTENDING COURSE AT THE TIME WAS WBOUND FROM 57 DEG N 30 DEG W TO 55 DEG N 40 DEG W. AUTOPLT WAS DISCOVERED TO HAVE DEFAULTED FROM 'NAV' MODE TO 'HDG' MODE. HDG BUG WAS SET APPROX 30 DEG R OF INTENDED COURSE. ACFT WAS PLOTTED ON COURSE AT A POS OF APPROX 56 DEG 40 MIN N 32 DEG 00 W ABOUT 10 MINS PRIOR TO INCIDENT. AUTOPLT WILL DEFAULT FROM 'NAV' TO 'HDG' DURING A COURSE TRANSFER ON EFIS COURSE/HDG PANEL, BUT THIS FUNCTION WASN'T ACCOMPLISHED, SO I HAVE NO IDEA HOW AUTOPLT GOT TO HDG MODE. NORMAL PROC CALLS FOR ONE INS TO REMAIN IN 'COURSE' PAGE FOR A READOUT OF TRACK ERROR (DISTANCE FROM TRACK CTRLINE) I WAS CONDUCTING IOE TRAINING AT THE TIME AND GOING OVER VARIOUS FUNCTIONS OF BOTH INS UNITS; CATALOGS, DATA PAGES, ETC, SO NEITHER INS WAS IN COURSE PAGE. ON ANALOG TYPE ACFT HSI NEEDLE WOULD BE FULL SCALE DEFLECTION BEFORE BEING 10 MI OFF COURSE. ON EFIS PRESENTATION IN 'MAP' MODE AND 600 MI SCALE 20 MI OFF COURSE IS HARDLY NOTICEABLE. MY FLT DIRECTOR WAS SHOWING A COMMAND TO TURN L, BUT THIS IS NOT UNUSUAL WHEN THE OPPOSITE SIDE INS IS CTLING THE AUTOPLT. AN ANALOG ACFT IF THE AUTOPLT DEFAULTS FROM 'AUX NAV' (INS CTLING AUTOPLT) IT GOES TO 'TURN NOB' -- WHICH MAINTAINS CURRENT HDG. ON EFIS ACFT A DEFAULT GOES TO 'HDG' WHICH, DEPENDING ON BUG SETTING, CAN CAUSE A RAPID DEP FROM INTENDED COURSE, AS HAPPENED TO US. I BELIEVE INCREASING CREW AWARENESS TO THE FACT THAT AN 'OFF-COURSE' SITUATION WILL NOT BE DISPLAYED IN THE SAME DRAMATIC FASHION ON EFIS ACFT AS ON ANALOG TYPE DISPLAYS IS IMPORTANT. I ALSO BELIEVE CREWS TRANSITIONING TO EFIS EQUIP SHOULD BE AWARE OF THE IMPORTANCE OF SCANNING ADI NAV MODE DISPLAYS WHICH SHOW WHAT IS CTLING THE AUTOPLT. MY OWN INEXPERIENCE ON EFIS ACFT (APPROX 100 HRS) CONTRIBUTED TO THIS INCIDENT.
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.