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Air carrier medium large transport aircraft deviation from prescribed holding pattern turn track due to mishandling circuit breakers while correcting another problem.
| Attributes | |
| ACN | 227145 |
| Time | |
| Date | 199211 |
| Day | Tue |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | atc facility : esl |
| State Reference | WV |
| Altitude | msl bound lower : 15000 msl bound upper : 15000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | artcc : zdc |
| Operator | common carrier : air carrier |
| Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
| Navigation In Use | Other Other |
| Flight Phase | other |
| Route In Use | arrival other arrival star : star |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 100 flight time total : 11200 flight time type : 170 |
| ASRS Report | 227145 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | aircraft equipment problem : critical non adherence : clearance other anomaly other other spatial deviation |
| Independent Detector | atc equipment other atc equipment : unspecified other controllera other flight crewa |
| Resolutory Action | flight crew : overcame equipment problem flight crew : returned to intended course or assigned course |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Prior to departure, maintenance was working to repair overhead panel rheostat. After engine start and taxi out, overhead panel rheostat worked normally, but aisle stand flood light could not be dimmed or switched off and was full bright. Attempted to locate circuit breaker prior to takeoff, but couldn't, and elected to try to find it in cruise. Finally located, pulled breaker during descent on the bucko 3 arrival into dca. During this time I was out of my seat and captain was flying with headset on and cockpit speakers off. Upon returning to my seat aircraft was just leveling at 15000 ft decelerating from 220 to 210 holding speed about 2 mi from intersection. The autothrottles did not advance at all. Captain applied power aggressively and we regained lost speed. Aircraft had begun its turn into the hold while this speed event was occurring. Now established on the outbound leg and checking the STAR chart, the aircraft had made a right holding pattern instead of the depicted one to the left. We turned the aircraft right, back to the fix to correct the error. ATC called to ask if we had made a right turn. The captain gave a brief explanation. The captain's CDU was still on the hold page from when he'd initially programmed the hold and all entered data was correct including left for turn direction of hold yet navigation CRT's showed right turn holding patterns. Captain reentered hold 3 more times with left turns and 3 times the CRT depicted right turn patterns. Only on the fourth attempt did the left turn pattern appear. A simple malfunctioning floodlight with a difficult to find circuit breaker started this easily preventable mistake. Had we taken a few more mins prior to takeoff to locate and pull the circuit breakers, there would have been 2 pilots monitoring the flight to catch the error of contradiction between FMC and CRT and the autothrottle's lack of response.
Original NASA ASRS Text
Title: ACR MLG ACFT DEV FROM PRESCRIBED HOLDING PATTERN TURN TRACK DUE TO MISHANDLING CIRCUIT BREAKERS WHILE CORRECTING ANOTHER PROBLEM.
Narrative: PRIOR TO DEP, MAINT WAS WORKING TO REPAIR OVERHEAD PANEL RHEOSTAT. AFTER ENG START AND TAXI OUT, OVERHEAD PANEL RHEOSTAT WORKED NORMALLY, BUT AISLE STAND FLOOD LIGHT COULD NOT BE DIMMED OR SWITCHED OFF AND WAS FULL BRIGHT. ATTEMPTED TO LOCATE CIRCUIT BREAKER PRIOR TO TKOF, BUT COULDN'T, AND ELECTED TO TRY TO FIND IT IN CRUISE. FINALLY LOCATED, PULLED BREAKER DURING DSCNT ON THE BUCKO 3 ARR INTO DCA. DURING THIS TIME I WAS OUT OF MY SEAT AND CAPT WAS FLYING WITH HEADSET ON AND COCKPIT SPEAKERS OFF. UPON RETURNING TO MY SEAT ACFT WAS JUST LEVELING AT 15000 FT DECELERATING FROM 220 TO 210 HOLDING SPD ABOUT 2 MI FROM INTXN. THE AUTOTHROTTLES DID NOT ADVANCE AT ALL. CAPT APPLIED PWR AGGRESSIVELY AND WE REGAINED LOST SPD. ACFT HAD BEGUN ITS TURN INTO THE HOLD WHILE THIS SPD EVENT WAS OCCURRING. NOW ESTABLISHED ON THE OUTBOUND LEG AND CHKING THE STAR CHART, THE ACFT HAD MADE A R HOLDING PATTERN INSTEAD OF THE DEPICTED ONE TO THE L. WE TURNED THE ACFT R, BACK TO THE FIX TO CORRECT THE ERROR. ATC CALLED TO ASK IF WE HAD MADE A R TURN. THE CAPT GAVE A BRIEF EXPLANATION. THE CAPT'S CDU WAS STILL ON THE HOLD PAGE FROM WHEN HE'D INITIALLY PROGRAMMED THE HOLD AND ALL ENTERED DATA WAS CORRECT INCLUDING L FOR TURN DIRECTION OF HOLD YET NAV CRT'S SHOWED R TURN HOLDING PATTERNS. CAPT REENTERED HOLD 3 MORE TIMES WITH L TURNS AND 3 TIMES THE CRT DEPICTED R TURN PATTERNS. ONLY ON THE FOURTH ATTEMPT DID THE L TURN PATTERN APPEAR. A SIMPLE MALFUNCTIONING FLOODLIGHT WITH A DIFFICULT TO FIND CIRCUIT BREAKER STARTED THIS EASILY PREVENTABLE MISTAKE. HAD WE TAKEN A FEW MORE MINS PRIOR TO TKOF TO LOCATE AND PULL THE CIRCUIT BREAKERS, THERE WOULD HAVE BEEN 2 PLTS MONITORING THE FLT TO CATCH THE ERROR OF CONTRADICTION BTWN FMC AND CRT AND THE AUTOTHROTTLE'S LACK OF RESPONSE.
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.