37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 242146 |
Time | |
Date | 199305 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : iad |
State Reference | VA |
Altitude | msl bound lower : 2800 msl bound upper : 3000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : iad artcc : czqm |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | descent : approach |
Route In Use | enroute : on vectors |
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 : 12000 |
ASRS Report | 242146 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : published procedure other anomaly other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : regained aircraft control |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was flying from frankfurt, germany, to iad. We had been airborne approximately 8 hours. We were under dulles approach. Due to area traffic congestion we were given numerous altitude, heading, and airspeed changes for sequencing. I was using the autoplt and autoflt panel to maintain speeds, altitudes, heading, dscnts. Plus I had to flap configure, clean up flaps and reconfigure during our maneuvering. On downwind, we were slowed and I was setting up the autoflt panel to use the autoplt and automatic throttles. In doing so, I thought that all was set and was looking out for ATC TA's. For whatever reason, I did not notice the airspeed go below the flap setting for 170 KTS. At approximately 145 KTS my scan caught the airspeed being low. I immediately applied full power, kicked off autoplt and noticed that during my quick recovery that no autothrottle alert light or flag was displayed. The point is that, if I did attempt to latch the autothrottles, that I did not verify so, as I had done several times prior during this approach phase. Altitude change was minimal, approximately plus 15 ft and I quickly hand flew it back to our assigned. As far as can be determined, there was no other discrepancy other than the 150 ft gain. The aircraft was well above stall speed, no stick shaker warning. Straight and level. My indication that something was not correct was the increased nose-up attitude which prompted my immediate application of power. In summary, during the numerous aircraft heading, altitude, flap, airspeed changes in a busy ATC environment including the fatigue of an 8 hour flight, that the distraction was my scan on the autoflt panel did not verify that when an attempt was made to latch the autothrottles, that indeed they were armed and operating. In addition, with a great amount of power being applied suddenly this can result in some uncomfortable feelings to some passenger due to the increase in noise and acceleration when they are expecting a landing. 2 passenger needed paramedic attention upon landing, one for an apparent seizure, etc, and the other unknown. It was heard but not confirmed that they were released approximately 30 mins after being deplaned, and as can happen, this can trigger some reactions among certain flyers. Although this report does not identify aviation system problems, it does reflect the possible effects of numerous autoflt inputs in a short period of time in a busy ATC environment after a long transatlantic crossing even when it appears all is going smoothly.
Original NASA ASRS Text
Title: WDB FLC ALLOWS AIRSPD TO DETERIORATE BELOW FLAP SETTING SPD. ABRUPT PWR INCREASE, PAX NEED MEDICAL ATTN.
Narrative: I WAS FLYING FROM FRANKFURT, GERMANY, TO IAD. WE HAD BEEN AIRBORNE APPROX 8 HRS. WE WERE UNDER DULLES APCH. DUE TO AREA TFC CONGESTION WE WERE GIVEN NUMEROUS ALT, HDG, AND AIRSPD CHANGES FOR SEQUENCING. I WAS USING THE AUTOPLT AND AUTOFLT PANEL TO MAINTAIN SPDS, ALTS, HDG, DSCNTS. PLUS I HAD TO FLAP CONFIGURE, CLEAN UP FLAPS AND RECONFIGURE DURING OUR MANEUVERING. ON DOWNWIND, WE WERE SLOWED AND I WAS SETTING UP THE AUTOFLT PANEL TO USE THE AUTOPLT AND AUTO THROTTLES. IN DOING SO, I THOUGHT THAT ALL WAS SET AND WAS LOOKING OUT FOR ATC TA'S. FOR WHATEVER REASON, I DID NOT NOTICE THE AIRSPD GO BELOW THE FLAP SETTING FOR 170 KTS. AT APPROX 145 KTS MY SCAN CAUGHT THE AIRSPD BEING LOW. I IMMEDIATELY APPLIED FULL PWR, KICKED OFF AUTOPLT AND NOTICED THAT DURING MY QUICK RECOVERY THAT NO AUTOTHROTTLE ALERT LIGHT OR FLAG WAS DISPLAYED. THE POINT IS THAT, IF I DID ATTEMPT TO LATCH THE AUTOTHROTTLES, THAT I DID NOT VERIFY SO, AS I HAD DONE SEVERAL TIMES PRIOR DURING THIS APCH PHASE. ALT CHANGE WAS MINIMAL, APPROX PLUS 15 FT AND I QUICKLY HAND FLEW IT BACK TO OUR ASSIGNED. AS FAR AS CAN BE DETERMINED, THERE WAS NO OTHER DISCREPANCY OTHER THAN THE 150 FT GAIN. THE ACFT WAS WELL ABOVE STALL SPD, NO STICK SHAKER WARNING. STRAIGHT AND LEVEL. MY INDICATION THAT SOMETHING WAS NOT CORRECT WAS THE INCREASED NOSE-UP ATTITUDE WHICH PROMPTED MY IMMEDIATE APPLICATION OF PWR. IN SUMMARY, DURING THE NUMEROUS ACFT HDG, ALT, FLAP, AIRSPD CHANGES IN A BUSY ATC ENVIRONMENT INCLUDING THE FATIGUE OF AN 8 HR FLT, THAT THE DISTR WAS MY SCAN ON THE AUTOFLT PANEL DID NOT VERIFY THAT WHEN AN ATTEMPT WAS MADE TO LATCH THE AUTOTHROTTLES, THAT INDEED THEY WERE ARMED AND OPERATING. IN ADDITION, WITH A GREAT AMOUNT OF PWR BEING APPLIED SUDDENLY THIS CAN RESULT IN SOME UNCOMFORTABLE FEELINGS TO SOME PAX DUE TO THE INCREASE IN NOISE AND ACCELERATION WHEN THEY ARE EXPECTING A LNDG. 2 PAX NEEDED PARAMEDIC ATTN UPON LNDG, ONE FOR AN APPARENT SEIZURE, ETC, AND THE OTHER UNKNOWN. IT WAS HEARD BUT NOT CONFIRMED THAT THEY WERE RELEASED APPROX 30 MINS AFTER BEING DEPLANED, AND AS CAN HAPPEN, THIS CAN TRIGGER SOME REACTIONS AMONG CERTAIN FLYERS. ALTHOUGH THIS RPT DOES NOT IDENT AVIATION SYS PROBS, IT DOES REFLECT THE POSSIBLE EFFECTS OF NUMEROUS AUTOFLT INPUTS IN A SHORT PERIOD OF TIME IN A BUSY ATC ENVIRONMENT AFTER A LONG TRANSATLANTIC XING EVEN WHEN IT APPEARS ALL IS GOING SMOOTHLY.
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.