37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 311017 |
Time | |
Date | 199507 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : rdu |
State Reference | NC |
Altitude | msl bound lower : 21000 msl bound upper : 22000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc tower : hgr |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 100 flight time total : 11000 flight time type : 100 |
ASRS Report | 311017 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 10500 flight time type : 150 |
ASRS Report | 310251 |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : overshoot altitude deviation : crossing restriction not met non adherence : clearance |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was the captain but not flying at the time. Center cleared us to FL220 by 10 mi north of phn VOR. The first officer (PF) set FL220 in the altitude window of the FCU but did not immediately pull or push the knob as it was still early for starting down. I then went off frequency to get ATIS and talk to our operations at rdu. While doing this, the first officer pushed the altitude knob to begin a 'managed' descent. After a moment or 2, I noticed on the navigation display we weren't going to make our FL220 at 10 mi north of hpw constraint. Then I noted that 21000 ft was now showing as the armed altitude on my pfd. I quickly glanced at the FCU altitude window, it said 21000 ft also. Having been off frequency and still needing to be off frequency. I assumed that we'd gotten a new clearance to FL210 and therefore the old constraint at 10 mi north of hpw was invalid and that 21000 ft was where we should be going. However, when I returned to the ATC frequency, my first officer said that there had been confusion about where we were cleared to, and that she had read back FL210 and center had said we had only been cleared to FL220 and then had cleared us to FL210 after the fact, so now we should stay at FL210. We couldn't figure out how it happened -- until the next day. We kept the same plane after our overnight. Twice, on the second day we saw the altitude window on the FCU change by 1000 ft when we pushed it to 'manage' descent to a lower altitude. So we set the altitude selector to 100 ft increments (to avoid 1000 ft changes hopefully) and wrote it up in the maintenance log. Callback conversation with reporter revealed the following information: as first officer, PF, began descent in order to make the ATC assigned altitude constraint of FL220, pushing the FCU altitude knob caused the altitude setting to change to FL210. At the time, pushing the managed descent knob, the first officer didn't notice the altitude change. The captain was obtaining ATIS and company communication, so was out of the loop. When the captain's attention was back in the cockpit, he saw that they were not going to make the altitude constraint and noting that the altitude now read FL210, assumed that a revised clearance had been received while he was 'off the air,' and, that the constraint was no longer valid. In the meantime, the first officer had heard a company aircraft with a similar call sign given a descent clearance to FL210 and the first officer said, 'I don't remember if I rogered their clearance by mistake or not, but assumed the FL210 set in the FCU was correct.' the flight crew continued the sequence in the same aircraft and then noted that the same thing happened when setting the FCU altitude and it changing when pushing the knob. It was written up, a captain report was sent to company, but reporter has had no further feedback from maintenance or company management.
Original NASA ASRS Text
Title: ACFT EQUIP PROB. FCU ALT AUTO-CHANGED WHEN PUSHING ALT KNOB. ALTDEV.
Narrative: I WAS THE CAPT BUT NOT FLYING AT THE TIME. CTR CLRED US TO FL220 BY 10 MI N OF PHN VOR. THE FO (PF) SET FL220 IN THE ALT WINDOW OF THE FCU BUT DID NOT IMMEDIATELY PULL OR PUSH THE KNOB AS IT WAS STILL EARLY FOR STARTING DOWN. I THEN WENT OFF FREQ TO GET ATIS AND TALK TO OUR OPS AT RDU. WHILE DOING THIS, THE FO PUSHED THE ALT KNOB TO BEGIN A 'MANAGED' DSCNT. AFTER A MOMENT OR 2, I NOTICED ON THE NAV DISPLAY WE WEREN'T GOING TO MAKE OUR FL220 AT 10 MI N OF HPW CONSTRAINT. THEN I NOTED THAT 21000 FT WAS NOW SHOWING AS THE ARMED ALT ON MY PFD. I QUICKLY GLANCED AT THE FCU ALT WINDOW, IT SAID 21000 FT ALSO. HAVING BEEN OFF FREQ AND STILL NEEDING TO BE OFF FREQ. I ASSUMED THAT WE'D GOTTEN A NEW CLRNC TO FL210 AND THEREFORE THE OLD CONSTRAINT AT 10 MI N OF HPW WAS INVALID AND THAT 21000 FT WAS WHERE WE SHOULD BE GOING. HOWEVER, WHEN I RETURNED TO THE ATC FREQ, MY FO SAID THAT THERE HAD BEEN CONFUSION ABOUT WHERE WE WERE CLRED TO, AND THAT SHE HAD READ BACK FL210 AND CTR HAD SAID WE HAD ONLY BEEN CLRED TO FL220 AND THEN HAD CLRED US TO FL210 AFTER THE FACT, SO NOW WE SHOULD STAY AT FL210. WE COULDN'T FIGURE OUT HOW IT HAPPENED -- UNTIL THE NEXT DAY. WE KEPT THE SAME PLANE AFTER OUR OVERNIGHT. TWICE, ON THE SECOND DAY WE SAW THE ALT WINDOW ON THE FCU CHANGE BY 1000 FT WHEN WE PUSHED IT TO 'MANAGE' DSCNT TO A LOWER ALT. SO WE SET THE ALT SELECTOR TO 100 FT INCREMENTS (TO AVOID 1000 FT CHANGES HOPEFULLY) AND WROTE IT UP IN THE MAINT LOG. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: AS FO, PF, BEGAN DSCNT IN ORDER TO MAKE THE ATC ASSIGNED ALT CONSTRAINT OF FL220, PUSHING THE FCU ALT KNOB CAUSED THE ALT SETTING TO CHANGE TO FL210. AT THE TIME, PUSHING THE MANAGED DSCNT KNOB, THE FO DIDN'T NOTICE THE ALT CHANGE. THE CAPT WAS OBTAINING ATIS AND COMPANY COM, SO WAS OUT OF THE LOOP. WHEN THE CAPT'S ATTN WAS BACK IN THE COCKPIT, HE SAW THAT THEY WERE NOT GOING TO MAKE THE ALT CONSTRAINT AND NOTING THAT THE ALT NOW READ FL210, ASSUMED THAT A REVISED CLRNC HAD BEEN RECEIVED WHILE HE WAS 'OFF THE AIR,' AND, THAT THE CONSTRAINT WAS NO LONGER VALID. IN THE MEANTIME, THE FO HAD HEARD A COMPANY ACFT WITH A SIMILAR CALL SIGN GIVEN A DSCNT CLRNC TO FL210 AND THE FO SAID, 'I DON'T REMEMBER IF I ROGERED THEIR CLRNC BY MISTAKE OR NOT, BUT ASSUMED THE FL210 SET IN THE FCU WAS CORRECT.' THE FLC CONTINUED THE SEQUENCE IN THE SAME ACFT AND THEN NOTED THAT THE SAME THING HAPPENED WHEN SETTING THE FCU ALT AND IT CHANGING WHEN PUSHING THE KNOB. IT WAS WRITTEN UP, A CAPT RPT WAS SENT TO COMPANY, BUT RPTR HAS HAD NO FURTHER FEEDBACK FROM MAINT OR COMPANY MGMNT.
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.