 |
37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Altitude deviation altitude excursion. Aircraft equipment problem in a night operation. In-flight engine shutdown.
| Attributes | |
| ACN | 311904 |
| Time | |
| Date | 199505 |
| Day | Wed |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : lax |
| State Reference | CA |
| Altitude | msl bound lower : 1600 msl bound upper : 2500 |
| Environment | |
| Flight Conditions | VMC |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tower : lax |
| Operator | common carrier : air carrier |
| Make Model Name | Commercial Fixed Wing |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other 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 : 150 flight time total : 7900 flight time type : 1000 |
| ASRS Report | 311904 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Events | |
| Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude non adherence : far non adherence : published procedure non adherence : clearance other anomaly other |
| Independent Detector | atc equipment other atc equipment : unspecified other controllera other flight crewa |
| Resolutory Action | flight crew : declared emergency flight crew : returned to intended course or assigned course other |
| Consequence | other |
| Supplementary | |
| Primary Problem | Aircraft |
| Air Traffic Incident | Pilot Deviation |
Narrative:
All phases of flight leading up to incident were normal. Aircraft was cleared to 'fly heading 220 degrees, maintain 2000 ft, and cleared for ILS runway 25L.' at approximately 2500 ft, I had just disconnected the autoplt to hand fly the approach (disconnect alert was still sounding). Simultaneously we heard a loud bang, and the aircraft shuddered. Our initial belief was that we had struck something. It was at that time the master caution light illuminated and we received an engine 1, 'N1' lo alert. I scanned the other engine parameters and they indicated that the engine had seized. The initial shock and disbelief that we had a possible midair and a definite seized engine caused a momentary breakdown in cockpit resource management, both pilots were making inputs to the flight guidance panel. The altitude alert was mistakenly reset to 1400 ft. I failed to notice this, and was following the flight director, while diverting some attention to the engine seizure checklist. Neither pilot noticed that we had gone through 2000 ft until advised by lax tower. The descent was arrested at 1600 ft. I climbed back to 2000 ft, and the remainder of the approach and landing was normal. Unfortunately, this incident would not have happened if cockpit resource management had been maintained. We all need to be able to allow the non-flying crewmembers to complete the appropriate procedures, while we fly the aircraft.
Original NASA ASRS Text
Title: ALTDEV ALT EXCURSION. ACFT EQUIP PROB IN A NIGHT OP. INFLT ENG SHUTDOWN.
Narrative: ALL PHASES OF FLT LEADING UP TO INCIDENT WERE NORMAL. ACFT WAS CLRED TO 'FLY HDG 220 DEGS, MAINTAIN 2000 FT, AND CLRED FOR ILS RWY 25L.' AT APPROX 2500 FT, I HAD JUST DISCONNECTED THE AUTOPLT TO HAND FLY THE APCH (DISCONNECT ALERT WAS STILL SOUNDING). SIMULTANEOUSLY WE HEARD A LOUD BANG, AND THE ACFT SHUDDERED. OUR INITIAL BELIEF WAS THAT WE HAD STRUCK SOMETHING. IT WAS AT THAT TIME THE MASTER CAUTION LIGHT ILLUMINATED AND WE RECEIVED AN ENG 1, 'N1' LO ALERT. I SCANNED THE OTHER ENG PARAMETERS AND THEY INDICATED THAT THE ENG HAD SEIZED. THE INITIAL SHOCK AND DISBELIEF THAT WE HAD A POSSIBLE MIDAIR AND A DEFINITE SEIZED ENG CAUSED A MOMENTARY BREAKDOWN IN COCKPIT RESOURCE MGMNT, BOTH PLTS WERE MAKING INPUTS TO THE FLT GUIDANCE PANEL. THE ALT ALERT WAS MISTAKENLY RESET TO 1400 FT. I FAILED TO NOTICE THIS, AND WAS FOLLOWING THE FLT DIRECTOR, WHILE DIVERTING SOME ATTN TO THE ENG SEIZURE CHKLIST. NEITHER PLT NOTICED THAT WE HAD GONE THROUGH 2000 FT UNTIL ADVISED BY LAX TWR. THE DSCNT WAS ARRESTED AT 1600 FT. I CLBED BACK TO 2000 FT, AND THE REMAINDER OF THE APCH AND LNDG WAS NORMAL. UNFORTUNATELY, THIS INCIDENT WOULD NOT HAVE HAPPENED IF COCKPIT RESOURCE MGMNT HAD BEEN MAINTAINED. WE ALL NEED TO BE ABLE TO ALLOW THE NON-FLYING CREWMEMBERS TO COMPLETE THE APPROPRIATE PROCS, WHILE WE FLY THE ACFT.
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.