37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 338760 |
Time | |
Date | 199605 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : mkg |
State Reference | MI |
Altitude | msl bound lower : 23000 msl bound upper : 25500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zau |
Operator | common carrier : air carrier |
Make Model Name | DC-10 30 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 90 flight time total : 5700 flight time type : 90 |
ASRS Report | 338760 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : crossing restriction not met non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were cleared pilot's discretion from FL350 to FL230, I believe. I started a 2500 FPM descent rate about 36 mi from the crossing restr of giber at FL230. Once we were in the descent, I planned to increase to 3000 FPM to 3500 FPM. We had been using the autoplt #1 the entire flight due to the #2 not tracking INS position. We just switched to #2 autoplt and was tracking VOR. The HSI in this aircraft shows INS mi on the top corners. Although I was tracking VOR I was using the DME from the INS on the top left which is the captain's #1 INS mileage. That was a habit from using it the entire flight. What I didn't realize was the captain had a different position than giber programmed in. I should have noticed the difference in DME from VOR and INS but did not, assuming we had the correct INS position acquired. That had been a change in our clearance some time earlier from the south arrival into dtw to the north arrival. Giber was not programmed in until the crossing restr was given. Evidently it was programmed only on the first officer side. The INS position still showed 11 mi to giber when chicago announced we passed giber at about 2500 ft above the crossing altitude. We told him our INS showed 11 mi to go and checked VOR/DME which showed we had passed giber. We were confused, thinking the INS were malfunctioning we used VOR/DME the remainder of the flight. When we landed and parked and went back over everything we realized our mistake of using an INS/DME that was not the point in the clearance. Some contributing factors: I had just flown a captain trip 2 or 3 days prior, so I had been using the l-hand DME. We had been using autoplt #1 which is tied to INS #1 for the entire flight up to that point but changed since I was now hand flying the aircraft. We relaxed and did not insure both #1 and #2 INS's were loaded the same which led me not to check the VOR/DME as a backup. To correct this increased diligence to backup position by any means and fight complacency. It would also help if all our DC10's had the same panel confign, although that is a very small item in this instance.
Original NASA ASRS Text
Title: XING RESTR NOT MET DUE TO IMPROPER COCKPIT INST NAV INFO. INTERMIX OF INS ON ONE PLT'S DISPLAY AND VOR ON THE OTHER PLUS THE AUTOPLTS TIED TO EACH CAUSED CONFUSION AND COMPLACENCY.
Narrative: WE WERE CLRED PLT'S DISCRETION FROM FL350 TO FL230, I BELIEVE. I STARTED A 2500 FPM DSCNT RATE ABOUT 36 MI FROM THE XING RESTR OF GIBER AT FL230. ONCE WE WERE IN THE DSCNT, I PLANNED TO INCREASE TO 3000 FPM TO 3500 FPM. WE HAD BEEN USING THE AUTOPLT #1 THE ENTIRE FLT DUE TO THE #2 NOT TRACKING INS POS. WE JUST SWITCHED TO #2 AUTOPLT AND WAS TRACKING VOR. THE HSI IN THIS ACFT SHOWS INS MI ON THE TOP CORNERS. ALTHOUGH I WAS TRACKING VOR I WAS USING THE DME FROM THE INS ON THE TOP L WHICH IS THE CAPT'S #1 INS MILEAGE. THAT WAS A HABIT FROM USING IT THE ENTIRE FLT. WHAT I DIDN'T REALIZE WAS THE CAPT HAD A DIFFERENT POS THAN GIBER PROGRAMMED IN. I SHOULD HAVE NOTICED THE DIFFERENCE IN DME FROM VOR AND INS BUT DID NOT, ASSUMING WE HAD THE CORRECT INS POS ACQUIRED. THAT HAD BEEN A CHANGE IN OUR CLRNC SOME TIME EARLIER FROM THE S ARR INTO DTW TO THE N ARR. GIBER WAS NOT PROGRAMMED IN UNTIL THE XING RESTR WAS GIVEN. EVIDENTLY IT WAS PROGRAMMED ONLY ON THE FO SIDE. THE INS POS STILL SHOWED 11 MI TO GIBER WHEN CHICAGO ANNOUNCED WE PASSED GIBER AT ABOUT 2500 FT ABOVE THE XING ALT. WE TOLD HIM OUR INS SHOWED 11 MI TO GO AND CHKED VOR/DME WHICH SHOWED WE HAD PASSED GIBER. WE WERE CONFUSED, THINKING THE INS WERE MALFUNCTIONING WE USED VOR/DME THE REMAINDER OF THE FLT. WHEN WE LANDED AND PARKED AND WENT BACK OVER EVERYTHING WE REALIZED OUR MISTAKE OF USING AN INS/DME THAT WAS NOT THE POINT IN THE CLRNC. SOME CONTRIBUTING FACTORS: I HAD JUST FLOWN A CAPT TRIP 2 OR 3 DAYS PRIOR, SO I HAD BEEN USING THE L-HAND DME. WE HAD BEEN USING AUTOPLT #1 WHICH IS TIED TO INS #1 FOR THE ENTIRE FLT UP TO THAT POINT BUT CHANGED SINCE I WAS NOW HAND FLYING THE ACFT. WE RELAXED AND DID NOT INSURE BOTH #1 AND #2 INS'S WERE LOADED THE SAME WHICH LED ME NOT TO CHK THE VOR/DME AS A BACKUP. TO CORRECT THIS INCREASED DILIGENCE TO BACKUP POS BY ANY MEANS AND FIGHT COMPLACENCY. IT WOULD ALSO HELP IF ALL OUR DC10'S HAD THE SAME PANEL CONFIGN, ALTHOUGH THAT IS A VERY SMALL ITEM IN THIS INSTANCE.
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.