37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 354826 |
Time | |
Date | 199612 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : las airport : lax |
State Reference | CA |
Altitude | msl bound lower : 7300 msl bound upper : 8000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : lax |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent : approach descent 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 : 200 flight time total : 6000 flight time type : 500 |
ASRS Report | 354826 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 135 flight time total : 17700 flight time type : 630 |
ASRS Report | 354898 |
Events | |
Anomaly | non adherence : far non adherence : clearance non adherence : published procedure |
Independent Detector | other controllera other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Reported altitude deviation of 700 ft below crossing altitude of 8000 ft at fuelr on lax ILS runway 25L. As with any deviation both pilots made errors and there were numerous contributing factors. The reported altitude deviation of 700 ft was greater than I as PNF recalled/realized, my impression was a deviation of around 300 ft. As first officer performing non-flying duties we were returning to lax on civet arrival to ILS runway 25L on an A320 airbus with autoplt and autothrottles connected. The 'profile descent' calls for numerous step-down fixes. After a 12 hour duty day (including deicing, moderate turbulence and early wake-up) we were ending a trip with this familiar approach. We received clearance for the civet arrival relatively late (previous clearance direct) and I was busy activating and setting up the approach, alerting the flight attendants and clearing for ATC called and TCASII traffic, ie, we were fairly busy. At a point around suzzi, but prior to fuelr the captain requested that I set 4000 ft (the crossing for downe). While not 'by the book' it is a rather common practice to set altitude that shouldn't be a step-down factor early on the A320 in order to facilitate a smooth autoflt operation and presentation (autoflt desirable due to traffic, etc, in the basin but hard to do smoothly with step-down altitudes). This is a procedure I don't like and have discussed with several capts, but run across fairly often (this was my first trip with this captain). Since I felt the 8000 ft step-down may still be a factor I questioned the captain, he still wanted it set so I set 4000 ft and repeated aloud '8000 ft at 26.4 DME' which he acknowledged. I believe we also received a speed restr at about this time. As we approached 8000 ft I noted we were at around 28 DME, I stated 8000 ft as we went through it, the captain said yes. As the A320 sidestick does not move with the captain's input I looked in his direction to confirm he was doing something to slow/stop the descent. I honestly don't recall other exact indications FD/FMA/GS as I was concentrating on DME and altitude. Once I realized we were not leveling off I considered taking over control of the aircraft, but my xchk showed 7800 ft and 27 DME. My belief was that with less than a mi to go (our DME does not indicate tenths at this point on the pfd and the crossing is 26.4) it was not appropriate to assume control of the aircraft. Assuming the 7300 ft report to be accurate I may have made a mistake in not leveling the aircraft myself. In the future I will be much more persistent in my effort to avoid setting step-down altitudes ahead of time even when they appear to be 'made' or cause the aircraft/autoplt to be less than smooth operationally. I also believe there were several factors that made me be more reluctant to assume control of the aircraft. The captain had proven to be extremely safe and knowledgeable on the aircraft and since he had acknowledged my 'warning' messages I thought he was on top of the situation. The A320 sidestick does not allow one to monitor the other pilot's inputs and due to the sidestick summing inputs it is not advisable to 'help' the other pilot as one may do with a conventional aircraft yoke. I also believe the lack of practicing pushing the red button (which in turn lights light and voice commands) to assume full control in the aircraft made me a little hesitant to do this for what I felt was a 'minor' correction. The most important lesson I learned was to be more assertive and don't rely on the other pilot even though he may be very skilled. I will discuss step-down setting prior to those approachs that require it with the captain. I will also suggest (and accomplish myself) that on IOE for the A320, pilots 'practice' taking control of the aircraft during line operations more often. I must also note the fact that the civet arrival makes a rather straight-forward approach quite complex and difficult to fly especially smoothly with autoflt. The step-downs occur in a busy area at a busy time in-flight with very exact speed requirements also to be met. By raising the GS to allow aircraft to follow the GS down or by lowering/moving the airways, etc, beneath the approach to allow aircraft to follow the current GS we would be removing an obstacle to safe flight. This does certainly not excuse what happened to us, however, by removing the step-downs and making approachs easier we allow pilots to concentrate on other items, ie, traffic watch. To 'hit' every crossing on the civet does require both pilots to spend a large part of their time heads down. Callback conversation with reporter revealed the following information: this air carrier first officer said that he attempted to reason with the captain who insisted that he set 4000 ft in the altitude alerter before crossing fuelr. He also said that he knew that they were low, but did not think that they were that low.
Original NASA ASRS Text
Title: AN ACR FLC GOES BELOW THE XING ALT OF 8000 FT AT FUELR WHEN THEY FOLLOW THE GS. THE FO WAS AWARE OF THE RISK AND ATTEMPTED TO FOLLOW THE CORRECT PROC, BUT WAS THWARTED BY THE CAPT. A320.
Narrative: RPTED ALTDEV OF 700 FT BELOW XING ALT OF 8000 FT AT FUELR ON LAX ILS RWY 25L. AS WITH ANY DEV BOTH PLTS MADE ERRORS AND THERE WERE NUMEROUS CONTRIBUTING FACTORS. THE RPTED ALTDEV OF 700 FT WAS GREATER THAN I AS PNF RECALLED/REALIZED, MY IMPRESSION WAS A DEV OF AROUND 300 FT. AS FO PERFORMING NON-FLYING DUTIES WE WERE RETURNING TO LAX ON CIVET ARR TO ILS RWY 25L ON AN A320 AIRBUS WITH AUTOPLT AND AUTOTHROTTLES CONNECTED. THE 'PROFILE DSCNT' CALLS FOR NUMEROUS STEP-DOWN FIXES. AFTER A 12 HR DUTY DAY (INCLUDING DEICING, MODERATE TURB AND EARLY WAKE-UP) WE WERE ENDING A TRIP WITH THIS FAMILIAR APCH. WE RECEIVED CLRNC FOR THE CIVET ARR RELATIVELY LATE (PREVIOUS CLRNC DIRECT) AND I WAS BUSY ACTIVATING AND SETTING UP THE APCH, ALERTING THE FLT ATTENDANTS AND CLRING FOR ATC CALLED AND TCASII TFC, IE, WE WERE FAIRLY BUSY. AT A POINT AROUND SUZZI, BUT PRIOR TO FUELR THE CAPT REQUESTED THAT I SET 4000 FT (THE XING FOR DOWNE). WHILE NOT 'BY THE BOOK' IT IS A RATHER COMMON PRACTICE TO SET ALT THAT SHOULDN'T BE A STEP-DOWN FACTOR EARLY ON THE A320 IN ORDER TO FACILITATE A SMOOTH AUTOFLT OP AND PRESENTATION (AUTOFLT DESIRABLE DUE TO TFC, ETC, IN THE BASIN BUT HARD TO DO SMOOTHLY WITH STEP-DOWN ALTS). THIS IS A PROC I DON'T LIKE AND HAVE DISCUSSED WITH SEVERAL CAPTS, BUT RUN ACROSS FAIRLY OFTEN (THIS WAS MY FIRST TRIP WITH THIS CAPT). SINCE I FELT THE 8000 FT STEP-DOWN MAY STILL BE A FACTOR I QUESTIONED THE CAPT, HE STILL WANTED IT SET SO I SET 4000 FT AND REPEATED ALOUD '8000 FT AT 26.4 DME' WHICH HE ACKNOWLEDGED. I BELIEVE WE ALSO RECEIVED A SPD RESTR AT ABOUT THIS TIME. AS WE APCHED 8000 FT I NOTED WE WERE AT AROUND 28 DME, I STATED 8000 FT AS WE WENT THROUGH IT, THE CAPT SAID YES. AS THE A320 SIDESTICK DOES NOT MOVE WITH THE CAPT'S INPUT I LOOKED IN HIS DIRECTION TO CONFIRM HE WAS DOING SOMETHING TO SLOW/STOP THE DSCNT. I HONESTLY DON'T RECALL OTHER EXACT INDICATIONS FD/FMA/GS AS I WAS CONCENTRATING ON DME AND ALT. ONCE I REALIZED WE WERE NOT LEVELING OFF I CONSIDERED TAKING OVER CTL OF THE ACFT, BUT MY XCHK SHOWED 7800 FT AND 27 DME. MY BELIEF WAS THAT WITH LESS THAN A MI TO GO (OUR DME DOES NOT INDICATE TENTHS AT THIS POINT ON THE PFD AND THE XING IS 26.4) IT WAS NOT APPROPRIATE TO ASSUME CTL OF THE ACFT. ASSUMING THE 7300 FT RPT TO BE ACCURATE I MAY HAVE MADE A MISTAKE IN NOT LEVELING THE ACFT MYSELF. IN THE FUTURE I WILL BE MUCH MORE PERSISTENT IN MY EFFORT TO AVOID SETTING STEP-DOWN ALTS AHEAD OF TIME EVEN WHEN THEY APPEAR TO BE 'MADE' OR CAUSE THE ACFT/AUTOPLT TO BE LESS THAN SMOOTH OPERATIONALLY. I ALSO BELIEVE THERE WERE SEVERAL FACTORS THAT MADE ME BE MORE RELUCTANT TO ASSUME CTL OF THE ACFT. THE CAPT HAD PROVEN TO BE EXTREMELY SAFE AND KNOWLEDGEABLE ON THE ACFT AND SINCE HE HAD ACKNOWLEDGED MY 'WARNING' MESSAGES I THOUGHT HE WAS ON TOP OF THE SIT. THE A320 SIDESTICK DOES NOT ALLOW ONE TO MONITOR THE OTHER PLT'S INPUTS AND DUE TO THE SIDESTICK SUMMING INPUTS IT IS NOT ADVISABLE TO 'HELP' THE OTHER PLT AS ONE MAY DO WITH A CONVENTIONAL ACFT YOKE. I ALSO BELIEVE THE LACK OF PRACTICING PUSHING THE RED BUTTON (WHICH IN TURN LIGHTS LIGHT AND VOICE COMMANDS) TO ASSUME FULL CTL IN THE ACFT MADE ME A LITTLE HESITANT TO DO THIS FOR WHAT I FELT WAS A 'MINOR' CORRECTION. THE MOST IMPORTANT LESSON I LEARNED WAS TO BE MORE ASSERTIVE AND DON'T RELY ON THE OTHER PLT EVEN THOUGH HE MAY BE VERY SKILLED. I WILL DISCUSS STEP-DOWN SETTING PRIOR TO THOSE APCHS THAT REQUIRE IT WITH THE CAPT. I WILL ALSO SUGGEST (AND ACCOMPLISH MYSELF) THAT ON IOE FOR THE A320, PLTS 'PRACTICE' TAKING CTL OF THE ACFT DURING LINE OPS MORE OFTEN. I MUST ALSO NOTE THE FACT THAT THE CIVET ARR MAKES A RATHER STRAIGHT-FORWARD APCH QUITE COMPLEX AND DIFFICULT TO FLY ESPECIALLY SMOOTHLY WITH AUTOFLT. THE STEP-DOWNS OCCUR IN A BUSY AREA AT A BUSY TIME INFLT WITH VERY EXACT SPD REQUIREMENTS ALSO TO BE MET. BY RAISING THE GS TO ALLOW ACFT TO FOLLOW THE GS DOWN OR BY LOWERING/MOVING THE AIRWAYS, ETC, BENEATH THE APCH TO ALLOW ACFT TO FOLLOW THE CURRENT GS WE WOULD BE REMOVING AN OBSTACLE TO SAFE FLT. THIS DOES CERTAINLY NOT EXCUSE WHAT HAPPENED TO US, HOWEVER, BY REMOVING THE STEP-DOWNS AND MAKING APCHS EASIER WE ALLOW PLTS TO CONCENTRATE ON OTHER ITEMS, IE, TFC WATCH. TO 'HIT' EVERY XING ON THE CIVET DOES REQUIRE BOTH PLTS TO SPEND A LARGE PART OF THEIR TIME HEADS DOWN. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THIS ACR FO SAID THAT HE ATTEMPTED TO REASON WITH THE CAPT WHO INSISTED THAT HE SET 4000 FT IN THE ALT ALERTER BEFORE XING FUELR. HE ALSO SAID THAT HE KNEW THAT THEY WERE LOW, BUT DID NOT THINK THAT THEY WERE THAT LOW.
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.