37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 356960 |
Time | |
Date | 199612 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : shb |
State Reference | IN |
Altitude | msl bound lower : 24000 msl bound upper : 28000 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Controlling Facilities | artcc : zau |
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 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 : commercial pilot : private pilot : instrument pilot : flight engineer |
Experience | flight time last 90 days : 200 flight time total : 5700 flight time type : 4000 |
ASRS Report | 356960 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : private pilot : instrument pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 200 flight time total : 12000 flight time type : 2000 |
ASRS Report | 355997 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : clearance non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : insufficient time other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were at FL280 expecting a clearance to cruise altitude of FL330. We were given a crossing clearance instead of FL240 55 mi north of shb. While programming FMS, we inadvertently didn't set the crossing altitude of FL240 in the altitude alert window. We noticed the error after the FMS failed to prompt us. The restr was not placed in the alert window and the controller asking us if we would make the restr as we were immediately starting the descent. The captain and I agree that setting FL240 in the altitude alert window first is a better technique than programming the FMS first. I also think it would be a good idea for crews to always have the VOR the restr is based on in the receiver so you can xref and back up the FMS and IRU system. Seeing the DME in the window might cue you into starting the descent. Humans are not good monitors and automation forces us to be more of a monitor then a pilot. We need to utilize ways to keep us more involved (situational awareness) and not trust or take the automation for granted. Supplemental information from acn 355997: first officer began setting up the crossing restr in the FMS computer, but several additional programming steps were required in order to delete the planned cruising altitude and reprogram for a descent with a crossing restr. When the descent was programmed to begin, it did not. To complicate the problem, the FMS, which normally displays a message to 'reset cleared altitude' (if it is not set for lower than cruise) did not display, which may be due to our being past the point where that message is displayed. Additionally, situational awareness was degraded by shb VOR not being manually tuned. When controller next checked with us, we realized the mis-set altitude alert window, began our descent, and reached 24000 ft about 5 mi past 55 mi fix.
Original NASA ASRS Text
Title: ALTDEV ALT UNDERSHOT IN DSCNT. ALT XING RESTR NOT MET. FO FAILED TO PLACE XING ALT IN FMC PRIOR TO DSCNT.
Narrative: WE WERE AT FL280 EXPECTING A CLRNC TO CRUISE ALT OF FL330. WE WERE GIVEN A XING CLRNC INSTEAD OF FL240 55 MI N OF SHB. WHILE PROGRAMMING FMS, WE INADVERTENTLY DIDN'T SET THE XING ALT OF FL240 IN THE ALT ALERT WINDOW. WE NOTICED THE ERROR AFTER THE FMS FAILED TO PROMPT US. THE RESTR WAS NOT PLACED IN THE ALERT WINDOW AND THE CTLR ASKING US IF WE WOULD MAKE THE RESTR AS WE WERE IMMEDIATELY STARTING THE DSCNT. THE CAPT AND I AGREE THAT SETTING FL240 IN THE ALT ALERT WINDOW FIRST IS A BETTER TECHNIQUE THAN PROGRAMMING THE FMS FIRST. I ALSO THINK IT WOULD BE A GOOD IDEA FOR CREWS TO ALWAYS HAVE THE VOR THE RESTR IS BASED ON IN THE RECEIVER SO YOU CAN XREF AND BACK UP THE FMS AND IRU SYS. SEEING THE DME IN THE WINDOW MIGHT CUE YOU INTO STARTING THE DSCNT. HUMANS ARE NOT GOOD MONITORS AND AUTOMATION FORCES US TO BE MORE OF A MONITOR THEN A PLT. WE NEED TO UTILIZE WAYS TO KEEP US MORE INVOLVED (SITUATIONAL AWARENESS) AND NOT TRUST OR TAKE THE AUTOMATION FOR GRANTED. SUPPLEMENTAL INFO FROM ACN 355997: FO BEGAN SETTING UP THE XING RESTR IN THE FMS COMPUTER, BUT SEVERAL ADDITIONAL PROGRAMMING STEPS WERE REQUIRED IN ORDER TO DELETE THE PLANNED CRUISING ALT AND REPROGRAM FOR A DSCNT WITH A XING RESTR. WHEN THE DSCNT WAS PROGRAMMED TO BEGIN, IT DID NOT. TO COMPLICATE THE PROB, THE FMS, WHICH NORMALLY DISPLAYS A MESSAGE TO 'RESET CLRED ALT' (IF IT IS NOT SET FOR LOWER THAN CRUISE) DID NOT DISPLAY, WHICH MAY BE DUE TO OUR BEING PAST THE POINT WHERE THAT MESSAGE IS DISPLAYED. ADDITIONALLY, SITUATIONAL AWARENESS WAS DEGRADED BY SHB VOR NOT BEING MANUALLY TUNED. WHEN CTLR NEXT CHKED WITH US, WE REALIZED THE MIS-SET ALT ALERT WINDOW, BEGAN OUR DSCNT, AND REACHED 24000 FT ABOUT 5 MI PAST 55 MI FIX.
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.