37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 366380 |
Time | |
Date | 199704 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : btg airport : pdx |
State Reference | WA |
Altitude | msl bound lower : 10000 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zse tower : cle |
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 : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 7000 flight time type : 500 |
ASRS Report | 366380 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : far |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The flight was cleared to cross wylee intersection at 250 KTS and 10000 ft, 3000-4000 ft above ATC said to maintain 11000 ft. The FMS was reprogrammed but the flight control panel (altitude window) was not. The profile mode of the FMS was disengaged because the FMS schedule was falling behind and the autoplt leveled the aircraft at 10000 ft. This is a classic case of relying on the automation and not flying the aircraft first. It is opposite the way I teach students (I am a line check airman) to manage the FMS system. I teach the student to fly the aircraft first and then program the FMS only if time allows. WX was very good with good visibility and the workload was very low. Company procedures should have prevented the incident, if followed correctly. The habit patterns I try to use are to prevent this type of incident if followed. The FMS was just relied upon too much. ATC said the altitude caused no problems and did not advise us to prevent the incident. We were VFR during the whole time, looking outside and did not see any other aircraft at all. We could see no reason for the change in altitude even though we intended to comply with it.
Original NASA ASRS Text
Title: ACR LGT CLRED CROSS WYLEE INTXN 10000 FT 250 KTS. AT 14000 FT ATC SAID TO MAINTAIN 11000 FT. FMS REPROGRAMMED BUT FLT CTL PANEL WAS NOT CHANGED. AUTOPLT LEVELED THE ACFT AT 10000 FT. CTLR ADVISED NO PROB.
Narrative: THE FLT WAS CLRED TO CROSS WYLEE INTXN AT 250 KTS AND 10000 FT, 3000-4000 FT ABOVE ATC SAID TO MAINTAIN 11000 FT. THE FMS WAS REPROGRAMMED BUT THE FLT CTL PANEL (ALT WINDOW) WAS NOT. THE PROFILE MODE OF THE FMS WAS DISENGAGED BECAUSE THE FMS SCHEDULE WAS FALLING BEHIND AND THE AUTOPLT LEVELED THE ACFT AT 10000 FT. THIS IS A CLASSIC CASE OF RELYING ON THE AUTOMATION AND NOT FLYING THE ACFT FIRST. IT IS OPPOSITE THE WAY I TEACH STUDENTS (I AM A LINE CHK AIRMAN) TO MANAGE THE FMS SYS. I TEACH THE STUDENT TO FLY THE ACFT FIRST AND THEN PROGRAM THE FMS ONLY IF TIME ALLOWS. WX WAS VERY GOOD WITH GOOD VISIBILITY AND THE WORKLOAD WAS VERY LOW. COMPANY PROCS SHOULD HAVE PREVENTED THE INCIDENT, IF FOLLOWED CORRECTLY. THE HABIT PATTERNS I TRY TO USE ARE TO PREVENT THIS TYPE OF INCIDENT IF FOLLOWED. THE FMS WAS JUST RELIED UPON TOO MUCH. ATC SAID THE ALT CAUSED NO PROBS AND DID NOT ADVISE US TO PREVENT THE INCIDENT. WE WERE VFR DURING THE WHOLE TIME, LOOKING OUTSIDE AND DID NOT SEE ANY OTHER ACFT AT ALL. WE COULD SEE NO REASON FOR THE CHANGE IN ALT EVEN THOUGH WE INTENDED TO COMPLY WITH IT.
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.