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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Altitude crossing not made when first officer fails to set the crossing altitude into the altitude select panel. The first officer, PF, had to 'build' a crossing fix with airspeed change into the FMS. The captain was on the PA with passenger information. Lack of cockpit coordination and situational awareness.
| Attributes | |
| ACN | 370840 |
| Time | |
| Date | 199706 |
| Day | Fri |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | atc facility : clt |
| State Reference | NC |
| Altitude | msl bound lower : 11000 msl bound upper : 14000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : ztl |
| Operator | common carrier : air carrier |
| Make Model Name | Fokker 100 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other Other |
| Flight Phase | descent other |
| Route In Use | arrival other arrival star : star enroute other |
| 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 : 7000 flight time type : 1000 |
| ASRS Report | 370840 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : flight engineer pilot : atp |
| Experience | flight time last 90 days : 150 flight time total : 11000 flight time type : 1800 |
| ASRS Report | 370841 |
| Events | |
| Anomaly | altitude deviation : undershoot altitude deviation : crossing restriction not met non adherence : clearance non adherence : published procedure other anomaly other |
| Independent Detector | other controllera |
| Resolutory Action | flight crew : regained aircraft control none taken : detected after the fact |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
We were inbound to clt on the chesterfield arrival descending to 14000 ft and expecting a clearance to cross booze intersection at 11000 ft. Before we leveled at 14000 ft we were given a clearance to cross 13 NM south of booze at 11000 ft and 210 KTS. I was the PF and I set up the FMS to display a fix 13 NM south of booze. Then I programmed the FMS to display the 210 KTS, 11000 ft restr on the moving map display. However, I did not set 11000 ft on the altitude select panel and this is necessary for the aircraft to respond to the FMS inputs. Therefore the aircraft leveled at 14000 ft and we missed the crossing restr. ZJX told us we missed the restr just as we crossed the 13 DME fix. I think the automation of the F100 was a contributing factor. In this aircraft when receiving a crossing restr, especially one that is not over an established intersection, the pilots must 1) build the point in the FMS, 2) program the altitude and speed in the FMS, 3) set the altitude select panel. In a less automated aircraft, the same clearance means simply dialing in the altitude on the altitude select panel. Over reliance on the automation was another factor. A breakdown of the established altitude awareness program was the third and most critical contributing factor. Supplemental information from acn 370841: I was busy performing the arrival announcement on the PA system. This interrupted my standard follow-up with our company altitude awareness procedures. Consequently I did not check the altitude set at the FMC panel.
Original NASA ASRS Text
Title: ALT XING NOT MADE WHEN FO FAILS TO SET THE XING ALT INTO THE ALT SELECT PANEL. THE FO, PF, HAD TO 'BUILD' A XING FIX WITH AIRSPD CHANGE INTO THE FMS. THE CAPT WAS ON THE PA WITH PAX INFO. LACK OF COCKPIT COORD AND SITUATIONAL AWARENESS.
Narrative: WE WERE INBOUND TO CLT ON THE CHESTERFIELD ARR DSNDING TO 14000 FT AND EXPECTING A CLRNC TO CROSS BOOZE INTXN AT 11000 FT. BEFORE WE LEVELED AT 14000 FT WE WERE GIVEN A CLRNC TO CROSS 13 NM S OF BOOZE AT 11000 FT AND 210 KTS. I WAS THE PF AND I SET UP THE FMS TO DISPLAY A FIX 13 NM S OF BOOZE. THEN I PROGRAMMED THE FMS TO DISPLAY THE 210 KTS, 11000 FT RESTR ON THE MOVING MAP DISPLAY. HOWEVER, I DID NOT SET 11000 FT ON THE ALT SELECT PANEL AND THIS IS NECESSARY FOR THE ACFT TO RESPOND TO THE FMS INPUTS. THEREFORE THE ACFT LEVELED AT 14000 FT AND WE MISSED THE XING RESTR. ZJX TOLD US WE MISSED THE RESTR JUST AS WE CROSSED THE 13 DME FIX. I THINK THE AUTOMATION OF THE F100 WAS A CONTRIBUTING FACTOR. IN THIS ACFT WHEN RECEIVING A XING RESTR, ESPECIALLY ONE THAT IS NOT OVER AN ESTABLISHED INTXN, THE PLTS MUST 1) BUILD THE POINT IN THE FMS, 2) PROGRAM THE ALT AND SPD IN THE FMS, 3) SET THE ALT SELECT PANEL. IN A LESS AUTOMATED ACFT, THE SAME CLRNC MEANS SIMPLY DIALING IN THE ALT ON THE ALT SELECT PANEL. OVER RELIANCE ON THE AUTOMATION WAS ANOTHER FACTOR. A BREAKDOWN OF THE ESTABLISHED ALT AWARENESS PROGRAM WAS THE THIRD AND MOST CRITICAL CONTRIBUTING FACTOR. SUPPLEMENTAL INFO FROM ACN 370841: I WAS BUSY PERFORMING THE ARR ANNOUNCEMENT ON THE PA SYS. THIS INTERRUPTED MY STANDARD FOLLOW-UP WITH OUR COMPANY ALT AWARENESS PROCS. CONSEQUENTLY I DID NOT CHK THE ALT SET AT THE FMC PANEL.
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.