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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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An air carrier B737 flight crew made several errors using the autoflt system and trigger an RA to which they properly react. After all of this they were able to complete the approach and landing.
| Attributes | |
| ACN | 376434 |
| Time | |
| Date | 199708 |
| Day | Wed |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | atc facility : ubr airport : san |
| State Reference | CA |
| Altitude | msl bound lower : 3600 msl bound upper : 3800 |
| Environment | |
| Flight Conditions | VMC |
| Light | Dusk |
| Aircraft 1 | |
| Controlling Facilities | tracon : san tracon : shv |
| Operator | common carrier : air carrier |
| Make Model Name | B737-400 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | Other Other |
| Flight Phase | descent : approach |
| Flight Plan | IFR |
| Aircraft 2 | |
| Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
| Operating Under FAR Part | other : unknown |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : commercial pilot : instrument pilot : private pilot : atp |
| Experience | flight time last 90 days : 180 flight time total : 7600 flight time type : 1500 |
| ASRS Report | 376434 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : atp |
| Experience | flight time last 90 days : 250 flight time total : 22000 flight time type : 10000 |
| ASRS Report | 376420 |
| Events | |
| Anomaly | altitude deviation : excursion from assigned altitude conflict : airborne less severe non adherence : far non adherence : published procedure non adherence : clearance other spatial deviation |
| Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
| Resolutory Action | flight crew : returned to intended course or assigned course flight crew : took evasive action |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
I was flying the localizer approach to runway 27 at san diego (lindberg field). Approach control had turned us base leg at 4000 ft (180 KTS) then gave us a heading of 240 degrees maintain 3800 ft until on approach. Cleared for the localizer approach runway 27. I reached down and switched the autotune to manual (unaware the other pilot had just done that for me) and mistakenly increased the airspeed to 240 KIAS instead of the heading bug. We were cleared behind another B737 which we had in sight. I immediately disengaged the autoplt and autothrottles because the aircraft was accelerating and not turning to intercept final. When I realized my radio was not tuned to the proper frequency I saw that we were going through final approach. I made an immediate turn. We ended up going slightly through final. I kept the aircraft I was following in sight and started a slow descent. We received the RA and followed the commands and advised ATC. We immediately re-established on the localizer (after clear of conflict) and the rest of the approach was normal. The factors from my end were that I rotated the wrong knob on the FMC panel (airspeed instead of heading) and when I thought I was tuning the localizer I actually put the navigation radios in autotune. Everything happened at the same time and it took a few seconds to analyze what was happening causing me to deviate through the course and descend lower than the assigned 3800 ft.
Original NASA ASRS Text
Title: AN ACR B737 FLC MADE SEVERAL ERRORS USING THE AUTOFLT SYS AND TRIGGER AN RA TO WHICH THEY PROPERLY REACT. AFTER ALL OF THIS THEY WERE ABLE TO COMPLETE THE APCH AND LNDG.
Narrative: I WAS FLYING THE LOC APCH TO RWY 27 AT SAN DIEGO (LINDBERG FIELD). APCH CTL HAD TURNED US BASE LEG AT 4000 FT (180 KTS) THEN GAVE US A HDG OF 240 DEGS MAINTAIN 3800 FT UNTIL ON APCH. CLRED FOR THE LOC APCH RWY 27. I REACHED DOWN AND SWITCHED THE AUTOTUNE TO MANUAL (UNAWARE THE OTHER PLT HAD JUST DONE THAT FOR ME) AND MISTAKENLY INCREASED THE AIRSPD TO 240 KIAS INSTEAD OF THE HEADING BUG. WE WERE CLRED BEHIND ANOTHER B737 WHICH WE HAD IN SIGHT. I IMMEDIATELY DISENGAGED THE AUTOPLT AND AUTOTHROTTLES BECAUSE THE ACFT WAS ACCELERATING AND NOT TURNING TO INTERCEPT FINAL. WHEN I REALIZED MY RADIO WAS NOT TUNED TO THE PROPER FREQ I SAW THAT WE WERE GOING THROUGH FINAL APCH. I MADE AN IMMEDIATE TURN. WE ENDED UP GOING SLIGHTLY THROUGH FINAL. I KEPT THE ACFT I WAS FOLLOWING IN SIGHT AND STARTED A SLOW DSCNT. WE RECEIVED THE RA AND FOLLOWED THE COMMANDS AND ADVISED ATC. WE IMMEDIATELY RE-ESTABLISHED ON THE LOC (AFTER CLR OF CONFLICT) AND THE REST OF THE APCH WAS NORMAL. THE FACTORS FROM MY END WERE THAT I ROTATED THE WRONG KNOB ON THE FMC PANEL (AIRSPD INSTEAD OF HEADING) AND WHEN I THOUGHT I WAS TUNING THE LOC I ACTUALLY PUT THE NAV RADIOS IN AUTOTUNE. EVERYTHING HAPPENED AT THE SAME TIME AND IT TOOK A FEW SECONDS TO ANALYZE WHAT WAS HAPPENING CAUSING ME TO DEVIATE THROUGH THE COURSE AND DSND LOWER THAN THE ASSIGNED 3800 FT.
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.