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|
Attributes | |
ACN | 391630 |
Time | |
Date | 199801 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : ukw |
State Reference | TX |
Altitude | msl bound lower : 24000 msl bound upper : 25000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | artcc : zfw |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent other |
Route In Use | arrival other |
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 : 6700 flight time type : 1500 |
ASRS Report | 391630 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : crossing restriction not met non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : insufficient time |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were flight planned to arrive dfw via the bowie (ukw) arrival. FMS was programmed to cross kajay intersection at the expected altitude of FL240, and also programmed to cross bambe intersection at 11000 ft. Prior to reaching the ukw 287 degree radial, in the vicinity of txo, we were reclred direct ukw, which eliminated the FMS programmed descent to FL240 at kajay. FMS descent profile is now computed to cross bambe at 11000 ft. While proceeding direct ukw, we were cleared to cross 40 DME west of ukw at FL240, pilot discretion. We reprogrammed the FMS with a navigation point 40 DME west of ukw, but apparently failed to include the altitude constraint of FL240, so the FMS descent profile was predicated on reaching bambe intersection at 11000 ft. The reason for this oversight is unknown, but probable causes are crew involvement with arrival procedures (approach briefing, contacting company for gate assignment, etc) and distraction due to a call from the lead flight attendant to report cabin maintenance discrepancies or passenger special assistance requests upon arrival. In any case, the FMS VNAV function initiated its descent according to the profile for meeting the bambe at 11000 ft restr. While in the descent, center subsequently cleared us to cross bambe at 11000 ft, which legally canceled the 40 DME at FL240 restr. Approaching the 40 DME fix, we realized we were too high to realistically meet the previous restr, and questioned ourselves as to why we were in that position, and the most logical reason was that we probably failed to enter the altitude constraint into the FMS and failed to back it up with raw data navigation due to crew preoccupation with ancillary duties. Lesson learned is nothing new: the priorities are 1) aviate, 2) navigation, 3) communicate, and 4) checks.
Original NASA ASRS Text
Title: B737-300 FLC MISPROGRAMS FMS ON RECEIVING DSCNT CLRNC CHANGE AND HAS AN ALTDEV.
Narrative: WE WERE FLT PLANNED TO ARRIVE DFW VIA THE BOWIE (UKW) ARR. FMS WAS PROGRAMMED TO CROSS KAJAY INTXN AT THE EXPECTED ALT OF FL240, AND ALSO PROGRAMMED TO CROSS BAMBE INTXN AT 11000 FT. PRIOR TO REACHING THE UKW 287 DEG RADIAL, IN THE VICINITY OF TXO, WE WERE RECLRED DIRECT UKW, WHICH ELIMINATED THE FMS PROGRAMMED DSCNT TO FL240 AT KAJAY. FMS DSCNT PROFILE IS NOW COMPUTED TO CROSS BAMBE AT 11000 FT. WHILE PROCEEDING DIRECT UKW, WE WERE CLRED TO CROSS 40 DME W OF UKW AT FL240, PLT DISCRETION. WE REPROGRAMMED THE FMS WITH A NAV POINT 40 DME W OF UKW, BUT APPARENTLY FAILED TO INCLUDE THE ALT CONSTRAINT OF FL240, SO THE FMS DSCNT PROFILE WAS PREDICATED ON REACHING BAMBE INTXN AT 11000 FT. THE REASON FOR THIS OVERSIGHT IS UNKNOWN, BUT PROBABLE CAUSES ARE CREW INVOLVEMENT WITH ARR PROCS (APCH BRIEFING, CONTACTING COMPANY FOR GATE ASSIGNMENT, ETC) AND DISTR DUE TO A CALL FROM THE LEAD FLT ATTENDANT TO RPT CABIN MAINT DISCREPANCIES OR PAX SPECIAL ASSISTANCE REQUESTS UPON ARR. IN ANY CASE, THE FMS VNAV FUNCTION INITIATED ITS DSCNT ACCORDING TO THE PROFILE FOR MEETING THE BAMBE AT 11000 FT RESTR. WHILE IN THE DSCNT, CTR SUBSEQUENTLY CLRED US TO CROSS BAMBE AT 11000 FT, WHICH LEGALLY CANCELED THE 40 DME AT FL240 RESTR. APCHING THE 40 DME FIX, WE REALIZED WE WERE TOO HIGH TO REALISTICALLY MEET THE PREVIOUS RESTR, AND QUESTIONED OURSELVES AS TO WHY WE WERE IN THAT POS, AND THE MOST LOGICAL REASON WAS THAT WE PROBABLY FAILED TO ENTER THE ALT CONSTRAINT INTO THE FMS AND FAILED TO BACK IT UP WITH RAW DATA NAV DUE TO CREW PREOCCUPATION WITH ANCILLARY DUTIES. LESSON LEARNED IS NOTHING NEW: THE PRIORITIES ARE 1) AVIATE, 2) NAV, 3) COMMUNICATE, AND 4) CHKS.
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.