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|
Attributes | |
ACN | 414560 |
Time | |
Date | 199809 |
Day | Wed |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | airport : sto |
State Reference | FO |
Altitude | msl bound lower : 2300 msl bound upper : 2500 |
Environment | |
Flight Conditions | Mixed |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : sto tracon : bgm |
Operator | common carrier : air carrier |
Make Model Name | B727 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach descent other |
Route In Use | arrival other enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 8000 flight time type : 2000 |
ASRS Report | 414560 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
First officer was flying approach. Speed brakes were in use during descent and he leveled at 2500 ft on vectors to intercept localizer runway 1. I went head down to change frequency and identify localizer and NDB as we leveled. First officer forgot to close speed brakes and I missed it. As he leveled, in a slight turn, the stick shaker activated and first officer deployed flaps to 2 degrees on his own, while calling out 'flaps 2 degrees.' the aircraft descended several hundred ft below assigned and high power was applied before the flight engineer caught the spoiler handle and called it out. The most interesting thing about this incident is that, when the first officer deployed the flaps the flap/spoiler handle warning horn went off and all 3 pilots failed to recognize it as a flap/spoiler warning but interpreted it as a cabin altitude warning (the same horn serves both functions), even though we were only 2500 ft and that warning was totally inappropriate for the situation. For 20-30 seconds, all 3 of us experienced in the airplane, misinterped the horn.
Original NASA ASRS Text
Title: B727 CREW HAD ALT EXCURSION WHEN THEY DID NOT RETRACT THE ACFT SPD BRAKES.
Narrative: FO WAS FLYING APCH. SPD BRAKES WERE IN USE DURING DSCNT AND HE LEVELED AT 2500 FT ON VECTORS TO INTERCEPT LOC RWY 1. I WENT HEAD DOWN TO CHANGE FREQ AND IDENT LOC AND NDB AS WE LEVELED. FO FORGOT TO CLOSE SPD BRAKES AND I MISSED IT. AS HE LEVELED, IN A SLIGHT TURN, THE STICK SHAKER ACTIVATED AND FO DEPLOYED FLAPS TO 2 DEGS ON HIS OWN, WHILE CALLING OUT 'FLAPS 2 DEGS.' THE ACFT DSNDED SEVERAL HUNDRED FT BELOW ASSIGNED AND HIGH PWR WAS APPLIED BEFORE THE FE CAUGHT THE SPOILER HANDLE AND CALLED IT OUT. THE MOST INTERESTING THING ABOUT THIS INCIDENT IS THAT, WHEN THE FO DEPLOYED THE FLAPS THE FLAP/SPOILER HANDLE WARNING HORN WENT OFF AND ALL 3 PLTS FAILED TO RECOGNIZE IT AS A FLAP/SPOILER WARNING BUT INTERPED IT AS A CABIN ALT WARNING (THE SAME HORN SERVES BOTH FUNCTIONS), EVEN THOUGH WE WERE ONLY 2500 FT AND THAT WARNING WAS TOTALLY INAPPROPRIATE FOR THE SIT. FOR 20-30 SECONDS, ALL 3 OF US EXPERIENCED IN THE AIRPLANE, MISINTERPED THE HORN.
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.