37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 420559 |
Time | |
Date | 199811 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : atl airport : atl |
State Reference | GA |
Altitude | msl bound lower : 5000 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : atl tracon : phl |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | descent : approach landing : go around landing other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | descent : approach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 212 flight time total : 11300 flight time type : 570 |
ASRS Report | 420559 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | conflict : airborne less severe non adherence : clearance other anomaly other other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance other other |
Consequence | Other |
Miss Distance | horizontal : 3000 vertical : 800 |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
Prior to top of descent, arrival ATIS was acquired and the expected approach (ILS runway 8L) was entered into the FMS. This allows the FMS to tune and identify the selected ILS and set the correct inbound course from the ILS database. During descent, the PF entered 'preselects' into the 'navigation/rad' page of the FMS and announced so doing. The PNF was preoccupied with other duties and did not verify the data entered into the 'navigation/rad' page. The 'preselects' on the 'navigation/rad' page allow the PNF to quickly 'hard tune' an approach if there is a last min runway change. The 'preselects' consist of radio identify or frequency and inbound course (eg, iabc/092 or 109.3/092). It is possible to hard tune the expected ILS and inbound course and still have 'preselects' for other runways. Hard tuning the expected ILS or other approach is considered technique and is not consistently done at our company. When the FMS has decoded the ILS identify, a display on the primary flight display changes from the ILS frequency to the ILS identify (eg, 109.3 to iabc). The pilot is not required to listen to the identify in this case. When the ILS identify was observed on the primary flight display on downwind leg, the PNF called out 'ILS runway 8L tuned and idented.' on dogleg (120 degrees magnetic) to final, the entire crew was slightly distraction when the PF reached across the overhead panel and deselected the left outboard and inboard and right inboard longitudinal stability augmentation system instead of calling for 'engine anti-ice on.' the need for engine anti-ice was already discussed and the PNF assured the PF that it would be used as necessary. The turbine air temperature never went below 16 degrees C so engine anti-ice was never necessary. The error was quickly corrected by the PF, but the noise of the autoplt disconnect alert probably drowned out an approach clearance call. Prior to localizer intercept, the PNF switched his display from 'missed approach' mode to 'approach' mode to check the course deviation indicator. This tactic is strictly technique and a holdover from his MD88 days when the aircraft were not as navigationally accurate (no INS). The immediate call was 'this picture is bad!' followed closely by 'you have reverse sensing.' we were within 1 DOT of the localizer so I asked approach control if we were cleared to intercept the localizer and he said 'yes, you're cleared for the ILS approach to runway 8L.' my next call was 'you're on the localizer...come left.' the aircraft was being flown through the autoplt and I believe at this point the PF selected the 'approach/land' mode. The PNF was 'head down' checking the 'navigation/rad' page to determine why the localizer had reverse sensing. It had the correct runway 8L ILS identify but an incorrect course of 272 degrees on the 'ILS/crs' line. Since the ILS was hard tuned with a bad course entered, the autoplt attempted to fly inbound on a 272 degree course which meant it was turning the aircraft to the left through about 050 degrees magnetic when the PF selected heading mode and corrected back to the localizer. The PNF cleared the hard tuned information and then got back in the loop. The heading was now 150 degrees magnetic and the PNF said 'that's too big of a cut...come back left.' this was before being able to interpret our position relative to the new localizer information. The approach controller asked if we were intercepting the localizer and the PNF said 'we have bad sensing on the localizer.' he gave us a heading of 360 degrees and maintain 5000 ft. We probably came within 3/4 - 1/2 mi of a B727 about 800 ft above us on a parallel approach. During an approach using the FMS database for tuning, identing and setting the inbound course for the ILS, the MD11 only displays the ILS identify (eg, iabc) when you are ready for the approach. If the ILS is also hard tuned, there is no additional display on the primary flight display or the navigation display. If the hard tuned inbound course is incorrect, the only way to discover it is to check the 'navigation/rad' page, use the 'approach' mode of the navigation display, or select 'approach/land' and chase the wrong course. In a perfect world (one without conflicting demands on one's attention), the PNF would have caught the mistake early on by xchking what was entered into the 'navigation/rad' page. When this reporter is the PF, he never hard tunes the ILS but he does enter 'preselects' for other possible runways. This difference in technique probably lessened this reporter's urgency to xchk the 'navigation/rad' page.
Original NASA ASRS Text
Title: MD11 CREW HAD CONFUSED NAV DISPLAY ON APCH AT ATL. ACFT HAD LESS THAN LEGAL SEPARATION FROM ANOTHER ACFT.
Narrative: PRIOR TO TOP OF DSCNT, ARR ATIS WAS ACQUIRED AND THE EXPECTED APCH (ILS RWY 8L) WAS ENTERED INTO THE FMS. THIS ALLOWS THE FMS TO TUNE AND IDENT THE SELECTED ILS AND SET THE CORRECT INBOUND COURSE FROM THE ILS DATABASE. DURING DSCNT, THE PF ENTERED 'PRESELECTS' INTO THE 'NAV/RAD' PAGE OF THE FMS AND ANNOUNCED SO DOING. THE PNF WAS PREOCCUPIED WITH OTHER DUTIES AND DID NOT VERIFY THE DATA ENTERED INTO THE 'NAV/RAD' PAGE. THE 'PRESELECTS' ON THE 'NAV/RAD' PAGE ALLOW THE PNF TO QUICKLY 'HARD TUNE' AN APCH IF THERE IS A LAST MIN RWY CHANGE. THE 'PRESELECTS' CONSIST OF RADIO IDENT OR FREQ AND INBOUND COURSE (EG, IABC/092 OR 109.3/092). IT IS POSSIBLE TO HARD TUNE THE EXPECTED ILS AND INBOUND COURSE AND STILL HAVE 'PRESELECTS' FOR OTHER RWYS. HARD TUNING THE EXPECTED ILS OR OTHER APCH IS CONSIDERED TECHNIQUE AND IS NOT CONSISTENTLY DONE AT OUR COMPANY. WHEN THE FMS HAS DECODED THE ILS IDENT, A DISPLAY ON THE PRIMARY FLT DISPLAY CHANGES FROM THE ILS FREQ TO THE ILS IDENT (EG, 109.3 TO IABC). THE PLT IS NOT REQUIRED TO LISTEN TO THE IDENT IN THIS CASE. WHEN THE ILS IDENT WAS OBSERVED ON THE PRIMARY FLT DISPLAY ON DOWNWIND LEG, THE PNF CALLED OUT 'ILS RWY 8L TUNED AND IDENTED.' ON DOGLEG (120 DEGS MAGNETIC) TO FINAL, THE ENTIRE CREW WAS SLIGHTLY DISTR WHEN THE PF REACHED ACROSS THE OVERHEAD PANEL AND DESELECTED THE L OUTBOARD AND INBOARD AND R INBOARD LONGITUDINAL STABILITY AUGMENTATION SYS INSTEAD OF CALLING FOR 'ENG ANTI-ICE ON.' THE NEED FOR ENG ANTI-ICE WAS ALREADY DISCUSSED AND THE PNF ASSURED THE PF THAT IT WOULD BE USED AS NECESSARY. THE TURBINE AIR TEMP NEVER WENT BELOW 16 DEGS C SO ENG ANTI-ICE WAS NEVER NECESSARY. THE ERROR WAS QUICKLY CORRECTED BY THE PF, BUT THE NOISE OF THE AUTOPLT DISCONNECT ALERT PROBABLY DROWNED OUT AN APCH CLRNC CALL. PRIOR TO LOC INTERCEPT, THE PNF SWITCHED HIS DISPLAY FROM 'MISSED APCH' MODE TO 'APCH' MODE TO CHK THE COURSE DEV INDICATOR. THIS TACTIC IS STRICTLY TECHNIQUE AND A HOLDOVER FROM HIS MD88 DAYS WHEN THE ACFT WERE NOT AS NAVIGATIONALLY ACCURATE (NO INS). THE IMMEDIATE CALL WAS 'THIS PICTURE IS BAD!' FOLLOWED CLOSELY BY 'YOU HAVE REVERSE SENSING.' WE WERE WITHIN 1 DOT OF THE LOC SO I ASKED APCH CTL IF WE WERE CLRED TO INTERCEPT THE LOC AND HE SAID 'YES, YOU'RE CLRED FOR THE ILS APCH TO RWY 8L.' MY NEXT CALL WAS 'YOU'RE ON THE LOC...COME L.' THE ACFT WAS BEING FLOWN THROUGH THE AUTOPLT AND I BELIEVE AT THIS POINT THE PF SELECTED THE 'APCH/LAND' MODE. THE PNF WAS 'HEAD DOWN' CHKING THE 'NAV/RAD' PAGE TO DETERMINE WHY THE LOC HAD REVERSE SENSING. IT HAD THE CORRECT RWY 8L ILS IDENT BUT AN INCORRECT COURSE OF 272 DEGS ON THE 'ILS/CRS' LINE. SINCE THE ILS WAS HARD TUNED WITH A BAD COURSE ENTERED, THE AUTOPLT ATTEMPTED TO FLY INBOUND ON A 272 DEG COURSE WHICH MEANT IT WAS TURNING THE ACFT TO THE L THROUGH ABOUT 050 DEGS MAGNETIC WHEN THE PF SELECTED HDG MODE AND CORRECTED BACK TO THE LOC. THE PNF CLRED THE HARD TUNED INFO AND THEN GOT BACK IN THE LOOP. THE HDG WAS NOW 150 DEGS MAGNETIC AND THE PNF SAID 'THAT'S TOO BIG OF A CUT...COME BACK L.' THIS WAS BEFORE BEING ABLE TO INTERPRET OUR POS RELATIVE TO THE NEW LOC INFO. THE APCH CTLR ASKED IF WE WERE INTERCEPTING THE LOC AND THE PNF SAID 'WE HAVE BAD SENSING ON THE LOC.' HE GAVE US A HDG OF 360 DEGS AND MAINTAIN 5000 FT. WE PROBABLY CAME WITHIN 3/4 - 1/2 MI OF A B727 ABOUT 800 FT ABOVE US ON A PARALLEL APCH. DURING AN APCH USING THE FMS DATABASE FOR TUNING, IDENTING AND SETTING THE INBOUND COURSE FOR THE ILS, THE MD11 ONLY DISPLAYS THE ILS IDENT (EG, IABC) WHEN YOU ARE READY FOR THE APCH. IF THE ILS IS ALSO HARD TUNED, THERE IS NO ADDITIONAL DISPLAY ON THE PRIMARY FLT DISPLAY OR THE NAV DISPLAY. IF THE HARD TUNED INBOUND COURSE IS INCORRECT, THE ONLY WAY TO DISCOVER IT IS TO CHK THE 'NAV/RAD' PAGE, USE THE 'APCH' MODE OF THE NAV DISPLAY, OR SELECT 'APCH/LAND' AND CHASE THE WRONG COURSE. IN A PERFECT WORLD (ONE WITHOUT CONFLICTING DEMANDS ON ONE'S ATTN), THE PNF WOULD HAVE CAUGHT THE MISTAKE EARLY ON BY XCHKING WHAT WAS ENTERED INTO THE 'NAV/RAD' PAGE. WHEN THIS RPTR IS THE PF, HE NEVER HARD TUNES THE ILS BUT HE DOES ENTER 'PRESELECTS' FOR OTHER POSSIBLE RWYS. THIS DIFFERENCE IN TECHNIQUE PROBABLY LESSENED THIS RPTR'S URGENCY TO XCHK THE 'NAV/RAD' PAGE.
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.