37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 423151 |
Time | |
Date | 199812 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sat |
State Reference | TX |
Altitude | msl bound lower : 10000 msl bound upper : 13000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | DC-8 50 |
Flight Phase | descent other |
Route In Use | arrival other arrival star : star enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain observation : company check pilot oversight : pic |
Experience | flight time last 90 days : 120 flight time total : 9000 flight time type : 2000 |
ASRS Report | 423151 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer instruction : trainee |
Qualification | pilot : commercial |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : crossing restriction not met altitude deviation : overshoot inflight encounter other non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Air Traffic Incident | Pilot Deviation |
Narrative:
The crew consisted of myself, captain aa, first officer bb, and flight engineer cc. First officer bb is new to the DC8 and I was giving him operating experience. We had started the night in dfw operating dfw-huf-dfw, returning to dfw at about XA00 CST. The flight plan I received indicated that there was to be no cargo and we were to tanker fuel to sat in order to minimize delays in sat due to fueling there. The fuel truck was waiting when we blocked in and I told the flight engineer to begin fueling to 84000 pounds of fuel. Soon after fueling began, I was told by a cargo worker that we would be carrying cargo to sat, and that the cargo would weigh as much as 50000 pounds. I stopped fueling and began computations as to fuel capacity based on a cargo load of 50000 pounds. At the same time, I contacted company flight following to obtain a valid flight plan based on a cargo load of 50000 pounds for valid fuel burn computations, in order to compute maximum fuel loading. At the same time, I was also concerned about a maintenance write-up I had made on the aircraft, and I was involved with that also. Quickly, we got the cargo weight. The plane was quickly loaded and we pushed back. I felt a need of urgency to hurry up and get going in order to get to sat in time to recover from the previous day's mechanical problems. I did not take time to review the stars into sat prior to pushback. I do not fly into sat very often (unlike dfw) and was not familiar with the procedures. I elected to perform the duties of the PF, as I could sense that my first officer was fatigued. The first officer does not have a great deal of experience in large aircraft and the IOE legs he has been flying had been wearing him down. In fact, we were all fatigued. It was the last day of our work week, the leg to sat was added on to our flight at the last min, and we were into the 10TH to 11TH hour of duty time for the day. We were cleared via the marcs 5 STAR. I glanced at the arrival and saw the crossing restr at the marcs intersection to be 13000 ft and at the next intersection (I am unable to remember the name of the intersection), which is 12 mi west of the marcs intersection, the crossing restr is 10000 ft. I asked my first officer to request a future descent. As he was preparing to ask, center cleared us direct to the marcs intersection and cleared us to descend via the arrival to sat. Passing FL180, I requested the descent checklist. At the time, bug speeds were not set. Normally they are set prior to FL180. I suspect fatigue was involved with the failure of us as a crew to not notice the bug speeds had not been set. We at this time set our speeds. This aircraft has an old attitude indicator with a small knob at the 7 O'clock position on the instrument that is used to move the horizon bar up and down on the instrument. This knob has no friction resistance to turning -- it rotates very easily. Most of the aircraft do not have this type of instrument and this was the first time the first officer had flown a DC8 with this type of instrumentation. During the setting of his airspeed bugs, I believe he inadvertently nudged the knob on the attitude indicator, causing the horizon bar to move much further down than my attitude indicator. This was not noticed by the first officer, the flight engineer, nor myself. During the same time of the descent, the ride became quite bumpy. I had heard center report some PIREPS as 'severe.' the autoplt disconnected itself twice during this time. Passing approximately 15000 ft or so, the first officer noticed his attitude indicator appeared different than mine and also the standby attitude indicator. He called it to my attention. I checked it against my instrument and the standby attitude indicator and suspected a pending gyro failure. I looked at my attitude indicator and noticed the horizon bar knob and realized that the first officer's may have been misset. I told the first officer to reset it. He did not really know what I was talking about. So I then reached over to his side of the panel and reset his horizon bar. During this stage of descent, I had failed to keep track of our progress to marcs and remembering the last fix to cross at 10000 ft, I continued on down to 10000 ft. The controller then asked us to verify that we were cleared via the marcs 5 arrival into sat and to cross marcs at 13000 ft. It was then I realized that we had crossed marcs below 13000 ft. We looked at each other and realized that we all had made an error. The crew and I debriefed on the ground and while we were awaiting a ride to the passenger terminal, my beeper goes off with crew scheduling's phone number. I called and was told that my fleet manager wanted to speak to me and a conference call was being dialed. This was done and he informed me that mr X of the FAA wanted to talk to me. About 30 mins later, I called mr X. We talked for about 10 mins. Mr X was concerned that there was something on the STAR chart that was confusing. I told him that I had not had a chance to review the chart since the deviation, but would look at it the next time I flew and call him if I had any suggestions. Reflecting on what happened, I feel that fatigue, combined with the apparent equipment failure at a very inopportune moment caused confusion and distraction in the cockpit. Combine this with the turbulence and the lack of experience of the PNF made for a dangerous error to be made.
Original NASA ASRS Text
Title: A DC8-54 PIC'S ACCOUNT OF HIS ALT BUST DURING THE MARCS 5 STAR ARR PROC INTO SAT.
Narrative: THE CREW CONSISTED OF MYSELF, CAPT AA, FO BB, AND FE CC. FO BB IS NEW TO THE DC8 AND I WAS GIVING HIM OPERATING EXPERIENCE. WE HAD STARTED THE NIGHT IN DFW OPERATING DFW-HUF-DFW, RETURNING TO DFW AT ABOUT XA00 CST. THE FLT PLAN I RECEIVED INDICATED THAT THERE WAS TO BE NO CARGO AND WE WERE TO TANKER FUEL TO SAT IN ORDER TO MINIMIZE DELAYS IN SAT DUE TO FUELING THERE. THE FUEL TRUCK WAS WAITING WHEN WE BLOCKED IN AND I TOLD THE FE TO BEGIN FUELING TO 84000 LBS OF FUEL. SOON AFTER FUELING BEGAN, I WAS TOLD BY A CARGO WORKER THAT WE WOULD BE CARRYING CARGO TO SAT, AND THAT THE CARGO WOULD WEIGH AS MUCH AS 50000 LBS. I STOPPED FUELING AND BEGAN COMPUTATIONS AS TO FUEL CAPACITY BASED ON A CARGO LOAD OF 50000 LBS. AT THE SAME TIME, I CONTACTED COMPANY FLT FOLLOWING TO OBTAIN A VALID FLT PLAN BASED ON A CARGO LOAD OF 50000 LBS FOR VALID FUEL BURN COMPUTATIONS, IN ORDER TO COMPUTE MAX FUEL LOADING. AT THE SAME TIME, I WAS ALSO CONCERNED ABOUT A MAINT WRITE-UP I HAD MADE ON THE ACFT, AND I WAS INVOLVED WITH THAT ALSO. QUICKLY, WE GOT THE CARGO WT. THE PLANE WAS QUICKLY LOADED AND WE PUSHED BACK. I FELT A NEED OF URGENCY TO HURRY UP AND GET GOING IN ORDER TO GET TO SAT IN TIME TO RECOVER FROM THE PREVIOUS DAY'S MECHANICAL PROBS. I DID NOT TAKE TIME TO REVIEW THE STARS INTO SAT PRIOR TO PUSHBACK. I DO NOT FLY INTO SAT VERY OFTEN (UNLIKE DFW) AND WAS NOT FAMILIAR WITH THE PROCS. I ELECTED TO PERFORM THE DUTIES OF THE PF, AS I COULD SENSE THAT MY FO WAS FATIGUED. THE FO DOES NOT HAVE A GREAT DEAL OF EXPERIENCE IN LARGE ACFT AND THE IOE LEGS HE HAS BEEN FLYING HAD BEEN WEARING HIM DOWN. IN FACT, WE WERE ALL FATIGUED. IT WAS THE LAST DAY OF OUR WORK WK, THE LEG TO SAT WAS ADDED ON TO OUR FLT AT THE LAST MIN, AND WE WERE INTO THE 10TH TO 11TH HR OF DUTY TIME FOR THE DAY. WE WERE CLRED VIA THE MARCS 5 STAR. I GLANCED AT THE ARR AND SAW THE XING RESTR AT THE MARCS INTXN TO BE 13000 FT AND AT THE NEXT INTXN (I AM UNABLE TO REMEMBER THE NAME OF THE INTXN), WHICH IS 12 MI W OF THE MARCS INTXN, THE XING RESTR IS 10000 FT. I ASKED MY FO TO REQUEST A FUTURE DSCNT. AS HE WAS PREPARING TO ASK, CTR CLRED US DIRECT TO THE MARCS INTXN AND CLRED US TO DSND VIA THE ARR TO SAT. PASSING FL180, I REQUESTED THE DSCNT CHKLIST. AT THE TIME, BUG SPDS WERE NOT SET. NORMALLY THEY ARE SET PRIOR TO FL180. I SUSPECT FATIGUE WAS INVOLVED WITH THE FAILURE OF US AS A CREW TO NOT NOTICE THE BUG SPDS HAD NOT BEEN SET. WE AT THIS TIME SET OUR SPDS. THIS ACFT HAS AN OLD ATTITUDE INDICATOR WITH A SMALL KNOB AT THE 7 O'CLOCK POS ON THE INST THAT IS USED TO MOVE THE HORIZON BAR UP AND DOWN ON THE INST. THIS KNOB HAS NO FRICTION RESISTANCE TO TURNING -- IT ROTATES VERY EASILY. MOST OF THE ACFT DO NOT HAVE THIS TYPE OF INST AND THIS WAS THE FIRST TIME THE FO HAD FLOWN A DC8 WITH THIS TYPE OF INSTRUMENTATION. DURING THE SETTING OF HIS AIRSPD BUGS, I BELIEVE HE INADVERTENTLY NUDGED THE KNOB ON THE ATTITUDE INDICATOR, CAUSING THE HORIZON BAR TO MOVE MUCH FURTHER DOWN THAN MY ATTITUDE INDICATOR. THIS WAS NOT NOTICED BY THE FO, THE FE, NOR MYSELF. DURING THE SAME TIME OF THE DSCNT, THE RIDE BECAME QUITE BUMPY. I HAD HEARD CTR RPT SOME PIREPS AS 'SEVERE.' THE AUTOPLT DISCONNECTED ITSELF TWICE DURING THIS TIME. PASSING APPROX 15000 FT OR SO, THE FO NOTICED HIS ATTITUDE INDICATOR APPEARED DIFFERENT THAN MINE AND ALSO THE STANDBY ATTITUDE INDICATOR. HE CALLED IT TO MY ATTN. I CHKED IT AGAINST MY INST AND THE STANDBY ATTITUDE INDICATOR AND SUSPECTED A PENDING GYRO FAILURE. I LOOKED AT MY ATTITUDE INDICATOR AND NOTICED THE HORIZON BAR KNOB AND REALIZED THAT THE FO'S MAY HAVE BEEN MISSET. I TOLD THE FO TO RESET IT. HE DID NOT REALLY KNOW WHAT I WAS TALKING ABOUT. SO I THEN REACHED OVER TO HIS SIDE OF THE PANEL AND RESET HIS HORIZON BAR. DURING THIS STAGE OF DSCNT, I HAD FAILED TO KEEP TRACK OF OUR PROGRESS TO MARCS AND REMEMBERING THE LAST FIX TO CROSS AT 10000 FT, I CONTINUED ON DOWN TO 10000 FT. THE CTLR THEN ASKED US TO VERIFY THAT WE WERE CLRED VIA THE MARCS 5 ARR INTO SAT AND TO CROSS MARCS AT 13000 FT. IT WAS THEN I REALIZED THAT WE HAD CROSSED MARCS BELOW 13000 FT. WE LOOKED AT EACH OTHER AND REALIZED THAT WE ALL HAD MADE AN ERROR. THE CREW AND I DEBRIEFED ON THE GND AND WHILE WE WERE AWAITING A RIDE TO THE PAX TERMINAL, MY BEEPER GOES OFF WITH CREW SCHEDULING'S PHONE NUMBER. I CALLED AND WAS TOLD THAT MY FLEET MGR WANTED TO SPEAK TO ME AND A CONFERENCE CALL WAS BEING DIALED. THIS WAS DONE AND HE INFORMED ME THAT MR X OF THE FAA WANTED TO TALK TO ME. ABOUT 30 MINS LATER, I CALLED MR X. WE TALKED FOR ABOUT 10 MINS. MR X WAS CONCERNED THAT THERE WAS SOMETHING ON THE STAR CHART THAT WAS CONFUSING. I TOLD HIM THAT I HAD NOT HAD A CHANCE TO REVIEW THE CHART SINCE THE DEV, BUT WOULD LOOK AT IT THE NEXT TIME I FLEW AND CALL HIM IF I HAD ANY SUGGESTIONS. REFLECTING ON WHAT HAPPENED, I FEEL THAT FATIGUE, COMBINED WITH THE APPARENT EQUIP FAILURE AT A VERY INOPPORTUNE MOMENT CAUSED CONFUSION AND DISTR IN THE COCKPIT. COMBINE THIS WITH THE TURB AND THE LACK OF EXPERIENCE OF THE PNF MADE FOR A DANGEROUS ERROR TO BE MADE.
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.