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|
Attributes | |
ACN | 437390 |
Time | |
Date | 199905 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | intersection : whigg |
State Reference | NV |
Altitude | msl bound lower : 22000 msl bound upper : 22350 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zla.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | cruise : enroute altitude change |
Route In Use | arrival star : creso 3 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 255 flight time total : 7200 flight time type : 4200 |
ASRS Report | 437390 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer pilot : multi engine |
Experience | flight time last 90 days : 250 flight time total : 18000 flight time type : 250 |
ASRS Report | 437387 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude conflict : airborne less severe non adherence : required legal separation non adherence : clearance |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued advisory controller : separated traffic |
Consequence | faa : reviewed incident with flight crew other |
Miss Distance | horizontal : 36000 vertical : 650 |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
The first officer was PF. I was descending on the creso 3 arrival into las. ZLA wanted us to descend to FL220 at 320 KTS or better. I was using the autoplt in the vertical speed mode. At approximately FL260 the mode control panel speed feature took control. I deselected the mode and using the yoke I began to slow the descent rate. Altitude acquire mode immediately took control with a 5000 FPM descent rate. The altitude acquire mode went about 100 ft low and began a slow ascent. About that time ZLA gave us a restr of 12000 ft at whigg. The captain (non-flying) put the restr in the altitude window of the autoplt. The captain went off frequency to get the ATIS. I looked in the CDU to gauge the distance to begin the descent to whigg. I and the captain thought the aircraft was in the altitude hold mode. When I next looked up the aircraft was about 250 ft high. When the altitude window was changed the vertical speed mode took control with a climb. I used the vertical speed wheel to begin a descent. We ballooned up to 350 ft. I then disconnected the autoplt and took over manually. At that time ATC asked us our altitude and we received a TA on an aircraft at FL230 about 6 mi away. During the descent we informed ATC of our mistake. Due to all the activity occurring simultaneously and an incorrect assumption by both pilots, our aircraft did not level off at the correct altitude. More attention needed to be paid to flying the aircraft during that critical phase of flight. Then the PF should have immediately disconnected the autoplt and begun the descent so as to not delay it. Supplemental information from acn 437387: the controller issued a clearance to cross whigg intersection at 12000 ft. I simultaneously selected 12000 ft in the altitude window on the mode control panel, and I immediately checked off center frequency to obtain the current ATIS in las. The first officer was distracted by my checking off and assumed altitude hold mode had engaged, while in fact the vertical speed mode had captured the 200 FPM ascent from the original autoplt correction of climbing back to FL220. During the continuing descent the controller and I discussed the situation, ie, possible conflict, and he insinuated that no conflict existed, but 'the machine' had triggered an alert at his end. I do believe that were we flying the old technology autoplt, this incident would not have occurred. We need to continue with the identical mindset on both old and new technology aircraft -- 'mind the store' during all altitude and heading changes. Do I like automatic leveloffs -- no. Am I more aware -- you bet.
Original NASA ASRS Text
Title: A B737-300 FLC MISUSES THEIR FMS MODE CTL PANEL SELECTIONS AND, THROUGH AN ALTDEV, INSPIRE AN ATC INQUIRY INTO THEIR ALT.
Narrative: THE FO WAS PF. I WAS DSNDING ON THE CRESO 3 ARR INTO LAS. ZLA WANTED US TO DSND TO FL220 AT 320 KTS OR BETTER. I WAS USING THE AUTOPLT IN THE VERT SPD MODE. AT APPROX FL260 THE MODE CTL PANEL SPD FEATURE TOOK CTL. I DESELECTED THE MODE AND USING THE YOKE I BEGAN TO SLOW THE DSCNT RATE. ALT ACQUIRE MODE IMMEDIATELY TOOK CTL WITH A 5000 FPM DSCNT RATE. THE ALT ACQUIRE MODE WENT ABOUT 100 FT LOW AND BEGAN A SLOW ASCENT. ABOUT THAT TIME ZLA GAVE US A RESTR OF 12000 FT AT WHIGG. THE CAPT (NON-FLYING) PUT THE RESTR IN THE ALT WINDOW OF THE AUTOPLT. THE CAPT WENT OFF FREQ TO GET THE ATIS. I LOOKED IN THE CDU TO GAUGE THE DISTANCE TO BEGIN THE DSCNT TO WHIGG. I AND THE CAPT THOUGHT THE ACFT WAS IN THE ALT HOLD MODE. WHEN I NEXT LOOKED UP THE ACFT WAS ABOUT 250 FT HIGH. WHEN THE ALT WINDOW WAS CHANGED THE VERT SPD MODE TOOK CTL WITH A CLB. I USED THE VERT SPD WHEEL TO BEGIN A DSCNT. WE BALLOONED UP TO 350 FT. I THEN DISCONNECTED THE AUTOPLT AND TOOK OVER MANUALLY. AT THAT TIME ATC ASKED US OUR ALT AND WE RECEIVED A TA ON AN ACFT AT FL230 ABOUT 6 MI AWAY. DURING THE DSCNT WE INFORMED ATC OF OUR MISTAKE. DUE TO ALL THE ACTIVITY OCCURRING SIMULTANEOUSLY AND AN INCORRECT ASSUMPTION BY BOTH PLTS, OUR ACFT DID NOT LEVEL OFF AT THE CORRECT ALT. MORE ATTN NEEDED TO BE PAID TO FLYING THE ACFT DURING THAT CRITICAL PHASE OF FLT. THEN THE PF SHOULD HAVE IMMEDIATELY DISCONNECTED THE AUTOPLT AND BEGUN THE DSCNT SO AS TO NOT DELAY IT. SUPPLEMENTAL INFO FROM ACN 437387: THE CTLR ISSUED A CLRNC TO CROSS WHIGG INTXN AT 12000 FT. I SIMULTANEOUSLY SELECTED 12000 FT IN THE ALT WINDOW ON THE MODE CTL PANEL, AND I IMMEDIATELY CHKED OFF CTR FREQ TO OBTAIN THE CURRENT ATIS IN LAS. THE FO WAS DISTRACTED BY MY CHKING OFF AND ASSUMED ALT HOLD MODE HAD ENGAGED, WHILE IN FACT THE VERT SPD MODE HAD CAPTURED THE 200 FPM ASCENT FROM THE ORIGINAL AUTOPLT CORRECTION OF CLBING BACK TO FL220. DURING THE CONTINUING DSCNT THE CTLR AND I DISCUSSED THE SIT, IE, POSSIBLE CONFLICT, AND HE INSINUATED THAT NO CONFLICT EXISTED, BUT 'THE MACHINE' HAD TRIGGERED AN ALERT AT HIS END. I DO BELIEVE THAT WERE WE FLYING THE OLD TECHNOLOGY AUTOPLT, THIS INCIDENT WOULD NOT HAVE OCCURRED. WE NEED TO CONTINUE WITH THE IDENTICAL MINDSET ON BOTH OLD AND NEW TECHNOLOGY ACFT -- 'MIND THE STORE' DURING ALL ALT AND HEADING CHANGES. DO I LIKE AUTO LEVELOFFS -- NO. AM I MORE AWARE -- YOU BET.
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.