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Attributes | |
ACN | 449588 |
Time | |
Date | 199909 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : cyn.vor |
State Reference | NJ |
Altitude | msl bound lower : 34500 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zdc.artcc |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 8000 flight time type : 200 |
ASRS Report | 449588 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : commercial pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 3500 flight time type : 400 |
ASRS Report | 449583 |
Events | |
Anomaly | altitude deviation : undershoot conflict : airborne less severe non adherence : company policies non adherence : far non adherence : published procedure non adherence : clearance non adherence : required legal separation other anomaly |
Independent Detector | other controllera other flight crewa other flight crewb |
Resolutory Action | controller : separated traffic flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | ATC Human Performance Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I am relatively new to FMC automated flight, and therefore, did not react fast enough to an automation failure that produced an altitude deviation upon leveloff. I had selected maximum rate climb on the FMC upon a center request for 'good rate.' while climbing through about FL345 for FL350, I observed airspeed falling off from the maximum rate command bug at a rapid rate. Nose was also pitching up. We managed to reach FL349 but at a very low energy state, with 'buffet warning' annunciated on the EICAS display. Prior to reaching this condition, I was involved in reselecting the climb page with a view to reinstating economy climb on the FMC. However, the aircraft needed immediate attention due to the rapidity of the energy loss. I was intent of reducing pitch right away, so I disengaged the autoplt to establish manual flight. Automatic follow-up pitch trim had not yet had time to catch up to the new low energy state, and so I was immediately presented with strong nose down pitch forces. This caused the nose to drop a little more than I had planned or would have desired, and altitude decreased to about FL345 again. This was not necessarily a bad thing aerodynamically speaking, however, I am aware that center was obliged to issue an avoidance vector to another carrier at the time. A factor in this incident was my relative slowness, upon observing the airspeed decrease and pitch up, in selecting climb page in order to institute a fix. I think I was momentarily transfixed by the phenomenon of the airspeed needle just dropping off the command bug, and dropping fast. 'It just wasn't supposed to do that.' by the time I had assimilated this information and integrated it, we had gained another 500 ft and the aircraft now needed immediate attention. This was a first for me in this aircraft -- to observe the autoplt all of a sudden start ignoring an FMC command and go off on its own -- with no other failure indications. Supplemental information from acn 449583: while climbing to FL350 the captain who was flying observed airspeed begin to decrease passing FL345. The autoplt was ignoring the FMS commanded airspeed of 260 KTS and raising the pitch. The FMS was directing a maximum rate climb at the time. The captain disconnected the autoplt to regain airspeed and the aircraft descended from FL349 to approximately FL345 where airspeed began to recover. At this time, I do not know why the autoplt ignored the FMC and began reducing airspeed. The altitude loss was a result of the low airspeed and the need to recover it above a safe buffet margin. I could have improved the situation by recognizing the airspeed loss sooner and bringing it to the captain's attention. Better CRM needed on my part.
Original NASA ASRS Text
Title: A B737-800 CREW SUBMITTED RPTS DESCRIBING HOW THEY NEARLY STALLED AS THEY ATTEMPTED TO CAPTURE THEIR CRUISING ALT.
Narrative: I AM RELATIVELY NEW TO FMC AUTOMATED FLT, AND THEREFORE, DID NOT REACT FAST ENOUGH TO AN AUTOMATION FAILURE THAT PRODUCED AN ALTDEV UPON LEVELOFF. I HAD SELECTED MAX RATE CLB ON THE FMC UPON A CTR REQUEST FOR 'GOOD RATE.' WHILE CLBING THROUGH ABOUT FL345 FOR FL350, I OBSERVED AIRSPD FALLING OFF FROM THE MAX RATE COMMAND BUG AT A RAPID RATE. NOSE WAS ALSO PITCHING UP. WE MANAGED TO REACH FL349 BUT AT A VERY LOW ENERGY STATE, WITH 'BUFFET WARNING' ANNUNCIATED ON THE EICAS DISPLAY. PRIOR TO REACHING THIS CONDITION, I WAS INVOLVED IN RESELECTING THE CLB PAGE WITH A VIEW TO REINSTATING ECONOMY CLB ON THE FMC. HOWEVER, THE ACFT NEEDED IMMEDIATE ATTN DUE TO THE RAPIDITY OF THE ENERGY LOSS. I WAS INTENT OF REDUCING PITCH RIGHT AWAY, SO I DISENGAGED THE AUTOPLT TO ESTABLISH MANUAL FLT. AUTOMATIC FOLLOW-UP PITCH TRIM HAD NOT YET HAD TIME TO CATCH UP TO THE NEW LOW ENERGY STATE, AND SO I WAS IMMEDIATELY PRESENTED WITH STRONG NOSE DOWN PITCH FORCES. THIS CAUSED THE NOSE TO DROP A LITTLE MORE THAN I HAD PLANNED OR WOULD HAVE DESIRED, AND ALT DECREASED TO ABOUT FL345 AGAIN. THIS WAS NOT NECESSARILY A BAD THING AERODYNAMICALLY SPEAKING, HOWEVER, I AM AWARE THAT CTR WAS OBLIGED TO ISSUE AN AVOIDANCE VECTOR TO ANOTHER CARRIER AT THE TIME. A FACTOR IN THIS INCIDENT WAS MY RELATIVE SLOWNESS, UPON OBSERVING THE AIRSPD DECREASE AND PITCH UP, IN SELECTING CLB PAGE IN ORDER TO INSTITUTE A FIX. I THINK I WAS MOMENTARILY TRANSFIXED BY THE PHENOMENON OF THE AIRSPD NEEDLE JUST DROPPING OFF THE COMMAND BUG, AND DROPPING FAST. 'IT JUST WASN'T SUPPOSED TO DO THAT.' BY THE TIME I HAD ASSIMILATED THIS INFO AND INTEGRATED IT, WE HAD GAINED ANOTHER 500 FT AND THE ACFT NOW NEEDED IMMEDIATE ATTN. THIS WAS A FIRST FOR ME IN THIS ACFT -- TO OBSERVE THE AUTOPLT ALL OF A SUDDEN START IGNORING AN FMC COMMAND AND GO OFF ON ITS OWN -- WITH NO OTHER FAILURE INDICATIONS. SUPPLEMENTAL INFO FROM ACN 449583: WHILE CLBING TO FL350 THE CAPT WHO WAS FLYING OBSERVED AIRSPD BEGIN TO DECREASE PASSING FL345. THE AUTOPLT WAS IGNORING THE FMS COMMANDED AIRSPD OF 260 KTS AND RAISING THE PITCH. THE FMS WAS DIRECTING A MAX RATE CLB AT THE TIME. THE CAPT DISCONNECTED THE AUTOPLT TO REGAIN AIRSPD AND THE ACFT DSNDED FROM FL349 TO APPROX FL345 WHERE AIRSPD BEGAN TO RECOVER. AT THIS TIME, I DO NOT KNOW WHY THE AUTOPLT IGNORED THE FMC AND BEGAN REDUCING AIRSPD. THE ALT LOSS WAS A RESULT OF THE LOW AIRSPD AND THE NEED TO RECOVER IT ABOVE A SAFE BUFFET MARGIN. I COULD HAVE IMPROVED THE SIT BY RECOGNIZING THE AIRSPD LOSS SOONER AND BRINGING IT TO THE CAPT'S ATTN. BETTER CRM NEEDED ON MY PART.
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.