37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 457985 |
Time | |
Date | 199912 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | intersection : knead |
State Reference | TX |
Altitude | msl single value : 16000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Thunderstorm Rain Turbulence |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : d10.tracon |
Operator | common carrier : air carrier |
Make Model Name | MD-88 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : vacating altitude |
Route In Use | arrival : on vectors arrival star : jumbo 2 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 14000 flight time type : 3200 |
ASRS Report | 457985 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | aircraft equipment problem : less severe altitude deviation : undershoot altitude deviation : crossing restriction not met inflight encounter : turbulence inflight encounter : weather non adherence : clearance non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : overcame equipment problem |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Environmental Factor Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This is an example of how a few seemingly insignificant problems, when added together, can lead to a potentially significant problem. I and my first officer left pbi at PM45Z on dec/sat/99. We left with the following problems: 1) the airplane had a history of autoplt disconnects due to 'elevator feel fault' and 'acu excitation' messages. 2) it was a dark night, very little moonlight and there were rain showers and thunderstorms at the destination airport, dfw. 3) there were significant winds at altitude. 4) my first officer's microphone was stowed on top of, rather than in, the wire cage designed to hold it. We were cleared direct to knead and the jumbo 2. It took us a moment to find the arrival in our books and we turned right to knead. ZFW then cleared us to cross knead at 11000 ft. (The mandatory crossing speed at knead is 250 KTS.) we were 30 mi from knead and had a 100 KT tailwind. First officer briefed an ILS to runway 36L. Passing 16000 ft at our maximum descent rate with speed brakes and with a 60 KT tailwind, we realized we would not make our crossing restr. At that point center sent us over to approach control on 133.62. I acknowledged and switched frequencys. I got no answer when I checked in with approach control. After several attempts I returned to center for another frequency and still no answer. After checking all of my radio buttons and switches and asking my first officer to do the same, I tried several other frequencys from my dfw approach plates, still no answer. I then attempted radio #2. In the meantime, as we approached 11000 ft on a dark night in the WX and surrounded by rain showers, the 'elevator feel fault' message came on and the autoplt disconnected. The 'acu excitation' message also came on and off repeatedly causing the master caution light to come on repeatedly. (In the dark the master caution light is very bright.) my first officer did a great job of hand flying the airplane through the arrival and toward TTT in the event we had to do a radio out descent and approach, considering the flurry of activity in the cockpit. Flying inbound to TTT, I put 7600 in our transponder but continued to search for a usable frequency. I heard some feedback from my first officer's microphone and again asked him to check his radio setting because I thought we might have a stuck microphone button. Finally, 12 mi from TTT at 11000 ft and 250 KTS, I made contact with approach control on #2 radio on frequency 118.1. Approach vectored us to a downwind and on for an ILS approach to runway 35C. We briefed the new approach and finished all checklists. Approach attempted 1 frequency change but when it was unsuccessful, we returned and he cleared us for the approach and cleared us to land. We broke out of the WX at about 600 ft. The master caution light continued to come on every 3-5 seconds throughout the entire event. On landing, my first officer made radio calls by switching from intercom to radio #2. After arrival at the gate we found my first officer's microphone wedged between the wire cage and the cockpit wall with the transmit button depressed. In retrospect, we discovered that whatever radio my first officer had selected on his radio intercom panel was blocked. Trying the same frequency on another radio didn't work because the frequency was blocked. That, combined with the fact that not all approach frequencys were being used initially, gave us the impression that our radios were out. The fact that we were on an arrival, being rushed by tailwinds, with a late route change and descent clearance, in the dark, in the WX, with the autoplt off and the master caution flashing, made it difficult to troubleshoot our radio problem. Callback conversation with reporter revealed the following information: the first officer stated that he normally uses the headset microphone and his yoke radio switch. This is while he is climbing, descending. In cruise he used the handheld microphone and had not realized he had placed it into an incorrect position just prior to 16000 ft.
Original NASA ASRS Text
Title: AN MD88 FO RPT ON AN ALT BUST WITH DFW APCH CTLR WHILE DSNDING OUT OF 16000 FT, WITH LOSS OF COM AND ASSOCIATED ACFT AUTOPLT PROBS ON THE JUMBO ARR, DFW, TX.
Narrative: THIS IS AN EXAMPLE OF HOW A FEW SEEMINGLY INSIGNIFICANT PROBS, WHEN ADDED TOGETHER, CAN LEAD TO A POTENTIALLY SIGNIFICANT PROB. I AND MY FO LEFT PBI AT PM45Z ON DEC/SAT/99. WE LEFT WITH THE FOLLOWING PROBS: 1) THE AIRPLANE HAD A HISTORY OF AUTOPLT DISCONNECTS DUE TO 'ELEVATOR FEEL FAULT' AND 'ACU EXCITATION' MESSAGES. 2) IT WAS A DARK NIGHT, VERY LITTLE MOONLIGHT AND THERE WERE RAIN SHOWERS AND TSTMS AT THE DEST ARPT, DFW. 3) THERE WERE SIGNIFICANT WINDS AT ALT. 4) MY FO'S MIKE WAS STOWED ON TOP OF, RATHER THAN IN, THE WIRE CAGE DESIGNED TO HOLD IT. WE WERE CLRED DIRECT TO KNEAD AND THE JUMBO 2. IT TOOK US A MOMENT TO FIND THE ARR IN OUR BOOKS AND WE TURNED R TO KNEAD. ZFW THEN CLRED US TO CROSS KNEAD AT 11000 FT. (THE MANDATORY XING SPD AT KNEAD IS 250 KTS.) WE WERE 30 MI FROM KNEAD AND HAD A 100 KT TAILWIND. FO BRIEFED AN ILS TO RWY 36L. PASSING 16000 FT AT OUR MAX DSCNT RATE WITH SPD BRAKES AND WITH A 60 KT TAILWIND, WE REALIZED WE WOULD NOT MAKE OUR XING RESTR. AT THAT POINT CTR SENT US OVER TO APCH CTL ON 133.62. I ACKNOWLEDGED AND SWITCHED FREQS. I GOT NO ANSWER WHEN I CHKED IN WITH APCH CTL. AFTER SEVERAL ATTEMPTS I RETURNED TO CTR FOR ANOTHER FREQ AND STILL NO ANSWER. AFTER CHKING ALL OF MY RADIO BUTTONS AND SWITCHES AND ASKING MY FO TO DO THE SAME, I TRIED SEVERAL OTHER FREQS FROM MY DFW APCH PLATES, STILL NO ANSWER. I THEN ATTEMPTED RADIO #2. IN THE MEANTIME, AS WE APCHED 11000 FT ON A DARK NIGHT IN THE WX AND SURROUNDED BY RAIN SHOWERS, THE 'ELEVATOR FEEL FAULT' MESSAGE CAME ON AND THE AUTOPLT DISCONNECTED. THE 'ACU EXCITATION' MESSAGE ALSO CAME ON AND OFF REPEATEDLY CAUSING THE MASTER CAUTION LIGHT TO COME ON REPEATEDLY. (IN THE DARK THE MASTER CAUTION LIGHT IS VERY BRIGHT.) MY FO DID A GREAT JOB OF HAND FLYING THE AIRPLANE THROUGH THE ARR AND TOWARD TTT IN THE EVENT WE HAD TO DO A RADIO OUT DSCNT AND APCH, CONSIDERING THE FLURRY OF ACTIVITY IN THE COCKPIT. FLYING INBOUND TO TTT, I PUT 7600 IN OUR XPONDER BUT CONTINUED TO SEARCH FOR A USABLE FREQ. I HEARD SOME FEEDBACK FROM MY FO'S MIKE AND AGAIN ASKED HIM TO CHK HIS RADIO SETTING BECAUSE I THOUGHT WE MIGHT HAVE A STUCK MIKE BUTTON. FINALLY, 12 MI FROM TTT AT 11000 FT AND 250 KTS, I MADE CONTACT WITH APCH CTL ON #2 RADIO ON FREQ 118.1. APCH VECTORED US TO A DOWNWIND AND ON FOR AN ILS APCH TO RWY 35C. WE BRIEFED THE NEW APCH AND FINISHED ALL CHKLISTS. APCH ATTEMPTED 1 FREQ CHANGE BUT WHEN IT WAS UNSUCCESSFUL, WE RETURNED AND HE CLRED US FOR THE APCH AND CLRED US TO LAND. WE BROKE OUT OF THE WX AT ABOUT 600 FT. THE MASTER CAUTION LIGHT CONTINUED TO COME ON EVERY 3-5 SECONDS THROUGHOUT THE ENTIRE EVENT. ON LNDG, MY FO MADE RADIO CALLS BY SWITCHING FROM INTERCOM TO RADIO #2. AFTER ARR AT THE GATE WE FOUND MY FO'S MIKE WEDGED BTWN THE WIRE CAGE AND THE COCKPIT WALL WITH THE XMIT BUTTON DEPRESSED. IN RETROSPECT, WE DISCOVERED THAT WHATEVER RADIO MY FO HAD SELECTED ON HIS RADIO INTERCOM PANEL WAS BLOCKED. TRYING THE SAME FREQ ON ANOTHER RADIO DIDN'T WORK BECAUSE THE FREQ WAS BLOCKED. THAT, COMBINED WITH THE FACT THAT NOT ALL APCH FREQS WERE BEING USED INITIALLY, GAVE US THE IMPRESSION THAT OUR RADIOS WERE OUT. THE FACT THAT WE WERE ON AN ARR, BEING RUSHED BY TAILWINDS, WITH A LATE RTE CHANGE AND DSCNT CLRNC, IN THE DARK, IN THE WX, WITH THE AUTOPLT OFF AND THE MASTER CAUTION FLASHING, MADE IT DIFFICULT TO TROUBLESHOOT OUR RADIO PROB. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE FO STATED THAT HE NORMALLY USES THE HEADSET MIKE AND HIS YOKE RADIO SWITCH. THIS IS WHILE HE IS CLBING, DSNDING. IN CRUISE HE USED THE HANDHELD MIKE AND HAD NOT REALIZED HE HAD PLACED IT INTO AN INCORRECT POS JUST PRIOR TO 16000 FT.
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.