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|
Attributes | |
ACN | 460500 |
Time | |
Date | 200001 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : lrp.vortac |
State Reference | PA |
Altitude | msl single value : 10500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zny.artcc |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other other vortac |
Flight Phase | descent : vacating altitude |
Route In Use | arrival : holding pattern arrival star : bunts 1 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain instruction : instructor oversight : pic |
Qualification | pilot : flight engineer pilot : instrument pilot : multi engine pilot : atp pilot : commercial |
Experience | flight time last 90 days : 100 flight time total : 14500 flight time type : 3100 |
ASRS Report | 460500 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer instruction : trainee |
Qualification | pilot : instrument pilot : commercial pilot : multi engine |
Events | |
Anomaly | non adherence : clearance non adherence : company policies non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : provided flight assist controller : issued new clearance flight crew : became reoriented |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Our aircraft was flying the bunts one arrival into phl. We had been descending and were given a hold at bunts as published, maintain speed our discretion. ZNY continued to make radio calls to us for altitude changes, to inform us radar service was terminated, inquire about our altitude and then switch us over to phl approach control. In this process of adherence to ZNY's instructions, we entered the holding fix information into our FMC and executed it, prior to checking with each other. Our normal flow of xchking became disrupted by a breakdown in the workload tasks. PF could have been made useful to answer ATC, while PNF entered holding fix data and xchking, would not have been interrupted. The B757-200 FMC defers all holding information into right turns. This breakdown on our part failed to pick this up. PNF was giving IOE instruction to PF at the time. Callback conversation with reporter revealed the following information: pilot indicates that the hold clearance was given at the last second. This along with a multitude of other clrncs at a speech rate that bordered on unintelligible. Cockpit FMS operating protocol broke down because of extreme time constraints.
Original NASA ASRS Text
Title: B757 CREW HELD THE WRONG DIRECTION AT A CHARTED HOLDING PATTERN.
Narrative: OUR ACFT WAS FLYING THE BUNTS ONE ARR INTO PHL. WE HAD BEEN DSNDING AND WERE GIVEN A HOLD AT BUNTS AS PUBLISHED, MAINTAIN SPD OUR DISCRETION. ZNY CONTINUED TO MAKE RADIO CALLS TO US FOR ALT CHANGES, TO INFORM US RADAR SVC WAS TERMINATED, INQUIRE ABOUT OUR ALT AND THEN SWITCH US OVER TO PHL APCH CTL. IN THIS PROCESS OF ADHERENCE TO ZNY'S INSTRUCTIONS, WE ENTERED THE HOLDING FIX INFO INTO OUR FMC AND EXECUTED IT, PRIOR TO CHKING WITH EACH OTHER. OUR NORMAL FLOW OF XCHKING BECAME DISRUPTED BY A BREAKDOWN IN THE WORKLOAD TASKS. PF COULD HAVE BEEN MADE USEFUL TO ANSWER ATC, WHILE PNF ENTERED HOLDING FIX DATA AND XCHKING, WOULD NOT HAVE BEEN INTERRUPTED. THE B757-200 FMC DEFERS ALL HOLDING INFO INTO R TURNS. THIS BREAKDOWN ON OUR PART FAILED TO PICK THIS UP. PNF WAS GIVING IOE INSTRUCTION TO PF AT THE TIME. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: PLT INDICATES THAT THE HOLD CLRNC WAS GIVEN AT THE LAST SECOND. THIS ALONG WITH A MULTITUDE OF OTHER CLRNCS AT A SPEECH RATE THAT BORDERED ON UNINTELLIGIBLE. COCKPIT FMS OPERATING PROTOCOL BROKE DOWN BECAUSE OF EXTREME TIME CONSTRAINTS.
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.