37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 478710 |
Time | |
Date | 200007 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | intersection : jaybo |
State Reference | MD |
Altitude | msl bound lower : 13600 msl bound upper : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc.artcc tower : grb.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-400 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : intermediate altitude |
Route In Use | arrival star : dupont |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 130 flight time total : 4500 flight time type : 300 |
ASRS Report | 478710 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 19000 flight time type : 6000 |
ASRS Report | 478707 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : company policies non adherence : clearance other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude |
Consequence | Other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
En route phl, ZDC (132.05) cleared flight to cross jaybo at 13000 ft (from 23000 ft 23 NM from jaybo). Subsequently told to level at 14000 ft. Aircraft reached 13600 ft before it was recognized that autoplt had abnormally disconnected with none of the normal visual or audio cues. Captain recovered aircraft to assigned 14000 ft without incident. Supplemental information from acn 478707: VNAV was engaged and FMC correctly commanded a high airspeed steep descent since 23 mi to lose 10000 ft is greater than a normal descent. FMC however did not respect stick shaker and I had to intervene by using level change (disengage VNAV). Autoplt once again continued to allow aircraft to fly at stick shaker and proceeded to descend below 14000 ft at which time I took over manually and arrested the descent at 13600 ft, climbing back to 14000 ft. We were monitoring the aircraft and fully expected a leveloff at 14000 ft not knowing the autoplt was disengaged. FMC allowed aircraft to fly at stick shaker. Autoplt was somehow disconnected without warnings that are supposed to be seen and heard, warning sound and flashing red light on FMA (flight mode annunciator panel) will pay more attention to entire mode indications in future: 'paddle' switch was down (autoplt disengaged position) which would have immediately told me why aircraft was flying at clacker speed. Also, there is a small 'autoplt off' indicator on FMA.
Original NASA ASRS Text
Title: A DSNDING B737-400 FLC OVERSHOOTS THEIR ASSIGNED ALT WHEN THE AUTOPLT DISCONNECTS PRIOR TO LEVELOFF ALT AT JAYBO, MD.
Narrative: ENRTE PHL, ZDC (132.05) CLRED FLT TO CROSS JAYBO AT 13000 FT (FROM 23000 FT 23 NM FROM JAYBO). SUBSEQUENTLY TOLD TO LEVEL AT 14000 FT. ACFT REACHED 13600 FT BEFORE IT WAS RECOGNIZED THAT AUTOPLT HAD ABNORMALLY DISCONNECTED WITH NONE OF THE NORMAL VISUAL OR AUDIO CUES. CAPT RECOVERED ACFT TO ASSIGNED 14000 FT WITHOUT INCIDENT. SUPPLEMENTAL INFO FROM ACN 478707: VNAV WAS ENGAGED AND FMC CORRECTLY COMMANDED A HIGH AIRSPD STEEP DSCNT SINCE 23 MI TO LOSE 10000 FT IS GREATER THAN A NORMAL DSCNT. FMC HOWEVER DID NOT RESPECT STICK SHAKER AND I HAD TO INTERVENE BY USING LEVEL CHANGE (DISENGAGE VNAV). AUTOPLT ONCE AGAIN CONTINUED TO ALLOW ACFT TO FLY AT STICK SHAKER AND PROCEEDED TO DSND BELOW 14000 FT AT WHICH TIME I TOOK OVER MANUALLY AND ARRESTED THE DSCNT AT 13600 FT, CLBING BACK TO 14000 FT. WE WERE MONITORING THE ACFT AND FULLY EXPECTED A LEVELOFF AT 14000 FT NOT KNOWING THE AUTOPLT WAS DISENGAGED. FMC ALLOWED ACFT TO FLY AT STICK SHAKER. AUTOPLT WAS SOMEHOW DISCONNECTED WITHOUT WARNINGS THAT ARE SUPPOSED TO BE SEEN AND HEARD, WARNING SOUND AND FLASHING RED LIGHT ON FMA (FLT MODE ANNUNCIATOR PANEL) WILL PAY MORE ATTN TO ENTIRE MODE INDICATIONS IN FUTURE: 'PADDLE' SWITCH WAS DOWN (AUTOPLT DISENGAGED POS) WHICH WOULD HAVE IMMEDIATELY TOLD ME WHY ACFT WAS FLYING AT CLACKER SPD. ALSO, THERE IS A SMALL 'AUTOPLT OFF' INDICATOR ON FMA.
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.