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|
Attributes | |
ACN | 479322 |
Time | |
Date | 200007 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : rjbb.airport |
State Reference | FO |
Altitude | msl single value : 19500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : maiko. two |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 8000 flight time type : 250 |
ASRS Report | 479322 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer pilot : cfi |
Experience | flight time last 90 days : 110 flight time total : 16000 flight time type : 3000 |
ASRS Report | 479326 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : company policies non adherence : clearance non adherence : published procedure other anomaly |
Independent Detector | aircraft equipment other aircraft equipment : stall warning other flight crewa other flight crewb |
Resolutory Action | flight crew : became reoriented flight crew : returned to assigned altitude flight crew : regained aircraft control |
Consequence | Other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Airspace Structure Company |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Crew copied IFR clearance given approximately by clearance delivery at pushback time. Departure clearance was a detailed, complicated one, involving 4 tight turns from 4 different navaids. Crew set up FMS for departure, but was done hurriedly to expedite pushback. Reporter is PF, decided to hand fly departure with FMS flight director assistance. After first departure turn, instructed PNF to speed intervene in order to maintain required course as accurately as possible. While making the third required turn, flight director called for slight descent while pilots were monitoring and discussing lateral guidance. PNF noticed 500 FPM rate of descent approximately 1500 ft below cleared altitude and called out the descent. PF raised the nose, encountered stick shaker for approximately 1 second prior to PNF pushing throttles up which caused aircraft to immediately climb back to desired altitude. Possible causes include: 1) clearance given late in sequence and during high workload time. 2) lack of attention to vsi due to complicated clearance and need to xchk navaids. Callback conversation with reporter acn 479326 revealed the following information: the departure is complicated and drawn by non flying people making it difficult to fly. His company has changed policy back and forth over how to manage the aircraft to keep within the track requirements. This involves nonstandard speeds and profiles. They have since gone to normal speed departures and let the track deviations during tight turns happen. The PF was new to the aircraft and just off the airbus type which is a different autoflt system type. Fatigue was an issue because of time zone changes and multi-day trips. Reporter is in reserve and feels it is an effort to keep proficiency with very little actual flight time. The departure was rushed and the FMC not completely loaded for the route.
Original NASA ASRS Text
Title: B747 CREW EXPERIENCES STALL WARNING DURING DEP FROM FOREIGN ARPT.
Narrative: CREW COPIED IFR CLRNC GIVEN APPROX BY CLRNC DELIVERY AT PUSHBACK TIME. DEP CLRNC WAS A DETAILED, COMPLICATED ONE, INVOLVING 4 TIGHT TURNS FROM 4 DIFFERENT NAVAIDS. CREW SET UP FMS FOR DEP, BUT WAS DONE HURRIEDLY TO EXPEDITE PUSHBACK. RPTR IS PF, DECIDED TO HAND FLY DEP WITH FMS FLT DIRECTOR ASSISTANCE. AFTER FIRST DEP TURN, INSTRUCTED PNF TO SPD INTERVENE IN ORDER TO MAINTAIN REQUIRED COURSE AS ACCURATELY AS POSSIBLE. WHILE MAKING THE THIRD REQUIRED TURN, FLT DIRECTOR CALLED FOR SLIGHT DSCNT WHILE PLTS WERE MONITORING AND DISCUSSING LATERAL GUIDANCE. PNF NOTICED 500 FPM RATE OF DSCNT APPROX 1500 FT BELOW CLRED ALT AND CALLED OUT THE DSCNT. PF RAISED THE NOSE, ENCOUNTERED STICK SHAKER FOR APPROX 1 SECOND PRIOR TO PNF PUSHING THROTTLES UP WHICH CAUSED ACFT TO IMMEDIATELY CLB BACK TO DESIRED ALT. POSSIBLE CAUSES INCLUDE: 1) CLRNC GIVEN LATE IN SEQUENCE AND DURING HIGH WORKLOAD TIME. 2) LACK OF ATTN TO VSI DUE TO COMPLICATED CLRNC AND NEED TO XCHK NAVAIDS. CALLBACK CONVERSATION WITH RPTR ACN 479326 REVEALED THE FOLLOWING INFO: THE DEP IS COMPLICATED AND DRAWN BY NON FLYING PEOPLE MAKING IT DIFFICULT TO FLY. HIS COMPANY HAS CHANGED POLICY BACK AND FORTH OVER HOW TO MANAGE THE ACFT TO KEEP WITHIN THE TRACK REQUIREMENTS. THIS INVOLVES NONSTANDARD SPDS AND PROFILES. THEY HAVE SINCE GONE TO NORMAL SPD DEPS AND LET THE TRACK DEVS DURING TIGHT TURNS HAPPEN. THE PF WAS NEW TO THE ACFT AND JUST OFF THE AIRBUS TYPE WHICH IS A DIFFERENT AUTOFLT SYS TYPE. FATIGUE WAS AN ISSUE BECAUSE OF TIME ZONE CHANGES AND MULTI-DAY TRIPS. RPTR IS IN RESERVE AND FEELS IT IS AN EFFORT TO KEEP PROFICIENCY WITH VERY LITTLE ACTUAL FLT TIME. THE DEP WAS RUSHED AND THE FMC NOT COMPLETELY LOADED FOR THE RTE.
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.