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|
Attributes | |
ACN | 521557 |
Time | |
Date | 200108 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : jct.vortac |
State Reference | CO |
Altitude | msl single value : 14000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdv.artcc artcc : zdc.artcc |
Operator | general aviation : corporate |
Make Model Name | Medium Transport, Low Wing, 2 Turbojet Eng |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : cfi |
Experience | flight time last 90 days : 50 flight time total : 5000 flight time type : 1000 |
ASRS Report | 521557 |
Person 2 | |
Affiliation | government : faa |
Function | controller : approach |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance other spatial deviation |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance Weather Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The aircraft had the navigation/communication replaced with the garmen GNS430. The new automation induced a chain of events that led to possible airspace compromise. The clearance was from gjt to 1v5 via the gjt 3 departure direct to dbl, then as filed (direct bjc, then direct 1v5), maintain 14000 ft and expect FL230 in 10 mins. There was some confusion with the departure procedure because the booklet fell to the floor on takeoff, but the issue soon resolved itself with altitude. While I was climbing to 14000 ft and in cloud (approach handed me off to center) I transmitted, but had no acknowledgement. I tried to recontact approach, but instead cycled navigation digits and lost navigation indications. Center may or may not have issued further climb clearance. I leveled briefly at 14000 ft, but realized I was not established on the airway and was headed into areas of 14000 ft mountains without navigation indication. I elected to continue the climb. In a few mins, I contacted (weak and garbled) center (they revised clearance limit to FL210) and re-established navigation. Later, I was cleared directly to 1v5. I tried to enter the destination into the GNS430, but each time characters disappeared whenever I tried to enter destination. I discovered afterward that this system uses the 'D>' key to initiate the direct to destination entry sequence, while other system use the 'D>' key to terminate that sequence! These details are unimportant except to illustrate that poor and inconsistent automation design can result in cockpit pandemonium. What is important is that no automation should be certificated into a flight cockpit unless basic functionality is continuously assured. That way, a pilot's instruction book is not a required component of the automation.
Original NASA ASRS Text
Title: A SMT PLT UNFAMILIAR WITH HIS ACFT'S NAV SYS DEVIATED FROM HIS ATC CLRNC.
Narrative: THE ACFT HAD THE NAV/COM REPLACED WITH THE GARMEN GNS430. THE NEW AUTOMATION INDUCED A CHAIN OF EVENTS THAT LED TO POSSIBLE AIRSPACE COMPROMISE. THE CLRNC WAS FROM GJT TO 1V5 VIA THE GJT 3 DEP DIRECT TO DBL, THEN AS FILED (DIRECT BJC, THEN DIRECT 1V5), MAINTAIN 14000 FT AND EXPECT FL230 IN 10 MINS. THERE WAS SOME CONFUSION WITH THE DEP PROC BECAUSE THE BOOKLET FELL TO THE FLOOR ON TKOF, BUT THE ISSUE SOON RESOLVED ITSELF WITH ALT. WHILE I WAS CLBING TO 14000 FT AND IN CLOUD (APCH HANDED ME OFF TO CTR) I XMITTED, BUT HAD NO ACKNOWLEDGEMENT. I TRIED TO RECONTACT APCH, BUT INSTEAD CYCLED NAV DIGITS AND LOST NAV INDICATIONS. CTR MAY OR MAY NOT HAVE ISSUED FURTHER CLB CLRNC. I LEVELED BRIEFLY AT 14000 FT, BUT REALIZED I WAS NOT ESTABLISHED ON THE AIRWAY AND WAS HEADED INTO AREAS OF 14000 FT MOUNTAINS WITHOUT NAV INDICATION. I ELECTED TO CONTINUE THE CLB. IN A FEW MINS, I CONTACTED (WEAK AND GARBLED) CTR (THEY REVISED CLRNC LIMIT TO FL210) AND RE-ESTABLISHED NAV. LATER, I WAS CLRED DIRECTLY TO 1V5. I TRIED TO ENTER THE DEST INTO THE GNS430, BUT EACH TIME CHARACTERS DISAPPEARED WHENEVER I TRIED TO ENTER DEST. I DISCOVERED AFTERWARD THAT THIS SYS USES THE 'D>' KEY TO INITIATE THE DIRECT TO DEST ENTRY SEQUENCE, WHILE OTHER SYS USE THE 'D>' KEY TO TERMINATE THAT SEQUENCE! THESE DETAILS ARE UNIMPORTANT EXCEPT TO ILLUSTRATE THAT POOR AND INCONSISTENT AUTOMATION DESIGN CAN RESULT IN COCKPIT PANDEMONIUM. WHAT IS IMPORTANT IS THAT NO AUTOMATION SHOULD BE CERTIFICATED INTO A FLT COCKPIT UNLESS BASIC FUNCTIONALITY IS CONTINUOUSLY ASSURED. THAT WAY, A PLT'S INSTRUCTION BOOK IS NOT A REQUIRED COMPONENT OF THE AUTOMATION.
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.