37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 525430 |
Time | |
Date | 200109 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | intersection : effta |
State Reference | UT |
Altitude | msl single value : 32000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Flight Phase | descent : approach descent : intermediate altitude |
Route In Use | arrival star : bearr |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 121 flight time total : 7000 flight time type : 3738 |
ASRS Report | 525430 |
Events | |
Anomaly | altitude deviation : crossing restriction not met non adherence : clearance non adherence : published procedure other spatial deviation |
Resolutory Action | controller : issued new clearance flight crew : returned to intended or assigned course none taken : detected after the fact |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
ZLC cleared us to cross effta at FL270. The copilot programmed the FMS and the descent was started. Both of us verbalized the restr and pointed to the altitude window on the mode control panel to confirm the altitude. I crosschecked the descent as we crossed byi VOR and things looked ok. Both of us were distracted with preparatory duties of listening to ATIS, removing approach plates, checking arrival gate, and re-computing the arrival time when center asked if we were going to make the restr. Now just a few mi before effta, with several thousand feet to go, it was evident that we couldn't make it. I asked center if we needed to make a turn to avoid a conflict and they said no, just hurry down. They had already turned the conflicting traffic to avoid a conflict. When we checked the FMS, it was showing the restr programmed for nordd, the next waypoint. The copilot was sure he had selected effta and confirmed it before 'executing' the change in the FMS. I listened to him read back the clearance to me as he entered it in the FMS, but didn't rechk it after he had entered it. Initially assuming we had made a mistake, we completed the flight uneventfully. As we left the plane and rode to the parking lot we continued discussing how this could have happened. We remembered a similar event earlier in the flight. As we had been radar vectored leaving sea, departure control had cleared us direct to summa. Since the copilot was hand-flying, I had line selected summa and entered it on the top line of the 'dir int' page. After seeing summa in the proper place, I had executed the change and selected LNAV on the mode control panel. The copilot started the turn then noted that it was going to bke, which was the next point. Baffled, I had to retype summa and reenter it. It seemed that in both incidents the FMS had skipped to the next point. Not believing that that was even a possibility, but just as sure as the copilot that we had entered the changes correctly, I returned to the terminal to talk to the avionics maintenance personnel. The avionics mechanic assured me that that type of software problem was in fact possible and that it had happened on a B737-800 about a week ago. In closing, I need to get into the habit of checking the FMS after executing a change instead of just before the execution. This is a B737-300, non EFIS, so the FMS screen and the raw data are the only way to verify its action.
Original NASA ASRS Text
Title: FLT CREW BELIEVED THEY HAD CORRECTLY PROGRAMMED THE FMS BUT LATER LEARNED SELECTING AN ENTRY TO THE TOP LINE OF THE 'DIR INT' PAGE WOULD CAUSE THE FMS TO SKIP TO THE NEXT POINT.
Narrative: ZLC CLRED US TO CROSS EFFTA AT FL270. THE COPLT PROGRAMMED THE FMS AND THE DSCNT WAS STARTED. BOTH OF US VERBALIZED THE RESTR AND POINTED TO THE ALT WINDOW ON THE MODE CTL PANEL TO CONFIRM THE ALT. I XCHKED THE DSCNT AS WE CROSSED BYI VOR AND THINGS LOOKED OK. BOTH OF US WERE DISTRACTED WITH PREPARATORY DUTIES OF LISTENING TO ATIS, REMOVING APCH PLATES, CHKING ARR GATE, AND RE-COMPUTING THE ARR TIME WHEN CTR ASKED IF WE WERE GOING TO MAKE THE RESTR. NOW JUST A FEW MI BEFORE EFFTA, WITH SEVERAL THOUSAND FEET TO GO, IT WAS EVIDENT THAT WE COULDN'T MAKE IT. I ASKED CTR IF WE NEEDED TO MAKE A TURN TO AVOID A CONFLICT AND THEY SAID NO, JUST HURRY DOWN. THEY HAD ALREADY TURNED THE CONFLICTING TFC TO AVOID A CONFLICT. WHEN WE CHKED THE FMS, IT WAS SHOWING THE RESTR PROGRAMMED FOR NORDD, THE NEXT WAYPOINT. THE COPLT WAS SURE HE HAD SELECTED EFFTA AND CONFIRMED IT BEFORE 'EXECUTING' THE CHANGE IN THE FMS. I LISTENED TO HIM READ BACK THE CLRNC TO ME AS HE ENTERED IT IN THE FMS, BUT DIDN'T RECHK IT AFTER HE HAD ENTERED IT. INITIALLY ASSUMING WE HAD MADE A MISTAKE, WE COMPLETED THE FLT UNEVENTFULLY. AS WE LEFT THE PLANE AND RODE TO THE PARKING LOT WE CONTINUED DISCUSSING HOW THIS COULD HAVE HAPPENED. WE REMEMBERED A SIMILAR EVENT EARLIER IN THE FLT. AS WE HAD BEEN RADAR VECTORED LEAVING SEA, DEP CTL HAD CLRED US DIRECT TO SUMMA. SINCE THE COPLT WAS HAND-FLYING, I HAD LINE SELECTED SUMMA AND ENTERED IT ON THE TOP LINE OF THE 'DIR INT' PAGE. AFTER SEEING SUMMA IN THE PROPER PLACE, I HAD EXECUTED THE CHANGE AND SELECTED LNAV ON THE MODE CTL PANEL. THE COPLT STARTED THE TURN THEN NOTED THAT IT WAS GOING TO BKE, WHICH WAS THE NEXT POINT. BAFFLED, I HAD TO RETYPE SUMMA AND REENTER IT. IT SEEMED THAT IN BOTH INCIDENTS THE FMS HAD SKIPPED TO THE NEXT POINT. NOT BELIEVING THAT THAT WAS EVEN A POSSIBILITY, BUT JUST AS SURE AS THE COPLT THAT WE HAD ENTERED THE CHANGES CORRECTLY, I RETURNED TO THE TERMINAL TO TALK TO THE AVIONICS MAINT PERSONNEL. THE AVIONICS MECH ASSURED ME THAT THAT TYPE OF SOFTWARE PROB WAS IN FACT POSSIBLE AND THAT IT HAD HAPPENED ON A B737-800 ABOUT A WK AGO. IN CLOSING, I NEED TO GET INTO THE HABIT OF CHKING THE FMS AFTER EXECUTING A CHANGE INSTEAD OF JUST BEFORE THE EXECUTION. THIS IS A B737-300, NON EFIS, SO THE FMS SCREEN AND THE RAW DATA ARE THE ONLY WAY TO VERIFY ITS ACTION.
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.