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|
Attributes | |
ACN | 532260 |
Time | |
Date | 200112 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | navaid : cqy.vortac |
State Reference | TX |
Altitude | msl bound lower : 9000 msl bound upper : 15500 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : intermediate altitude |
Route In Use | arrival star : ns |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 400 flight time total : 10000 flight time type : 5500 |
ASRS Report | 532260 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : commercial |
Experience | flight time last 90 days : 250 flight time total : 4000 flight time type : 1700 |
ASRS Report | 532264 |
Events | |
Anomaly | altitude deviation : crossing restriction not met inflight encounter : weather inflight encounter : turbulence non adherence : published procedure non adherence : far non adherence : company policies non adherence : clearance other anomaly other |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued new clearance controller : issued alert none taken : detected after the fact other |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Narrative:
Altitude deviation. We flew from ZZZ to dal. Operations normal until starting descent. Center was just slightly late beginning our descent for the dumpy 2 arrival to meet orvil at 9000 ft. Once descent was started, corrected to the proper profile. He then advised me of a runway change from runway 31 to runway 13 at dal. When I went to put this in the FMC instead of pushing departure/arrival then R2, pushed legs then R2. This wrote the orvil restr of 240 degrees 9000 ft to the scratch pad. This confused me slightly, but I erased the pad and entered runway 13 ILS at dal. When I returned to the descent page, it showed descent profile. I went back to the legs page to check it. At this point I changed the page from orvil at 9000 ft to dumpy at 9000 ft. This was an error, but I did not catch it. Returning to the descent page, it showed us back below profile, so I assumed we were ok. During all this, ATC gave us a report of moderate turbulence from FL190 to FL180. I was occupied with the fasten seatbelt sign along with seating and the getting the flight attendants get back up. (Nothing more than light was encountered.) at about 15500 ft, ATC asked us if we would be 'anywhere close' to making orvil at 9000 ft. The first officer said we would try. We were only 8-9 mi away, so I informed ZZZ center we would need a vector. We were vectored 350 degree heading to join cve 298 degree radial and handed over to approach. We descended as quickly as possible to 9000 ft, but were inside yeager and orvil on reaching 9000 ft. I had gotten 7 1/2 hours sleep, but felt tired. We had a 2 hour ground time in ZZZ1, which didn't help. I was surprised by this as I felt we were doing fine, but neither the first officer nor myself caught the error. No traffic conflict occurred. Supplemental information from acn 532264: on-time departure, preflight normal. Put orvil at 9000 ft in FMC when programming. Expecting standard arrival into dal. Taxi, takeoff, departure normal. After leveloff, captain talked to passenger about a reminder of seatbelts. ATC had advised us of moderate turbulence 17000 ft to FL190 on descent. We were cruising at FL350. Shortly after he went off, we were given pilot's discretion to FL240. When he came back up on course, I told him of new clearance pilot's discretion FL240 and pointed to FMC showing we were approaching descent point. We were cleared to cross at orvil at 9000 ft. I didn't make the connection about the FMC error at the time. We had planned on runway 31L (dispatch showed landing runway 3L). When I heard this, I made a comment whereupon he went to FMC. I wasn't watching what he was doing, but I figured it was reprogramming runway to runway 13R. I came back on communication. I had the full ATIS. He informed me the 9000 ft restr had been entered wrong and that the restr was at dumpy not orvil. It didn't register with me that I had programmed it correctly and that the captain was wrong. After changing the FMC to reflect dumpy at 9000 ft, we were immediately low on profile. We slowed the descent rate. The captain then went off radio to tell the flight attendants to situation down, since we were approaching the 17000 ft to FL190 altitude back where the moderate turbulence. We passed this altitude and I continued to monitor this descent, but never reconfirmed the new altitude restr the captain changed. I remember thinking 'how could I make such a mistake when I fly this recovery so often?' I just assumed I was wrong and he was right. Approaching orvil, ATC asked us if we were going to make the restr. This was my first clue we were not flying to the right altitude. The captain covered my initial call by saying we weren't going to make it and we were given a vector for descent and leveling away from orvil. We made the descent and got turned back to dumpy. The rest of the approach and descent and loading were normal.
Original NASA ASRS Text
Title: B737-300 CREW DID NOT FOLLOW PROPER FMC PROGRAMMING PROTOCOL OR COMPANY SOP.
Narrative: ALTDEV. WE FLEW FROM ZZZ TO DAL. OPS NORMAL UNTIL STARTING DSCNT. CTR WAS JUST SLIGHTLY LATE BEGINNING OUR DSCNT FOR THE DUMPY 2 ARR TO MEET ORVIL AT 9000 FT. ONCE DSCNT WAS STARTED, CORRECTED TO THE PROPER PROFILE. HE THEN ADVISED ME OF A RWY CHANGE FROM RWY 31 TO RWY 13 AT DAL. WHEN I WENT TO PUT THIS IN THE FMC INSTEAD OF PUSHING DEP/ARR THEN R2, PUSHED LEGS THEN R2. THIS WROTE THE ORVIL RESTR OF 240 DEGS 9000 FT TO THE SCRATCH PAD. THIS CONFUSED ME SLIGHTLY, BUT I ERASED THE PAD AND ENTERED RWY 13 ILS AT DAL. WHEN I RETURNED TO THE DSCNT PAGE, IT SHOWED DSCNT PROFILE. I WENT BACK TO THE LEGS PAGE TO CHK IT. AT THIS POINT I CHANGED THE PAGE FROM ORVIL AT 9000 FT TO DUMPY AT 9000 FT. THIS WAS AN ERROR, BUT I DID NOT CATCH IT. RETURNING TO THE DSCNT PAGE, IT SHOWED US BACK BELOW PROFILE, SO I ASSUMED WE WERE OK. DURING ALL THIS, ATC GAVE US A RPT OF MODERATE TURB FROM FL190 TO FL180. I WAS OCCUPIED WITH THE FASTEN SEATBELT SIGN ALONG WITH SEATING AND THE GETTING THE FLT ATTENDANTS GET BACK UP. (NOTHING MORE THAN LIGHT WAS ENCOUNTERED.) AT ABOUT 15500 FT, ATC ASKED US IF WE WOULD BE 'ANYWHERE CLOSE' TO MAKING ORVIL AT 9000 FT. THE FO SAID WE WOULD TRY. WE WERE ONLY 8-9 MI AWAY, SO I INFORMED ZZZ CTR WE WOULD NEED A VECTOR. WE WERE VECTORED 350 DEG HDG TO JOIN CVE 298 DEG RADIAL AND HANDED OVER TO APCH. WE DSNDED AS QUICKLY AS POSSIBLE TO 9000 FT, BUT WERE INSIDE YEAGER AND ORVIL ON REACHING 9000 FT. I HAD GOTTEN 7 1/2 HRS SLEEP, BUT FELT TIRED. WE HAD A 2 HR GND TIME IN ZZZ1, WHICH DIDN'T HELP. I WAS SURPRISED BY THIS AS I FELT WE WERE DOING FINE, BUT NEITHER THE FO NOR MYSELF CAUGHT THE ERROR. NO TFC CONFLICT OCCURRED. SUPPLEMENTAL INFO FROM ACN 532264: ON-TIME DEP, PREFLT NORMAL. PUT ORVIL AT 9000 FT IN FMC WHEN PROGRAMMING. EXPECTING STANDARD ARR INTO DAL. TAXI, TKOF, DEP NORMAL. AFTER LEVELOFF, CAPT TALKED TO PAX ABOUT A REMINDER OF SEATBELTS. ATC HAD ADVISED US OF MODERATE TURB 17000 FT TO FL190 ON DSCNT. WE WERE CRUISING AT FL350. SHORTLY AFTER HE WENT OFF, WE WERE GIVEN PLT'S DISCRETION TO FL240. WHEN HE CAME BACK UP ON COURSE, I TOLD HIM OF NEW CLRNC PLT'S DISCRETION FL240 AND POINTED TO FMC SHOWING WE WERE APCHING DSCNT POINT. WE WERE CLRED TO CROSS AT ORVIL AT 9000 FT. I DIDN'T MAKE THE CONNECTION ABOUT THE FMC ERROR AT THE TIME. WE HAD PLANNED ON RWY 31L (DISPATCH SHOWED LNDG RWY 3L). WHEN I HEARD THIS, I MADE A COMMENT WHEREUPON HE WENT TO FMC. I WASN'T WATCHING WHAT HE WAS DOING, BUT I FIGURED IT WAS REPROGRAMMING RWY TO RWY 13R. I CAME BACK ON COM. I HAD THE FULL ATIS. HE INFORMED ME THE 9000 FT RESTR HAD BEEN ENTERED WRONG AND THAT THE RESTR WAS AT DUMPY NOT ORVIL. IT DIDN'T REGISTER WITH ME THAT I HAD PROGRAMMED IT CORRECTLY AND THAT THE CAPT WAS WRONG. AFTER CHANGING THE FMC TO REFLECT DUMPY AT 9000 FT, WE WERE IMMEDIATELY LOW ON PROFILE. WE SLOWED THE DSCNT RATE. THE CAPT THEN WENT OFF RADIO TO TELL THE FLT ATTENDANTS TO SIT DOWN, SINCE WE WERE APCHING THE 17000 FT TO FL190 ALT BACK WHERE THE MODERATE TURB. WE PASSED THIS ALT AND I CONTINUED TO MONITOR THIS DSCNT, BUT NEVER RECONFIRMED THE NEW ALT RESTR THE CAPT CHANGED. I REMEMBER THINKING 'HOW COULD I MAKE SUCH A MISTAKE WHEN I FLY THIS RECOVERY SO OFTEN?' I JUST ASSUMED I WAS WRONG AND HE WAS RIGHT. APCHING ORVIL, ATC ASKED US IF WE WERE GOING TO MAKE THE RESTR. THIS WAS MY FIRST CLUE WE WERE NOT FLYING TO THE R ALT. THE CAPT COVERED MY INITIAL CALL BY SAYING WE WEREN'T GOING TO MAKE IT AND WE WERE GIVEN A VECTOR FOR DSCNT AND LEVELING AWAY FROM ORVIL. WE MADE THE DSCNT AND GOT TURNED BACK TO DUMPY. THE REST OF THE APCH AND DSCNT AND LOADING WERE NORMAL.
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.