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|
Attributes | |
ACN | 534546 |
Time | |
Date | 200201 |
Day | Sun |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | intersection : taffy |
State Reference | FO |
Altitude | msl single value : 28000 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : czul.artcc |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 19800 flight time type : 4000 |
ASRS Report | 534546 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 10000 flight time type : 750 |
ASRS Report | 534679 |
Events | |
Anomaly | non adherence : clearance non adherence : company policies non adherence : far non adherence : published procedure other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar other controllera other flight crewa other flight crewb other other : 3 |
Resolutory Action | flight crew : returned to intended or assigned course |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
During a flight from ebbr to jfk, about 100 mi ene of taffy intersection, my first officer asked if we could review how to flush INS updates. We were navigating and coupled on #1 INS. Neither INS had any updates inserted at that time. I demonstrated how to flush the updates using both INS #1 and #2. I accidentally left out the first step of the procedure, which is to push the hold button. By performing the next 3 steps of the procedure -- selecting desired track, pressing 'zero,' and pressing insert, I unknowingly commanded a manual track change of true north. Both my first officer and myself were engaged in a practice position update and flush of the #2 INS. The autoplt used such a slow and shallow turn that we had turned about 70 degrees when my first officer noticed the change. We had just started turning back when montreal center asked about the turn. Supplemental information from acn 534679: the steps are: 1) select desired track status, 2) press hold, 3) press zero, 4) press insert. He inadvertently left out step #2 to press hold. Leaving out that step commands the INS to fly a selected course in reference to true north. We did not select a course to track, therefore, the INS began a right turn to true north since the display reads 000.0 with no input from us. Montreal center said he noticed we were turning north. We told him we had an INS screw-up and were correcting it. Only later, after reading the INS manual, were we able to determine what had happened.
Original NASA ASRS Text
Title: A DC8 CREW, CRUISING OVER NORTHEASTERN CANADA, ATTEMPTING AN INS UPDATE FLUSH, UNINTENTIONALLY COMMANDED A MANUAL TRACK CHANGE OF TRUE N, CAUSING THE ACFT TO TURN IN THAT UNWANTED DIRECTION.
Narrative: DURING A FLT FROM EBBR TO JFK, ABOUT 100 MI ENE OF TAFFY INTXN, MY FO ASKED IF WE COULD REVIEW HOW TO FLUSH INS UPDATES. WE WERE NAVIGATING AND COUPLED ON #1 INS. NEITHER INS HAD ANY UPDATES INSERTED AT THAT TIME. I DEMONSTRATED HOW TO FLUSH THE UPDATES USING BOTH INS #1 AND #2. I ACCIDENTALLY LEFT OUT THE FIRST STEP OF THE PROC, WHICH IS TO PUSH THE HOLD BUTTON. BY PERFORMING THE NEXT 3 STEPS OF THE PROC -- SELECTING DESIRED TRACK, PRESSING 'ZERO,' AND PRESSING INSERT, I UNKNOWINGLY COMMANDED A MANUAL TRACK CHANGE OF TRUE N. BOTH MY FO AND MYSELF WERE ENGAGED IN A PRACTICE POS UPDATE AND FLUSH OF THE #2 INS. THE AUTOPLT USED SUCH A SLOW AND SHALLOW TURN THAT WE HAD TURNED ABOUT 70 DEGS WHEN MY FO NOTICED THE CHANGE. WE HAD JUST STARTED TURNING BACK WHEN MONTREAL CTR ASKED ABOUT THE TURN. SUPPLEMENTAL INFO FROM ACN 534679: THE STEPS ARE: 1) SELECT DESIRED TRACK STATUS, 2) PRESS HOLD, 3) PRESS ZERO, 4) PRESS INSERT. HE INADVERTENTLY LEFT OUT STEP #2 TO PRESS HOLD. LEAVING OUT THAT STEP COMMANDS THE INS TO FLY A SELECTED COURSE IN REF TO TRUE N. WE DID NOT SELECT A COURSE TO TRACK, THEREFORE, THE INS BEGAN A R TURN TO TRUE N SINCE THE DISPLAY READS 000.0 WITH NO INPUT FROM US. MONTREAL CTR SAID HE NOTICED WE WERE TURNING N. WE TOLD HIM WE HAD AN INS SCREW-UP AND WERE CORRECTING IT. ONLY LATER, AFTER READING THE INS MANUAL, WERE WE ABLE TO DETERMINE WHAT HAD HAPPENED.
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.