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|
Attributes | |
ACN | 564021 |
Time | |
Date | 200210 |
Day | Sat |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | atc facility : mmex.artcc |
State Reference | FO |
Altitude | msl bound lower : 10000 msl bound upper : 14000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Turbulence Ice Rain Thunderstorm |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : mmex.artcc tower : jvl.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level descent : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 17000 flight time type : 2800 |
ASRS Report | 564021 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical inflight encounter : weather inflight encounter other non adherence : far non adherence : company policies non adherence : published procedure other spatial deviation other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued alert controller : issued new clearance other |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Aircraft did not follow heading commands and pilots failed to catch the error. Approach entered in FMC in accordance commercial chart for mex, but was being vectored at 300 KTS by approach and maneuvering to avoid thunderstorms in vicinity of positive control area and smo vors. Approach cleared us direct to smo, operating in autoplt a with heading select, vertical speed, MCP speed engaged. Turned heading to smo using forward visual display. Moved smo to #1 on CDU and executed. I then became engaged in attempting to get back on approach profile by smo and neglected to xchk that aircraft was performing as commanded -- it was not. Approach reclred direct smo. We then encountered moderate freezing precipitation -- not painting on radar -- and light to moderate turbulence. At some point, I realized the aircraft was not obeying heading commands, disengaged heading and re-engaged successfully. Approaching smo, was given a heading by approach to reintercept south of smo. Aircraft again did not follow heading command. Disconnected autoplt and flew manually. Made logbook entry. Did not observe control wheel steering or heading disengagement. Might have flown near terrain in vicinity of mex were it not for mex approach control and eventual visual conditions. I did not observe aircraft deviating from MCP commands. First officer did not catch events. High workload environment. This event is unusual; in that I am still not sure whether we failed to observe a warning that the heading select feature disconnected, or if it was a mechanical problem. If the event was a mechanical failure, I have not seen it before and it would be a very unusual event. If, however, it was a warning missed by the crew, preventive action would be increased scan by both. It would have been difficult to decrease workload in this case.
Original NASA ASRS Text
Title: B737-700 CREW HAD HDG DEV IN MMEX CLASS B AIRSPACE.
Narrative: ACFT DID NOT FOLLOW HDG COMMANDS AND PLTS FAILED TO CATCH THE ERROR. APCH ENTERED IN FMC IN ACCORDANCE COMMERCIAL CHART FOR MEX, BUT WAS BEING VECTORED AT 300 KTS BY APCH AND MANEUVERING TO AVOID TSTMS IN VICINITY OF PCA AND SMO VORS. APCH CLRED US DIRECT TO SMO, OPERATING IN AUTOPLT A WITH HDG SELECT, VERT SPD, MCP SPD ENGAGED. TURNED HDG TO SMO USING FORWARD VISUAL DISPLAY. MOVED SMO TO #1 ON CDU AND EXECUTED. I THEN BECAME ENGAGED IN ATTEMPTING TO GET BACK ON APCH PROFILE BY SMO AND NEGLECTED TO XCHK THAT ACFT WAS PERFORMING AS COMMANDED -- IT WAS NOT. APCH RECLRED DIRECT SMO. WE THEN ENCOUNTERED MODERATE FREEZING PRECIP -- NOT PAINTING ON RADAR -- AND LIGHT TO MODERATE TURB. AT SOME POINT, I REALIZED THE ACFT WAS NOT OBEYING HDG COMMANDS, DISENGAGED HDG AND RE-ENGAGED SUCCESSFULLY. APCHING SMO, WAS GIVEN A HDG BY APCH TO REINTERCEPT S OF SMO. ACFT AGAIN DID NOT FOLLOW HDG COMMAND. DISCONNECTED AUTOPLT AND FLEW MANUALLY. MADE LOGBOOK ENTRY. DID NOT OBSERVE CTL WHEEL STEERING OR HDG DISENGAGEMENT. MIGHT HAVE FLOWN NEAR TERRAIN IN VICINITY OF MEX WERE IT NOT FOR MEX APCH CTL AND EVENTUAL VISUAL CONDITIONS. I DID NOT OBSERVE ACFT DEVIATING FROM MCP COMMANDS. FO DID NOT CATCH EVENTS. HIGH WORKLOAD ENVIRONMENT. THIS EVENT IS UNUSUAL; IN THAT I AM STILL NOT SURE WHETHER WE FAILED TO OBSERVE A WARNING THAT THE HDG SELECT FEATURE DISCONNECTED, OR IF IT WAS A MECHANICAL PROB. IF THE EVENT WAS A MECHANICAL FAILURE, I HAVE NOT SEEN IT BEFORE AND IT WOULD BE A VERY UNUSUAL EVENT. IF, HOWEVER, IT WAS A WARNING MISSED BY THE CREW, PREVENTIVE ACTION WOULD BE INCREASED SCAN BY BOTH. IT WOULD HAVE BEEN DIFFICULT TO DECREASE WORKLOAD IN THIS CASE.
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.