37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 573557 |
Time | |
Date | 200302 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | intersection : misen |
State Reference | NV |
Altitude | msl single value : 19000 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zla.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : intermediate altitude |
Route In Use | arrival star : skebr |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 11000 flight time type : 8000 |
ASRS Report | 573557 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | non adherence : clearance non adherence : far non adherence : company policies non adherence : published procedure other spatial deviation |
Independent Detector | other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued alert flight crew : became reoriented flight crew : overrode automation flight crew : returned to intended or assigned course |
Consequence | other |
Supplementary | |
Problem Areas | Company FAA Maintenance Human Performance Aircraft |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While on the skebr arrival in to las, we approached misen. Just prior to misen, ZLA gave us claar at 13000 ft and 250 KTS. Misen is programmed at FL240. We were at FL190 due to turbulence conditions (our final altitude). So that we could obtain the descent profile in the FMC immediately prior to misen, we hit the 'delete' button and key 1R to delete the input altitude at misen and entered FL190 and hit execute. This took maybe 5-10 seconds to complete, but it just so happened that it took place as we passed over misen (started just prior and executed just past). For some reason, misen never dropped out as we passed over (possible software glitch). After the execute button was pushed, we had actually passed over misen, but since it did not drop out, the aircraft started a left turn. Since we were expecting a turn to the north anyway (at claar), we didn't realize what the aircraft was doing was not right. My 1ST indication that something was wrong was my HSI was 180 degrees out with the course line fully deflected to the left. We probably turned approximately 40 degrees before we were able to figure out what was going on. Being IMC and operating about XA00 body clock time probably contributed to our temporary loss of situational awareness. When we realized what was going on, I selected 'heading select' and started a turn back to claar. Lax center asked if we were turning. We responded 'yes, back to claar.' we felt there was no problem with lax center and did not consider a company report at the time. After thinking about the potential consequences of this happening possibly in a more mountainous terrain (air carrier in south america), felt the need to submit.
Original NASA ASRS Text
Title: B737-300 CREW HAD TRACK DEV WHILE FLYING THE SKEBR 2 RNAV APCH INTO LAS.
Narrative: WHILE ON THE SKEBR ARR IN TO LAS, WE APCHED MISEN. JUST PRIOR TO MISEN, ZLA GAVE US CLAAR AT 13000 FT AND 250 KTS. MISEN IS PROGRAMMED AT FL240. WE WERE AT FL190 DUE TO TURB CONDITIONS (OUR FINAL ALT). SO THAT WE COULD OBTAIN THE DSCNT PROFILE IN THE FMC IMMEDIATELY PRIOR TO MISEN, WE HIT THE 'DELETE' BUTTON AND KEY 1R TO DELETE THE INPUT ALT AT MISEN AND ENTERED FL190 AND HIT EXECUTE. THIS TOOK MAYBE 5-10 SECONDS TO COMPLETE, BUT IT JUST SO HAPPENED THAT IT TOOK PLACE AS WE PASSED OVER MISEN (STARTED JUST PRIOR AND EXECUTED JUST PAST). FOR SOME REASON, MISEN NEVER DROPPED OUT AS WE PASSED OVER (POSSIBLE SOFTWARE GLITCH). AFTER THE EXECUTE BUTTON WAS PUSHED, WE HAD ACTUALLY PASSED OVER MISEN, BUT SINCE IT DID NOT DROP OUT, THE ACFT STARTED A L TURN. SINCE WE WERE EXPECTING A TURN TO THE N ANYWAY (AT CLAAR), WE DIDN'T REALIZE WHAT THE ACFT WAS DOING WAS NOT RIGHT. MY 1ST INDICATION THAT SOMETHING WAS WRONG WAS MY HSI WAS 180 DEGS OUT WITH THE COURSE LINE FULLY DEFLECTED TO THE L. WE PROBABLY TURNED APPROX 40 DEGS BEFORE WE WERE ABLE TO FIGURE OUT WHAT WAS GOING ON. BEING IMC AND OPERATING ABOUT XA00 BODY CLOCK TIME PROBABLY CONTRIBUTED TO OUR TEMPORARY LOSS OF SITUATIONAL AWARENESS. WHEN WE REALIZED WHAT WAS GOING ON, I SELECTED 'HDG SELECT' AND STARTED A TURN BACK TO CLAAR. LAX CTR ASKED IF WE WERE TURNING. WE RESPONDED 'YES, BACK TO CLAAR.' WE FELT THERE WAS NO PROB WITH LAX CTR AND DID NOT CONSIDER A COMPANY RPT AT THE TIME. AFTER THINKING ABOUT THE POTENTIAL CONSEQUENCES OF THIS HAPPENING POSSIBLY IN A MORE MOUNTAINOUS TERRAIN (ACR IN SOUTH AMERICA), FELT THE NEED TO SUBMIT.
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.