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|
Attributes | |
ACN | 575077 |
Time | |
Date | 200303 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ewr.airport |
State Reference | NJ |
Altitude | msl bound lower : 2700 msl bound upper : 3000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90.tracon |
Operator | common carrier : air carrier |
Make Model Name | DC-10 30 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 22l |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision |
Flight Plan | IFR |
Aircraft 2 | |
Route In Use | approach : instrument precision |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 50 flight time total : 7000 flight time type : 1300 |
ASRS Report | 575077 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : atp pilot : flight engineer pilot : instrument pilot : multi engine |
Experience | flight time last 90 days : 100 flight time total : 5000 flight time type : 500 |
ASRS Report | 575474 |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : overshoot inflight encounter : weather inflight encounter other maintenance problem : non compliance with mel non adherence : published procedure non adherence : clearance non adherence : company policies non adherence : far |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : returned to assigned altitude other |
Consequence | other |
Factors | |
Maintenance | contributing factor : schedule pressure performance deficiency : repair performance deficiency : non compliance with legal requirements |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance Company |
Primary Problem | Company |
Air Traffic Incident | Pilot Deviation |
Narrative:
Aircraft dispatched out of oak with #3 pneumatic system inoperative. Ewr approach WX such that engine and wing anti-ice required for approach. Talking to ewr approach, being vectored and descended for an ILS to runway 22L. Level at 4000 ft. Given a descent to 3000 ft and turned to a new heading, with a clearance of 'air carrier X, turn right to a heading of XXX position XXX, maintain 3000 ft until established. Cleared for the ILS runway 22L.' we acknowledged such. PNF (captain) set, armed, and confirmed 3000 ft as per SOP with PF (first officer). As throttles pulled back for descent to idle, pneumatic system #1 failed. So advised captain, phase 1 procedures complied with and an alternate source of pneumatics for the wing anti-ice was in the process of being established. Captain working with so (as per SOP) to ensure such. Coincidentally, ewr approach gave us a frequency change. As captain turned around to dial in new frequency, I glanced at the front instrument panel and saw the altimeter at approximately 2750-2700 ft. Immediately advised the first officer, he corrected without delay back to 3000 ft mentioning that the autoplt must have not autocaptured the preselected altitude. Within a few seconds, we captured the localizer. Uneventful ILS runway 22L to ewr and subsequent landing. Ewr approach never mentioned anything about our altitude deviation. Relevant factors -- aircraft dispatched with 1 pneumatic source inoperative, thereby making the loss of a second one quite significant, especially when wing anti-ice was required for landing. High workload time compression when all happens at once. Loss of pneumatics, clearance to descend, heading and frequency changes, clearance for approach. Captain working with so as per SOP and in accordance with fom and airplane flight manual to ensure restoration of wing anti-ice. New altitude set armed and confirmed by PNF with PF before aircraft ever left 4000 ft. Too many distrs all at once. Captain relied on first officer as PF to do his job! Crew had a postflt debrief, all in concurrence with events. Supplemental information from acn 575474: during descent in IMC, first officer flying aircraft, on autoplt descent to assigned altitude, 800 ft prior to altitude, pneumatic system malfunctioned, aircraft lost pressurization and wing anti-ice in icing conditions. While so reconfigured system to regain wing anti-ice, autoplt failed to capture and level off at assigned altitude. First officer arrested descent at 2700 ft MSL and returned to assigned altitude.
Original NASA ASRS Text
Title: DC10-30 CREW WAS DISPATCHED INTO TERMINAL AREA ICING CONDITIONS WITH #3 PNEUMATIC SYS MEL'ED INOP, AND WHILE ON APCH HAD AN ADDITIONAL PNEUMATIC SYS FAILURE.
Narrative: ACFT DISPATCHED OUT OF OAK WITH #3 PNEUMATIC SYS INOP. EWR APCH WX SUCH THAT ENG AND WING ANTI-ICE REQUIRED FOR APCH. TALKING TO EWR APCH, BEING VECTORED AND DSNDED FOR AN ILS TO RWY 22L. LEVEL AT 4000 FT. GIVEN A DSCNT TO 3000 FT AND TURNED TO A NEW HDG, WITH A CLRNC OF 'ACR X, TURN R TO A HDG OF XXX POS XXX, MAINTAIN 3000 FT UNTIL ESTABLISHED. CLRED FOR THE ILS RWY 22L.' WE ACKNOWLEDGED SUCH. PNF (CAPT) SET, ARMED, AND CONFIRMED 3000 FT AS PER SOP WITH PF (FO). AS THROTTLES PULLED BACK FOR DSCNT TO IDLE, PNEUMATIC SYS #1 FAILED. SO ADVISED CAPT, PHASE 1 PROCS COMPLIED WITH AND AN ALTERNATE SOURCE OF PNEUMATICS FOR THE WING ANTI-ICE WAS IN THE PROCESS OF BEING ESTABLISHED. CAPT WORKING WITH SO (AS PER SOP) TO ENSURE SUCH. COINCIDENTALLY, EWR APCH GAVE US A FREQ CHANGE. AS CAPT TURNED AROUND TO DIAL IN NEW FREQ, I GLANCED AT THE FRONT INST PANEL AND SAW THE ALTIMETER AT APPROX 2750-2700 FT. IMMEDIATELY ADVISED THE FO, HE CORRECTED WITHOUT DELAY BACK TO 3000 FT MENTIONING THAT THE AUTOPLT MUST HAVE NOT AUTOCAPTURED THE PRESELECTED ALT. WITHIN A FEW SECONDS, WE CAPTURED THE LOC. UNEVENTFUL ILS RWY 22L TO EWR AND SUBSEQUENT LNDG. EWR APCH NEVER MENTIONED ANYTHING ABOUT OUR ALTDEV. RELEVANT FACTORS -- ACFT DISPATCHED WITH 1 PNEUMATIC SOURCE INOP, THEREBY MAKING THE LOSS OF A SECOND ONE QUITE SIGNIFICANT, ESPECIALLY WHEN WING ANTI-ICE WAS REQUIRED FOR LNDG. HIGH WORKLOAD TIME COMPRESSION WHEN ALL HAPPENS AT ONCE. LOSS OF PNEUMATICS, CLRNC TO DSND, HDG AND FREQ CHANGES, CLRNC FOR APCH. CAPT WORKING WITH SO AS PER SOP AND IN ACCORDANCE WITH FOM AND AIRPLANE FLT MANUAL TO ENSURE RESTORATION OF WING ANTI-ICE. NEW ALT SET ARMED AND CONFIRMED BY PNF WITH PF BEFORE ACFT EVER LEFT 4000 FT. TOO MANY DISTRS ALL AT ONCE. CAPT RELIED ON FO AS PF TO DO HIS JOB! CREW HAD A POSTFLT DEBRIEF, ALL IN CONCURRENCE WITH EVENTS. SUPPLEMENTAL INFO FROM ACN 575474: DURING DSCNT IN IMC, FO FLYING ACFT, ON AUTOPLT DSCNT TO ASSIGNED ALT, 800 FT PRIOR TO ALT, PNEUMATIC SYS MALFUNCTIONED, ACFT LOST PRESSURIZATION AND WING ANTI-ICE IN ICING CONDITIONS. WHILE SO RECONFIGURED SYS TO REGAIN WING ANTI-ICE, AUTOPLT FAILED TO CAPTURE AND LEVEL OFF AT ASSIGNED ALT. FO ARRESTED DSCNT AT 2700 FT MSL AND RETURNED TO ASSIGNED ALT.
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.