37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 576584 |
Time | |
Date | 200303 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | intersection : tejay |
State Reference | CA |
Altitude | msl bound lower : 10000 msl bound upper : 12000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : approach |
Route In Use | arrival star : pdz |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : cfi pilot : atp pilot : commercial pilot : multi engine |
Experience | flight time last 90 days : 210 flight time total : 12000 flight time type : 2000 |
ASRS Report | 576584 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot non adherence : clearance non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On mar/fri/03, I was serving as a first officer on an airbus 320 with approximately 150 passenger plus 5 crew members, from phx to lax. As we approached lax, approach control cleared us to 'descend via the pdz runway 24R' approach. When we first received the runway change from ATC, we were at 17000 ft between trtle and rifft intxns doing approximately 300 KIAS. The crossing altitude at rifft intersection is 'at or above 14000 ft.' since I had initially entered runway 25L in the FMGS on the ground in phx, a change in runways was now required. The captain who was the designated PF selected 'heading' and 10000 ft in the FCU respective windows and began an 'open descent' because the aircraft will not begin a managed descent with 'heading' selected. He selected 10000 ft because we were slightly high on the arrival and needed to begin a descent to place ourselves in a proper vertical position once the secondary approach was activated. He started a descent to 10000 ft because the intersection that intersected the runway centerline listed a crossing altitude of 10000 ft. The captain then selected the secondary flight plan page on the FMGS computer (mcdu) to select runway 24R, which I had entered on the ground in phx in anticipation of a runway change in lax. The captain struggled to activate the secondary flight plan making several attempts with no success. Meanwhile, I failed to maintain awareness of the now rapidly unwinding altimeter in 'open descent.' I was watching the captain as he was struggling with activating the secondary flight plan. When he finally activated the flight plan the display was not correct. It showed the arrival properly, but also a second green lateral flight plan line off of rifft intersection going to the southwest away from the proper flight path. He managed the navigation mode, but the flight began drifting off of the course. I mentioned the irregularity of the unusual green lateral line to the captain who then selected direct rifft on the mcdu and the aircraft proceeded to the intersection properly. Once he had completed the secondary activation, he did not immediately manage the descent, which I didn't notice until later. About this time we began a descent checklist, but I had to re-enter the landing data into the landing performance page on the mcdu, which I had previously entered on runway 25L. After I made the entries we continued with the checklist. During this time ATC gave us 2 airspeed changes for the arrival. About this time I noticed that the managed vertical descent 'donut' rapidly came from the bottom of my primary flight display moving upwards. Since the aircraft was still in 'open descent' I mentioned to the captain that he should select managed descent, which he did. However, the managed descent path (the donut) was now above us and the airbus FMGS is not designed to aggressively capture the descent profile from the bottom of the profile descent path and strives to maintain a smooth 1G transition from 'open descent' to 'managed descent.' when 'managed descent' is selected from 'open descent' the airbus will slow its descent in the managed mode to 1000 FPM until it captures the profile altitude. At this point we both failed to monitor the descent and the capturing of the managed descent profile. Furthermore, since the captain had selected 10000 ft in the altitude window of the FCU the flight continued down regardless of crossing restrs that were now above it, which neither of us noticed. At leveloff at 10000 ft, the captain immediately recognized we were 2000 ft below where we should have been on the arrival. Tejay intersection was 2 mi ahead of us now at a crossing altitude of '12000 ft or above.' ATC did not mention this altitude discrepancy to us. The captain began a climb back to 12000 ft, but only made it to 11000 ft before crossing tejay intersection. We then successfully re-entered the descent profile and continued without further incident. Shortcomings of pilot performance noted here include: 1) the captain's inadequate handling of the descent and the selection of the secondary flight plan. 2) the first officer's loss of situational awareness of the aircraft's altitude and proper crossing restrs of the arrival. This incident highlights several problems with automation of modern aircraft that includes: 1) uncertainty where to focus attention when multiple tasks need to be completed.2) effective strategies to deal with the situation are limited by multiple tasks being performed during these high load periods. 3) increased workload during high work demand periods. 4) loss of situational awareness. 5) a definite increase in stress. 6) confusion of the automation by the user during high stress periods.
Original NASA ASRS Text
Title: A320 FLT CREW HAS ALTDEV DURING 'PDZ 4' ARR TO LAX.
Narrative: ON MAR/FRI/03, I WAS SERVING AS A FO ON AN AIRBUS 320 WITH APPROX 150 PAX PLUS 5 CREW MEMBERS, FROM PHX TO LAX. AS WE APCHED LAX, APCH CTL CLRED US TO 'DSND VIA THE PDZ RWY 24R' APCH. WHEN WE FIRST RECEIVED THE RWY CHANGE FROM ATC, WE WERE AT 17000 FT BTWN TRTLE AND RIFFT INTXNS DOING APPROX 300 KIAS. THE XING ALT AT RIFFT INTXN IS 'AT OR ABOVE 14000 FT.' SINCE I HAD INITIALLY ENTERED RWY 25L IN THE FMGS ON THE GND IN PHX, A CHANGE IN RWYS WAS NOW REQUIRED. THE CAPT WHO WAS THE DESIGNATED PF SELECTED 'HDG' AND 10000 FT IN THE FCU RESPECTIVE WINDOWS AND BEGAN AN 'OPEN DSCNT' BECAUSE THE ACFT WILL NOT BEGIN A MANAGED DSCNT WITH 'HDG' SELECTED. HE SELECTED 10000 FT BECAUSE WE WERE SLIGHTLY HIGH ON THE ARR AND NEEDED TO BEGIN A DSCNT TO PLACE OURSELVES IN A PROPER VERT POS ONCE THE SECONDARY APCH WAS ACTIVATED. HE STARTED A DSCNT TO 10000 FT BECAUSE THE INTXN THAT INTERSECTED THE RWY CTRLINE LISTED A XING ALT OF 10000 FT. THE CAPT THEN SELECTED THE SECONDARY FLT PLAN PAGE ON THE FMGS COMPUTER (MCDU) TO SELECT RWY 24R, WHICH I HAD ENTERED ON THE GND IN PHX IN ANTICIPATION OF A RWY CHANGE IN LAX. THE CAPT STRUGGLED TO ACTIVATE THE SECONDARY FLT PLAN MAKING SEVERAL ATTEMPTS WITH NO SUCCESS. MEANWHILE, I FAILED TO MAINTAIN AWARENESS OF THE NOW RAPIDLY UNWINDING ALTIMETER IN 'OPEN DSCNT.' I WAS WATCHING THE CAPT AS HE WAS STRUGGLING WITH ACTIVATING THE SECONDARY FLT PLAN. WHEN HE FINALLY ACTIVATED THE FLT PLAN THE DISPLAY WAS NOT CORRECT. IT SHOWED THE ARR PROPERLY, BUT ALSO A SECOND GREEN LATERAL FLT PLAN LINE OFF OF RIFFT INTXN GOING TO THE SW AWAY FROM THE PROPER FLT PATH. HE MANAGED THE NAV MODE, BUT THE FLT BEGAN DRIFTING OFF OF THE COURSE. I MENTIONED THE IRREGULARITY OF THE UNUSUAL GREEN LATERAL LINE TO THE CAPT WHO THEN SELECTED DIRECT RIFFT ON THE MCDU AND THE ACFT PROCEEDED TO THE INTXN PROPERLY. ONCE HE HAD COMPLETED THE SECONDARY ACTIVATION, HE DID NOT IMMEDIATELY MANAGE THE DSCNT, WHICH I DIDN'T NOTICE UNTIL LATER. ABOUT THIS TIME WE BEGAN A DSCNT CHKLIST, BUT I HAD TO RE-ENTER THE LNDG DATA INTO THE LNDG PERFORMANCE PAGE ON THE MCDU, WHICH I HAD PREVIOUSLY ENTERED ON RWY 25L. AFTER I MADE THE ENTRIES WE CONTINUED WITH THE CHKLIST. DURING THIS TIME ATC GAVE US 2 AIRSPD CHANGES FOR THE ARR. ABOUT THIS TIME I NOTICED THAT THE MANAGED VERT DSCNT 'DONUT' RAPIDLY CAME FROM THE BOTTOM OF MY PRIMARY FLT DISPLAY MOVING UPWARDS. SINCE THE ACFT WAS STILL IN 'OPEN DSCNT' I MENTIONED TO THE CAPT THAT HE SHOULD SELECT MANAGED DSCNT, WHICH HE DID. HOWEVER, THE MANAGED DSCNT PATH (THE DONUT) WAS NOW ABOVE US AND THE AIRBUS FMGS IS NOT DESIGNED TO AGGRESSIVELY CAPTURE THE DSCNT PROFILE FROM THE BOTTOM OF THE PROFILE DSCNT PATH AND STRIVES TO MAINTAIN A SMOOTH 1G TRANSITION FROM 'OPEN DSCNT' TO 'MANAGED DSCNT.' WHEN 'MANAGED DSCNT' IS SELECTED FROM 'OPEN DSCNT' THE AIRBUS WILL SLOW ITS DSCNT IN THE MANAGED MODE TO 1000 FPM UNTIL IT CAPTURES THE PROFILE ALT. AT THIS POINT WE BOTH FAILED TO MONITOR THE DSCNT AND THE CAPTURING OF THE MANAGED DSCNT PROFILE. FURTHERMORE, SINCE THE CAPT HAD SELECTED 10000 FT IN THE ALT WINDOW OF THE FCU THE FLT CONTINUED DOWN REGARDLESS OF XING RESTRS THAT WERE NOW ABOVE IT, WHICH NEITHER OF US NOTICED. AT LEVELOFF AT 10000 FT, THE CAPT IMMEDIATELY RECOGNIZED WE WERE 2000 FT BELOW WHERE WE SHOULD HAVE BEEN ON THE ARR. TEJAY INTXN WAS 2 MI AHEAD OF US NOW AT A XING ALT OF '12000 FT OR ABOVE.' ATC DID NOT MENTION THIS ALT DISCREPANCY TO US. THE CAPT BEGAN A CLB BACK TO 12000 FT, BUT ONLY MADE IT TO 11000 FT BEFORE XING TEJAY INTXN. WE THEN SUCCESSFULLY RE-ENTERED THE DSCNT PROFILE AND CONTINUED WITHOUT FURTHER INCIDENT. SHORTCOMINGS OF PLT PERFORMANCE NOTED HERE INCLUDE: 1) THE CAPT'S INADEQUATE HANDLING OF THE DSCNT AND THE SELECTION OF THE SECONDARY FLT PLAN. 2) THE FO'S LOSS OF SITUATIONAL AWARENESS OF THE ACFT'S ALT AND PROPER XING RESTRS OF THE ARR. THIS INCIDENT HIGHLIGHTS SEVERAL PROBS WITH AUTOMATION OF MODERN ACFT THAT INCLUDES: 1) UNCERTAINTY WHERE TO FOCUS ATTN WHEN MULTIPLE TASKS NEED TO BE COMPLETED.2) EFFECTIVE STRATEGIES TO DEAL WITH THE SIT ARE LIMITED BY MULTIPLE TASKS BEING PERFORMED DURING THESE HIGH LOAD PERIODS. 3) INCREASED WORKLOAD DURING HIGH WORK DEMAND PERIODS. 4) LOSS OF SITUATIONAL AWARENESS. 5) A DEFINITE INCREASE IN STRESS. 6) CONFUSION OF THE AUTOMATION BY THE USER DURING HIGH STRESS PERIODS.
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.