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|
Attributes | |
ACN | 592707 |
Time | |
Date | 200309 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
State Reference | OH |
Altitude | msl bound lower : 12000 msl bound upper : 13000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zid.artcc tower : egll.tower |
Operator | other |
Make Model Name | Starlifter (C141) |
Operating Under FAR Part | Part 91 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zid.artcc |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | cruise : level |
Person 1 | |
Affiliation | government : military |
Function | flight crew : captain oversight : pic |
Qualification | pilot : private pilot : multi engine pilot : instrument pilot : commercial pilot : atp pilot : flight engineer |
Experience | flight time total : 8500 flight time type : 5000 |
ASRS Report | 592707 |
Person 2 | |
Affiliation | government : military |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : private pilot : multi engine pilot : flight engineer pilot : commercial pilot : cfi |
Experience | flight time total : 500 flight time type : 15 |
ASRS Report | 592729 |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : overshoot conflict : airborne less severe non adherence : clearance non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | aircraft equipment : tcas other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued alert flight crew : returned to assigned altitude none taken : detected after the fact |
Consequence | faa : investigated faa : reviewed incident with flight crew |
Miss Distance | vertical : 800 |
Supplementary | |
Problem Areas | Company Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
On sep/tue/03, a military C-141C was on a 1-TIME ferry flight with a waiver for no passenger or cargo with numerous maintenance discrepancies. The major discrepancies before the flight included an inoperative APU, a pitch trim actuator with previous write-ups for a louder than normal 'noise' when moving nose trim up and down, and inspections for previously discovered wing cracks. The wing cracks were inspected in accordance with directives from the warner-robbins air logistics center, and performed by our maintenance, and the airplane was cleared for a 1-TIME flight to davis-monthan AFB, az, for retirement to the aerospace maintenance and regeneration center. The previous flight for this aircraft was in the month of mar/03, as over 5 months had passed since the flight on sep/tue/03. During the early phase of our mission, we developed several maintenance, avionics, and autoplt problems. INS #1 had failed, in both the heading and attitude portions, necessitating the use of our back-up attitude heading and reference system, for heading and attitude on the pilot's side of the cockpit. Shortly thereafter, we began receiving continuous and erroneous 'pull-up' aural warnings from our terrain and warning system computer, necessitating our crew to pull the terrain and warning system circuit breaker. During the rest of our initial climb, as the copilot was flying, several times the autoplt would disengage completely, with us having to switch between autoplt #1 and #2, in the meantime hand flying in between attempts to re-engage an autoplt, as the VNAV function was also unusable. We eventually were able to fly with the basic mode of the autoplt with the thumbwheel in the climb, however, it would not hold an engagement completely until we later leveled off at cruise altitude later in the flight. We were given an assigned heading between the dqn VOR, and the vhp VOR, expecting an eventual clearance direct to the vhp VOR. As we were climbing through 10000 ft, with a clearance to 12000 ft, our jumpseat crew member, 'cleared off' the flight deck and our flight engineer began to troubleshoot an additional problem of our #1 transformer/rectifier failing. All this was happening when on the pilot's side our navigation processor #1 failed, as well as our #1 display unit. As the pilot's side 'moving map' became blank on the left screen, we used the copilot's moving map, as well as the moving map display on the center mfd unit, which also displays our color WX radar, and our TCASII system display. In addition to the numerous avionics problems noted above, our primary flight display was intermittently alternating back and forth between the normal display of 'no declutter' to the next level degradation of 'declutter.' in the normal level of 'no declutter,' the primary flight display shows our normal airspeed and altitude displays of the vertical tapes with the actual readout of the current airspeed and altitude digitally for the pilots to see our exact airspeed and altitude. In the first degradation level of 'declutter,' the airspeed and altitude tapes show just the tapes with no digital readout of the exact numerical reading of your current airspeed and altitude. Of critical note, prior to all of these events happening, we still had the terrain and warning system circuit breaker pulled for the erroneous and continuous 'pull-up' warnings. Since this circuit breaker was pulled, most of our aural warnings in the aircraft were inoperative, to include the altitude 'beeps' of 1000 ft and 300 ft below or above our preselected altitude in our altitude alert window, which we set when we are given an altitude clearance by the ATC controllers. While we were passing 10000 ft, in the climb to 12000 ft, between the dayton and brickyard vors, amidst all these problems, I was trying to restore my #1 display unit, as well as the moving map display on the pilot's side, when we received a 'traffic, traffic' aural advisory from our TCASII unit. My attention immediately was diverted to our mfd unit, which shows the traffic symbols on the display. I then decreased the range on the unit, in order to better see exactly where the traffic was in relation to our aircraft, as the mileage scale was on 160 at the time. It was after I brought the range scale back down when I noticed that we had climbed through our assigned altitude of 12000 ft, and was near 13000 ft when we started back down to 12000 ft. I immediately ensured we were in the descent back down to 12000 ft, as we leveled the aircraft. ZID called out traffic at our 10 O'clock position, as we were back in the descent to 12000 ft. The controller, as I remember, asked if we were at level 12200 ft and I said we were leveling at 12000 ft. No mention of the deviation was made by the controller to us at the time. We were handed off 2 more times, and on the third handoff at FL220, the controller asked us to call ZID which was ZID's quality assurance phone number. After landing at davis-monthan AFB, I called the number and spoke with an individual who was familiar with incident. I explained what had happened and apologized, and informed him that we had several autoplt and avionics problems. However, he stated that a report was being forwarded to the cincinnati FSDO and it was out of his hands. I also mentioned that I did not want to discuss our numerous problems with the airplane to the controller at the time, as would have cluttered the frequency. The supervisor on the phone agreed. These are the events as best as I can recollect them. Certainly, nothing was intentionally done in regards to this incident. Recommendations to prevent recurrence may include emphasis on 'fly the airplane first' as an utmost during malfunctions, and possibly changing our flight manuals procedures for setting and acknowledging altitude clrncs for both pilots in our new glass cockpits.
Original NASA ASRS Text
Title: C-141 MIL CREW HAD NUMEROUS SERIOUS DEFERRED ITEMS, AND CONTINUING ADDITIONAL SERIOUS SYS FAILURES WHILE FERRYING THE ACFT TO THE BONE YARD. THE CREW HAD AN ALT OVERSHOOT AND A TCASII TA WHEN DISTR BY THE INOP SYS.
Narrative: ON SEP/TUE/03, A MIL C-141C WAS ON A 1-TIME FERRY FLT WITH A WAIVER FOR NO PAX OR CARGO WITH NUMEROUS MAINT DISCREPANCIES. THE MAJOR DISCREPANCIES BEFORE THE FLT INCLUDED AN INOP APU, A PITCH TRIM ACTUATOR WITH PREVIOUS WRITE-UPS FOR A LOUDER THAN NORMAL 'NOISE' WHEN MOVING NOSE TRIM UP AND DOWN, AND INSPECTIONS FOR PREVIOUSLY DISCOVERED WING CRACKS. THE WING CRACKS WERE INSPECTED IN ACCORDANCE WITH DIRECTIVES FROM THE WARNER-ROBBINS AIR LOGISTICS CENTER, AND PERFORMED BY OUR MAINT, AND THE AIRPLANE WAS CLRED FOR A 1-TIME FLT TO DAVIS-MONTHAN AFB, AZ, FOR RETIREMENT TO THE AEROSPACE MAINT AND REGENERATION CENTER. THE PREVIOUS FLT FOR THIS ACFT WAS IN THE MONTH OF MAR/03, AS OVER 5 MONTHS HAD PASSED SINCE THE FLT ON SEP/TUE/03. DURING THE EARLY PHASE OF OUR MISSION, WE DEVELOPED SEVERAL MAINT, AVIONICS, AND AUTOPLT PROBS. INS #1 HAD FAILED, IN BOTH THE HDG AND ATTITUDE PORTIONS, NECESSITATING THE USE OF OUR BACK-UP ATTITUDE HDG AND REF SYS, FOR HDG AND ATTITUDE ON THE PLT'S SIDE OF THE COCKPIT. SHORTLY THEREAFTER, WE BEGAN RECEIVING CONTINUOUS AND ERRONEOUS 'PULL-UP' AURAL WARNINGS FROM OUR TERRAIN AND WARNING SYS COMPUTER, NECESSITATING OUR CREW TO PULL THE TERRAIN AND WARNING SYS CIRCUIT BREAKER. DURING THE REST OF OUR INITIAL CLB, AS THE COPLT WAS FLYING, SEVERAL TIMES THE AUTOPLT WOULD DISENGAGE COMPLETELY, WITH US HAVING TO SWITCH BTWN AUTOPLT #1 AND #2, IN THE MEANTIME HAND FLYING IN BTWN ATTEMPTS TO RE-ENGAGE AN AUTOPLT, AS THE VNAV FUNCTION WAS ALSO UNUSABLE. WE EVENTUALLY WERE ABLE TO FLY WITH THE BASIC MODE OF THE AUTOPLT WITH THE THUMBWHEEL IN THE CLB, HOWEVER, IT WOULD NOT HOLD AN ENGAGEMENT COMPLETELY UNTIL WE LATER LEVELED OFF AT CRUISE ALT LATER IN THE FLT. WE WERE GIVEN AN ASSIGNED HDG BTWN THE DQN VOR, AND THE VHP VOR, EXPECTING AN EVENTUAL CLRNC DIRECT TO THE VHP VOR. AS WE WERE CLBING THROUGH 10000 FT, WITH A CLRNC TO 12000 FT, OUR JUMPSEAT CREW MEMBER, 'CLRED OFF' THE FLT DECK AND OUR FE BEGAN TO TROUBLESHOOT AN ADDITIONAL PROB OF OUR #1 TRANSFORMER/RECTIFIER FAILING. ALL THIS WAS HAPPENING WHEN ON THE PLT'S SIDE OUR NAV PROCESSOR #1 FAILED, AS WELL AS OUR #1 DISPLAY UNIT. AS THE PLT'S SIDE 'MOVING MAP' BECAME BLANK ON THE L SCREEN, WE USED THE COPLT'S MOVING MAP, AS WELL AS THE MOVING MAP DISPLAY ON THE CENTER MFD UNIT, WHICH ALSO DISPLAYS OUR COLOR WX RADAR, AND OUR TCASII SYS DISPLAY. IN ADDITION TO THE NUMEROUS AVIONICS PROBS NOTED ABOVE, OUR PRIMARY FLT DISPLAY WAS INTERMITTENTLY ALTERNATING BACK AND FORTH BTWN THE NORMAL DISPLAY OF 'NO DECLUTTER' TO THE NEXT LEVEL DEGRADATION OF 'DECLUTTER.' IN THE NORMAL LEVEL OF 'NO DECLUTTER,' THE PRIMARY FLT DISPLAY SHOWS OUR NORMAL AIRSPD AND ALT DISPLAYS OF THE VERT TAPES WITH THE ACTUAL READOUT OF THE CURRENT AIRSPD AND ALT DIGITALLY FOR THE PLTS TO SEE OUR EXACT AIRSPD AND ALT. IN THE FIRST DEGRADATION LEVEL OF 'DECLUTTER,' THE AIRSPD AND ALT TAPES SHOW JUST THE TAPES WITH NO DIGITAL READOUT OF THE EXACT NUMERICAL READING OF YOUR CURRENT AIRSPD AND ALT. OF CRITICAL NOTE, PRIOR TO ALL OF THESE EVENTS HAPPENING, WE STILL HAD THE TERRAIN AND WARNING SYS CIRCUIT BREAKER PULLED FOR THE ERRONEOUS AND CONTINUOUS 'PULL-UP' WARNINGS. SINCE THIS CIRCUIT BREAKER WAS PULLED, MOST OF OUR AURAL WARNINGS IN THE ACFT WERE INOP, TO INCLUDE THE ALT 'BEEPS' OF 1000 FT AND 300 FT BELOW OR ABOVE OUR PRESELECTED ALT IN OUR ALT ALERT WINDOW, WHICH WE SET WHEN WE ARE GIVEN AN ALT CLRNC BY THE ATC CTLRS. WHILE WE WERE PASSING 10000 FT, IN THE CLB TO 12000 FT, BTWN THE DAYTON AND BRICKYARD VORS, AMIDST ALL THESE PROBS, I WAS TRYING TO RESTORE MY #1 DISPLAY UNIT, AS WELL AS THE MOVING MAP DISPLAY ON THE PLT'S SIDE, WHEN WE RECEIVED A 'TFC, TFC' AURAL ADVISORY FROM OUR TCASII UNIT. MY ATTN IMMEDIATELY WAS DIVERTED TO OUR MFD UNIT, WHICH SHOWS THE TFC SYMBOLS ON THE DISPLAY. I THEN DECREASED THE RANGE ON THE UNIT, IN ORDER TO BETTER SEE EXACTLY WHERE THE TFC WAS IN RELATION TO OUR ACFT, AS THE MILEAGE SCALE WAS ON 160 AT THE TIME. IT WAS AFTER I BROUGHT THE RANGE SCALE BACK DOWN WHEN I NOTICED THAT WE HAD CLBED THROUGH OUR ASSIGNED ALT OF 12000 FT, AND WAS NEAR 13000 FT WHEN WE STARTED BACK DOWN TO 12000 FT. I IMMEDIATELY ENSURED WE WERE IN THE DSCNT BACK DOWN TO 12000 FT, AS WE LEVELED THE ACFT. ZID CALLED OUT TFC AT OUR 10 O'CLOCK POS, AS WE WERE BACK IN THE DSCNT TO 12000 FT. THE CTLR, AS I REMEMBER, ASKED IF WE WERE AT LEVEL 12200 FT AND I SAID WE WERE LEVELING AT 12000 FT. NO MENTION OF THE DEV WAS MADE BY THE CTLR TO US AT THE TIME. WE WERE HANDED OFF 2 MORE TIMES, AND ON THE THIRD HDOF AT FL220, THE CTLR ASKED US TO CALL ZID WHICH WAS ZID'S QUALITY ASSURANCE PHONE NUMBER. AFTER LNDG AT DAVIS-MONTHAN AFB, I CALLED THE NUMBER AND SPOKE WITH AN INDIVIDUAL WHO WAS FAMILIAR WITH INCIDENT. I EXPLAINED WHAT HAD HAPPENED AND APOLOGIZED, AND INFORMED HIM THAT WE HAD SEVERAL AUTOPLT AND AVIONICS PROBS. HOWEVER, HE STATED THAT A RPT WAS BEING FORWARDED TO THE CINCINNATI FSDO AND IT WAS OUT OF HIS HANDS. I ALSO MENTIONED THAT I DID NOT WANT TO DISCUSS OUR NUMEROUS PROBS WITH THE AIRPLANE TO THE CTLR AT THE TIME, AS WOULD HAVE CLUTTERED THE FREQ. THE SUPVR ON THE PHONE AGREED. THESE ARE THE EVENTS AS BEST AS I CAN RECOLLECT THEM. CERTAINLY, NOTHING WAS INTENTIONALLY DONE IN REGARDS TO THIS INCIDENT. RECOMMENDATIONS TO PREVENT RECURRENCE MAY INCLUDE EMPHASIS ON 'FLY THE AIRPLANE FIRST' AS AN UTMOST DURING MALFUNCTIONS, AND POSSIBLY CHANGING OUR FLT MANUALS PROCS FOR SETTING AND ACKNOWLEDGING ALT CLRNCS FOR BOTH PLTS IN OUR NEW GLASS COCKPITS.
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.