37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 675629 |
Time | |
Date | 200510 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sna.airport |
State Reference | CA |
Altitude | msl bound lower : 5000 msl bound upper : 6200 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : sna.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Route In Use | departure sid : n/s |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tower : sna.tower |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 675629 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial |
Experience | flight time last 90 days : 549 flight time total : 8567 flight time type : 2986 |
ASRS Report | 675626 |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : company policies |
Independent Detector | aircraft equipment : tcas other flight crewa other flight crewb |
Resolutory Action | flight crew : returned to assigned altitude flight crew : took evasive action flight crew : exited adverse environment |
Supplementary | |
Problem Areas | Aircraft Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
During climb out from sna between 5000-6000 ft; approaching leveloff at 6000 ft; we received a TCAS RA that said 'monitor climb.' at that point the indication on the pdf turned red. I misunderstood the appropriate action and thought I needed to increase rate of climb. Because I thought we needed to go up; I ignored the altitude clearance. My first officer called out 'level at 6000 ft.' I said 'no' and continued up. At approximately 6200 ft; I realized my error; began to level off; and then ATC cleared me to 7000 ft. Supplemental information from acn 675626: I performed outside and inside preflight duties in accordance with company regulations and was informed by captain that we would have an FAA inspector riding along as a cockpit observer. At approximately 5500 ft we received a TA callout which coincided with the contact at the 10 O'clock position. I gave an advisement callout that we were 'approaching leveloff altitude' and then almost immediately the TA became an RA warning. I also saw we were rapidly approaching our leveloff altitude. I emphatically directed captain 'we need to level off!' he responded 'no! I am flying the RA maneuver.' I immediately checked the navigation display to confirm my observations and saw we were climbing into the RA area versus away from it; and then placed pressure on the yoke in the required direction and noticed our reduced climb rate which placed us at 6100-6200 ft MSL; but still climbing. Once at altitude; captain and the cockpit crew (PNF; FAA inspector) reviewed the incident and it was determined that 2 critical errors were committed. 1) the RA evasive maneuver was performed incorrectly. 2) the captain acknowledged his reluctance and decision to disregard the PNF's leveloff callouts. The flight then continued to destination and landed without further incident. In reviewing the events and further discussion with captain; I feel several human factor elements may have exacerbated this incident: communication: while it was my perception that CRM communication between myself and captain was excellent during this trip series; there was an obvious element of confusion that was induced by the RA alert display. The navigation display RA warning display; because of its nature; requires immediate action; but also requires the PF to correctly ascertain that the remedy is to fly away from the area. Due to the fact that this maneuver is usually conducted once during annual recurrent training; it is easy to see where it might take a PF a few seconds to observe/analyze the data and then correctly execute the evasive maneuver. The PNF has to be the voice of reason and; if not seeing a proper response to his challenges; be prepared to perform a more aggressive response. Situational awareness/workload management: level 2 automation (aircraft flown with flight director guidance only) departure. 'Level III (autoplt and autothrottle engaged) should be used when responding to ATC instructions in dynamic environments such as terminal operations....' in our discussion following the flight; captain felt that his decision to execute a level ii departure versus a level III departure clearly hampered his situational awareness/workload management. This; coupled with the added stress of having an FAA inspector on board; high density traffic environment; and early morning operations; we felt all contributed to detracting from his optimum efficiency in executing the departure phase. Corrective action: 1) have instructor pilots set up simulated scenarios where the PNF is unaware that the PF has been pre-briefed to fly the RA evasive maneuver in error thereby exercising the PNF's advocacy position. 2) while it is clearly the prerogative of the PF to choose his selected level of automation for all phases of flight; highly recommend that level ii automation departures be highly discouraged from high density traffic areas.
Original NASA ASRS Text
Title: A B737-700 FO; AS PNF; OVERRODE A PF CAPT WHEN THE CAPT INCORRECTLY ACTED OPPOSITE A TCASII RA AND CONTINUED A CLB WHEN LEVELOFF WAS COMMANDED.
Narrative: DURING CLBOUT FROM SNA BTWN 5000-6000 FT; APCHING LEVELOFF AT 6000 FT; WE RECEIVED A TCAS RA THAT SAID 'MONITOR CLB.' AT THAT POINT THE INDICATION ON THE PDF TURNED RED. I MISUNDERSTOOD THE APPROPRIATE ACTION AND THOUGHT I NEEDED TO INCREASE RATE OF CLB. BECAUSE I THOUGHT WE NEEDED TO GO UP; I IGNORED THE ALT CLRNC. MY FO CALLED OUT 'LEVEL AT 6000 FT.' I SAID 'NO' AND CONTINUED UP. AT APPROX 6200 FT; I REALIZED MY ERROR; BEGAN TO LEVEL OFF; AND THEN ATC CLRED ME TO 7000 FT. SUPPLEMENTAL INFO FROM ACN 675626: I PERFORMED OUTSIDE AND INSIDE PREFLT DUTIES IN ACCORDANCE WITH COMPANY REGS AND WAS INFORMED BY CAPT THAT WE WOULD HAVE AN FAA INSPECTOR RIDING ALONG AS A COCKPIT OBSERVER. AT APPROX 5500 FT WE RECEIVED A TA CALLOUT WHICH COINCIDED WITH THE CONTACT AT THE 10 O'CLOCK POS. I GAVE AN ADVISEMENT CALLOUT THAT WE WERE 'APCHING LEVELOFF ALT' AND THEN ALMOST IMMEDIATELY THE TA BECAME AN RA WARNING. I ALSO SAW WE WERE RAPIDLY APCHING OUR LEVELOFF ALT. I EMPHATICALLY DIRECTED CAPT 'WE NEED TO LEVEL OFF!' HE RESPONDED 'NO! I AM FLYING THE RA MANEUVER.' I IMMEDIATELY CHKED THE NAV DISPLAY TO CONFIRM MY OBSERVATIONS AND SAW WE WERE CLBING INTO THE RA AREA VERSUS AWAY FROM IT; AND THEN PLACED PRESSURE ON THE YOKE IN THE REQUIRED DIRECTION AND NOTICED OUR REDUCED CLB RATE WHICH PLACED US AT 6100-6200 FT MSL; BUT STILL CLBING. ONCE AT ALT; CAPT AND THE COCKPIT CREW (PNF; FAA INSPECTOR) REVIEWED THE INCIDENT AND IT WAS DETERMINED THAT 2 CRITICAL ERRORS WERE COMMITTED. 1) THE RA EVASIVE MANEUVER WAS PERFORMED INCORRECTLY. 2) THE CAPT ACKNOWLEDGED HIS RELUCTANCE AND DECISION TO DISREGARD THE PNF'S LEVELOFF CALLOUTS. THE FLT THEN CONTINUED TO DEST AND LANDED WITHOUT FURTHER INCIDENT. IN REVIEWING THE EVENTS AND FURTHER DISCUSSION WITH CAPT; I FEEL SEVERAL HUMAN FACTOR ELEMENTS MAY HAVE EXACERBATED THIS INCIDENT: COM: WHILE IT WAS MY PERCEPTION THAT CRM COM BTWN MYSELF AND CAPT WAS EXCELLENT DURING THIS TRIP SERIES; THERE WAS AN OBVIOUS ELEMENT OF CONFUSION THAT WAS INDUCED BY THE RA ALERT DISPLAY. THE NAV DISPLAY RA WARNING DISPLAY; BECAUSE OF ITS NATURE; REQUIRES IMMEDIATE ACTION; BUT ALSO REQUIRES THE PF TO CORRECTLY ASCERTAIN THAT THE REMEDY IS TO FLY AWAY FROM THE AREA. DUE TO THE FACT THAT THIS MANEUVER IS USUALLY CONDUCTED ONCE DURING ANNUAL RECURRENT TRAINING; IT IS EASY TO SEE WHERE IT MIGHT TAKE A PF A FEW SECONDS TO OBSERVE/ANALYZE THE DATA AND THEN CORRECTLY EXECUTE THE EVASIVE MANEUVER. THE PNF HAS TO BE THE VOICE OF REASON AND; IF NOT SEEING A PROPER RESPONSE TO HIS CHALLENGES; BE PREPARED TO PERFORM A MORE AGGRESSIVE RESPONSE. SITUATIONAL AWARENESS/WORKLOAD MGMNT: LEVEL 2 AUTOMATION (ACFT FLOWN WITH FLT DIRECTOR GUIDANCE ONLY) DEP. 'LEVEL III (AUTOPLT AND AUTOTHROTTLE ENGAGED) SHOULD BE USED WHEN RESPONDING TO ATC INSTRUCTIONS IN DYNAMIC ENVIRONMENTS SUCH AS TERMINAL OPS....' IN OUR DISCUSSION FOLLOWING THE FLT; CAPT FELT THAT HIS DECISION TO EXECUTE A LEVEL II DEP VERSUS A LEVEL III DEP CLRLY HAMPERED HIS SITUATIONAL AWARENESS/WORKLOAD MGMNT. THIS; COUPLED WITH THE ADDED STRESS OF HAVING AN FAA INSPECTOR ON BOARD; HIGH DENSITY TFC ENVIRONMENT; AND EARLY MORNING OPS; WE FELT ALL CONTRIBUTED TO DETRACTING FROM HIS OPTIMUM EFFICIENCY IN EXECUTING THE DEP PHASE. CORRECTIVE ACTION: 1) HAVE INSTRUCTOR PLTS SET UP SIMULATED SCENARIOS WHERE THE PNF IS UNAWARE THAT THE PF HAS BEEN PRE-BRIEFED TO FLY THE RA EVASIVE MANEUVER IN ERROR THEREBY EXERCISING THE PNF'S ADVOCACY POS. 2) WHILE IT IS CLRLY THE PREROGATIVE OF THE PF TO CHOOSE HIS SELECTED LEVEL OF AUTOMATION FOR ALL PHASES OF FLT; HIGHLY RECOMMEND THAT LEVEL II AUTOMATION DEPS BE HIGHLY DISCOURAGED FROM HIGH DENSITY TFC AREAS.
Data retrieved from NASA's ASRS site as of January 2009 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.