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|
Attributes | |
ACN | 688501 |
Time | |
Date | 200602 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : nfff.artcc |
State Reference | FO |
Altitude | msl bound lower : 34730 msl bound upper : 35000 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : nfff.artcc tower : iad.tower |
Operator | common carrier : air carrier |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level cruise : enroute altitude change |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 120 flight time total : 14000 flight time type : 6000 |
ASRS Report | 688501 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : excursion from assigned altitude inflight encounter : turbulence |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude flight crew : overcame equipment problem flight crew : overrode automation |
Consequence | other |
Supplementary | |
Problem Areas | FAA Aircraft Flight Crew Human Performance |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Narrative:
Approximately 3-5 mins prior to this incident; the aircraft got 1 single jolt of light to moderate turbulence. There was no turbulence prior to or after this incident for quite awhile. This jolt succeeded in waking up the off watch captain who then went back for a restroom visit. Following normal SOP procedures; I got out of the left seat to let him back into the cockpit. When I was getting back into the left seat; the other relief pilot called out that we were in a vertical speed descent of 100 FPM! We immediately proceeded to stop the descent. I first hit 'flight level change' since FL350 was still in the altitude window; but the autoplt remained in vertical speed. So I just rolled up the vertical speed to +200 to climb back up. We both read off the altitude at FL347.3. Prior to this incident; we had requested FL360 from nadi. Once established back at FL350 and in VNAV; we received our climb clearance to FL360. The PNF selected FL360 in the altitude window and much to our amazement; the vertical speed window opened on its own showing +100 FPM! After climbing to FL360 we later tried duplicating the problem. Unable to duplicate. Did VNAV revert back to vertical speed on its own; did the turbulence do it; or did I inadvertently hit the vertical speed select button while getting out of my seat? We tested the last theory; not an easy thing to do. But this was our only rationale -- until we descended into sydney. Now the captain was back in the left seat; hand flying; autoplt off; in VMC. We received clearance from 9000 ft to 8000 ft; but when the PNF pushed flight level change instead of getting flight level change; the vertical speed windows opened up again. This happened several times and we wrote it up. There was something wrong with the MCP. Did it contribute to our altitude deviation; or was it just a coincidence? This incident proves that even with diligent pilots; minor altdevs can happen. Should we be motoring down the middle of airways with head-on traffic in rvsm airspace? Or would it be better to have a built-in offset to preclude the obvious? The necessary door security procedures are definitely a distraction. It is still prudent to allow the autoplt to deviate from the altitude window by more than 200 ft (maximum allowed in rvsm) without a warning? I shudder at the consequences of our not recognizing the altitude deviation as quickly as was done if there had been intervening traffic below us in rvsm airspace. The SOP to call out changes when the other pilot returns to his seat is a good one; and may have saved us; but it was still too little too late.
Original NASA ASRS Text
Title: FLT CREW OF B747-400 IS CONCERNED THAT AUTOFLT VERT NAV MALFUNCTION IN PACIFIC RVSM AIRSPACE RESULTED IN A MORE SERIOUS SEPARATION HAZARD THAN PRIOR TO RVSM PROCS.
Narrative: APPROX 3-5 MINS PRIOR TO THIS INCIDENT; THE ACFT GOT 1 SINGLE JOLT OF LIGHT TO MODERATE TURB. THERE WAS NO TURB PRIOR TO OR AFTER THIS INCIDENT FOR QUITE AWHILE. THIS JOLT SUCCEEDED IN WAKING UP THE OFF WATCH CAPT WHO THEN WENT BACK FOR A RESTROOM VISIT. FOLLOWING NORMAL SOP PROCS; I GOT OUT OF THE L SEAT TO LET HIM BACK INTO THE COCKPIT. WHEN I WAS GETTING BACK INTO THE L SEAT; THE OTHER RELIEF PLT CALLED OUT THAT WE WERE IN A VERT SPD DSCNT OF 100 FPM! WE IMMEDIATELY PROCEEDED TO STOP THE DSCNT. I FIRST HIT 'FLT LEVEL CHANGE' SINCE FL350 WAS STILL IN THE ALT WINDOW; BUT THE AUTOPLT REMAINED IN VERT SPD. SO I JUST ROLLED UP THE VERT SPD TO +200 TO CLB BACK UP. WE BOTH READ OFF THE ALT AT FL347.3. PRIOR TO THIS INCIDENT; WE HAD REQUESTED FL360 FROM NADI. ONCE ESTABLISHED BACK AT FL350 AND IN VNAV; WE RECEIVED OUR CLB CLRNC TO FL360. THE PNF SELECTED FL360 IN THE ALT WINDOW AND MUCH TO OUR AMAZEMENT; THE VERT SPD WINDOW OPENED ON ITS OWN SHOWING +100 FPM! AFTER CLBING TO FL360 WE LATER TRIED DUPLICATING THE PROB. UNABLE TO DUPLICATE. DID VNAV REVERT BACK TO VERT SPD ON ITS OWN; DID THE TURB DO IT; OR DID I INADVERTENTLY HIT THE VERT SPD SELECT BUTTON WHILE GETTING OUT OF MY SEAT? WE TESTED THE LAST THEORY; NOT AN EASY THING TO DO. BUT THIS WAS OUR ONLY RATIONALE -- UNTIL WE DSNDED INTO SYDNEY. NOW THE CAPT WAS BACK IN THE L SEAT; HAND FLYING; AUTOPLT OFF; IN VMC. WE RECEIVED CLRNC FROM 9000 FT TO 8000 FT; BUT WHEN THE PNF PUSHED FLT LEVEL CHANGE INSTEAD OF GETTING FLT LEVEL CHANGE; THE VERT SPD WINDOWS OPENED UP AGAIN. THIS HAPPENED SEVERAL TIMES AND WE WROTE IT UP. THERE WAS SOMETHING WRONG WITH THE MCP. DID IT CONTRIBUTE TO OUR ALTDEV; OR WAS IT JUST A COINCIDENCE? THIS INCIDENT PROVES THAT EVEN WITH DILIGENT PLTS; MINOR ALTDEVS CAN HAPPEN. SHOULD WE BE MOTORING DOWN THE MIDDLE OF AIRWAYS WITH HEAD-ON TFC IN RVSM AIRSPACE? OR WOULD IT BE BETTER TO HAVE A BUILT-IN OFFSET TO PRECLUDE THE OBVIOUS? THE NECESSARY DOOR SECURITY PROCS ARE DEFINITELY A DISTR. IT IS STILL PRUDENT TO ALLOW THE AUTOPLT TO DEVIATE FROM THE ALT WINDOW BY MORE THAN 200 FT (MAX ALLOWED IN RVSM) WITHOUT A WARNING? I SHUDDER AT THE CONSEQUENCES OF OUR NOT RECOGNIZING THE ALTDEV AS QUICKLY AS WAS DONE IF THERE HAD BEEN INTERVENING TFC BELOW US IN RVSM AIRSPACE. THE SOP TO CALL OUT CHANGES WHEN THE OTHER PLT RETURNS TO HIS SEAT IS A GOOD ONE; AND MAY HAVE SAVED US; BUT IT WAS STILL TOO LITTLE TOO LATE.
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.