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|
Attributes | |
ACN | 762476 |
Time | |
Date | 200711 |
Place | |
Locale Reference | airport : zzzz.airport |
State Reference | FO |
Altitude | msl single value : 11000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : zzzz.tracon |
Operator | common carrier : air carrier |
Make Model Name | B747-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : approach |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 148 flight time total : 12000 flight time type : 7000 |
ASRS Report | 762476 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : regained aircraft control |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Narrative:
While leveling off during a descent to 11000 ft for an approach into ZZZ1; the aircraft began to shudder. I applied power; but could not arrest the speed decay without lowering the nose; which caused me to descend 500 ft below the assigned altitude. We were told to continue the descent to 10000 ft at which time I realized that the speed brakes were still out; causing the problem. The entire crew was so fatigued from our almost 20 hour day that no one recognized the problem. I feel that crew fatigue played a major role in this incident. The trip for me started on nov/xa/07. This leg started 17 days later when my augmented crew (3 pilots and 2 flight engineer's) were to operate ZZZZ1-ZZZZ2. The crew started out rested for an XA30L departure but due to maintenance problems that were known prior to alerting the crew; the crew ran out of crew duty day before the maintenance problem was fixed. The crew returned for minimum crew rest (10 hours). We were then alerted to operate the 2 legs scheduled for a 19 hour duty day. When we returned to the airplane; no one was really rested. I myself only was able to get 1-2 hours of sleep. Unfortunately; pilots are human beings and cannot sleep on command. We were just getting sleepy when it was time to wake up again. There must be a better system to account for human factors.
Original NASA ASRS Text
Title: AN INTL B747 PILOT REPORTS A PILOTAGE ERROR AFTER 20 HOURS ON DUTY FOLLOWING A MIN REST PERIOD.
Narrative: WHILE LEVELING OFF DURING A DSCNT TO 11000 FT FOR AN APCH INTO ZZZ1; THE ACFT BEGAN TO SHUDDER. I APPLIED PWR; BUT COULD NOT ARREST THE SPD DECAY WITHOUT LOWERING THE NOSE; WHICH CAUSED ME TO DSND 500 FT BELOW THE ASSIGNED ALT. WE WERE TOLD TO CONTINUE THE DSCNT TO 10000 FT AT WHICH TIME I REALIZED THAT THE SPD BRAKES WERE STILL OUT; CAUSING THE PROB. THE ENTIRE CREW WAS SO FATIGUED FROM OUR ALMOST 20 HR DAY THAT NO ONE RECOGNIZED THE PROB. I FEEL THAT CREW FATIGUE PLAYED A MAJOR ROLE IN THIS INCIDENT. THE TRIP FOR ME STARTED ON NOV/XA/07. THIS LEG STARTED 17 DAYS LATER WHEN MY AUGMENTED CREW (3 PLTS AND 2 FE'S) WERE TO OPERATE ZZZZ1-ZZZZ2. THE CREW STARTED OUT RESTED FOR AN XA30L DEP BUT DUE TO MAINT PROBS THAT WERE KNOWN PRIOR TO ALERTING THE CREW; THE CREW RAN OUT OF CREW DUTY DAY BEFORE THE MAINT PROB WAS FIXED. THE CREW RETURNED FOR MINIMUM CREW REST (10 HRS). WE WERE THEN ALERTED TO OPERATE THE 2 LEGS SCHEDULED FOR A 19 HR DUTY DAY. WHEN WE RETURNED TO THE AIRPLANE; NO ONE WAS REALLY RESTED. I MYSELF ONLY WAS ABLE TO GET 1-2 HRS OF SLEEP. UNFORTUNATELY; PLTS ARE HUMAN BEINGS AND CANNOT SLEEP ON COMMAND. WE WERE JUST GETTING SLEEPY WHEN IT WAS TIME TO WAKE UP AGAIN. THERE MUST BE A BETTER SYS TO ACCOUNT FOR HUMAN FACTORS.
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.