37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 852988 |
Time | |
Date | 200909 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | LAX.Airport |
State Reference | CA |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | Initial Approach |
Route In Use | STAR RIIVR 2 |
Flight Plan | IFR |
Component | |
Aircraft Component | Altitude Alert |
Person 1 | |
Function | Captain Pilot Not Flying |
Experience | Flight Crew Last 90 Days 203 Flight Crew Type 10000 |
Events | |
Anomaly | Deviation - Altitude Crossing Restriction Not Met Deviation - Altitude Overshoot Deviation - Procedural Published Material / Policy Deviation - Procedural Clearance Deviation - Speed All Types |
Narrative:
We were flying to lax on the last day of our 3 day pairing. The weather was great and we were well prepared to fly the riivr 2 arrival into lax. The approach was briefed and the points verified. We were anticipating flying the ILS 24R; but had not selected it in the FMC until it was in fact assigned by socal approach control. The approach and proper transition were selected without a problem. Socal cleared us to maintain 250 KTS until further advised. At this point our level of automation was full up. We incorrectly set 2200 ft in the altitude window of the MCP for the jetsa restriction. This was the error that caused the altitude bust. As we transitioned from the arrival to the approach; the FMC called for a speed of 193 KTS and for flaps. Since this was not our clearance; I went heads down into the FMC to try to convince the FMS that it was proper for us to be at 250 KTS. As we slowed through 230 KTS; the first officer (pilot flying) correctly deselected both VNAV and autothrottles; but failed to reset the altitude window to 10;000 ft (the altitude for skoll). He announced the change; but I did not hear it as he is somewhat soft spoken and I was distracted. The aircraft descended through our 10;000 ft restriction and at 9300 ft (700 ft below our restriction) we both noticed the error. Since our next restriction was 9000 ft and we were passing the 10;000 ft restriction point; we continued to our next required altitude of 9000 ft. ATC subsequently cleared us for a visual approach and the remainder of the approach and landing was uneventful. Our mistake was setting 2200 ft in the MCP altitude window in contrast to clear policy that VNAV and autothrottle use was limited to the final point on the arrival. We should have been in the FMC mode of automation as soon as we turned from riivr to the ILS 24R. We weren't much later than that; but it was too late. It was certainly not a willful disregard of procedure that caused this approach as both the first officer and I were doing our level best to embrace the changes and had talked extensively about the new technology. The procedures are clear when we are to transition from VNAV to 'traditional' vertical navigation. We certainly have been warned about this 'hot spot' on the riivr arrival. More than any other arrival in the country; this arrival was designed to 'flow' seamlessly from arrival to approach. I failed to mentally move from the arrival phase into the approach phase; and hence have the correct level of automation in place at the appropriate time. Perhaps in our quest to have the computer correctly programmed we got target fixation and made the very mistake we were trying so hard to avoid. When I was learning to fly; my instructors stressed the appropriate order of things are: aviate; navigate and communicate in that order. I think the lines are becoming somewhat blurred between the first two items. This was an honest mistake. It did not even occur to me that we had set 2200 ft incorrectly until hours later. That is my fault and I take full responsibility. I believe company and their training department have done a great job preparing us for the changes. I thought I knew my stuff; but I made a mistake.
Original NASA ASRS Text
Title: A B737-700 crew missed the LAX RIIVR TWO 10;000 FT SKOLL altitude constraint because they incorrectly set the JETSA 2;200 FT too early.
Narrative: We were flying to LAX on the last day of our 3 day pairing. The weather was great and we were well prepared to fly the RIIVR 2 Arrival into LAX. The approach was briefed and the points verified. We were anticipating flying the ILS 24R; but had not selected it in the FMC until it was in fact assigned by SoCal Approach Control. The approach and proper transition were selected without a problem. SoCal cleared us to maintain 250 KTS until further advised. At this point our level of automation was full up. We incorrectly set 2200 FT in the altitude window of the MCP for the JETSA restriction. This was the error that caused the altitude bust. As we transitioned from the arrival to the approach; the FMC called for a speed of 193 KTS and for flaps. Since this was not our clearance; I went heads down into the FMC to try to convince the FMS that it was proper for us to be at 250 KTS. As we slowed through 230 KTS; the First Officer (pilot flying) correctly deselected both VNAV and autothrottles; but failed to reset the altitude window to 10;000 FT (the altitude for SKOLL). He announced the change; but I did not hear it as he is somewhat soft spoken and I was distracted. The aircraft descended through our 10;000 FT restriction and at 9300 FT (700 FT below our restriction) we both noticed the error. Since our next restriction was 9000 FT and we were passing the 10;000 FT restriction point; we continued to our next required altitude of 9000 FT. ATC subsequently cleared us for a visual approach and the remainder of the approach and landing was uneventful. Our mistake was setting 2200 FT in the MCP altitude window in contrast to clear policy that VNAV and autothrottle use was limited to the final point on the arrival. We should have been in the FMC mode of automation as soon as we turned from RIIVR to the ILS 24R. We weren't much later than that; but it was too late. It was certainly not a willful disregard of procedure that caused this approach as both the First Officer and I were doing our level best to embrace the changes and had talked extensively about the new technology. The procedures are clear when we are to transition from VNAV to 'traditional' vertical navigation. We certainly have been warned about this 'Hot Spot' on the RIIVR Arrival. More than any other arrival in the country; this arrival was designed to 'flow' seamlessly from arrival to approach. I failed to mentally move from the arrival phase into the approach phase; and hence have the correct level of automation in place at the appropriate time. Perhaps in our quest to have the computer correctly programmed we got target fixation and made the very mistake we were trying so hard to avoid. When I was learning to fly; my instructors stressed the appropriate order of things are: Aviate; Navigate and Communicate in that order. I think the lines are becoming somewhat blurred between the first two items. This was an honest mistake. It did not even occur to me that we had set 2200 FT incorrectly until hours later. That is my fault and I take full responsibility. I believe Company and their Training Department have done a great job preparing us for the changes. I thought I knew my stuff; but I made a mistake.
Data retrieved from NASA's ASRS site as of April 2012 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.