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Flight crew in advanced cockpit heavy transport aircraft misinterpreted FMC display, missed crossing altitude.
| Attributes | |
| ACN | 183689 |
| Time | |
| Date | 199107 |
| Day | Sat |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | atc facility : lax |
| State Reference | CA |
| Altitude | msl bound lower : 13000 msl bound upper : 14000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | artcc : zla tower : hpn |
| Operator | common carrier : air carrier |
| Make Model Name | Widebody, Low Wing, 2 Turbojet Eng |
| Navigation In Use | Other Other |
| Flight Phase | climbout : intermediate altitude |
| Route In Use | departure other departure sid : sid |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : instrument pilot : atp pilot : commercial |
| Experience | flight time last 90 days : 120 flight time total : 14800 flight time type : 210 |
| ASRS Report | 183689 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : atp pilot : instrument pilot : commercial |
| Events | |
| Anomaly | altitude deviation : crossing restriction not met non adherence : published procedure non adherence : clearance |
| Independent Detector | other flight crewa |
| Resolutory Action | none taken : detected after the fact |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Heavy widebody transport. Captain new to glass cockpit. First officer on first trip after IOE. Loop 8 departure was displayed and flown. Airspeed restr by ATC to 250 knots. Lax 041/8 DME was not in data base and was not displayed on map. Upon reaching 10000 ft just prior to crossing the lax VOR, ATC gave instruction to resume normal speed. 'VNAV' was selected and aircraft began accelerating to 310 knots. Rate of climb was reduced. At 14000 ft captain went to VOR 'manual' to check distance and discovered he was 3 mi beyond 8 DME fix already. Captain was unsure of altitude when crossing the 8 DME fix. Reduced climb rate due to increasing speed to economy climb was not monitored adequately to assure meeting the crossing restriction. The lax 041/8 DME fix should have been entered by crew and displayed on map. Crew relied too heavily on 'glass' and for a short period, lost situational awareness. Nothing was said by ATC to indicate that the crossing altitude was not reached, but crew did not monitor position closely enough to be sure.
Original NASA ASRS Text
Title: FLC IN ADVANCED COCKPIT HVT ACFT MISINTERPRETED FMC DISPLAY, MISSED XING ALT.
Narrative: HVY WDB. CAPT NEW TO GLASS COCKPIT. FO ON FIRST TRIP AFTER IOE. LOOP 8 DEP WAS DISPLAYED AND FLOWN. AIRSPEED RESTR BY ATC TO 250 KNOTS. LAX 041/8 DME WAS NOT IN DATA BASE AND WAS NOT DISPLAYED ON MAP. UPON REACHING 10000 FT JUST PRIOR TO XING THE LAX VOR, ATC GAVE INSTRUCTION TO RESUME NORMAL SPEED. 'VNAV' WAS SELECTED AND ACFT BEGAN ACCELERATING TO 310 KNOTS. RATE OF CLB WAS REDUCED. AT 14000 FT CAPT WENT TO VOR 'MANUAL' TO CHK DISTANCE AND DISCOVERED HE WAS 3 MI BEYOND 8 DME FIX ALREADY. CAPT WAS UNSURE OF ALT WHEN XING THE 8 DME FIX. REDUCED CLB RATE DUE TO INCREASING SPEED TO ECONOMY CLB WAS NOT MONITORED ADEQUATELY TO ASSURE MEETING THE XING RESTRICTION. THE LAX 041/8 DME FIX SHOULD HAVE BEEN ENTERED BY CREW AND DISPLAYED ON MAP. CREW RELIED TOO HEAVILY ON 'GLASS' AND FOR A SHORT PERIOD, LOST SITUATIONAL AWARENESS. NOTHING WAS SAID BY ATC TO INDICATE THAT THE XING ALT WAS NOT REACHED, BUT CREW DID NOT MONITOR POS CLOSELY ENOUGH TO BE SURE.
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.