Narrative:

This narrative is from my perspective as the relief pilot, third seat, and is stated here to the best of my recollection. The flight was to be a routine ferry flight from a maintenance facility (where it received an 'a' check) to los angeles. The scheduled departure was XA00. The actual block out was XB45. The departure was delayed due to last min problems with the air system and the FMC. Once maintenance cleared the FMC problems we were on our way. The air system problems were believed to be heat related, as the outside air temperature was 40 degrees C. Maintenance, the captain, and both first officer's believed the air system would be fine once the aircraft cooled off in flight. We elect to go. The flight plan called for a short flight of 56 mins. Taxi, takeoff, climb and cruise were all normal, with the exception of the air system, which the captain instructed the first officer to try in automatic. This did not work. Manual was re-selected and the captain instructed the first officer to try again in 15 mins. This was done and again was unsuccessful. The captain set up the FMS for the civet arrival and runway 24R. A clearance is received to go direct tnp and konzl for the paradise four arrival to lax. The captain inserts the new arrival into the FMS. Altitude restrs are reviewed and inserted as well. Around this time I attempt several times to contact operations so as to get a parking assignment. I also pick up the new ATIS. I am not monitoring ATC during this time, but I can hear ATC in the background on the overhead speakers. The captain requests and fills out a company form. He then briefs the arrival to runway 24R and the paradise four arrival. We receive a clearance to cross konzl at 17000 ft. Prior to konzl we are switched to socal approach and are told to expect runway 25L. The captain asks the first officer to request runway 24R and he does. Socal responds that they are aware of where we will be parking and he will let us know if runway 24R becomes available. I am still on the #2 and #3 radios getting ATIS and parking assignments. I am still at the scribe station. Once I have received this information I complete the card, pass it forward and bring my seat around and into position to assist in monitoring the descent. There is some discussion about our descent profile and restr, which we have just missed by 400 ft high at konzl. I bring myself into the picture at 17500 ft and am about to ask if the in-range check is started just as the first officer prompts the captain for the same. First officer starts checklist and I notice the runway selected is still runway 24R and not runway 25L. I bring this to attention. The captain instructs the first officer to update the FMS with the correct runway. The first officer does this and the arrival drops out completely. There is now no navigation information for the arrival. The captain immediately starts to insert the next waypoint. (It should be noted that the waypoints for this arrival are very closely spaced.) as soon as the waypoint is inserted, the captain selects navigation just as the aircraft passes the waypoint. This caused the aircraft to start a right turn back towards pdz. I immediately notice the turn and call 'heading' at the same time the first officer sees and calls heading. The captain looks up and selects the heading knob to correct the errant heading. He once again goes head down to insert the next waypoint, same thing happens. Once again the first officer and I see the aircraft begin to turn and again call out 'heading.' the first officer makes the turn back with the heading knob. I believe it is at this point the first officer asks the captain if he (the first officer) should be doing the FMS/navigation work and asks what is the radial off pdz. The captain responds 277 degrees. The first officer begins to insert this. Realizing we have deviated from standard practice, (PF flies and PNF runs the FMS) I then take the arrival plate from the captain and make the statement 'you fly the aircraft and I will read the waypoints to the first officer.' as I begin to assist the first officer with the waypoints, we receive clearance to intercept the runway 25L localizer and cross fuelr at 8000 ft and 250 KTS. 8000 ft is selected and verified by captain and first officer. Since the aircraft is in heading mode the turn inbound is started late, manually, and the localizer is overshot. ATC notices this and states 'air carrier X I show you north of the localizer.' the captain has already made a heading correction, manually turning towards hundi. The first officer is busy inserting suzzi and fuelr. Still slightly north of course ATC advises of traffic for runway 24R and I see the traffic visually, and so state. Our TCASII alerts us at about this time as well. I xchk the localizer frequency and then notice that the ILS frequency for runway 25L is not hard tuned, I state this and the first officer hard tunes the frequency. With the aircraft descending, and still prior to fuelr, I notice we are going right through 8000 ft and call 'altitude.' first officer also makes the same call. (I believe this is when the autoplt was turned off.) the captain levels at 7500 ft, and selects 7500 ft in the glare shield. I again say 'altitude' and I state, '8000 ft as assigned.' captain replies that he will just capture GS from here. Socal clears us to 6000 ft right at this time, so the point becomes moot. 6000 ft is set in the glare shield. I made the call 'verified.' I then notice that the ILS frequency for runway 25L is not hard tuned, and tell the first officer. He hard tunes the frequency. Socal advises we are gaining on traffic and to slow down. The captain starts to configure and slow down. Socal gives us clearance, cleared the runway 25L approach and to contact the tower. I now notice that land/armed is no longer selected and so state. It is re-armed. I also assist with the frequency change as the first officer is task saturated at this point. Tower asks us why we haven't maintained 180 KTS to the marker. This clearance was not heard or acknowledged by any of the flight crew. The captain speeds up to 180 KTS briefly and then slows and configures at the marker. The landing checklist is completed and the first officer confirms clearance to land. The landing and taxi are uneventful. We blocked in at XC57. Total block 1 hour 12 mins. Total flight 48 mins. In conclusion, I believe we made several violations. Altitude crossing restrs, arrival procedures, including speed and heading/navigation errors. Deviation from company procedures, poor planning, FMS mistakes combined with poor CRM and the relatively short flight along with system malfunctions all played a part in this event.

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Original NASA ASRS Text

Title: AN MD11 FERRY FLT CREW SUFFERS A MULTITUDE OF ERRORS PERTAINING TO TFC CONFLICTS, NAV, CRM, HEADING TRACK DEVS AND ERRORS INVOLVED IN ALT AND SPD CTL FOR THE PDZ ARR PROC INTO LAX, CA.

Narrative: THIS NARRATIVE IS FROM MY PERSPECTIVE AS THE RELIEF PLT, THIRD SEAT, AND IS STATED HERE TO THE BEST OF MY RECOLLECTION. THE FLT WAS TO BE A ROUTINE FERRY FLT FROM A MAINT FACILITY (WHERE IT RECEIVED AN 'A' CHK) TO LOS ANGELES. THE SCHEDULED DEP WAS XA00. THE ACTUAL BLOCK OUT WAS XB45. THE DEP WAS DELAYED DUE TO LAST MIN PROBS WITH THE AIR SYS AND THE FMC. ONCE MAINT CLRED THE FMC PROBS WE WERE ON OUR WAY. THE AIR SYS PROBS WERE BELIEVED TO BE HEAT RELATED, AS THE OUTSIDE AIR TEMP WAS 40 DEGS C. MAINT, THE CAPT, AND BOTH FO'S BELIEVED THE AIR SYS WOULD BE FINE ONCE THE ACFT COOLED OFF IN FLT. WE ELECT TO GO. THE FLT PLAN CALLED FOR A SHORT FLT OF 56 MINS. TAXI, TKOF, CLB AND CRUISE WERE ALL NORMAL, WITH THE EXCEPTION OF THE AIR SYS, WHICH THE CAPT INSTRUCTED THE FO TO TRY IN AUTOMATIC. THIS DID NOT WORK. MANUAL WAS RE-SELECTED AND THE CAPT INSTRUCTED THE FO TO TRY AGAIN IN 15 MINS. THIS WAS DONE AND AGAIN WAS UNSUCCESSFUL. THE CAPT SET UP THE FMS FOR THE CIVET ARR AND RWY 24R. A CLRNC IS RECEIVED TO GO DIRECT TNP AND KONZL FOR THE PARADISE FOUR ARR TO LAX. THE CAPT INSERTS THE NEW ARR INTO THE FMS. ALT RESTRS ARE REVIEWED AND INSERTED AS WELL. AROUND THIS TIME I ATTEMPT SEVERAL TIMES TO CONTACT OPS SO AS TO GET A PARKING ASSIGNMENT. I ALSO PICK UP THE NEW ATIS. I AM NOT MONITORING ATC DURING THIS TIME, BUT I CAN HEAR ATC IN THE BACKGROUND ON THE OVERHEAD SPEAKERS. THE CAPT REQUESTS AND FILLS OUT A COMPANY FORM. HE THEN BRIEFS THE ARR TO RWY 24R AND THE PARADISE FOUR ARR. WE RECEIVE A CLRNC TO CROSS KONZL AT 17000 FT. PRIOR TO KONZL WE ARE SWITCHED TO SOCAL APCH AND ARE TOLD TO EXPECT RWY 25L. THE CAPT ASKS THE FO TO REQUEST RWY 24R AND HE DOES. SOCAL RESPONDS THAT THEY ARE AWARE OF WHERE WE WILL BE PARKING AND HE WILL LET US KNOW IF RWY 24R BECOMES AVAILABLE. I AM STILL ON THE #2 AND #3 RADIOS GETTING ATIS AND PARKING ASSIGNMENTS. I AM STILL AT THE SCRIBE STATION. ONCE I HAVE RECEIVED THIS INFO I COMPLETE THE CARD, PASS IT FORWARD AND BRING MY SEAT AROUND AND INTO POS TO ASSIST IN MONITORING THE DSCNT. THERE IS SOME DISCUSSION ABOUT OUR DSCNT PROFILE AND RESTR, WHICH WE HAVE JUST MISSED BY 400 FT HIGH AT KONZL. I BRING MYSELF INTO THE PICTURE AT 17500 FT AND AM ABOUT TO ASK IF THE IN-RANGE CHK IS STARTED JUST AS THE FO PROMPTS THE CAPT FOR THE SAME. FO STARTS CHKLIST AND I NOTICE THE RWY SELECTED IS STILL RWY 24R AND NOT RWY 25L. I BRING THIS TO ATTN. THE CAPT INSTRUCTS THE FO TO UPDATE THE FMS WITH THE CORRECT RWY. THE FO DOES THIS AND THE ARR DROPS OUT COMPLETELY. THERE IS NOW NO NAV INFO FOR THE ARR. THE CAPT IMMEDIATELY STARTS TO INSERT THE NEXT WAYPOINT. (IT SHOULD BE NOTED THAT THE WAYPOINTS FOR THIS ARR ARE VERY CLOSELY SPACED.) AS SOON AS THE WAYPOINT IS INSERTED, THE CAPT SELECTS NAV JUST AS THE ACFT PASSES THE WAYPOINT. THIS CAUSED THE ACFT TO START A R TURN BACK TOWARDS PDZ. I IMMEDIATELY NOTICE THE TURN AND CALL 'HEADING' AT THE SAME TIME THE FO SEES AND CALLS HEADING. THE CAPT LOOKS UP AND SELECTS THE HEADING KNOB TO CORRECT THE ERRANT HEADING. HE ONCE AGAIN GOES HEAD DOWN TO INSERT THE NEXT WAYPOINT, SAME THING HAPPENS. ONCE AGAIN THE FO AND I SEE THE ACFT BEGIN TO TURN AND AGAIN CALL OUT 'HEADING.' THE FO MAKES THE TURN BACK WITH THE HEADING KNOB. I BELIEVE IT IS AT THIS POINT THE FO ASKS THE CAPT IF HE (THE FO) SHOULD BE DOING THE FMS/NAV WORK AND ASKS WHAT IS THE RADIAL OFF PDZ. THE CAPT RESPONDS 277 DEGS. THE FO BEGINS TO INSERT THIS. REALIZING WE HAVE DEVIATED FROM STANDARD PRACTICE, (PF FLIES AND PNF RUNS THE FMS) I THEN TAKE THE ARR PLATE FROM THE CAPT AND MAKE THE STATEMENT 'YOU FLY THE ACFT AND I WILL READ THE WAYPOINTS TO THE FO.' AS I BEGIN TO ASSIST THE FO WITH THE WAYPOINTS, WE RECEIVE CLRNC TO INTERCEPT THE RWY 25L LOC AND CROSS FUELR AT 8000 FT AND 250 KTS. 8000 FT IS SELECTED AND VERIFIED BY CAPT AND FO. SINCE THE ACFT IS IN HEADING MODE THE TURN INBOUND IS STARTED LATE, MANUALLY, AND THE LOC IS OVERSHOT. ATC NOTICES THIS AND STATES 'ACR X I SHOW YOU N OF THE LOC.' THE CAPT HAS ALREADY MADE A HEADING CORRECTION, MANUALLY TURNING TOWARDS HUNDI. THE FO IS BUSY INSERTING SUZZI AND FUELR. STILL SLIGHTLY N OF COURSE ATC ADVISES OF TFC FOR RWY 24R AND I SEE THE TFC VISUALLY, AND SO STATE. OUR TCASII ALERTS US AT ABOUT THIS TIME AS WELL. I XCHK THE LOC FREQ AND THEN NOTICE THAT THE ILS FREQ FOR RWY 25L IS NOT HARD TUNED, I STATE THIS AND THE FO HARD TUNES THE FREQ. WITH THE ACFT DSNDING, AND STILL PRIOR TO FUELR, I NOTICE WE ARE GOING RIGHT THROUGH 8000 FT AND CALL 'ALT.' FO ALSO MAKES THE SAME CALL. (I BELIEVE THIS IS WHEN THE AUTOPLT WAS TURNED OFF.) THE CAPT LEVELS AT 7500 FT, AND SELECTS 7500 FT IN THE GLARE SHIELD. I AGAIN SAY 'ALT' AND I STATE, '8000 FT AS ASSIGNED.' CAPT REPLIES THAT HE WILL JUST CAPTURE GS FROM HERE. SOCAL CLRS US TO 6000 FT RIGHT AT THIS TIME, SO THE POINT BECOMES MOOT. 6000 FT IS SET IN THE GLARE SHIELD. I MADE THE CALL 'VERIFIED.' I THEN NOTICE THAT THE ILS FREQ FOR RWY 25L IS NOT HARD TUNED, AND TELL THE FO. HE HARD TUNES THE FREQ. SOCAL ADVISES WE ARE GAINING ON TFC AND TO SLOW DOWN. THE CAPT STARTS TO CONFIGURE AND SLOW DOWN. SOCAL GIVES US CLRNC, CLRED THE RWY 25L APCH AND TO CONTACT THE TWR. I NOW NOTICE THAT LAND/ARMED IS NO LONGER SELECTED AND SO STATE. IT IS RE-ARMED. I ALSO ASSIST WITH THE FREQ CHANGE AS THE FO IS TASK SATURATED AT THIS POINT. TWR ASKS US WHY WE HAVEN'T MAINTAINED 180 KTS TO THE MARKER. THIS CLRNC WAS NOT HEARD OR ACKNOWLEDGED BY ANY OF THE FLT CREW. THE CAPT SPDS UP TO 180 KTS BRIEFLY AND THEN SLOWS AND CONFIGURES AT THE MARKER. THE LNDG CHKLIST IS COMPLETED AND THE FO CONFIRMS CLRNC TO LAND. THE LNDG AND TAXI ARE UNEVENTFUL. WE BLOCKED IN AT XC57. TOTAL BLOCK 1 HR 12 MINS. TOTAL FLT 48 MINS. IN CONCLUSION, I BELIEVE WE MADE SEVERAL VIOLATIONS. ALT XING RESTRS, ARR PROCS, INCLUDING SPD AND HEADING/NAV ERRORS. DEV FROM COMPANY PROCS, POOR PLANNING, FMS MISTAKES COMBINED WITH POOR CRM AND THE RELATIVELY SHORT FLT ALONG WITH SYS MALFUNCTIONS ALL PLAYED A PART IN THIS EVENT.

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.