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Flight crew of B747-400 experience a classic work overload on departure from zspd. Altitude overshoot and altitude undershoot and stall warning activation result.
| Attributes | |
| ACN | 628738 |
| Time | |
| Date | 200408 |
| Day | Wed |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : zspd.airport |
| State Reference | FO |
| Altitude | msl single value : 3000 |
| Environment | |
| Flight Conditions | Marginal |
| Weather Elements | Turbulence |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tracon : zspd.tracon |
| Operator | common carrier : air carrier |
| Make Model Name | B747-400 |
| Operating Under FAR Part | Part 121 |
| Navigation In Use | other |
| Flight Phase | climbout : intermediate altitude |
| Route In Use | departure sid : akara |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Experience | flight time last 90 days : 100 flight time total : 20000 flight time type : 800 |
| ASRS Report | 628738 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Experience | flight time last 90 days : 150 flight time total : 18000 flight time type : 1500 |
| ASRS Report | 628422 |
| Events | |
| Anomaly | altitude deviation : undershoot altitude deviation : overshoot inflight encounter : turbulence non adherence : clearance non adherence : company policies other anomaly |
| Independent Detector | aircraft equipment other aircraft equipment : stall warning system other flight crewa other flight crewb |
| Resolutory Action | controller : issued new clearance flight crew : returned to assigned altitude flight crew : regained aircraft control flight crew : overrode automation |
| Supplementary | |
| Problem Areas | Weather ATC Human Performance Aircraft Flight Crew Human Performance |
| Primary Problem | Flight Crew Human Performance |
Narrative:
The WX at pvg (zspd, shanghai pudong airport) was low overcast and the usual haze. Clearance was to fly the akara departure to 900 meters (3000 ft). At the 5 DME, the SID has you doing a 180 degree course reversal. On the climb, we had continuous turbulence. While accelerating and going through flap retraction, when we broke out through layers and while the first officer was in the turn, I saw a small twring cumulous in the direction of the turn. (Not visible by radar). I brought it to his attention, and asked him to try to stay inside of it, knowing that we would skirt the edge of it. Flaps were retracting to 1 degree, and when he called for flaps up, I mentioned that the flaps were still in transit to the 1 degree position. (Unusually long time for retraction.) (the assumption was of course made that we may have a possible flap problem.) at that point we received an ATC call for a frequency change. I looked up and saw that the flap indication was now showing green at flaps 1 degree. I called out 'flaps are showing normal' and I retracted the flaps to the 'up' position. The first officer acknowledged. While I was channeling the radio, the relief pilot called out 'altitude.' I looked up, and saw us approaching and overshooting through 900 meters. The first officer started the correction immediately back to assigned altitude. Seeing that he was making the correction, I contacted the next controller. I received and read back the usual long clearance. At that point I heard a very short burst of the stick shaker, while still in the turn, while climbing back up to 900 meters and while still in turbulence. First officer corrected and continued the climb up to the new assigned altitude. There were never any traffic concerns, or questions asked by pvg ATC. This situation was a classic example of high workload, a low altitude leveloff, and many distrs coming at us all at once. Having the third set of eyes in the cockpit by calling out 'altitude' made a big difference. Supplemental information from acn 628422: overshoot of the altitude again on the lower side. My view of the instrument panel and throttle quadrant blocked at this time. Solid correction upwards while still in a bank angle and turbulence, followed by a very brief stick shaker at something above 270 KTS. Captain advanced more power, copilot regained throttles and continued climb to newly assigned higher altitude.
Original NASA ASRS Text
Title: FLT CREW OF B747-400 EXPERIENCE A CLASSIC WORK OVERLOAD ON DEP FROM ZSPD. ALT OVERSHOOT AND ALT UNDERSHOOT AND STALL WARNING ACTIVATION RESULT.
Narrative: THE WX AT PVG (ZSPD, SHANGHAI PUDONG ARPT) WAS LOW OVCST AND THE USUAL HAZE. CLRNC WAS TO FLY THE AKARA DEP TO 900 METERS (3000 FT). AT THE 5 DME, THE SID HAS YOU DOING A 180 DEG COURSE REVERSAL. ON THE CLB, WE HAD CONTINUOUS TURB. WHILE ACCELERATING AND GOING THROUGH FLAP RETRACTION, WHEN WE BROKE OUT THROUGH LAYERS AND WHILE THE FO WAS IN THE TURN, I SAW A SMALL TWRING CUMULOUS IN THE DIRECTION OF THE TURN. (NOT VISIBLE BY RADAR). I BROUGHT IT TO HIS ATTN, AND ASKED HIM TO TRY TO STAY INSIDE OF IT, KNOWING THAT WE WOULD SKIRT THE EDGE OF IT. FLAPS WERE RETRACTING TO 1 DEG, AND WHEN HE CALLED FOR FLAPS UP, I MENTIONED THAT THE FLAPS WERE STILL IN TRANSIT TO THE 1 DEG POS. (UNUSUALLY LONG TIME FOR RETRACTION.) (THE ASSUMPTION WAS OF COURSE MADE THAT WE MAY HAVE A POSSIBLE FLAP PROB.) AT THAT POINT WE RECEIVED AN ATC CALL FOR A FREQ CHANGE. I LOOKED UP AND SAW THAT THE FLAP INDICATION WAS NOW SHOWING GREEN AT FLAPS 1 DEG. I CALLED OUT 'FLAPS ARE SHOWING NORMAL' AND I RETRACTED THE FLAPS TO THE 'UP' POS. THE FO ACKNOWLEDGED. WHILE I WAS CHANNELING THE RADIO, THE RELIEF PLT CALLED OUT 'ALT.' I LOOKED UP, AND SAW US APCHING AND OVERSHOOTING THROUGH 900 METERS. THE FO STARTED THE CORRECTION IMMEDIATELY BACK TO ASSIGNED ALT. SEEING THAT HE WAS MAKING THE CORRECTION, I CONTACTED THE NEXT CTLR. I RECEIVED AND READ BACK THE USUAL LONG CLRNC. AT THAT POINT I HEARD A VERY SHORT BURST OF THE STICK SHAKER, WHILE STILL IN THE TURN, WHILE CLBING BACK UP TO 900 METERS AND WHILE STILL IN TURB. FO CORRECTED AND CONTINUED THE CLB UP TO THE NEW ASSIGNED ALT. THERE WERE NEVER ANY TFC CONCERNS, OR QUESTIONS ASKED BY PVG ATC. THIS SIT WAS A CLASSIC EXAMPLE OF HIGH WORKLOAD, A LOW ALT LEVELOFF, AND MANY DISTRS COMING AT US ALL AT ONCE. HAVING THE THIRD SET OF EYES IN THE COCKPIT BY CALLING OUT 'ALT' MADE A BIG DIFFERENCE. SUPPLEMENTAL INFO FROM ACN 628422: OVERSHOOT OF THE ALT AGAIN ON THE LOWER SIDE. MY VIEW OF THE INST PANEL AND THROTTLE QUADRANT BLOCKED AT THIS TIME. SOLID CORRECTION UPWARDS WHILE STILL IN A BANK ANGLE AND TURB, FOLLOWED BY A VERY BRIEF STICK SHAKER AT SOMETHING ABOVE 270 KTS. CAPT ADVANCED MORE PWR, COPLT REGAINED THROTTLES AND CONTINUED CLB TO NEWLY ASSIGNED HIGHER ALT.
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.