|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1801 To 2400|
|Locale Reference||navaid : fim.vortac|
|Altitude||msl single value : 11000|
|Controlling Facilities||artcc : zla.artcc|
|Operator||common carrier : air carrier|
|Make Model Name||B737-300|
|Operating Under FAR Part||Part 121|
|Flight Phase||descent : intermediate altitude|
|Route In Use||arrival star : fernando|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Experience||flight time last 90 days : 240|
flight time total : 12000
flight time type : 9000
|Affiliation||company : air carrier|
|Function||flight crew : first officer|
|Anomaly||altitude deviation : crossing restriction not met|
non adherence : clearance
other spatial deviation
|Independent Detector||other controllera|
|Resolutory Action||controller : issued new clearance|
|Problem Areas||ATC Human Performance|
Flight Crew Human Performance
|Primary Problem||Flight Crew Human Performance|
|Air Traffic Incident||Pilot Deviation|
Flight was from sjc to bur. Sjc was landing/departing southeast, lax was landing east, bur was landing ILS to runway 8 (4 mi overcast, 2 mi visibility +right wind 130 degrees at 15 KTS gusting to 25 KTS). We were on the fim fern 5 arrival and I was expecting to cross baill at 11000 ft. I had asked the first officer to have the flight attendants secure the cabin prior to top of descent. We then encountered moderate turbulence and I sat the flight attendants down over the PA. We started our descent and the ride smoothed out. I asked the first officer (a new guy) to coordination with the flight attendants to see if they wanted to continue to secure the cabin or wait until after landing. While the first officer was off, ZLA gave the clearance, 'cross 20 mi west of fim at 11000 ft, and 10 mi west of fim 9000 ft.' I had to have the controller repeat the clearance since I was expecting the standard baill at 11000 ft. I programmed the FMC with fim/-10 and fim/-20 and plugged in the respective altitudes 9000 ft and 11000 ft. The first officer came back up and I briefed him on the clearance and showed him the FMC programming. I was concerned that the 10 mi west of fim at 9000 ft was low (terrain). I continued to cycle the radar display between radar and terrain. I easily complied with the first altitude restr. I mentioned to my first officer my concerns about terrain and started a slow descent to meet the second restr. Soon thereafter, at about 10500 ft, ZLA said, 'stop your descent' and then 'maintain 10000 ft.' I had misprogrammed the FMC, the fim/-10 was correct but the fim/-20 was actually the fim/-10 and additional -20. I had 'made the restr' but had started the descent for the second restr too early. The disappointing part was I failed to observe that fim/-10 corresponded to the baill fix and fim/-20 corresponded to the burnz fix. I don't know why the controller didn't issue 'cross burnz at 11000 ft and baill at 9000 ft.' we were on the STAR and had never left it. The negatives from this experience are: 1) poor crew coordination (I made a mistake and my first officer did not catch it. 2) poor FMC programming. 3) poor situational awareness. (I should have caught 10 mi west was baill and 20 mi west was burnz). The positives: 1) good situational awareness (knew high terrain was there and monitored clearance with egpws. The egpws is probably one of the most valuable pieces of equipment on the aircraft.
Original NASA ASRS Text
Title: A B737-300 PLT DSNDED BELOW THE MINIMUM ENRTE ALT BECAUSE OF A MISPROGRAMMED FMC.
Narrative: FLT WAS FROM SJC TO BUR. SJC WAS LNDG/DEPARTING SE, LAX WAS LNDG E, BUR WAS LNDG ILS TO RWY 8 (4 MI OVCST, 2 MI VISIBILITY +R WIND 130 DEGS AT 15 KTS GUSTING TO 25 KTS). WE WERE ON THE FIM FERN 5 ARR AND I WAS EXPECTING TO CROSS BAILL AT 11000 FT. I HAD ASKED THE FO TO HAVE THE FLT ATTENDANTS SECURE THE CABIN PRIOR TO TOP OF DSCNT. WE THEN ENCOUNTERED MODERATE TURB AND I SAT THE FLT ATTENDANTS DOWN OVER THE PA. WE STARTED OUR DSCNT AND THE RIDE SMOOTHED OUT. I ASKED THE FO (A NEW GUY) TO COORD WITH THE FLT ATTENDANTS TO SEE IF THEY WANTED TO CONTINUE TO SECURE THE CABIN OR WAIT UNTIL AFTER LNDG. WHILE THE FO WAS OFF, ZLA GAVE THE CLRNC, 'CROSS 20 MI W OF FIM AT 11000 FT, AND 10 MI W OF FIM 9000 FT.' I HAD TO HAVE THE CTLR REPEAT THE CLRNC SINCE I WAS EXPECTING THE STANDARD BAILL AT 11000 FT. I PROGRAMMED THE FMC WITH FIM/-10 AND FIM/-20 AND PLUGGED IN THE RESPECTIVE ALTS 9000 FT AND 11000 FT. THE FO CAME BACK UP AND I BRIEFED HIM ON THE CLRNC AND SHOWED HIM THE FMC PROGRAMMING. I WAS CONCERNED THAT THE 10 MI W OF FIM AT 9000 FT WAS LOW (TERRAIN). I CONTINUED TO CYCLE THE RADAR DISPLAY BTWN RADAR AND TERRAIN. I EASILY COMPLIED WITH THE FIRST ALT RESTR. I MENTIONED TO MY FO MY CONCERNS ABOUT TERRAIN AND STARTED A SLOW DSCNT TO MEET THE SECOND RESTR. SOON THEREAFTER, AT ABOUT 10500 FT, ZLA SAID, 'STOP YOUR DSCNT' AND THEN 'MAINTAIN 10000 FT.' I HAD MISPROGRAMMED THE FMC, THE FIM/-10 WAS CORRECT BUT THE FIM/-20 WAS ACTUALLY THE FIM/-10 AND ADDITIONAL -20. I HAD 'MADE THE RESTR' BUT HAD STARTED THE DSCNT FOR THE SECOND RESTR TOO EARLY. THE DISAPPOINTING PART WAS I FAILED TO OBSERVE THAT FIM/-10 CORRESPONDED TO THE BAILL FIX AND FIM/-20 CORRESPONDED TO THE BURNZ FIX. I DON'T KNOW WHY THE CTLR DIDN'T ISSUE 'CROSS BURNZ AT 11000 FT AND BAILL AT 9000 FT.' WE WERE ON THE STAR AND HAD NEVER LEFT IT. THE NEGATIVES FROM THIS EXPERIENCE ARE: 1) POOR CREW COORD (I MADE A MISTAKE AND MY FO DID NOT CATCH IT. 2) POOR FMC PROGRAMMING. 3) POOR SITUATIONAL AWARENESS. (I SHOULD HAVE CAUGHT 10 MI W WAS BAILL AND 20 MI W WAS BURNZ). THE POSITIVES: 1) GOOD SITUATIONAL AWARENESS (KNEW HIGH TERRAIN WAS THERE AND MONITORED CLRNC WITH EGPWS. THE EGPWS IS PROBABLY ONE OF THE MOST VALUABLE PIECES OF EQUIP ON THE ACFT.
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.