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From NASA's Aviation Safety Reporting System�
Number 195
August 1995
Murphy�sLaw—
The source of Murphy’s Law is obscure, but it is thought to have originated with engineers and scientists: “When something can go wrong, it will.” One of those scientists or engineers must also have invented the altitude alerter, an example of electronic wizardry designed to increase flight safety and decrease pilot workload. But when alerters don’t work, due either to mechanical or human error, they can be worse than useless—they can become a hazard. More from this Part 135 First Officer reporting to ASRS:
Aviators’ Version
means to maintain his awareness of his assigned altitude. He discovered that even the normal required cockpit tasks can cause a distraction, and a resultant failure to set the altitude alerter.
■ Center issued instructions for us to hold...at 7,000 feet. As we entered the hold, I saw the altimeter pass through 6,800 feet. I said “7,000” and arrested the descent, stopping at 6,700 feet, and began to climb back to 7,000 feet.
Three ATC clearances in rapid succession, coupled with a confusing hold clearance, caused a rapid rise in workload. The F/O [First Officer] had not changed the altitude in the FMC [Flight Management Computer]. Both pilots have a high level of altitude awareness, and always set the altitude alert and confirm it upon receipt of a clearance. But not this time. I had turned away to write down the clearance. The F/O went right to the CDU [Control Display Unit] to program the hold. The normal sequence of events was broken. Thus, no one set the altitude window. The lesson here is one of prioritization. Set the altitude window before anything else is accomplished. In portions of their reports not quoted here, both reporters acknowledged that ATC came to the rescue. In the first case, there was a clearance to a lower altitude; in the second, a request for confirmation of altitude. The controllers’ transmissions were enough to refocus the attention of the flight crews.
■ While we were climbing, Center advised us to “climb to 15,000 feet, traffic at 16,000 feet...” Passing through 12,000 feet, the #1 prop governor started to lose control, [but] was found to be within tolerances. I decided to try to adjust the condition levers while hand-flying the aircraft. I became preoccupied with the situation, and was waiting to hear the altitude alerter, which of course malfunctioned. So naturally, we passed through our altitude by approximately 800 feet. The alerter never signaled in with the pre- or post400 foot alarm mode as it is designed to do. Additionally, the Captain had gotten preoccupied with some company paperwork, so he had missed his “1,000 feet to go” call.
I feel the problem arose from my reliance on the altitude alerter, and the Captain’s attention being taken away to perform company business. In another incident, a Captain also counted on mechanical
More Murphy
A General Aviation pilot offers another example of “things just not going as planned”: to alter his plan accordingly. Over-reliance on fuel gauge indications added to the problem.
■ The fuel tanks were topped off, which would mean a 4.22hour endurance according to the aircraft flight manual. The flight lasted 3.5 hours, at which time the engine quit on final approach. An emergency was declared and the aircraft was landed safely on a dirt road one mile from the runway.
The cause of the problem was two-fold: not taking into account the effect of a hot day on fuel expansion and evaporation, especially on auto gas which was used in the airplane; and incorrect leaning of the engine... The right fuel gauge was reading empty, but the left gauge showed nearly a quarter of a tank, further leading me to believe I would have plenty of fuel to finish the flight. The pilot’s basic pre-flight preparation was in the ball park, but hot weather changed the game plan and the pilot forgot
A Real “Saab Story”
■ We were on the 45 degree intercept for 17L when Approach asked us if we had the Saab in sight in front of us. The First Officer [F/O] answered in the affirmative. Spacing looked good to me—probably because I was looking at the wrong Saab... It was TCAS that alerted me to the close proximity of the traffic [we] were actually to be following. The target...was probably about two miles at my two o'clock position. We turned left off the intercept heading and continued to the southeast and were instructed to contact Approach Control for another approach.
Arrival into the sun, multiple similar aircraft, F/O calling out traffic in sight prior to Captain’s positive verification are all contributory.
ASRS Recently Issued Alerts On...
FM radio interference with a Tennessee ILS frequency Multiple controller reports of inaccurate ASOS information Practice military intercept of a jetliner in Brazilian airspace Uncommanded deployment in cruise of a B757 speed brake Distribution of AIM revisions after effective dates of changes
A Monthly Safety Bulletin from The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
June 1995 Report Intake
Air Carrier Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other 1863 785 107 33
TOTAL
2788
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_195.pdf
From NASA's Aviation Safety Reporting System�
Number 195
August 1995
Murphy�sLaw—
The source of Murphy’s Law is obscure, but it is thought to have originated with engineers and scientists: “When something can go wrong, it will.” One of those scientists or engineers must also have invented the altitude alerter, an example of electronic wizardry designed to increase flight safety and decrease pilot workload. But when alerters don’t work, due either to mechanical or human error, they can be worse than useless—they can become a hazard. More from this Part 135 First Officer reporting to ASRS:
Aviators’ Version
means to maintain his awareness of his assigned altitude. He discovered that even the normal required cockpit tasks can cause a distraction, and a resultant failure to set the altitude alerter.
■ Center issued instructions for us to hold...at 7,000 feet. As we entered the hold, I saw the altimeter pass through 6,800 feet. I said “7,000” and arrested the descent, stopping at 6,700 feet, and began to climb back to 7,000 feet.
Three ATC clearances in rapid succession, coupled with a confusing hold clearance, caused a rapid rise in workload. The F/O [First Officer] had not changed the altitude in the FMC [Flight Management Computer]. Both pilots have a high level of altitude awareness, and always set the altitude alert and confirm it upon receipt of a clearance. But not this time. I had turned away to write down the clearance. The F/O went right to the CDU [Control Display Unit] to program the hold. The normal sequence of events was broken. Thus, no one set the altitude window. The lesson here is one of prioritization. Set the altitude window before anything else is accomplished. In portions of their reports not quoted here, both reporters acknowledged that ATC came to the rescue. In the first case, there was a clearance to a lower altitude; in the second, a request for confirmation of altitude. The controllers’ transmissions were enough to refocus the attention of the flight crews.
■ While we were climbing, Center advised us to “climb to 15,000 feet, traffic at 16,000 feet...” Passing through 12,000 feet, the #1 prop governor started to lose control, [but] was found to be within tolerances. I decided to try to adjust the condition levers while hand-flying the aircraft. I became preoccupied with the situation, and was waiting to hear the altitude alerter, which of course malfunctioned. So naturally, we passed through our altitude by approximately 800 feet. The alerter never signaled in with the pre- or post400 foot alarm mode as it is designed to do. Additionally, the Captain had gotten preoccupied with some company paperwork, so he had missed his “1,000 feet to go” call.
I feel the problem arose from my reliance on the altitude alerter, and the Captain’s attention being taken away to perform company business. In another incident, a Captain also counted on mechanical
More Murphy
A General Aviation pilot offers another example of “things just not going as planned”: to alter his plan accordingly. Over-reliance on fuel gauge indications added to the problem.
■ The fuel tanks were topped off, which would mean a 4.22hour endurance according to the aircraft flight manual. The flight lasted 3.5 hours, at which time the engine quit on final approach. An emergency was declared and the aircraft was landed safely on a dirt road one mile from the runway.
The cause of the problem was two-fold: not taking into account the effect of a hot day on fuel expansion and evaporation, especially on auto gas which was used in the airplane; and incorrect leaning of the engine... The right fuel gauge was reading empty, but the left gauge showed nearly a quarter of a tank, further leading me to believe I would have plenty of fuel to finish the flight. The pilot’s basic pre-flight preparation was in the ball park, but hot weather changed the game plan and the pilot forgot
A Real “Saab Story”
■ We were on the 45 degree intercept for 17L when Approach asked us if we had the Saab in sight in front of us. The First Officer [F/O] answered in the affirmative. Spacing looked good to me—probably because I was looking at the wrong Saab... It was TCAS that alerted me to the close proximity of the traffic [we] were actually to be following. The target...was probably about two miles at my two o'clock position. We turned left off the intercept heading and continued to the southeast and were instructed to contact Approach Control for another approach.
Arrival into the sun, multiple similar aircraft, F/O calling out traffic in sight prior to Captain’s positive verification are all contributory.
ASRS Recently Issued Alerts On...
FM radio interference with a Tennessee ILS frequency Multiple controller reports of inaccurate ASOS information Practice military intercept of a jetliner in Brazilian airspace Uncommanded deployment in cruise of a B757 speed brake Distribution of AIM revisions after effective dates of changes
A Monthly Safety Bulletin from The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
June 1995 Report Intake
Air Carrier Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other 1863 785 107 33
TOTAL
2788
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_195.pdf
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