Number 219
September 1997
Monitoring and Flying
On the back page of this CALLBACK issue, we summarize several ASRS research papers recently presented at the Ohio State University’s Ninth International Aviation Psychology Symposium. One of these, a study of ASRS reports related to inadequate flight crew monitoring, showed that Flight Management System programming was the task most often being performed when a monitoring error occurred. A First Officer’s report points out the difficulty that pilots of “glass cockpit” aircraft may have balancing monitoring and programming duties.
A Balancing Act
properly programmed with the arrival and altitude over fix. LNAV and VNAV were engaged, and the aircraft was descending properly. (The altitude crossing restriction was projected to be 13,000 feet by the computer.) As a line check airman doing Initial Operating Experience (IOE) with a new Captain, we began to discuss the LDA ‘A’ approach (we were at FL240 at the time) because it is very important for new Captains to know the FMC thoroughly...During this discussion neither of us was watching the aircraft very well because of our interest in the approach and because the aircraft was engaged in VNAV. Just past the fix, our discussion ended and our attention went back to the aircraft situation as we anticipated flight below 10,000 feet and the checklists. Much to our amazement, we were descending to 13,000 feet from 17,000 feet. We had missed the crossing restriction by over 4,000 feet! The computer was still in VNAV and LNAV with appropriate annunciations on the FMA. I immediately knew what had happened. The [aircraft] FMC deletes crossing altitudes on Standard Terminal Arrival Routes (STARs) whenever a runway is changed or a different approach is selected at destination. We had given the computer a hard crossing altitude, but...during our discussion we had reselected the Runway 22 ILS and the computer automatically deselected and disregarded our hard crossing altitude ...I constantly warn new pilots about this trap in the FMC. It had now caught me. Our reporter concludes, “This incident reinforces the requirement that someone must be flying the plane!”
s Problem arose when the autopilot didn’t level off at FL240. It was discovered when the ‘ALT’ warning sounded passing FL236. Switched to manual control and returned aircraft to FL240. Contributing factors: Vectored off-course for spacing on arrival, and after Flight Management Annunciator (FMA) displayed ‘ALT CAP,’ I diverted my attention to constructing a new descent profile into FMS...It is very easy to put too much confidence in aircraft automation, resulting in lack of proper monitoring during events such as level-offs and course intercepts. It is important to always find the proper balance for using/not using automation and programming it.
Another report from the ASRS study shows that pilots can still fall into monitoring “traps” in spite of extensive experience and thorough knowledge of the FMC.
s We were descending on the arrival into ABC airport with a clearance to cross fix at 13,000 feet. The FMS was
“CRM Strikes Again”
Two reports address the more general topic of Crew Resource Management (CRM). An air carrier Captain describes how CRM skills came into play while the aircraft was still on the ground.
s During cruise, we got a #1 engine overheat light…then it
went out. [Later], the light came back on, followed by a fire loop fault light. We got clearance to divert to the nearest airport. While completing the emergency checklists, we got a #1 engine fire light and bell. We declared an emergency and fired both extinguisher bottles. We landed without further problems. The fire trucks reported no evidence of smoke or fire, and [later] the mechanics confirmed a shortcircuit in the #1 engine fire detection system. I had the co-pilot fly while I got hold of company. We had a jumpseat pilot…who made an announcement to the passengers, after which he handled ATC communications. I completed checklists, kept an eye on aircraft position, and talked to the lead flight attendant. CRM can take full credit for the uneventful completion of this flight.
s I noticed a strong [fuel] odor down the jetway and throughout the aircraft cabin. Explanation from ground personnel ranged from conditioned air to bug spray. Since I could not substantiate the bug-spray theory, I elected not to accept the aircraft. We had a [write-up] on the auxiliary fuel tank, which on investigation had an internal fuel leak. Apparently the fueler pumped fuel into the tank by mistake without telling anyone. The strongly-voiced concern from the cabin crew significantly contributed to the safe conclusion of this incident. CRM strikes again.
Another Captain, faced with what appeared to be an inflight engine fire, applied CRM skills to make use of all on-board personnel to cope with the emergency. ASRS Recently Issued Alerts On...
In-flight engine cowling separation on a PA-31 Communications blind spot at a North Carolina airport B-757 EFIS failure attributed to a generator malfunction Unclear “hold short” lines on a taxiway at an Ohio airport Static electricity causing power outages at an ATC Tower
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System, P.O. Box 189, Moffett Field, CA 94035-0189 http://olias.arc.nasa.gov/asrs
July 1997 Report Intake
Air Carrier Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other 2051 762 113 64
TOTAL
2990
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_219.pdf
September 1997
Monitoring and Flying
On the back page of this CALLBACK issue, we summarize several ASRS research papers recently presented at the Ohio State University’s Ninth International Aviation Psychology Symposium. One of these, a study of ASRS reports related to inadequate flight crew monitoring, showed that Flight Management System programming was the task most often being performed when a monitoring error occurred. A First Officer’s report points out the difficulty that pilots of “glass cockpit” aircraft may have balancing monitoring and programming duties.
A Balancing Act
properly programmed with the arrival and altitude over fix. LNAV and VNAV were engaged, and the aircraft was descending properly. (The altitude crossing restriction was projected to be 13,000 feet by the computer.) As a line check airman doing Initial Operating Experience (IOE) with a new Captain, we began to discuss the LDA ‘A’ approach (we were at FL240 at the time) because it is very important for new Captains to know the FMC thoroughly...During this discussion neither of us was watching the aircraft very well because of our interest in the approach and because the aircraft was engaged in VNAV. Just past the fix, our discussion ended and our attention went back to the aircraft situation as we anticipated flight below 10,000 feet and the checklists. Much to our amazement, we were descending to 13,000 feet from 17,000 feet. We had missed the crossing restriction by over 4,000 feet! The computer was still in VNAV and LNAV with appropriate annunciations on the FMA. I immediately knew what had happened. The [aircraft] FMC deletes crossing altitudes on Standard Terminal Arrival Routes (STARs) whenever a runway is changed or a different approach is selected at destination. We had given the computer a hard crossing altitude, but...during our discussion we had reselected the Runway 22 ILS and the computer automatically deselected and disregarded our hard crossing altitude ...I constantly warn new pilots about this trap in the FMC. It had now caught me. Our reporter concludes, “This incident reinforces the requirement that someone must be flying the plane!”
s Problem arose when the autopilot didn’t level off at FL240. It was discovered when the ‘ALT’ warning sounded passing FL236. Switched to manual control and returned aircraft to FL240. Contributing factors: Vectored off-course for spacing on arrival, and after Flight Management Annunciator (FMA) displayed ‘ALT CAP,’ I diverted my attention to constructing a new descent profile into FMS...It is very easy to put too much confidence in aircraft automation, resulting in lack of proper monitoring during events such as level-offs and course intercepts. It is important to always find the proper balance for using/not using automation and programming it.
Another report from the ASRS study shows that pilots can still fall into monitoring “traps” in spite of extensive experience and thorough knowledge of the FMC.
s We were descending on the arrival into ABC airport with a clearance to cross fix at 13,000 feet. The FMS was
“CRM Strikes Again”
Two reports address the more general topic of Crew Resource Management (CRM). An air carrier Captain describes how CRM skills came into play while the aircraft was still on the ground.
s During cruise, we got a #1 engine overheat light…then it
went out. [Later], the light came back on, followed by a fire loop fault light. We got clearance to divert to the nearest airport. While completing the emergency checklists, we got a #1 engine fire light and bell. We declared an emergency and fired both extinguisher bottles. We landed without further problems. The fire trucks reported no evidence of smoke or fire, and [later] the mechanics confirmed a shortcircuit in the #1 engine fire detection system. I had the co-pilot fly while I got hold of company. We had a jumpseat pilot…who made an announcement to the passengers, after which he handled ATC communications. I completed checklists, kept an eye on aircraft position, and talked to the lead flight attendant. CRM can take full credit for the uneventful completion of this flight.
s I noticed a strong [fuel] odor down the jetway and throughout the aircraft cabin. Explanation from ground personnel ranged from conditioned air to bug spray. Since I could not substantiate the bug-spray theory, I elected not to accept the aircraft. We had a [write-up] on the auxiliary fuel tank, which on investigation had an internal fuel leak. Apparently the fueler pumped fuel into the tank by mistake without telling anyone. The strongly-voiced concern from the cabin crew significantly contributed to the safe conclusion of this incident. CRM strikes again.
Another Captain, faced with what appeared to be an inflight engine fire, applied CRM skills to make use of all on-board personnel to cope with the emergency. ASRS Recently Issued Alerts On...
In-flight engine cowling separation on a PA-31 Communications blind spot at a North Carolina airport B-757 EFIS failure attributed to a generator malfunction Unclear “hold short” lines on a taxiway at an Ohio airport Static electricity causing power outages at an ATC Tower
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System, P.O. Box 189, Moffett Field, CA 94035-0189 http://olias.arc.nasa.gov/asrs
July 1997 Report Intake
Air Carrier Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other 2051 762 113 64
TOTAL
2990
飞行翻译公司 www.aviation.cn 本文链接地址：美国ASRS安全公告CALLBACK cb_219.pdf
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