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美国ASRS安全公告CALLBACK cb_247.pdf2页

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Number 247

January 2000

Ready for the Millennium

The New ASRS Web Site
Early in January 2000, ASRS will unveil a redesigned internet Web site. It will have a new address (Uniform Resource Locator) as well as a more contemporary look and feel—and all your favorite information from the old site will still be available. The new site’s address will be easier to remember, too: http://asrs.arc.nasa.gov. When you access the new ASRS Home Page, you will be able to choose a browser option that is compatible with your computer’s software. One option is an updated html version for those with older browsers. The other utilizes Macromedia’s Flash technology, a component of many new browsers, also available as a free plug-in (a link to Macromedia’s download site is provided). Both versions have been optimized to reduce download times. The old ASRS web site will be maintained for a short time, after which a direct link from the old site to the new will be provided.

What’s Available?
Here’s what will be available on ASRS’s new web site: ➣ Current and past issues of the ASRS publications CALLBACK and Directline ➣ Operational Issues Bulletins

➣ NASA Reporting Forms in Adobe’s Acrobat (PDF) format. ➣ Information on ASRS immunity policies, including Advisory Circular 00-46D, Federal Aviation Regulation (FAR) 91.25, and Facility Operations and Administration Handbook (7210.3M), Para. 2-2-9. ➣ ASRS database report sets (in Rich Text Format). There are currently 27 report sets available for downloading on topics of broad interest to the aviation community. ➣ ASRS Program Overview, including a brief overview of ASRS functions and products, as well as a more detailed Program description. ➣ Contact information for ASRS services/staff. ➣ Other useful aviation links. Come visit us soon at http://asrs.arc.nasa.gov.

Y2 Confirm Altitude Assignments
A First Officer’s report of a crossing altitude deviation illustrates how cockpit procedures may be vulnerable to a multiple error chain. In this instance, the error chain included distraction, a common clearance misunderstanding, and forgetting to confirm the altitude assignment with ATC. recall pointing to the Altitude Window after the Captain was supposed to enter 11,000... The Captain thought he had 11,000 in and doesn’t know how 10,000 got selected... I have read that ten and eleven thousand feet are the most often confused altitudes and I believe it. In the future I intend to train myself to be extra vigilant with clearances and setting to those altitudes. The last chance to break the chain of events came with the ATC hand-off to Approach Control. Because of congestion on the frequency Approach Control called us first with a spacing vector behind a B-747. This is not at all unusual in a busy terminal environment. The radio chatter is nonstop… The lesson learned here is that if the controller initiates communication, read back your…current and cleared-to altitudes to ATC, even if [you] must tack the info onto another readback. In addition to heeding our reporter’s words of wisdom, readers may want to check out a widely reprinted ASRS Directline article on the 10,000-11,000 foot clearance confusion problem. The article, “One Zero Ways to Bust an Altitude,” is available from the ASRS web site, and was originally published in Directline Issue No. 2 (1991).

I The Captain was the Pilot Flying (PF), the autopilot was engaged, and he was making the FMS entries and selections on the mode control panel. He had programmed the FMS VNAV to cross intersection at 250 knots and 11,000 feet altitude, as depicted on the STAR [Standard Terminal Arrival Route]. I confirmed this entry as correct. Center cleared us to “cross [fix] at 11,000, 250 knots,” which is what I read back. At that time the Lead Flight Attendant (F/A) came forward with 2 cabin discrepancies. I briefly reviewed them to see if they were considered “airworthiness items” by our company policy, as those require a logbook entry. This all took about a minute. I feel that this distraction broke down my PNF habit patterns of back-up and confirmation of the PF’s navigation.
Our company promotes an…altitude confirmation technique [by both PNF and PF] for what altitude is set in the mode control panel. Because of the F/A call bell, I don’t

ASRS Recently Issued Alerts On…
LR-25 stuck throttle incident at FL370 Nose gear collapse during evacuation of a DC-8-71 “Land and Hold Short” confusion at a Midwest airport Cabin overhead bin smoke attributed to a butane lighter Vision obscuration problems with A-320 full-face masks

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

November 1999 Report Intake
Air Carrier / Air Taxi Pilots General Aviation Pilots Controllers Cabin/Mechanics/Military/Other TOTAL 2021 678 66 154 2919


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