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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!”
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.
n  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.
n  We were descending on the arrival into ABC airport
with a clearance to cross fix at 13,000 feet. The FMS was
A Monthly Safety Bulletin
from
The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
July 1997 Report Intake
Air Carrier Pilots 2051
General Aviation Pilots 762
Controllers 113
Cabin/Mechanics/Military/Other 64
TOTAL 2990
ASRS Recently Issued Alerts On...
http://olias.arc.nasa.gov/asrs
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
Number 219 September 1997
In-flight engine cowling separation on a PA-31
Communications blind spot at a North Carolina airport
n  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.
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.
n  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.
　
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