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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 post-
400 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
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.
More Murphy
A General Aviation pilot offers another example of “things
just not going as planned”:
■ The fuel tanks were topped off, which would mean a 4.22-
hour 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
to alter his plan accordingly. Over-reliance on fuel gauge
indications added to the problem.
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 1863
General Aviation Pilots 785
Controllers 107
Cabin/Mechanics/Military/Other 33
TOTAL 2788
Turbojet ”Upset” Reports Needed for NTSB Study
Are you a pilot of a multi-engine turbojet air transport category
aircraft who has recently experienced an uncommanded roll,
yaw, or other loss of aircraft control? If you’re willing to share
your experience with the Aviation Safety Reporting System
(ASRS), you can help support an effort by the National
Transportation Safety Board (NTSB) to review first-hand
　
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