1994-12 · NASA ASRS report 291326
AN ACR MD11 FLT CREW TAXIED TO THE WRONG RWY AT IAD.
WE HAD INPUT THE TKOF RWY INTO THE COMPUTER WHILE AT THE RAMP. WHEN WE WERE GIVEN TAXI INSTRUCTIONS; IT WAS TO A DIFFERENT RWY FROM THAT ALREADY PROGRAMMED; THE NEW RWY BEING ON A DIFFERENT SIDE OF THE ARPT THAN EITHER THE FO OR I HAD EVER USED BEFORE. IT WAS A DARK NIGHT IN POURING RAIN; WHICH LIMITED VISIBILITY. ON TAXI OUT; THE FO'S NORMAL DUTIES REQUIRE HIM TO CONTACT THE COMPANY TO OBTAIN THE FINAL TKOF WT; CG; AND STABILIZER SETTING. HE MUST THEN PROGRAM THE COMPUTER FOR THE CORRECT WT AND CG; THEN SET THE STABILIZER TO THE CORRECT SETTING. HE MUST THEN SET THE FLAPS AND CHK THE FLT CTLS FOR FREEDOM OF MOVEMENT. THE FO MUST THEN SHUT DOWN THE APU; ACCOMPLISH A SEVEN ITEM SILENT CHKLIST; WHICH INVOLVES PAGING THROUGH DISPLAYS OF EVERY ACFT SYS TO CONFIRM NORMAL OP; AND THEN READ A 10 ITEM CHALLENGE CHKLIST; TO WHICH THE CAPT MUST RESPOND. THE FO MUST ALSO COMMUNICATE WITH THE CTLRS; ACKNOWLEDGE TAXI CLRNCS; HOLDING INSTRUCTIONS; ETC. A RWY CHANGE PRESENTS THE FO WITH A WHILE NEW SET OF PROBS. HE STARTS BY PAGING DOWN 2 LEVELS IN THE COMPUTER AND SELECTING THE NEW RWY AND THE PROPER SID. HE MUST THEN RETRIEVE A LARGE MANUAL FROM THE SHIP'S MANUALS LIBRARY; LOCATE THE PAGE WITH THE PROPER ARPT AND RWY; REVIEW THE WIND CONDITIONS AND THE ACFT WT; THEN FIND THE PROPER ROW AND COLUMN FOR EXISTING CONDITIONS. HE MUST THEN NOTE THE ALLOWED FLEX TEMP; THE PROPER FLAP SETTING; AND THE RWY SLOPE. HE THEN PROGRAMS THE NEW FLEX TEMP; FLAP SETTING AND SLOPE INTO THE COMPUTER. THEN; BECAUSE OF AN AIRWORTHINESS DIRECTIVE; HE MUST DETERMINE THE PROPER V-SPDS FROM THE MANUAL USING INTERPOLATION FOR ACTUAL ACFT WT; THEN MANUALLY PROGRAM THE V-SPDS INTO THE COMPUTER. FINALLY; HE CHKS THAT THE FLAPS ARE PROPERLY SET FOR THE NEW RWY. THE CAPT'S DUTIES INCLUDE NOT ONLY TAXIING AND LOCATING THE PROPER RWY; BUT ALSO CHKING THE RUDDERS; AND DUE TO ANOTHER AIRWORTHINESS DIRECTIVE; THE AILERONS FOR FREEDOM OF MOVEMENT. HE MUST CHK AND RESPOND TO EACH ITEM ON A 10 ITEM CHKLIST; AND COMMUNICATE WITH THE PAX AND THE FLT ATTENDANTS. ON THE NIGHT IN QUESTION; I WAS TRYING TO TAXI TO AN UNFAMILIAR SECTION OF THE ARPT IN POURING RAIN; WHILE TRYING TO READ A MAP OF THE ARPT IN A DARK COCKPIT. THE FO RARELY HAS TIME TO COMPLETE HIS DUTIES PRIOR TO ARRIVING AT THE TKOF RWY. WHAT IT BOILS DOWN TO IS THAT; IN ADDITION TO HIS DUTIES NOTED ABOVE; THE CAPT IS SOLO ON TAXI-OUT AS FAR AS RTE FINDING IS CONCERNED; BECAUSE THE FO NEVER HAS TIME TO LOOK OUT OF THE WINDOW. ALL RWYS AT DULLES REQUIRE YOU TO TAXI TO THE END OF THE TXWY BEFORE TURNING ONTO THE RWY; EXCEPT RWY 1L. THE SAME TXWY; W2; IS USED FOR BOTH RWY 1L AND RWY 30. BOTH RWYS REQUIRE A R TURN TO GET ONTO THE RWY. HOWEVER; FOR RWY 1L; YOU MUST TURN ONTO THE RWY BEFORE YOU REACH THE END OF THE TXWY. I MADE A TURN ONTO RWY 30 AFTER BEING CLRED INTO POS ONTO RWY 1L. MY FO WAS STILL COMPLETING THE FINAL CHKLIST AND DID NOT NOTICE THE ERROR. AS WE SWUNG INTO POS; I; MY FO; AND THE TWR CTLR ALL PICKED UP ON THE ERROR AT THE SAME TIME. A FEATURE OF THE GLASS COCKPIT WAS ALSO A CONTRIBUTOR TO THIS INCIDENT. WITH A FULL COMPASS ROSE DISPLAY; IT WOULD HAVE BEEN VERY OBVIOUS THAT YOU WERE AT THE WRONG RWY LONG BEFORE YOU TURNED ONTO IT. BUT THE GLASS COCKPIT COMPASS; ONLY A FEW DEGS ARE DISPLAYED AT THE TOP OF THE COMPASS; AND THEREFORE IT DOES NOT BECOME VISUALLY OBVIOUS THAT YOU ARE LINING UP ON THE WRONG RWY UNTIL YOU ARE NEARLY ALIGNED WITH THE RWY AND YOUR HDG APPEARS AT THE TOP OF THE COMPASS ARC. I USUALLY SELECT THE FULL COMPASS ROSE DISPLAY ON TAXI-OUT FOR THIS VERY REASON. YES; I MOST ASSUREDLY GOOFED; BUT UPON REFLECTION; IT SEEMS I HAD A LOT OF HELP. THERE WAS THE PRESIDENTIAL 2-MAN CREW COMMISSION (NO AIRLINE PLTS INCLUDED); WHICH CONCLUDED THAT 2 PLTS WERE AMPLE FOR A GLASS COCKPIT JUMBO JET UNDER ANY AND ALL CONDITIONS. THERE WAS THE MANUFACTURER; WHO; FOR ECONOMIC REASONS; PUSHED THE PRESIDENTIAL COMMISSION TOWARD THE 2-MAN CREW; AND WHO PROVIDED INCREDIBLY POOR COCKPIT LIGHTING FOR MAP READING. THERE WERE THE AIRWORTHINESS DIRECTIVES WHICH INCREASED OUR WORKLOAD; AND THE RIDICULOUS NUMBER OF PRE-TKOF CHKLIST ITEMS FOR A 2-MAN COCKPIT. FINALLY; THERE WAS THE CHANGE OF RWYS; THE DARKNESS; THE RAIN; AND A FO WHO IS KEPT TOO BUSY BY PROCEDURAL REQUIREMENTS TO BE OF ANY HELP DURING TAXI. WHAT STARTED OUT AS PRESIDENTIAL COMMISSION- ENVISIONED MANUFACTURER-SIMPLIFIED CREW WORKLOAD HAS EVOLVED INTO SOMETHING QUITE DIFFERENT. INOPERATIVE AUTOMATIC SYS MUST BE WORKED MANUALLY. MANY SYS DON'T WORK AS THE MANUFACTURER ORIGINALLY INTENDED DUE TO 'ERRORS IN THE COMPUTER SOFTWARE.' AIRWORTHINESS DIRECTIVES WHICH PROHIBIT SOME SYS FORM BEING OPERATED AS INTENDED INCREASE THE WORKLOAD. AIRLINE MGMNTS WHICH REFUSE TO ACCEPT THE MANUFACTURER'S CHKLIST RECOMMENDATIONS; AND WHO COMPILE HUGE CHKLISTS SO THAT THEY WILL BE COMMON WITH OTHER ACFT IN THE FLEET; INCLUDING 3-MAN ACFT; ADD TO THE PROB. AND FINALLY; THE GLASS COCKPIT; FAR FROM DECREASING OUR WORKLOAD; INCREASES IT TREMENDOUSLY. I DO NOT BELIEVE MANY OF THESE THINGS WERE CONSIDERED BY THE PRESIDENTIAL COMMISSION. I WISH THE ENTIRE PRESIDENTIAL COMMISSION COULD HAVE BEEN SITTING ON THE JUMPSEAT THAT NIGHT TO SEE WHAT THEY HAD WROUGHT. THE FACT OF THE MATTER IS THOUGH; THAT WHEN AN ACCIDENT OR AN INCIDENT OCCURS; THE INCREDIBLY OVERLOADED CREW GETS THE BLAME; BECAUSE IT HAS BEEN DETERMINED THAT THEY SHOULD BE ABLE TO COPE WITH ANY AND EVERY SIT; NO MATTER WHAT. 'POOR COCKPIT COORD' AND 'INADEQUATE CREW RESOURCE MGMNT TECHNIQUES' ARE THE BUZZWORDS IN CURRENT FAVOR. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR FLEW THE MD-11 FOR AN ACR THAT HAS SINCE CEASED OPS. HE WAS TRAINED BY AN ACR THAT HAS A LARGE FLEET OF VARIOUS TYPES OF ACFT. THE ACR THAT TRAINED HIM; AND LEASED THE MD-11'S; HAS GONE TO A CONCEPT OF A 'STANDARDIZED CHKLIST;' WHEREIN ALL OF THE ACFT HAVE A VERY SIMILAR CHKLIST. THIS PRODUCES AN INCREASED WORKLOAD ON THE MD-11 BECAUSE MANY ITEMS ARE INCLUDED THAT DO NOT HAVE TO BE DONE. HIS ACRDID NOT USE ACARS AS THERE IS NO ACARS COVERAGE IN JOHANNESBURG AND THE OTHER REGULAR STOP. THEREFORE; ALL PERFORMANCE CALCULATIONS HAD TO BE DONE BY THE COCKPIT. THE RPTR BELIEVES; AS DOES THIS VETERAN ANALYST; THAT THE GLASS COCKPIT REDUCES WORKLOAD IN CRUISE; WHEN THERE IS VERY LITTLE WORKLOAD IN THE FIRST PLACE; AND CAN SIGNIFICANTLY INCREASE THE WORKLOAD ON PREFLT AND IN THE APCH PHASE OF FLT. THE RPTR DOES NOT LIKE THE DIGITAL AIRSPD AND ALTIMETER PRESENTATION. HE HAS NOT HEARD FROM THE FAA ON THIS MATTER.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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