A DC8-54 PIC'S ACCOUNT OF HIS ALT BUST DURING THE MARCS 5 STAR ARR PROC INTO SAT.

1998-12 · NASA ASRS report 423151

Date: 1998-12 · Aircraft: DC-8 50

Anomalies: aircraft-equipment-problem-less-severe|deviation-altitude-overshoot|deviation-altitude-crossing-restriction-not-met|deviation-discrepancy-procedural-published-material-policy|inflight-event-encounter-other-unknown

Synopsis

A DC8-54 PIC'S ACCOUNT OF HIS ALT BUST DURING THE MARCS 5 STAR ARR PROC INTO SAT.

Narrative

THE CREW CONSISTED OF MYSELF; CAPT AA; FO BB; AND FE CC. FO BB IS NEW TO THE DC8 AND I WAS GIVING HIM OPERATING EXPERIENCE. WE HAD STARTED THE NIGHT IN DFW OPERATING DFW-HUF-DFW; RETURNING TO DFW AT ABOUT XA00 CST. THE FLT PLAN I RECEIVED INDICATED THAT THERE WAS TO BE NO CARGO AND WE WERE TO TANKER FUEL TO SAT IN ORDER TO MINIMIZE DELAYS IN SAT DUE TO FUELING THERE. THE FUEL TRUCK WAS WAITING WHEN WE BLOCKED IN AND I TOLD THE FE TO BEGIN FUELING TO 84000 LBS OF FUEL. SOON AFTER FUELING BEGAN; I WAS TOLD BY A CARGO WORKER THAT WE WOULD BE CARRYING CARGO TO SAT; AND THAT THE CARGO WOULD WEIGH AS MUCH AS 50000 LBS. I STOPPED FUELING AND BEGAN COMPUTATIONS AS TO FUEL CAPACITY BASED ON A CARGO LOAD OF 50000 LBS. AT THE SAME TIME; I CONTACTED COMPANY FLT FOLLOWING TO OBTAIN A VALID FLT PLAN BASED ON A CARGO LOAD OF 50000 LBS FOR VALID FUEL BURN COMPUTATIONS; IN ORDER TO COMPUTE MAX FUEL LOADING. AT THE SAME TIME; I WAS ALSO CONCERNED ABOUT A MAINT WRITE-UP I HAD MADE ON THE ACFT; AND I WAS INVOLVED WITH THAT ALSO. QUICKLY; WE GOT THE CARGO WT. THE PLANE WAS QUICKLY LOADED AND WE PUSHED BACK. I FELT A NEED OF URGENCY TO HURRY UP AND GET GOING IN ORDER TO GET TO SAT IN TIME TO RECOVER FROM THE PREVIOUS DAY'S MECHANICAL PROBS. I DID NOT TAKE TIME TO REVIEW THE STARS INTO SAT PRIOR TO PUSHBACK. I DO NOT FLY INTO SAT VERY OFTEN (UNLIKE DFW) AND WAS NOT FAMILIAR WITH THE PROCS. I ELECTED TO PERFORM THE DUTIES OF THE PF; AS I COULD SENSE THAT MY FO WAS FATIGUED. THE FO DOES NOT HAVE A GREAT DEAL OF EXPERIENCE IN LARGE ACFT AND THE IOE LEGS HE HAS BEEN FLYING HAD BEEN WEARING HIM DOWN. IN FACT; WE WERE ALL FATIGUED. IT WAS THE LAST DAY OF OUR WORK WK; THE LEG TO SAT WAS ADDED ON TO OUR FLT AT THE LAST MIN; AND WE WERE INTO THE 10TH TO 11TH HR OF DUTY TIME FOR THE DAY. WE WERE CLRED VIA THE MARCS 5 STAR. I GLANCED AT THE ARR AND SAW THE XING RESTR AT THE MARCS INTXN TO BE 13000 FT AND AT THE NEXT INTXN (I AM UNABLE TO REMEMBER THE NAME OF THE INTXN); WHICH IS 12 MI W OF THE MARCS INTXN; THE XING RESTR IS 10000 FT. I ASKED MY FO TO REQUEST A FUTURE DSCNT. AS HE WAS PREPARING TO ASK; CTR CLRED US DIRECT TO THE MARCS INTXN AND CLRED US TO DSND VIA THE ARR TO SAT. PASSING FL180; I REQUESTED THE DSCNT CHKLIST. AT THE TIME; BUG SPDS WERE NOT SET. NORMALLY THEY ARE SET PRIOR TO FL180. I SUSPECT FATIGUE WAS INVOLVED WITH THE FAILURE OF US AS A CREW TO NOT NOTICE THE BUG SPDS HAD NOT BEEN SET. WE AT THIS TIME SET OUR SPDS. THIS ACFT HAS AN OLD ATTITUDE INDICATOR WITH A SMALL KNOB AT THE 7 O'CLOCK POS ON THE INST THAT IS USED TO MOVE THE HORIZON BAR UP AND DOWN ON THE INST. THIS KNOB HAS NO FRICTION RESISTANCE TO TURNING -- IT ROTATES VERY EASILY. MOST OF THE ACFT DO NOT HAVE THIS TYPE OF INST AND THIS WAS THE FIRST TIME THE FO HAD FLOWN A DC8 WITH THIS TYPE OF INSTRUMENTATION. DURING THE SETTING OF HIS AIRSPD BUGS; I BELIEVE HE INADVERTENTLY NUDGED THE KNOB ON THE ATTITUDE INDICATOR; CAUSING THE HORIZON BAR TO MOVE MUCH FURTHER DOWN THAN MY ATTITUDE INDICATOR. THIS WAS NOT NOTICED BY THE FO; THE FE; NOR MYSELF. DURING THE SAME TIME OF THE DSCNT; THE RIDE BECAME QUITE BUMPY. I HAD HEARD CTR RPT SOME PIREPS AS 'SEVERE.' THE AUTOPLT DISCONNECTED ITSELF TWICE DURING THIS TIME. PASSING APPROX 15000 FT OR SO; THE FO NOTICED HIS ATTITUDE INDICATOR APPEARED DIFFERENT THAN MINE AND ALSO THE STANDBY ATTITUDE INDICATOR. HE CALLED IT TO MY ATTN. I CHKED IT AGAINST MY INST AND THE STANDBY ATTITUDE INDICATOR AND SUSPECTED A PENDING GYRO FAILURE. I LOOKED AT MY ATTITUDE INDICATOR AND NOTICED THE HORIZON BAR KNOB AND REALIZED THAT THE FO'S MAY HAVE BEEN MISSET. I TOLD THE FO TO RESET IT. HE DID NOT REALLY KNOW WHAT I WAS TALKING ABOUT. SO I THEN REACHED OVER TO HIS SIDE OF THE PANEL AND RESET HIS HORIZON BAR. DURING THIS STAGE OF DSCNT; I HAD FAILED TO KEEP TRACK OF OUR PROGRESS TO MARCS AND REMEMBERING THE LAST FIX TO CROSS AT 10000 FT; I CONTINUED ON DOWN TO 10000 FT. THE CTLR THEN ASKED US TO VERIFY THAT WE WERE CLRED VIA THE MARCS 5 ARR INTO SAT AND TO CROSS MARCS AT 13000 FT. IT WAS THEN I REALIZED THAT WE HAD CROSSED MARCS BELOW 13000 FT. WE LOOKED AT EACH OTHER AND REALIZED THAT WE ALL HAD MADE AN ERROR. THE CREW AND I DEBRIEFED ON THE GND AND WHILE WE WERE AWAITING A RIDE TO THE PAX TERMINAL; MY BEEPER GOES OFF WITH CREW SCHEDULING'S PHONE NUMBER. I CALLED AND WAS TOLD THAT MY FLEET MGR WANTED TO SPEAK TO ME AND A CONFERENCE CALL WAS BEING DIALED. THIS WAS DONE AND HE INFORMED ME THAT MR X OF THE FAA WANTED TO TALK TO ME. ABOUT 30 MINS LATER; I CALLED MR X. WE TALKED FOR ABOUT 10 MINS. MR X WAS CONCERNED THAT THERE WAS SOMETHING ON THE STAR CHART THAT WAS CONFUSING. I TOLD HIM THAT I HAD NOT HAD A CHANCE TO REVIEW THE CHART SINCE THE DEV; BUT WOULD LOOK AT IT THE NEXT TIME I FLEW AND CALL HIM IF I HAD ANY SUGGESTIONS. REFLECTING ON WHAT HAPPENED; I FEEL THAT FATIGUE; COMBINED WITH THE APPARENT EQUIP FAILURE AT A VERY INOPPORTUNE MOMENT CAUSED CONFUSION AND DISTR IN THE COCKPIT. COMBINE THIS WITH THE TURB AND THE LACK OF EXPERIENCE OF THE PNF MADE FOR A DANGEROUS ERROR TO BE MADE.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.

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