B757 FLC ERRONEOUSLY DSNDED BELOW 10000 FT WITHOUT PROPER CLRNC ON CIVET ARR TO LAX; CA.

Date: 1999-01 · Aircraft: B757 Undifferentiated or Other Model

Anomalies: deviation-altitude-overshoot

Synopsis

B757 FLC ERRONEOUSLY DSNDED BELOW 10000 FT WITHOUT PROPER CLRNC ON CIVET ARR TO LAX; CA.

Narrative

ACR XYZ SLC-LAX. OUR CLRNC WAS FOR CIVET 4 INTO LAX. WE HAD BEEN CLRED TO FL180 AND WE WERE PASSING THROUGH APPROX FL220 APCHING CIVET (APPROX 10-15 NM). RWY 25L WAS BRIEFED USING CIVET 4. LAX CALLS AND GIVES MITTS 1 TO RWY 24R BECAUSE OF TFC. THE AUTOPLT WAS ON AND THE PF WAS THE FO; WHO ELECTED TO PROGRAM THE AUTOPLT. THE STAR WAS PULLED OUT AND RWY 24R ILS APCH WAS ALSO PULLED OUT. THE CLRNC WAS MITTS 1 DIRECT SNRKL AT OR ABOVE 12000 FT. DSND VIA MITTS 1. THE FMS WAS PROGRAMMED FOR MITTS 1 BUT SNRKL WASN'T SHOWING. CAPT SUGGESTED CIVET TRANSITION WHICH WHEN SELECTED SHOWED SNRKL. ACFT DIRECT SNRKL. THERE HAD BEEN NUMEROUS AIRSPD CHANGES; IE; 300 KTS; 280 KTS; 250 KTS; AND AT SOME POINT THE ACFT HAD BEEN TAKEN OUT OF VNAV AND 250 KTS SET MANUALLY (250 KTS ALSO SET IN DSCNT PAGE); LNAV WAS ENGAGED; RWY 24R BRIEFED. I DON'T KNOW IF THE PNF SET 250 KTS MANUALLY OR I DID. I DON'T REMEMBER DOING IT; THINGS WERE HAPPENING FAST. APCHING MITTS (11000 B; 10000 A) IT APPEARED THAT THE ACFT WAS GOING TO DSND BELOW 10000 FT (NOT IN VNAV AND ALT SET FOR DENAY AT 8000 FT). ALT HOLD SELECTED; AT WHICH POINT I NOTED THAT THE ACFT WASN'T IN VNAV. ACFT DSNDED TO ABOUT 9600 FT BEFORE I CLBED BACK TOWARDS 10000 FT. AT MITTS; REINITIATED DSCNT FOR NORMAL APCH. ONCE I POINTED OUT WE HAD DSNDED BELOW 10000 FT; THE CAPT NOTED WE HADN'T DONE DSCNT OR APCH CHKLISTS (ALTHOUGH ALL ITEMS HAD BEEN COMPLETED EXCEPT ALTIMETER -- 9600 FT AT 29.92 VICE 30.17). CAUSAL FACTORS: 1) LAST MIN STAR CHANGE. 2) PF PROGRAMMED FMS INSTEAD OF PNF. 3) NUMEROUS AIRSPD CHANGES. 4) ACFT IN MANUAL SPD INSTEAD OF VNAV. 5) POOR CREW COORD. 6) PF DIDN'T CALL FOR CHKLISTS; DIDN'T BACK UP. 7) CONFUSION AND TIME CRUNCH. NOTE: LAX IS STARTING TO DO THIS A LOT. WE OBVIOUSLY COULD HAVE HANDLED IT BETTER.

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