FLC OF A CPR DA50 HAS ALTDEV ON DSCNT.
Synopsis
FLC OF A CPR DA50 HAS ALTDEV ON DSCNT.
Narrative
THIS WAS A FAR 91 CPR FLT FROM EGE TO SFO. IT WAS THE SECOND FLT OF THE DAY FOR THIS CREW THAT HAD SPENT THE NIGHT IN DENVER. THE ACFT HAD A CREW OF 2 PLTS AND 1 FLT ATTENDANT. WE HAD 4 PAX ON BOARD. I WAS THE PIC AND WAS FLYING THE ACFT FROM THE L SEAT. ALL THE NAV; AUTOPLT; FMC; TCASII; AND RADIO COM SYS WERE OPERATING NORMALLY. THE WX WAS CLR AND WE HAD A TAILWIND; WHICH WAS UNUSUAL FOR OUR DIRECTION OF FLT (W) AND ALT (FL350). OUR ROUTING WAS CONFIRMED AS DIRECT TO OAK WITH A MODESTO 2 ARR TO SFO. THIS RTE IS VERY FAMILIAR TO ME; AS I HAVE FLOWN IT HUNDREDS OF TIMES OVER 9 YRS AS AN SFO BASED PLT. WE WERE FLYING AT OUR ASSIGNED ALT OF FL350. ABOUT 150 MI E OF OAK; ATC REQUESTED WE SLOW THE ACFT TO .82 MACH. THE SIC ACKNOWLEDGED AND I COMPLIED IMMEDIATELY. THIS WAS OUR FIRST INDICATION OF ATC SEQUENCING PROBS ALONG OUR RTE. ADDITIONAL SPD REDUCTIONS WERE REQUESTED TO 280 KTS; THEN 270 KTS; THEN AS WE WERE DECREASING THROUGH 265 KTS; ATC REQUESTED 260 KTS. LATER; ATC REQUESTED 250 KTS. EACH SPD REDUCTION WAS ACKNOWLEDGED BY THE SIC AND I IMMEDIATELY COMPLIED. AT ABOUT 50 MI EARLIER THAN NORMAL; ATC REQUESTED A DSCNT TO FL310 FOR TFC CONFLICT PROBS. THE SIC ACKNOWLEDGED AND HE RESET THE ALT PRESELECT TO FL310. DURING THE DSCNT; ATC BEGAN GIVING US NUMEROUS HDG CHANGES; FIRST N OF COURSE AND THEN S OF OUR W COURSE. I DISCONNECTED THE AUTOPLT AND BEGAN TO MAKE ALL THE NUMEROUS HDG CHANGES MANUALLY BECAUSE I FELT I COULD COMPLY WITH THE NUMEROUS ATC REQUESTS WITH MORE RAPID RESPONSE TIME AND WITH LESS DISCOMFORT TO THE PAX. AT THIS POINT IN OUR RTE; ATC NORMALLY CLRS OUR ACFT TO FL240. AS WE PASSED THROUGH FL320; THE ALT ALERT AURAL TONE SOUNDED AND THE SIC CALLED THE ALERT AND I RESPONDED. I CALLED FOR THE DSCNT CHKLIST AND THE SIC BEGAN OBTAINING THE ATIS; COMPUTING THE V REF SPD; SETTING THE PRESSURE CTLR; ETC. I WAS DSNDING AT A RATE OF ABOUT 1500 FPM. THE SIC CALLED MY ATTN TO THE LOWER THAN ASSIGNED ALT AND I IMMEDIATELY BEGAN AGGRESSIVE PITCH AND PWR CHANGES CONSISTENT WITH SAFE OPERATING PROCS. AFTER I BEGAN THE CORRECTION; ATC CALLED ABOUT OUR ALT WHICH THE SIC ACKNOWLEDGED. THE LOWEST ALT INDICATION I SAW WAS ABOUT FL297. THERE WERE NO WARNINGS ISSUED BY THE TCASII EITHER AS TA'S OR RA'S. THE FLT CONTINUED TO SFO WITHOUT INCIDENT. THE WX AT SFO ARPT WAS VFR AND WE FLEW THE USUAL VISUAL APCH TO RWY 28R. CHAIN OF EVENTS: IT STARTED WITH THE UNUSUAL TAILWIND AND HVY INBOUND AND OUTBOUND HIGH ALT TFC TO AND FROM THE SAN FRANCISCO BAY AREA ARPTS. THE PROB WAS COMPOUNDED BY THE NUMEROUS SPD AND HDG CHANGES REQUESTED BY ATC. THE ACFT MAY HAVE BEEN VECTORED OUTSIDE THE NORMAL AIRSPACE RESERVED FOR INBOUND ACFT. CONTRIBUTING FACTOR OCCURRED AS THE PIC DISCONNECTED THE AUTOPLT TO MORE RAPIDLY COMPLY WITH THOSE NUMEROUS REQUESTS. THERE WAS A LACK OF CREW COORD IN THE COCKPIT. CREW: THE CREW MUST EMPHASIZE CRM AND RETHINK THE PROCESS THAT LED TO THIS INCIDENT. PERHAPS ADDITIONAL VISUAL CUES SUCH AS HAND MOVEMENTS -- POINTING TO THE ALT PRESELECT; THE ALTIMETER; AND THE VERT SPD INDICATORS SHOULD BE INSTITUTED. ALL DISTRACTING FACTORS SHOULD BE PROHIBITED DURING A PHASE OF FLT SUCH AS DSCNT. THE PIC SHOULD NOTIFY THE SIC WHEN THE AUTOPLT IS DISCONNECTED TO ALERT THE CREW THAT A HIGHER LEVEL OF AWARENESS IS REQUIRED. THE CREW SHOULD VISIT ZOA TO GAIN A NEW AWARENESS OF THE MULTITUDE OF TFC FACTORS THAT A CTLR MUST HANDLE. THE CREW IS SCHEDULED TO ATTEND ROUTINE 6 MONTH RECURRENT TRAINING WITHIN 30 DAYS. THIS INCIDENT COULD BE DUPLICATED IN THE SIMULATOR TO COORDINATE NEW COCKPIT PROCS.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.