B737-300 CREW DID NOT FOLLOW PROPER FMC PROGRAMMING PROTOCOL OR COMPANY SOP.

2001-12 · NASA ASRS report 532260

Date: 2001-12 · Aircraft: B737-300 · Phase: descent

Anomalies: deviation-altitude-crossing-restriction-not-met|deviation-discrepancy-procedural-published-material-policy|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-far|inflight-event-encounter-weather-turbulence|other-fms-programming-protocol-not-followed

Synopsis

B737-300 CREW DID NOT FOLLOW PROPER FMC PROGRAMMING PROTOCOL OR COMPANY SOP.

Narrative

ALTDEV. WE FLEW FROM ZZZ TO DAL. OPS NORMAL UNTIL STARTING DSCNT. CTR WAS JUST SLIGHTLY LATE BEGINNING OUR DSCNT FOR THE DUMPY 2 ARR TO MEET ORVIL AT 9000 FT. ONCE DSCNT WAS STARTED; CORRECTED TO THE PROPER PROFILE. HE THEN ADVISED ME OF A RWY CHANGE FROM RWY 31 TO RWY 13 AT DAL. WHEN I WENT TO PUT THIS IN THE FMC INSTEAD OF PUSHING DEP/ARR THEN R2; PUSHED LEGS THEN R2. THIS WROTE THE ORVIL RESTR OF 240 DEGS 9000 FT TO THE SCRATCH PAD. THIS CONFUSED ME SLIGHTLY; BUT I ERASED THE PAD AND ENTERED RWY 13 ILS AT DAL. WHEN I RETURNED TO THE DSCNT PAGE; IT SHOWED DSCNT PROFILE. I WENT BACK TO THE LEGS PAGE TO CHK IT. AT THIS POINT I CHANGED THE PAGE FROM ORVIL AT 9000 FT TO DUMPY AT 9000 FT. THIS WAS AN ERROR; BUT I DID NOT CATCH IT. RETURNING TO THE DSCNT PAGE; IT SHOWED US BACK BELOW PROFILE; SO I ASSUMED WE WERE OK. DURING ALL THIS; ATC GAVE US A RPT OF MODERATE TURB FROM FL190 TO FL180. I WAS OCCUPIED WITH THE FASTEN SEATBELT SIGN ALONG WITH SEATING AND THE GETTING THE FLT ATTENDANTS GET BACK UP. (NOTHING MORE THAN LIGHT WAS ENCOUNTERED.) AT ABOUT 15500 FT; ATC ASKED US IF WE WOULD BE 'ANYWHERE CLOSE' TO MAKING ORVIL AT 9000 FT. THE FO SAID WE WOULD TRY. WE WERE ONLY 8-9 MI AWAY; SO I INFORMED ZZZ CTR WE WOULD NEED A VECTOR. WE WERE VECTORED 350 DEG HDG TO JOIN CVE 298 DEG RADIAL AND HANDED OVER TO APCH. WE DSNDED AS QUICKLY AS POSSIBLE TO 9000 FT; BUT WERE INSIDE YEAGER AND ORVIL ON REACHING 9000 FT. I HAD GOTTEN 7 1/2 HRS SLEEP; BUT FELT TIRED. WE HAD A 2 HR GND TIME IN ZZZ1; WHICH DIDN'T HELP. I WAS SURPRISED BY THIS AS I FELT WE WERE DOING FINE; BUT NEITHER THE FO NOR MYSELF CAUGHT THE ERROR. NO TFC CONFLICT OCCURRED. SUPPLEMENTAL INFO FROM ACN 532264: ON-TIME DEP; PREFLT NORMAL. PUT ORVIL AT 9000 FT IN FMC WHEN PROGRAMMING. EXPECTING STANDARD ARR INTO DAL. TAXI; TKOF; DEP NORMAL. AFTER LEVELOFF; CAPT TALKED TO PAX ABOUT A REMINDER OF SEATBELTS. ATC HAD ADVISED US OF MODERATE TURB 17000 FT TO FL190 ON DSCNT. WE WERE CRUISING AT FL350. SHORTLY AFTER HE WENT OFF; WE WERE GIVEN PLT'S DISCRETION TO FL240. WHEN HE CAME BACK UP ON COURSE; I TOLD HIM OF NEW CLRNC PLT'S DISCRETION FL240 AND POINTED TO FMC SHOWING WE WERE APCHING DSCNT POINT. WE WERE CLRED TO CROSS AT ORVIL AT 9000 FT. I DIDN'T MAKE THE CONNECTION ABOUT THE FMC ERROR AT THE TIME. WE HAD PLANNED ON RWY 31L (DISPATCH SHOWED LNDG RWY 3L). WHEN I HEARD THIS; I MADE A COMMENT WHEREUPON HE WENT TO FMC. I WASN'T WATCHING WHAT HE WAS DOING; BUT I FIGURED IT WAS REPROGRAMMING RWY TO RWY 13R. I CAME BACK ON COM. I HAD THE FULL ATIS. HE INFORMED ME THE 9000 FT RESTR HAD BEEN ENTERED WRONG AND THAT THE RESTR WAS AT DUMPY NOT ORVIL. IT DIDN'T REGISTER WITH ME THAT I HAD PROGRAMMED IT CORRECTLY AND THAT THE CAPT WAS WRONG. AFTER CHANGING THE FMC TO REFLECT DUMPY AT 9000 FT; WE WERE IMMEDIATELY LOW ON PROFILE. WE SLOWED THE DSCNT RATE. THE CAPT THEN WENT OFF RADIO TO TELL THE FLT ATTENDANTS TO SIT DOWN; SINCE WE WERE APCHING THE 17000 FT TO FL190 ALT BACK WHERE THE MODERATE TURB. WE PASSED THIS ALT AND I CONTINUED TO MONITOR THIS DSCNT; BUT NEVER RECONFIRMED THE NEW ALT RESTR THE CAPT CHANGED. I REMEMBER THINKING 'HOW COULD I MAKE SUCH A MISTAKE WHEN I FLY THIS RECOVERY SO OFTEN?' I JUST ASSUMED I WAS WRONG AND HE WAS RIGHT. APCHING ORVIL; ATC ASKED US IF WE WERE GOING TO MAKE THE RESTR. THIS WAS MY FIRST CLUE WE WERE NOT FLYING TO THE R ALT. THE CAPT COVERED MY INITIAL CALL BY SAYING WE WEREN'T GOING TO MAKE IT AND WE WERE GIVEN A VECTOR FOR DSCNT AND LEVELING AWAY FROM ORVIL. WE MADE THE DSCNT AND GOT TURNED BACK TO DUMPY. THE REST OF THE APCH AND DSCNT AND LOADING WERE NORMAL.

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

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