B747-400 CREW DID NOT COMPLY WITH AN ATC ISSUED XING RESTR IN ZOB CLASS A.

Date: 2004-09 · Aircraft: B747-400 · Phase: descent

Anomalies: deviation-altitude-crossing-restriction-not-met|deviation-altitude-undershoot|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-far|deviation-discrepancy-procedural-published-material-policy|flight-deck-cabin-aircraft-event-illness-injury|flight-deck-cabin-aircraft-event-passenger-misconduct

Synopsis

B747-400 CREW DID NOT COMPLY WITH AN ATC ISSUED XING RESTR IN ZOB CLASS A.

Narrative

I WAS PF. WE WERE INBOUND DTW; FL330; FROM ZZZZ;FO. WE WERE GIVEN CLRNC TO CROSS 65 NM NW OF POLAR INTXN AT FL230. I SET 23000 FT IN ALT WINDOW. CAPT WORKED FMC. WE WERE DIRECT POLAR WITH SEVERAL ABEAM FIXES PRECEDING POLAR ON LEGS PAGE. ACFT IN VNAV PATH. CAPT CREATED POLAR/-65/230 FIX AND VERY SHORTLY AFTER ACFT STARTED DSCNT. WHEN CTR CALLED TO CONFIRM OUR CLRNC; WE WERE PASSING FL260 APCHING THE 65 NM FIX. WE WERE WELL HIGH OF OUR XING RESTR. 1) DISTRS. DURING AND AFTER THE DIRECT CLRNC; WE WERE EXTREMELY BUSY WITH FLT ATTENDANT CALLS (FROM PAX PROBS; MEDICAL AND BEHAVIORAL; CONNECTING GATE/HURRICANE UPDATES; COMMUTING INFO; ETC); OFF-DUTY CREW RETURNING TO COCKPIT; SEVERAL RADIO FREQ CHANGES; APCH BRIEFINGS; ETC. 2) FATIGUE. WE WERE FULLY AUGMENTED CREW; BUT I HAD VERY POOR/LITTLE SLEEP DURING MY FIRST HALF BREAK; AS WELL AS THE NIGHT BEFORE; WITH THE EFFECT OF TIME ZONE CHANGES/CIRCADIAN RHYTHM; ETC. 3) AUTOMATION COMPLACENCY. THE FMC DOES SUCH A PERFECT JOB OF FLYING THE ACFT; USUALLY SET IT AND FORGET IT IS A NON FACTOR. 4) SUMMARY. AS ALL PLTS DO; I NORMALLY CHK AND DOUBLE CHK THE AUTOMATION. IN THIS CASE; MANUALLY COMPUTE THE DSCNT RATE/SPDS/PROGRESS; ETC; TO ENSURE MEETING THE XING RESTR. BUT TODAY; DISTRS AND TIREDNESS EQUALED POOR PRIORITIZING AND FAILURE TO CHK. I HAVE NO RECOMMENDATION EXCEPT TO REEMPHASIZE THE CRITICAL NEED TO SET CORRECT PRIORITIES; TO OVERCOME THE DISTRS AND TIREDNESS AND 'AUTOMATION COMPLACENCY;' TO FLY THE ACFT FIRST. SUPPLEMENTAL INFO FROM ACN 630901: AT TOP OF DSCNT THE ACFT STARTED THE DSCNT IN VNAV PATH. SOMEWHERE IN THE DSCNT TO FL230 THE PITCH MODE CHANGED TO VNAV SPD. WE FAILED TO RECOGNIZE THE PITCH MODE CHANGE AND ALSO FAILED TO RECOGNIZE THAT WE WOULD BE HIGH AT THE FIX. WE DID NOT PROPERLY SEPARATE PF DUTIES FROM PNF DUTIES OR PROPERLY PRIORITIZE TASKS BECAUSE OF DISTRS DURING THAT STAGE OF THE DSCNT. DISTRS: THERE WAS A LOT OF CONVERSATION BTWN THE CABIN AND COCKPIT. THE ENTIRE CREW WAS CATCHING UP ON DUTIES DELAYED BECAUSE OF PROBS EARLIER WITH A SICK PAX; A VERBALLY ABUSIVE PAX AND 2 OTHER MINOR INFLT PAX INCIDENTS. ALSO; WE WERE CHKING FLTS S BECAUSE HURRICANE HAD JUST HIT THE COAST. ALSO; WE LET THE OFF DUTY CREW BACK IN THE COCKPIT AT THAT TIME.

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