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appearing and then clearing. While trying to interpret
what was happening and determine what data was
accurate, we climbed through our assigned FL190.
[Center] called us and asked our altitude. We reported
FL228 where we had arrested the climb. We advised them
of our problem and asked for an immediate return to
ZZZ…. We were still unsure of the reliability of our
instruments and compared them with our standby
instruments until landing to ensure accuracy. We also
made approach control aware of our situation and had
them monitor our ground path and altitude readouts.
Failure messages were appearing and going away so
rapidly during the episode that we were unable to
determine what the main problem was. We had as many as
ten failure messages at a time appearing. Failure to level
at FL190 was caused by failure of the autoflight system
complicated by the multiple other failures. Lesson learnedfly
the airplane first.
A C-141 flight crew recommends that pilots should
prioritize their tasks, but always put one item at the top
of the list... fly the airplane.
Situation: We were flying a C-141 on a one-time ferry
flight with…numerous maintenance discrepancies…. We
had the terrain warning system circuit breaker pulled for
erroneous and continuous “Pull up” warnings. Since this
circuit breaker was pulled, most of our aural warnings in
the aircraft were inoperative, including the altitude
“beeps” of 1,000 feet and 300 feet below or above the preselected
altitude…. While we were passing 10,000 feet, in
the climb to 12,000 feet, we were trying to restore the #1
Display unit, as well as the Moving Map display on the
pilot’s side, when we received a “Traffic” aural advisory
from our TCASII. Our attention was diverted to the Multi-
Function Display unit which displays the traffic symbols.
We decreased the range on the unit, in order to better see
exactly where the traffic was in relation to our aircraft.
Then we noticed we had climbed through our assigned
altitude of 12,000 feet and were near 13,000 before we
started back down. Center called out traffic at our 10
o’clock position, while we were in the descent….
Recommendation: Remember that flying the airplane is
the first priority no matter what else is happening.
Military Attention
Meet the Staff
Captain Dave “Sherlock” Austin
joined the staff of the Aviation
Safety Reporting System in 2004
as an Aviation Safety Analyst.
After serving as a Naval Aviator,
Dave was an air carrier pilot for
28 years. Captain Austin has
accumulated more than 15,000
flight hours in a wide variety of
aircraft including the A-330, B-767, B-757, B-737, MD-80,
DC-9, P-3, and P2V.
From 1995 to 2000 Dave completed a Master’s Thesis
(with research at NASA Ames Research Center) on a
formal methodology for examining human actions in an
active complex machine system. He also provided
operational airline experience and consulted on various
NASA projects before joining the ASRS team.
A Monthly Safety Bulletin
from
The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
January 2006 Report Intake
Air Carrier / Air Taxi Pilots 2209
General Aviation Pilots 661
Controllers 76
Cabin/Mechanics/Military/Other 268
TOTAL 3214
Number 316 February 2006
ASRS Alerts Issued in January 2006
Subject of Alert No. of Alerts
Aircraft or aircraft equipment 7
Airport facility or procedure 5
ATC procedure or equipment 3
Chart or publication 1
Total 16
“Heads Up”
The Aviation Safety Reporting System receives
approximately 3,000 reports each month. The
subject matter of these reports runs the gamut from
predictable “regulars,” such as runway incursions
and altitude busts — to noteworthy new issues that
may generate specific ASRS actions to help the
industry resolve the issues.
From time to time we note an increase of reports
discussing these routine, but important tasks
or actions; they often become quite visible when
those performing them become less cautious in
performing them and unexpected operational errors
result.
This issue of CALLBACK will provide a “Heads Up”
regarding a few such recurring issues. Our hope is
that reading about them will refresh your memory,
and reduce the likelihood of an error.
A second type of “Heads Up” we’ll discuss in this
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