July 30, 2018 | Susan Napier-Sewell

Monday Accidents & Lessons Learned: Zooming to “Too Low Terrain”

When the Electronic Flight Bag (EFB) platform—frequently a tablet device—was introduced as a human-machine interface into the aviation industry and the cockpit, the platform proved to  facilitate improvements for both pilots and the aviation community, but the human-machine interface has encountered operational threats in the early years of EFB utilization.

NASA’s Aviation Safety Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. One routine problem occurs when a pilot “zooms,” or expands the screen to enlarge a detail, and unknowingly “slides” important information off the screen, making it no longer visible. A second type of problem manifests itself in difficulty operating the EFB in specific flight or lighting conditions. Yet a third wrinkle relates to EFB operation in a particular flight phase.

Let’s look at what happened in an A319 when “zoom” went awry:

Prior to departure, an A319 crew had to manage multiple distractions. An oversight, a technique, and a subtle EFB characteristic all subsequently combined to produce a unrecognized controlled flight toward terrain.

“We received clearance from Billings Ground, ‘Cleared … via the Billings 4 Departure, climb via the SID.’ During takeoff on Runway 10L from Billings, we entered IMC. The Pilot Flying (PF) leveled off at approximately 4,600 feet MSL, heading 098 [degrees]. We received clearance for a turn to the southeast … to join J136. We initiated the turn and then requested a climb from ATC. ATC cleared us up to 15,000 feet. As I was inputting the altitude, we received the GPWS alert, ‘TOO LOW TERRAIN.’ Immediately, the PF went to Take Off/Go Around (TO/GA) Thrust and pitched the nose up. The Pilot Monitoring (PM) confirmed TO/GA Thrust and hit the Speed Brake handle … to ensure the Speed Brakes were stowed. Passing 7,000 feet MSL, the PM announced that the Minimum Sector Altitude (MSA) was 6,500 feet within 10 nautical miles of the Billings VOR. The PF reduced the pitch, then the power, and we began an open climb up to 15,000 feet MSL. The rest of the flight was uneventful.

“On the inbound leg [to Billings], the aircraft had experienced three APU auto shutdowns. This drove the Captain to start working with Maintenance Control. During the turn, after completion of the walkaround, I started referencing multiple checklists … to prepare for the non-normal, first deicing of the year. I then started looking at the standard items. It was during this time that I looked at the BILLINGS 4 Departure, [pages] 10-3 and 10-3-1. There are no altitudes on … page [10-3], so I referenced [page] 10-3-1. On [page] 10-3-1 for the BILLINGS 4 Departure at the bottom, I saw RWY 10L, so I zoomed in to read this line. When I did the zoom, it cut off the bottom of the page, which is the ROUTING. Here it clearly states, ‘Maintain 15,000 or assigned lower.’ I never saw this line. When we briefed prior to push, the departure was briefed as, ‘Heading 098, climb to 4,600 feet MSL’; so neither the PF nor the PM saw the number 15,000 feet MSL. The 45-minute turn was busy with multiple nonstandard events. The weather was not great. However, that is no excuse for missing the 15,000-foot altitude on the SID.”

The award-winning publication and monthly safety newsletter, CALLBACK, from NASA’s Aviation Safety Reporting System, shares reports, such as the one above, that reveal current issues, incidents, and episodes.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to apprehend, find, and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

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