Textual WB-Graph
______ Project: Cali08.final
________ Date: Nov 7, 1997
________ User: Loer, K.
________ Terminal: draupadi.rvs
WHY BECAUSE DESCRIPTION
[1] AC impacts mountain
/\ <-.1> GPWS manoeuvre failed: since [1.1.1]
/\ <[-.2]> AC in mountainous terrain: since [1.2.1.2]
<1.1> /\ [-.1] GPWS manoeuvre initiated
/\ <-.2> AC did not exhibit optimal climb performance
/\ [-.3] AC very close to mountains @ [1.1.1]
[1.1.1] [-.1] GPWS warning sounds
[1.1.1.1] [-.1] AC dangerously close to terrain
[1.1.1.1.1] /\ [1.2.1.1]
/\ [1.2.1.3]
/\ <1.2.2.2>
<1.1.2> /\ <-.1> AC speedbrakes are extended: since [1.2.2.1.2]
/\ <-.2> AC performs non-optimal pitch manoeuvre
<1.1.2.1> /\ <-.1> CRW didn't retract speedbrakes according to procedure
(Action failure)
/\ [1.2.2.2.1]
<1.1.2.1.1> <-.1> CRW unaware of extended speedbrakes (Awareness failure)
<1.1.2.1.1.1> <-.1> CD displays speedbrakes-extended
<1.1.2.2> <-.1> PF doesn't hold optimal steady pitch attitude
(Action failure)
<1.1.3> /\ <1.2.1>
/\ <1.2.2>
<1.2> /\ <-.1> AC on wrong course/position (2D-planar): since [1.2.1.3.1.1]
/\ <-.2> AC flying too low for cleared airspace (3rdD): since [1.2.1.3.1.1]
<1.2.1> /\ [-.1] CRW turned to "inbound heading" at [1.2.1.3]
(Decision Failure:
Reasoning Failure)
/\ <-.2> CRW without situational awareness: since [1.2.1.3.1.1]
(Perception Failure)
/\ [-.3] AC arrived at (false) Position B: end of left turn
<1.2.1.2> /\ <-.1> CRW unfamiliar with ROZO One Arrival and Rwy 19 Approach
/\ <-.2> CRW high workload
/\ <-.3> CRW used procedural shortcuts
/\ [-.4] CRW request for confirmation of false clearance
twice confirmed by ATC
/\ [-.5] FMC erases intermediate waypoints @ [1.2.1.3.1.1]
<1.2.1.2.2> /\ <-.1> CRW must expedite arrival
/\ <-.2> lack of external visual reference
/\ <1.2.1.2.1>
<1.2.1.2.2.1> /\ <-.1> lack of time for executing arrival procedure
/\ [1.2.2.1.1]
<1.2.1.2.2.2> /\ <-.1> arrival takes place at night
/\ <-.2> few lighted areas on ground
[1.2.1.2.4] [-.1] ATC misuse of Aviation English
[1.2.1.2.4.1] /\ [-.1] discourse under cultural dependencies
/\ <-.2> ATC lack of fluency in English
/\ <-.3> ATC lack of knowledge of AC position
<1.2.1.2.4.1.2> <-.1> Colombian ATC Use-of-English
training/certification
<1.2.1.2.4.1.3> <-.1> no ATC radar coverage
[1.2.1.2.5] /\ <-.1> FMC design
/\ [1.2.1.3.1.1]
[1.2.1.3] /\ <[-.1]> AC left turn from true course for 90 seconds:
since [1.2.1.3.1.1]
/\ <-.2> CRW didn't notice left turn:
since [1.2.1.3.1.1]; until [1.2.1.3]
<[1.2.1.3.1]> /\ [-.1] PNF gives 'R' to FMC
/\ <-.2> FMC-database uses `R' to denote ROMEO
/\ <-.3> CRW didn't realize <1.2.1.3.1.2>: since [1.2.1.3.1.1]
(Perception Failure)
/\ <-.4> PNF didn't correctly verify FMS-entry: since [1.2.1.3.1.1]
(Action Failure)
[1.2.1.3.1.1] /\ <-.1> CRW believes 'R' denotes 'ROZO' in FMC
(Awareness Failure)
/\ [-.2] CRW decides to fly direct 'ROZO'
<1.2.1.3.1.1.1> <-.1> ID `R' and FREQ for ROZO on the approach plate correspond
with an FMC database entry
<-.2> ID/FREQ combination usually suffice to identify
uniquely an NDB within range
<1.2.1.3.1.1.1.1> <1.2.1.3.1.2.1> ARINC 424 Specification
<1.2.1.3.1.1.2> <1.2.1.2.1> CRW unfamiliar with ROZO One Arrival
and Rwy 19 Approach
<1.2.1.3.1.2> /\ <-.1> ARINC 424 Specification
/\ <-.2> Jeppesen FMC-database design
<1.2.1.3.1.3> /\ <-.1> FMC-displayed ID and FREQ valid for ROZO
/\ <-.2> CRW didn't perceive FMC-displayed Lat/Long
(Awareness Failure)
<1.2.1.3.1.3.1> <-.1> ROZO and ROMEO have same ID `R' and FREQ
<1.2.1.3.1.3.1.1> <-.1> Colombian government decision
<1.2.1.3.1.3.2> /\ <-.1> FMC display figures small
/\ <-.2> CRW not trained to check Lat/Long
/\ <1.2.1.2.2>
<1.2.1.3.1.4> /\ <1.2.1.3.1.3.1>
/\ <1.2.1.3.1.3.2>
<1.2.2> /\ [-.1] AC starts expedited descent from FL230
/\ <-.2> AC expedited-descent continuous: until [1.1.1]
[1.2.2.1] [-.1] CRW decision to accept Rwy 19 Approach
<1.2.2.2> /\ [-.1] CRW extends speedbrakes
/\ <-.2> CRW failed to arrest descent: until [1.1.1]
(Action Failure)
<1.2.2.2.2> <1.2.1.2> CRW without situational awareness: since [1.2.1.3.1.1]
Glossary:
AC Aircraft
ARINC ARINC, Inc.
ATC Air Traffic Control
CD Cockpit Display
Course Two-dimensional straight-line ground track
CRW Crew
FLxyz Flight Level xyz = Altitude at which altimeter reads
xyz00ft @ barometric setting 29.92"=1013hPa
FMC Flight Management Computer
FREQ (Navaid) radio Frequency
GPWS Ground Proximity Warning System
Heading Magnetic compass direction along which course is flown
ID (Navaid) Identifier (sequence of symbols)
Jeppesen Jeppesen-Sanderson, Inc.
Lat/Long Latitude and Longitude Values
Navaid Navigation Aid (radio beacon)
NDB Non-Directional Beacon (a navaid)
PF Pilot Flying
PNF Pilot Not Flying
ROMEO NDB near Bogota
ROZO NDB near Cali
Rwy xy Runway with heading xy0 degrees magnetic (to nearest 10 degrees)