PPRuNe Forums - View Single Post - Singapore AAIB Report - B777-300ER Loss of Separation Incident (Houston)
Old 27th Nov 2015, 03:17
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JammedStab
 
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The obvious thing to say of course is, read everything on the chart. Easy to say but the question is, why did they not?

You can see what happened in this quote from the report which shows how easy you can miss something with EFB charts.

"According to the PF, after reading the first line in the ‘Routing’
section of the text box at the bottom left corner of the chart, he
scrolled to the pictorial portion at the right of the chart and zoomed
in to check on the track and distances. He ended his briefing on the
chart without returning to the ‘Routing’ section of the chart, which
contained an altitude restriction of 4,000ft"

So with EFB charts which may be a bit difficult to read, you can easily find yourself zoomed in to one area, then scrolling to another area. Then it turns out you missed something. So, it is probably best to read everything in the one area such as the initial climb portion and the routing section, then move to the pictorial/notes/climb gradient/etc areas. And at the end, zoom out and look over the chart to see if you can find anything you missed.

It was also strange that the report seemed to agree with the statement that the RA "Climb, Crossing, Climb"(I think this may no longer exist) had not been experienced before and was therefore the reason for not climbing. But the RA does say Climb so why descend. And pretty much everyone else has never had a "climb, crossing, climb" so would we all be expected to also not do it properly and not climb when it says climb. Plus you typically follow the commands of on the PFD in this situation so why put the vertical speed in the red even if you misinterpret what the ADI is saying to do. I would suspect that they likely had another reason for not climbing such as not hearing the RA as they were so focused on the ATC instruction. Audio warnings can be tuned out in times of stress.

Last edited by JammedStab; 27th Nov 2015 at 16:06.
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