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|
Attributes | |
ACN | 114089 |
Time | |
Date | 198906 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | msl bound lower : 4000 msl bound upper : 5000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : oak |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Small Transport, Low Wing, 2 Recip Eng |
Flight Phase | cruise other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 13000 flight time type : 700 |
ASRS Report | 114089 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 65 flight time total : 5000 flight time type : 65 |
ASRS Report | 114094 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude altitude deviation : overshoot conflict : airborne less severe non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : investigated |
Miss Distance | horizontal : 6000 vertical : 250 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
Taking off from sfo on runway 01L 'porte seven' departure, avenal transition, first officer flying. We intercepted the sfo 350 degree right. At approximately 2000' we were cleared to turn left to a heading of 170 degree and maintain 4000' and advised there was traffic (small transport) at 11 O'clock. The first officer started a turn to 170 degree. I saw an aircraft at about 10 O'clock but it was too big for an small transport. I kept looking for small transport. I did not change original altitude of 230 in the altitude alert window immediately because I was looking outside for traffic and to do south would have required me to redirect my attention to inside the cockpit while in a left turn in the vicinity of traffic. I thought the first officer heard the clearance since I repeated it to ATC and he started turn to 170 degree. He later told me he had not heard the maintain 4000' portion. Approaching 5000' still in left turn, I saw the small transport. At the same time departure control told us we were at 5000' and had been told to maintain 4000'. We started a descent immediately to 4000' and stopped our turn so as to pass behind and below the small transport. Departure control then advised us to continue our climb and told the small transport to descend to 4000'. I did not think we were seriously close to the small transport. I flew the same trip the next 4 days and noticed the initial clearance is always to maintain FL230. Frequently after takeoff we were advised to maintain a lower altitude due to traffic. I feel they should give a lower altitude in the initial clearance, then clear you to FL230 when applicable. In reviewing causes for deviation, the PNF should have set the revised altitude in the 'altitude alert window' immediately instead of looking for traffic and assuming pilot flying would level off at revised altitude. There would then have been an altitude alert signal to remind both pilots. Supplemental information from acn 114094: I'm relatively new to piloting after serving more than 10 yrs as a wide body F/east. I believe this has some bearing on what took place. At the time of the incident I was a 22 day old first officer. My usual routine after block arrival is to set the navigation receiver to the next radial and frequency to be used for departure. Thistime I did not do this. Departure climb was into a low overcast layer of about 1000-1500' thick. We broke out about 2500 to 3000'. I remained on instruments after this for a short time as we were directed to make a left turn to 170 degree. Our original altitude was to FL230, however soon after departure we were told to level at 4000' due to traffic. During the climb I was confused as to why I couldn't intercept the radial when I noticed I had the wrong frequency set into my navigation receiver. About this time departure control called and said we were supposed to be at 4000' and we were not out of 5000. I remember seeing 5200 on the altimeter as I pulled the power back and nose over. After starting down I looked up and saw our traffic about 1000 above and slightly ahead of us. I don't know if the other aircraft took evasive action. In my confusion of trying to sort out the radial I didn't hear ATC change our altitude or call our attention to traffic. I did remember hearing the heading assignment when the captain repeated it as a backup. I don't recall him repeating the altitude. He did not set 4000 in the altitude alert right away because he was more concerned about the traffic and didn't want to divert his attention for the 8-10 seconds that it takes to crank the altitude alert from 23,000 to 4000. My attention and concentration was almost totally directed to flying instruments (new copilot) and the navigation problem. Had I not been so distracted I probably would have heard and remembered the new altitude assignment. I also feel that initially ATC should not assign a high altitude and then change to a much lower altitude so soon after departure. It would be better to assign a lower altitude first if necessary. Some towers do this with takeoff clearance. Also according to what the departure control supervisor told me, we were out of 5000 at XA32:18 uct. Traffic was issued to us at XA32:50. So we were out of 5000 28 seconds after getting traffic issued to us. I'm not sure if 5000 was issued at that time, but if it was, it was given approximately 8 seconds before reaching 3000'. Our rate of climb was about 3000 FPM so to climb 1000 would take about 20 seconds, leaving 8 seconds to level off from a 3000 FPM climb. It can be done, but it is at the limit. Actually I think we were given 5000 earlier than that. I have resolved to keep a sharper ear open when it's my turn to fy and double-check my navigation receiver to the proper frequency prior to takeoff. Also I think it is a good operating practice to repeat the important things (heading, altitudes, and airspeed) to the pilot flying, especially when things are taking place fast.
Original NASA ASRS Text
Title: ALT DEVIATION ON SID. LESS THAN STANDARD SEPARATION OCCURRED WITH INBOUND ACFT. AVOIDANCE MANEUVER NECESSARY.
Narrative: TAKING OFF FROM SFO ON RWY 01L 'PORTE SEVEN' DEP, AVENAL TRANSITION, F/O FLYING. WE INTERCEPTED THE SFO 350 DEG R. AT APPROX 2000' WE WERE CLRED TO TURN LEFT TO A HDG OF 170 DEG AND MAINTAIN 4000' AND ADVISED THERE WAS TFC (SMT) AT 11 O'CLOCK. THE F/O STARTED A TURN TO 170 DEG. I SAW AN ACFT AT ABOUT 10 O'CLOCK BUT IT WAS TOO BIG FOR AN SMT. I KEPT LOOKING FOR SMT. I DID NOT CHANGE ORIGINAL ALT OF 230 IN THE ALT ALERT WINDOW IMMEDIATELY BECAUSE I WAS LOOKING OUTSIDE FOR TFC AND TO DO S WOULD HAVE REQUIRED ME TO REDIRECT MY ATTN TO INSIDE THE COCKPIT WHILE IN A LEFT TURN IN THE VICINITY OF TFC. I THOUGHT THE F/O HEARD THE CLRNC SINCE I REPEATED IT TO ATC AND HE STARTED TURN TO 170 DEG. HE LATER TOLD ME HE HAD NOT HEARD THE MAINTAIN 4000' PORTION. APCHING 5000' STILL IN LEFT TURN, I SAW THE SMT. AT THE SAME TIME DEP CTL TOLD US WE WERE AT 5000' AND HAD BEEN TOLD TO MAINTAIN 4000'. WE STARTED A DSCNT IMMEDIATELY TO 4000' AND STOPPED OUR TURN SO AS TO PASS BEHIND AND BELOW THE SMT. DEP CTL THEN ADVISED US TO CONTINUE OUR CLIMB AND TOLD THE SMT TO DSND TO 4000'. I DID NOT THINK WE WERE SERIOUSLY CLOSE TO THE SMT. I FLEW THE SAME TRIP THE NEXT 4 DAYS AND NOTICED THE INITIAL CLRNC IS ALWAYS TO MAINTAIN FL230. FREQUENTLY AFTER TKOF WE WERE ADVISED TO MAINTAIN A LOWER ALT DUE TO TFC. I FEEL THEY SHOULD GIVE A LOWER ALT IN THE INITIAL CLRNC, THEN CLEAR YOU TO FL230 WHEN APPLICABLE. IN REVIEWING CAUSES FOR DEVIATION, THE PNF SHOULD HAVE SET THE REVISED ALT IN THE 'ALT ALERT WINDOW' IMMEDIATELY INSTEAD OF LOOKING FOR TFC AND ASSUMING PLT FLYING WOULD LEVEL OFF AT REVISED ALT. THERE WOULD THEN HAVE BEEN AN ALT ALERT SIGNAL TO REMIND BOTH PLTS. SUPPLEMENTAL INFORMATION FROM ACN 114094: I'M RELATIVELY NEW TO PILOTING AFTER SERVING MORE THAN 10 YRS AS A WIDE BODY F/E. I BELIEVE THIS HAS SOME BEARING ON WHAT TOOK PLACE. AT THE TIME OF THE INCIDENT I WAS A 22 DAY OLD F/O. MY USUAL ROUTINE AFTER BLOCK ARR IS TO SET THE NAV RECEIVER TO THE NEXT RADIAL AND FREQ TO BE USED FOR DEP. THISTIME I DID NOT DO THIS. DEP CLIMB WAS INTO A LOW OVCST LAYER OF ABOUT 1000-1500' THICK. WE BROKE OUT ABOUT 2500 TO 3000'. I REMAINED ON INSTRUMENTS AFTER THIS FOR A SHORT TIME AS WE WERE DIRECTED TO MAKE A LEFT TURN TO 170 DEG. OUR ORIGINAL ALT WAS TO FL230, HOWEVER SOON AFTER DEP WE WERE TOLD TO LEVEL AT 4000' DUE TO TFC. DURING THE CLIMB I WAS CONFUSED AS TO WHY I COULDN'T INTERCEPT THE RADIAL WHEN I NOTICED I HAD THE WRONG FREQ SET INTO MY NAV RECEIVER. ABOUT THIS TIME DEP CTL CALLED AND SAID WE WERE SUPPOSED TO BE AT 4000' AND WE WERE NOT OUT OF 5000. I REMEMBER SEEING 5200 ON THE ALTIMETER AS I PULLED THE POWER BACK AND NOSE OVER. AFTER STARTING DOWN I LOOKED UP AND SAW OUR TFC ABOUT 1000 ABOVE AND SLIGHTLY AHEAD OF US. I DON'T KNOW IF THE OTHER ACFT TOOK EVASIVE ACTION. IN MY CONFUSION OF TRYING TO SORT OUT THE RADIAL I DIDN'T HEAR ATC CHANGE OUR ALT OR CALL OUR ATTN TO TFC. I DID REMEMBER HEARING THE HDG ASSIGNMENT WHEN THE CAPT REPEATED IT AS A BACKUP. I DON'T RECALL HIM REPEATING THE ALT. HE DID NOT SET 4000 IN THE ALT ALERT RIGHT AWAY BECAUSE HE WAS MORE CONCERNED ABOUT THE TFC AND DIDN'T WANT TO DIVERT HIS ATTN FOR THE 8-10 SECS THAT IT TAKES TO CRANK THE ALT ALERT FROM 23,000 TO 4000. MY ATTN AND CONCENTRATION WAS ALMOST TOTALLY DIRECTED TO FLYING INSTRUMENTS (NEW COPLT) AND THE NAV PROBLEM. HAD I NOT BEEN SO DISTRACTED I PROBABLY WOULD HAVE HEARD AND REMEMBERED THE NEW ALT ASSIGNMENT. I ALSO FEEL THAT INITIALLY ATC SHOULD NOT ASSIGN A HIGH ALT AND THEN CHANGE TO A MUCH LOWER ALT SO SOON AFTER DEP. IT WOULD BE BETTER TO ASSIGN A LOWER ALT FIRST IF NECESSARY. SOME TWRS DO THIS WITH TKOF CLRNC. ALSO ACCORDING TO WHAT THE DEP CTL SUPVR TOLD ME, WE WERE OUT OF 5000 AT XA32:18 UCT. TFC WAS ISSUED TO US AT XA32:50. SO WE WERE OUT OF 5000 28 SECS AFTER GETTING TFC ISSUED TO US. I'M NOT SURE IF 5000 WAS ISSUED AT THAT TIME, BUT IF IT WAS, IT WAS GIVEN APPROX 8 SECS BEFORE REACHING 3000'. OUR RATE OF CLIMB WAS ABOUT 3000 FPM SO TO CLIMB 1000 WOULD TAKE ABOUT 20 SECS, LEAVING 8 SECS TO LEVEL OFF FROM A 3000 FPM CLIMB. IT CAN BE DONE, BUT IT IS AT THE LIMIT. ACTUALLY I THINK WE WERE GIVEN 5000 EARLIER THAN THAT. I HAVE RESOLVED TO KEEP A SHARPER EAR OPEN WHEN IT'S MY TURN TO FY AND DOUBLE-CHECK MY NAV RECEIVER TO THE PROPER FREQ PRIOR TO TKOF. ALSO I THINK IT IS A GOOD OPERATING PRACTICE TO REPEAT THE IMPORTANT THINGS (HDG, ALTS, AND AIRSPEED) TO THE PLT FLYING, ESPECIALLY WHEN THINGS ARE TAKING PLACE FAST.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.