37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1197025 |
Time | |
Date | 201408 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | ATL.Airport |
State Reference | GA |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 125 |
Flight Phase | Climb |
Route In Use | SID THRSR 7 |
Flight Plan | IFR |
Person 1 | |
Function | First Officer Pilot Not Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 200 Flight Crew Total 13500 Flight Crew Type 1500 |
Person 2 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Multiengine Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 90 Flight Crew Total 5500 Flight Crew Type 1500 |
Events | |
Anomaly | Deviation - Altitude Excursion From Assigned Altitude Deviation - Procedural Clearance Deviation - Procedural Published Material / Policy |
Miss Distance | Horizontal 12000 Vertical 2000 |
Narrative:
We departed for a planned 4-hour; post 'C'-check; functional check flight. The captain brought nos plates and charts instead of our usual jeppesen plates and charts. After receiving our ATC clearance; which included the thrsr seven departure; the captain inputted the departure procedure (dp) into the FMS computer. I was reviewing the dp and after looking over the over-head diagram of the dp on the nos plate; I began to read the noted instructions for a departure off of runway 08L. My eyes then jumped to the bottom of the page to note the takeoff obstacle notes for our runway. I then verified the navigation points in the FMS with those on the plate. I completely missed the '...maintain 10;000...' verbiage. I noticed that there were not any 'canned' altitudes loaded in the FMS as part of the dp. I then looked at the thrsr 7 plates; after having dropped them once or twice onto the cockpit floor; in the mean time; and was becoming a bit frustrated with their cumbersomeness; since they are designed for kneeboards and not a boeing yoke/chart clips. After finding the dp again; I scanned the over-head view of the plate for an initial and/or top altitude. I noticed '14;000' at thrsr; made a mental note of it; and then continued onto the next page of the dp; visually scanned it; and not noticing any altitude information; I inputted '14;000' at thrsr; which I assumed to be the charted 'top altitude.' I again completely missed the '...maintain 10;000...' note. (The 14;000 feet note was actually the MEA between thrsr and luckk). The captain did a somewhat rushed; pre-departure briefing; and apparently did not read the dp closely enough to notice the '14;000 at thrsr' error as well as the '...maintain 10;000...' verbiage. After we departed atl's runway 08L; I checked in with departure using the '...climbing via the SID' verbiage. When we were a few miles from hyzmn; I called out traffic high and to our 10 o'clock position (on TCAS) and 2400 feet above us and descending. We immediately acquired the traffic and naturally were maintaining visual separation; as it seemed to be heading for hyzmn as well. When I realized that the regional jet might very soon become a conflict; I instructed the captain to flatten-out our climb; which he did; so we would not get an RA on our TCAS. The controller asked us to what altitude we were climbing to and to descend to 10;000 feet. I said '14;000;' realizing that it was apparently wrong. After the rj passed overhead; ATC again asked what altitude we were climbing to and then cleared us higher. He then told us '...possible pilot deviation' and gave us a number to call. This event would never have happened if we would have more carefully read the dp. Since I personally have almost no experience using nos plates; I should have spent some time familiarizing myself with them outside of the cockpit well before our fcif mission that day. We also should have had a more disciplined and thorough pre-departure briefing that would have had us both reviewing the dp together; which is obviously a best practice; and one I normally insist on; but especially at atl; which is a non-familiar airport to the both of us. Also; instead of using the phraseology; '...climbing via the SID'; if the initial call would have included either the charted top altitude or the ATC assigned altitude; i.e.; in our case; if I would have checked-in with departure control and said '...climbing 14;000' instead of or along with; '...climbing via the SID'; the ATC controller probably would have caught our error well before it became a deviation.
Original NASA ASRS Text
Title: B737 flight crew reports an altitude deviation departing ATL on the THRSR 7 due to not noticing the 10;000 foot limit in the routing box. The First Officer was using NOS plates which he was not familiar with.
Narrative: We departed for a planned 4-hour; post 'C'-check; Functional Check Flight. The Captain brought NOS plates and charts instead of our usual Jeppesen plates and charts. After receiving our ATC clearance; which included the THRSR Seven departure; the Captain inputted the Departure Procedure (DP) into the FMS computer. I was reviewing the DP and after looking over the over-head diagram of the DP on the NOS plate; I began to read the noted instructions for a departure off of Runway 08L. My eyes then jumped to the bottom of the page to note the Takeoff Obstacle Notes for our runway. I then verified the navigation points in the FMS with those on the plate. I completely missed the '...Maintain 10;000...' verbiage. I noticed that there were not any 'canned' altitudes loaded in the FMS as part of the DP. I then looked at the THRSR 7 plates; after having dropped them once or twice onto the cockpit floor; in the mean time; and was becoming a bit frustrated with their cumbersomeness; since they are designed for kneeboards and not a Boeing yoke/chart clips. After finding the DP again; I scanned the over-head view of the plate for an Initial and/or Top altitude. I noticed '14;000' at THRSR; made a mental note of it; and then continued onto the next page of the DP; visually scanned it; and not noticing any altitude information; I inputted '14;000' at THRSR; which I assumed to be the charted 'Top Altitude.' I again completely missed the '...Maintain 10;000...' note. (The 14;000 feet note was actually the MEA between THRSR and LUCKK). The Captain did a somewhat rushed; pre-departure briefing; and apparently did not read the DP closely enough to notice the '14;000 at THRSR' error as well as the '...Maintain 10;000...' verbiage. After we departed ATL's Runway 08L; I checked in with Departure using the '...climbing via the SID' verbiage. When we were a few miles from HYZMN; I called out traffic high and to our 10 o'clock position (on TCAS) and 2400 feet above us and descending. We immediately acquired the traffic and naturally were maintaining visual separation; as it seemed to be heading for HYZMN as well. When I realized that the regional jet might very soon become a conflict; I instructed the Captain to flatten-out our climb; which he did; so we would not get an RA on our TCAS. The controller asked us to what altitude we were climbing to and to descend to 10;000 feet. I said '14;000;' realizing that it was apparently wrong. After the RJ passed overhead; ATC again asked what altitude we were climbing to and then cleared us higher. He then told us '...possible pilot deviation' and gave us a number to call. This event would never have happened if we would have more carefully read the DP. Since I personally have almost no experience using NOS plates; I should have spent some time familiarizing myself with them outside of the cockpit well before our FCIF mission that day. We also should have had a more disciplined and thorough pre-departure briefing that would have had us both reviewing the DP together; which is obviously a best practice; and one I normally insist on; but especially at ATL; which is a non-familiar airport to the both of us. Also; instead of using the phraseology; '...climbing via the SID'; if the initial call would have included either the charted top altitude or the ATC assigned altitude; i.e.; in our case; if I would have checked-in with Departure Control and said '...climbing 14;000' instead of OR along with; '...climbing via the SID'; the ATC Controller probably would have caught our error well before it became a deviation.
Data retrieved from NASA's ASRS site 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.