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|
Attributes | |
ACN | 121736 |
Time | |
Date | 198909 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : rdu |
State Reference | NC |
Altitude | msl bound lower : 10000 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc tracon : gsb |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | descent other |
Route In Use | arrival other enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
ASRS Report | 121736 |
Person 2 | |
Affiliation | government : faa |
Function | controller : radar |
Qualification | controller : radar |
ASRS Report | 121546 |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : excursion from assigned altitude non adherence : published procedure non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : investigated |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation Operational Deviation |
Narrative:
Air carrier X was descended to 11000' MSL by ewn, sector 25. Air carrier X acknowledged the assigned altitude and stated '1-1-thousand.' approximately 2 mins later, air carrier X checked out FL210 for '1-0-thousand,' which was different from his assigned altitude. Ewn low controllers did not hear air carrier X say '1-0-thousand.' they subsequently switched air carrier X to rmt sector 28. Air carrier X checked on the rmt frequency, 'out of 1-2-thousand for 1-0-thousand.' neither the radar nor the radar-associate controller realized air carrier X was descending to 10000'. Immediately after air carrier X checked on the rmt frequency I plugged in to relieve the radar controller at rmt. I assumed control of the sector. I noticed air carrier X was level at 10000' and was turning toward rdu, although he was still approximately 15 mi south of the arrival right for the brade 2 arrival (rdu 120 degree right). I issued a climb clearance to '1-1-thousand' and asked air carrier what radial he was tracking in to rdu. I instructed the radar associate controller to listen to the readback while I made a pointout to seymour johnson approach, who owned the airspace at 10000' at air carrier X point of deviation. Air carrier X advised that he had the wrong radial tuned in and apologized. He never explained why he thought he was cleared to 10000'. At this point I did not realize what had happened on the ewn frequency. I assigned air carrier X a 360 degree heading and handed him off to rdu approach. I advised the area supervisor in charge of the deviation. Reference the pointout to seymour johnson, they advised that they had no traffic and approved the pointout. I believe that this situation is wholly the result of air carrier X incorrectly thinking that his assigned altitude was 10000'. It is especially confusing when you realize that he originally acknowledged 11000'! Additionally, air carrier X did not navigation the arrival properly, causing him to turn nwbnd 15 mi early. I do not believe air carrier X was as attentive to the operation as he should have been considering he was arriving at a very busy hub airport for air carrier X airlines. The original misstatement of assigned altitude was not detected by the controllers involved. Had it been, this situation would not have occurred. However, the mistake was made in the cockpit, both on altitude and route. Closer attention in the cockpit may have helped avoid this situation. Supplemental information from acn 121550: air carrier X during descent the brade 2 arrival into rdu. Aircraft was leveled off at 10000' and turned on course to follow the 320 degree right of rdu. At that time, ATC asked what we were doing, and advised we were supposed to level at 11000' and turn inbound on the 300 degree right. Aircraft was immediately climbed to 11000' and turned to intercept the 300 degree right. ATC then assigned 360 degree vector to intercept the 300 degree right. Looking back, I realized I had incorrectly dialed in the 320 degree right on my CDI, and had advised the captain of the intercept. The 10000' altitude was dialed into the altitude select, and I feel certain when I checked into ZDC I had stated our passing altitude (approximately 12000') and assigned altitude; ie, 'ZDC, xxxxx passing 12300 for 10000.' human performance: these deviations were caused by lack of communications and attention to details. I have never experienced such deviations in an 11 yr flying career and do not expect to in the future.
Original NASA ASRS Text
Title: ACR X RECEIVED AND ACKNOWLEDGED CLRNC TO 11000'. FLT CREW DESCENDED TO 10000'. PLT DEVIATION. ARTCC RADAR CTLRS FAILED TO HEAR PLT'S REPORTS DESCENDING TO 10000'. OPERATIONAL DEVIATION.
Narrative: ACR X WAS DSNDED TO 11000' MSL BY EWN, SECTOR 25. ACR X ACKNOWLEDGED THE ASSIGNED ALT AND STATED '1-1-THOUSAND.' APPROX 2 MINS LATER, ACR X CHKED OUT FL210 FOR '1-0-THOUSAND,' WHICH WAS DIFFERENT FROM HIS ASSIGNED ALT. EWN LOW CTLRS DID NOT HEAR ACR X SAY '1-0-THOUSAND.' THEY SUBSEQUENTLY SWITCHED ACR X TO RMT SECTOR 28. ACR X CHKED ON THE RMT FREQ, 'OUT OF 1-2-THOUSAND FOR 1-0-THOUSAND.' NEITHER THE RADAR NOR THE RADAR-ASSOCIATE CTLR REALIZED ACR X WAS DSNDING TO 10000'. IMMEDIATELY AFTER ACR X CHKED ON THE RMT FREQ I PLUGGED IN TO RELIEVE THE RADAR CTLR AT RMT. I ASSUMED CTL OF THE SECTOR. I NOTICED ACR X WAS LEVEL AT 10000' AND WAS TURNING TOWARD RDU, ALTHOUGH HE WAS STILL APPROX 15 MI S OF THE ARR R FOR THE BRADE 2 ARR (RDU 120 DEG R). I ISSUED A CLB CLRNC TO '1-1-THOUSAND' AND ASKED ACR WHAT RADIAL HE WAS TRACKING IN TO RDU. I INSTRUCTED THE RADAR ASSOCIATE CTLR TO LISTEN TO THE READBACK WHILE I MADE A POINTOUT TO SEYMOUR JOHNSON APCH, WHO OWNED THE AIRSPACE AT 10000' AT ACR X POINT OF DEVIATION. ACR X ADVISED THAT HE HAD THE WRONG RADIAL TUNED IN AND APOLOGIZED. HE NEVER EXPLAINED WHY HE THOUGHT HE WAS CLRED TO 10000'. AT THIS POINT I DID NOT REALIZE WHAT HAD HAPPENED ON THE EWN FREQ. I ASSIGNED ACR X A 360 DEG HDG AND HANDED HIM OFF TO RDU APCH. I ADVISED THE AREA SUPVR IN CHARGE OF THE DEVIATION. REF THE POINTOUT TO SEYMOUR JOHNSON, THEY ADVISED THAT THEY HAD NO TFC AND APPROVED THE POINTOUT. I BELIEVE THAT THIS SITUATION IS WHOLLY THE RESULT OF ACR X INCORRECTLY THINKING THAT HIS ASSIGNED ALT WAS 10000'. IT IS ESPECIALLY CONFUSING WHEN YOU REALIZE THAT HE ORIGINALLY ACKNOWLEDGED 11000'! ADDITIONALLY, ACR X DID NOT NAV THE ARR PROPERLY, CAUSING HIM TO TURN NWBND 15 MI EARLY. I DO NOT BELIEVE ACR X WAS AS ATTENTIVE TO THE OPERATION AS HE SHOULD HAVE BEEN CONSIDERING HE WAS ARRIVING AT A VERY BUSY HUB ARPT FOR ACR X AIRLINES. THE ORIGINAL MISSTATEMENT OF ASSIGNED ALT WAS NOT DETECTED BY THE CTLRS INVOLVED. HAD IT BEEN, THIS SITUATION WOULD NOT HAVE OCCURRED. HOWEVER, THE MISTAKE WAS MADE IN THE COCKPIT, BOTH ON ALT AND ROUTE. CLOSER ATTN IN THE COCKPIT MAY HAVE HELPED AVOID THIS SITUATION. SUPPLEMENTAL INFO FROM ACN 121550: ACR X DURING DSCNT THE BRADE 2 ARR INTO RDU. ACFT WAS LEVELED OFF AT 10000' AND TURNED ON COURSE TO FOLLOW THE 320 DEG R OF RDU. AT THAT TIME, ATC ASKED WHAT WE WERE DOING, AND ADVISED WE WERE SUPPOSED TO LEVEL AT 11000' AND TURN INBND ON THE 300 DEG R. ACFT WAS IMMEDIATELY CLBED TO 11000' AND TURNED TO INTERCEPT THE 300 DEG R. ATC THEN ASSIGNED 360 DEG VECTOR TO INTERCEPT THE 300 DEG R. LOOKING BACK, I REALIZED I HAD INCORRECTLY DIALED IN THE 320 DEG R ON MY CDI, AND HAD ADVISED THE CAPT OF THE INTERCEPT. THE 10000' ALT WAS DIALED INTO THE ALT SELECT, AND I FEEL CERTAIN WHEN I CHKED INTO ZDC I HAD STATED OUR PASSING ALT (APPROX 12000') AND ASSIGNED ALT; IE, 'ZDC, XXXXX PASSING 12300 FOR 10000.' HUMAN PERFORMANCE: THESE DEVIATIONS WERE CAUSED BY LACK OF COMS AND ATTN TO DETAILS. I HAVE NEVER EXPERIENCED SUCH DEVIATIONS IN AN 11 YR FLYING CAREER AND DO NOT EXPECT TO IN THE FUTURE.
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.