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|
Attributes | |
ACN | 138320 |
Time | |
Date | 199002 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | msl bound lower : 3000 msl bound upper : 3700 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : oak |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : initial |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 14000 flight time type : 1500 |
ASRS Report | 138320 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 32650 flight time type : 1300 |
ASRS Report | 138208 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We took off from sfo runway 1R with a clearance to a magnetic heading of 350 degrees, climb and maintain 10000'. I was flying the aircraft. After takeoff departure control reclred us to maintain 3000' and called out traffic--a VFR small aircraft at 3500' over the city. This was acknowledged by the captain. We continued on a magnetic heading of 350 degrees, and as we were retracting flaps a clearance was received to turn left to a magnetic heading of 230 dgs. On reaching maneuvering speed I commenced a left turn at approximately 1800'. The captain observed the twin towers on peak just south of the city and ascertained that our turn to a 230 degrees would place us in close proximity to the terrain and immediately x-chked the MSA on the charts. In the meantime, I had the small aircraft in sight and determined that our vector was intercepting the track of the aircraft and told the captain that I was stopping the turn to pass behind the small aircraft above us. The magnetic heading was approximately 270 degrees. The captain had noted that the MSA in that sector to be 3700', as depicted on sfo 13-1, as of 7/X/88 (13-2 is the same), and I proceeded to level at 3700', clear of reported traffic. Supplemental information from acn 138208: controller advised us that we had VFR traffic 9:30-10 O'clock at 3500', circling the city. I advised him that we had the traffic in sight. I said to the crew, 'those tower look very high--I don't think that 3000' is a legal altitude.' I turned the pages of my manual to an approach page to get the minimum sector altitude. I announced to the crew that it looked to me like the altitude should be no lower than 3700'. The controller said we were assigned 3000'. The first officer leveled at 3700'. The frequency was busy. As I looked at my plate pages again I saw 3100' on a different page. I nudged the control column as I told the first officer to go back to 3000'. 2 ingredients involved in this scenario could lead to a real catastrophe. First, the sfo approach page shows 3700' to be the minimum sector altitude, while another page shows 3100'. This caused confusion during a critical phase of flight. Secondly the controller used poor judgement in attempted to sandwich a widebody transport between minimum terrain and VFR traffic only 500' higher. I would suggest that any time a controller uses less than standard chart vectors altitudes, that he inform the pilot as to exactly what his minimum vector altitude is. This will provide a double-check, to help ensure against the possibility of error.
Original NASA ASRS Text
Title: ACR ON DEP CLIMBED ABOVE ASSIGNED ALT AND FLEW DIFFERENT HEADING.
Narrative: WE TOOK OFF FROM SFO RWY 1R WITH A CLRNC TO A MAGNETIC HDG OF 350 DEGS, CLB AND MAINTAIN 10000'. I WAS FLYING THE ACFT. AFTER TKOF DEP CTL RECLRED US TO MAINTAIN 3000' AND CALLED OUT TFC--A VFR SMA AT 3500' OVER THE CITY. THIS WAS ACKNOWLEDGED BY THE CAPT. WE CONTINUED ON A MAGNETIC HDG OF 350 DEGS, AND AS WE WERE RETRACTING FLAPS A CLRNC WAS RECEIVED TO TURN LEFT TO A MAGNETIC HDG OF 230 DGS. ON REACHING MANEUVERING SPD I COMMENCED A LEFT TURN AT APPROX 1800'. THE CAPT OBSERVED THE TWIN TWRS ON PEAK JUST S OF THE CITY AND ASCERTAINED THAT OUR TURN TO A 230 DEGS WOULD PLACE US IN CLOSE PROX TO THE TERRAIN AND IMMEDIATELY X-CHKED THE MSA ON THE CHARTS. IN THE MEANTIME, I HAD THE SMA IN SIGHT AND DETERMINED THAT OUR VECTOR WAS INTERCEPTING THE TRACK OF THE ACFT AND TOLD THE CAPT THAT I WAS STOPPING THE TURN TO PASS BEHIND THE SMA ABOVE US. THE MAGNETIC HDG WAS APPROX 270 DEGS. THE CAPT HAD NOTED THAT THE MSA IN THAT SECTOR TO BE 3700', AS DEPICTED ON SFO 13-1, AS OF 7/X/88 (13-2 IS THE SAME), AND I PROCEEDED TO LEVEL AT 3700', CLR OF RPTED TFC. SUPPLEMENTAL INFO FROM ACN 138208: CTLR ADVISED US THAT WE HAD VFR TFC 9:30-10 O'CLOCK AT 3500', CIRCLING THE CITY. I ADVISED HIM THAT WE HAD THE TFC IN SIGHT. I SAID TO THE CREW, 'THOSE TWR LOOK VERY HIGH--I DON'T THINK THAT 3000' IS A LEGAL ALT.' I TURNED THE PAGES OF MY MANUAL TO AN APCH PAGE TO GET THE MINIMUM SECTOR ALT. I ANNOUNCED TO THE CREW THAT IT LOOKED TO ME LIKE THE ALT SHOULD BE NO LOWER THAN 3700'. THE CTLR SAID WE WERE ASSIGNED 3000'. THE F/O LEVELED AT 3700'. THE FREQ WAS BUSY. AS I LOOKED AT MY PLATE PAGES AGAIN I SAW 3100' ON A DIFFERENT PAGE. I NUDGED THE CONTROL COLUMN AS I TOLD THE F/O TO GO BACK TO 3000'. 2 INGREDIENTS INVOLVED IN THIS SCENARIO COULD LEAD TO A REAL CATASTROPHE. FIRST, THE SFO APCH PAGE SHOWS 3700' TO BE THE MINIMUM SECTOR ALT, WHILE ANOTHER PAGE SHOWS 3100'. THIS CAUSED CONFUSION DURING A CRITICAL PHASE OF FLT. SECONDLY THE CTLR USED POOR JUDGEMENT IN ATTEMPTED TO SANDWICH A WDB BTWN MINIMUM TERRAIN AND VFR TFC ONLY 500' HIGHER. I WOULD SUGGEST THAT ANY TIME A CTLR USES LESS THAN STANDARD CHART VECTORS ALTS, THAT HE INFORM THE PLT AS TO EXACTLY WHAT HIS MINIMUM VECTOR ALT IS. THIS WILL PROVIDE A DOUBLE-CHK, TO HELP ENSURE AGAINST THE POSSIBILITY OF ERROR.
Data retrieved from NASA's ASRS site as of July 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.