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|
Attributes | |
ACN | 141679 |
Time | |
Date | 199004 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : yyz |
State Reference | ON |
Altitude | msl bound lower : 7000 msl bound upper : 7700 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : yyz |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : flight engineer pilot : cfi |
Experience | flight time last 90 days : 20 flight time total : 1200 flight time type : 50 |
ASRS Report | 141679 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer pilot : cfi |
Experience | flight time last 90 days : 150 flight time total : 15000 flight time type : 2000 |
ASRS Report | 141284 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
The clearance by ATC read as follows: '320 heading then as filed eck, J94, fnt, pmm ord, runway 25, toronto 3 departure, squawk XXXX, departure frequency 132.47.' after taking off runway 33, we proceeded on 320 degree heading, intercepting the 337 degree right of toronto, to the 2.5 DME point. Now the discrepancy begins--my thoughts were, after 2.5 DME, to proceed direct eck. Captain tuning radio to eck frequency thought it was idented. RMI indicated a right turn instead of left. It briefly crossed my mind that eck was to the left, but I still proceeded right, thinking the VOR was idented. At that point we had clearance to 7000'. The captain questioned my turn to the east. I looked at my INS to find out where we were. At that instant we inadvertently went by 7000' and stopped at 7700' to return to 7000'. ATC responded, 'climb to FL230, and turn left to heading 270 degrees and get back on course and intercept V320 from yyz. My confusion comes in on the toronto 3 (runway 33 departure. It doesn't say intercept V320 to eck. Plus, it was not given in clearance. To summarize, initial clearance was not clear. Confusion in cockpit led to altitude deviation. Should have believed initial thoughts and not unidented radio/INS. Proper corrective action was taken to return to altitude and heading. Supplemental information from acn 141284: no vector had yet been issued by departure control. The flight had been cleared to 7000' and at this point, as the first officer was turning back left, the aircraft passed through 7000' at 4000 FPM rate of climb. Captain assumed control of the aircraft and leveled at 7700', then returned to 7000' and returned control to the first officer. Causes: inadequate departure briefing by crew, and inadequate line oriented training of flight crews.
Original NASA ASRS Text
Title: ALT HEADING DEVIATION.
Narrative: THE CLRNC BY ATC READ AS FOLLOWS: '320 HDG THEN AS FILED ECK, J94, FNT, PMM ORD, RWY 25, TORONTO 3 DEP, SQUAWK XXXX, DEP FREQ 132.47.' AFTER TAKING OFF RWY 33, WE PROCEEDED ON 320 DEG HDG, INTERCEPTING THE 337 DEG R OF TORONTO, TO THE 2.5 DME POINT. NOW THE DISCREPANCY BEGINS--MY THOUGHTS WERE, AFTER 2.5 DME, TO PROCEED DIRECT ECK. CAPT TUNING RADIO TO ECK FREQ THOUGHT IT WAS IDENTED. RMI INDICATED A RIGHT TURN INSTEAD OF LEFT. IT BRIEFLY CROSSED MY MIND THAT ECK WAS TO THE LEFT, BUT I STILL PROCEEDED RIGHT, THINKING THE VOR WAS IDENTED. AT THAT POINT WE HAD CLRNC TO 7000'. THE CAPT QUESTIONED MY TURN TO THE E. I LOOKED AT MY INS TO FIND OUT WHERE WE WERE. AT THAT INSTANT WE INADVERTENTLY WENT BY 7000' AND STOPPED AT 7700' TO RETURN TO 7000'. ATC RESPONDED, 'CLB TO FL230, AND TURN LEFT TO HDG 270 DEGS AND GET BACK ON COURSE AND INTERCEPT V320 FROM YYZ. MY CONFUSION COMES IN ON THE TORONTO 3 (RWY 33 DEP. IT DOESN'T SAY INTERCEPT V320 TO ECK. PLUS, IT WAS NOT GIVEN IN CLRNC. TO SUMMARIZE, INITIAL CLRNC WAS NOT CLEAR. CONFUSION IN COCKPIT LED TO ALT DEVIATION. SHOULD HAVE BELIEVED INITIAL THOUGHTS AND NOT UNIDENTED RADIO/INS. PROPER CORRECTIVE ACTION WAS TAKEN TO RETURN TO ALT AND HDG. SUPPLEMENTAL INFO FROM ACN 141284: NO VECTOR HAD YET BEEN ISSUED BY DEP CTL. THE FLT HAD BEEN CLRED TO 7000' AND AT THIS POINT, AS THE F/O WAS TURNING BACK LEFT, THE ACFT PASSED THROUGH 7000' AT 4000 FPM RATE OF CLB. CAPT ASSUMED CONTROL OF THE ACFT AND LEVELED AT 7700', THEN RETURNED TO 7000' AND RETURNED CONTROL TO THE F/O. CAUSES: INADEQUATE DEP BRIEFING BY CREW, AND INADEQUATE LINE ORIENTED TRNING OF FLT CREWS.
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.