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|
Attributes | |
ACN | 145073 |
Time | |
Date | 199005 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : ama |
State Reference | TX |
Altitude | msl bound lower : 32750 msl bound upper : 33000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zab artcc : zob |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other cruise other descent other |
Route In Use | enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 250 flight time total : 7000 flight time type : 1500 |
ASRS Report | 145073 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 220 flight time total : 20000 |
ASRS Report | 145070 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This was a flight from sea-dfw. Uneventful until approaching ama. We were given a 30 degree turn to the left for spacing. I believe the controller said to expect direct to ama. We were cleared direct wichita falls, sps. I heard direct sps, read back direct sps, but in my mind thought and started south turn direct ama (sps frequency 112.8, ama frequency 117.2). At approximately 17 DME this would have almost resulted in a circle around ama because of turn radius. I questioned the controller 3 times, but each time referred to sps but thinking ama. The controller responded quite rightly that he didn't understand the problem. Since there was other traffic in the area, he cleared us to FL330, which we did, and during which we discovered our error. On descent and level off, even though the FMA was properly armed, it achieved capture mode, but not hold. We descended 250' below altitude, but corrected quickly. Could have been major and compounded the problem. We read many times about readback and other types of communication errors. I heard mentally what I expected and wanted to hear. We know everyone needs to be in the loop. We had a check airman engineer checking out a new engineer on the aircraft. Also another cockpit rider who was a new hire to the airline. Result: I was flying, making most radio calls and taking most clrncs. Even when I repeatedly questioned the controller about my misunderstood clearance no one picked up. No excuses--I misunderstood, took the wrong action based on what I thought I heard, and even though in one respect I was the one doing my job, I didn't require another's confirmation. Not again. Supplemental information from acn 145070: we had an flight engineer trnee on the flight engineer panel and a minor mechanical problem in progress, so my attention was distracted from the radio as the first officer was flying. Supplemental information from acn 146367: pilot, who had been talking to a jump seat passenger, became aware of wrong turn and wrong flight level.
Original NASA ASRS Text
Title: ACR WDB TRACK HEADING DEVIATION AND ALT DEVIATION OVERSHOT IN DESCENT.
Narrative: THIS WAS A FLT FROM SEA-DFW. UNEVENTFUL UNTIL APCHING AMA. WE WERE GIVEN A 30 DEG TURN TO THE LEFT FOR SPACING. I BELIEVE THE CTLR SAID TO EXPECT DIRECT TO AMA. WE WERE CLRED DIRECT WICHITA FALLS, SPS. I HEARD DIRECT SPS, READ BACK DIRECT SPS, BUT IN MY MIND THOUGHT AND STARTED S TURN DIRECT AMA (SPS FREQ 112.8, AMA FREQ 117.2). AT APPROX 17 DME THIS WOULD HAVE ALMOST RESULTED IN A CIRCLE AROUND AMA BECAUSE OF TURN RADIUS. I QUESTIONED THE CTLR 3 TIMES, BUT EACH TIME REFERRED TO SPS BUT THINKING AMA. THE CTLR RESPONDED QUITE RIGHTLY THAT HE DIDN'T UNDERSTAND THE PROB. SINCE THERE WAS OTHER TFC IN THE AREA, HE CLRED US TO FL330, WHICH WE DID, AND DURING WHICH WE DISCOVERED OUR ERROR. ON DSNT AND LEVEL OFF, EVEN THOUGH THE FMA WAS PROPERLY ARMED, IT ACHIEVED CAPTURE MODE, BUT NOT HOLD. WE DSNDED 250' BELOW ALT, BUT CORRECTED QUICKLY. COULD HAVE BEEN MAJOR AND COMPOUNDED THE PROB. WE READ MANY TIMES ABOUT READBACK AND OTHER TYPES OF COM ERRORS. I HEARD MENTALLY WHAT I EXPECTED AND WANTED TO HEAR. WE KNOW EVERYONE NEEDS TO BE IN THE LOOP. WE HAD A CHK AIRMAN ENGINEER CHKING OUT A NEW ENGINEER ON THE ACFT. ALSO ANOTHER COCKPIT RIDER WHO WAS A NEW HIRE TO THE AIRLINE. RESULT: I WAS FLYING, MAKING MOST RADIO CALLS AND TAKING MOST CLRNCS. EVEN WHEN I REPEATEDLY QUESTIONED THE CTLR ABOUT MY MISUNDERSTOOD CLRNC NO ONE PICKED UP. NO EXCUSES--I MISUNDERSTOOD, TOOK THE WRONG ACTION BASED ON WHAT I THOUGHT I HEARD, AND EVEN THOUGH IN ONE RESPECT I WAS THE ONE DOING MY JOB, I DIDN'T REQUIRE ANOTHER'S CONFIRMATION. NOT AGAIN. SUPPLEMENTAL INFO FROM ACN 145070: WE HAD AN FE TRNEE ON THE FE PANEL AND A MINOR MECHANICAL PROB IN PROGRESS, SO MY ATTN WAS DISTRACTED FROM THE RADIO AS THE FO WAS FLYING. SUPPLEMENTAL INFO FROM ACN 146367: PLT, WHO HAD BEEN TALKING TO A JUMP SEAT PAX, BECAME AWARE OF WRONG TURN AND WRONG FLT LEVEL.
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.