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|
Attributes | |
ACN | 149007 |
Time | |
Date | 199006 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : jot airport : mdw |
State Reference | IL |
Altitude | msl bound lower : 15000 msl bound upper : 25000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zau tracon : ord |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | cruise other descent : approach descent other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 195 flight time total : 6800 flight time type : 275 |
ASRS Report | 149007 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 12000 |
ASRS Report | 149431 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Controller called and assigned us a descent clearance with a crossing restriction. I thought that the captain read back '5 south of joliet at 1-5000.' as that is quite close to our destination to be at 15000', I questioned the captain after I made a written record of the clearance. However, when I questioned him, he thought I said, '5-5 south of joliet' (our actual crossing restriction) when I really said (and wrote down) '5 south of joliet at 15; is that what you understand?' he responded in the affirmative. When we were 60 mi south of joliet and still level at FL250, the controller questioned us and the whole matter finally came to light. We began an immediate descent. The next clearance we received was 'cross 25 south of joliet at or below 12000, descend to 10000.' the captain read back the clearance and again, I made a written record. I crossed 25 south of joliet at 12000' and continued down toward 10000'. The captain left the ATC radio at about the time we left 12000' to talk to company. At about 11000', ATC gave me a frequency change to chicago approach. I was busy leveling the aircraft and I did not get the new frequency set in the standby communication head. A few seconds later, we were level at 10000'. The captain came back on and I briefed him about the frequency change. He went back to the old frequency to get the correct new frequency and the controller advised that we were only cleared to 11000'. I'm sure he was mistaken; he had cleared us to 10000'. Next, we received vectors for the ILS 31L at mdw. That had us intercept the localizer, inside the OM and 900' above the G/south. We ended up going missed approach at 800' AGL. The next turn on the subsequent ILS was about the same, but we cheated 20 degrees right and it was still tough to get stabilized, but we did. Lessons: I should have more actively questioned the captain about the original descent clearance that didn't seem right to me. We both should have listened more closely to each other. The information we needed was in the cockpit--we just didn't share it effectively. The captain should not have attempted to call company when a frequency change was pending and I was descending at a high rate with the assigned altitude coming up soon. He was trying to comply with the sterile cockpit rule. It seems that the strict, literal enforcement of this rule has led to situations like this where making the call out of 8000' a few seconds later would have been technically illegal, but much safer. The controllers should have listened more carefully to our readbacks and should not attempt to vector jets so close to the marker when the field is IFR. I should have seen the short vector coming sooner than I did and done a better job of preparing for it. As a crew, we let things continue to pile up on us when we got behind the aircraft after the initial descent clearance confusion. If at any time I would have taken a step back, relaxed and prioritized, verified, briefed, listened and closely monitored the flight, the entire very bad flight could have been uneventful.
Original NASA ASRS Text
Title: ACR MLG ALT DEVIATION UNDERSHOT ALT CROSSING RESTRICTION, THEN OVERSHOT AMENDED CLRNC ALT AND HAD TO GO AROUND WHEN NOT CONFIGURED FOR THE APCH.
Narrative: CTLR CALLED AND ASSIGNED US A DSNT CLRNC WITH A XING RESTRICTION. I THOUGHT THAT THE CAPT READ BACK '5 S OF JOLIET AT 1-5000.' AS THAT IS QUITE CLOSE TO OUR DEST TO BE AT 15000', I QUESTIONED THE CAPT AFTER I MADE A WRITTEN RECORD OF THE CLRNC. HOWEVER, WHEN I QUESTIONED HIM, HE THOUGHT I SAID, '5-5 S OF JOLIET' (OUR ACTUAL XING RESTRICTION) WHEN I REALLY SAID (AND WROTE DOWN) '5 S OF JOLIET AT 15; IS THAT WHAT YOU UNDERSTAND?' HE RESPONDED IN THE AFFIRMATIVE. WHEN WE WERE 60 MI S OF JOLIET AND STILL LEVEL AT FL250, THE CTLR QUESTIONED US AND THE WHOLE MATTER FINALLY CAME TO LIGHT. WE BEGAN AN IMMEDIATE DSNT. THE NEXT CLRNC WE RECEIVED WAS 'CROSS 25 S OF JOLIET AT OR BELOW 12000, DSND TO 10000.' THE CAPT READ BACK THE CLRNC AND AGAIN, I MADE A WRITTEN RECORD. I CROSSED 25 S OF JOLIET AT 12000' AND CONTINUED DOWN TOWARD 10000'. THE CAPT LEFT THE ATC RADIO AT ABOUT THE TIME WE LEFT 12000' TO TALK TO COMPANY. AT ABOUT 11000', ATC GAVE ME A FREQ CHANGE TO CHICAGO APCH. I WAS BUSY LEVELING THE ACFT AND I DID NOT GET THE NEW FREQ SET IN THE STANDBY COM HEAD. A FEW SECS LATER, WE WERE LEVEL AT 10000'. THE CAPT CAME BACK ON AND I BRIEFED HIM ABOUT THE FREQ CHANGE. HE WENT BACK TO THE OLD FREQ TO GET THE CORRECT NEW FREQ AND THE CTLR ADVISED THAT WE WERE ONLY CLRED TO 11000'. I'M SURE HE WAS MISTAKEN; HE HAD CLRED US TO 10000'. NEXT, WE RECEIVED VECTORS FOR THE ILS 31L AT MDW. THAT HAD US INTERCEPT THE LOC, INSIDE THE OM AND 900' ABOVE THE G/S. WE ENDED UP GOING MISSED APCH AT 800' AGL. THE NEXT TURN ON THE SUBSEQUENT ILS WAS ABOUT THE SAME, BUT WE CHEATED 20 DEGS RIGHT AND IT WAS STILL TOUGH TO GET STABILIZED, BUT WE DID. LESSONS: I SHOULD HAVE MORE ACTIVELY QUESTIONED THE CAPT ABOUT THE ORIGINAL DSNT CLRNC THAT DIDN'T SEEM RIGHT TO ME. WE BOTH SHOULD HAVE LISTENED MORE CLOSELY TO EACH OTHER. THE INFO WE NEEDED WAS IN THE COCKPIT--WE JUST DIDN'T SHARE IT EFFECTIVELY. THE CAPT SHOULD NOT HAVE ATTEMPTED TO CALL COMPANY WHEN A FREQ CHANGE WAS PENDING AND I WAS DSNDING AT A HIGH RATE WITH THE ASSIGNED ALT COMING UP SOON. HE WAS TRYING TO COMPLY WITH THE STERILE COCKPIT RULE. IT SEEMS THAT THE STRICT, LITERAL ENFORCEMENT OF THIS RULE HAS LED TO SITUATIONS LIKE THIS WHERE MAKING THE CALL OUT OF 8000' A FEW SECS LATER WOULD HAVE BEEN TECHNICALLY ILLEGAL, BUT MUCH SAFER. THE CTLRS SHOULD HAVE LISTENED MORE CAREFULLY TO OUR READBACKS AND SHOULD NOT ATTEMPT TO VECTOR JETS SO CLOSE TO THE MARKER WHEN THE FIELD IS IFR. I SHOULD HAVE SEEN THE SHORT VECTOR COMING SOONER THAN I DID AND DONE A BETTER JOB OF PREPARING FOR IT. AS A CREW, WE LET THINGS CONTINUE TO PILE UP ON US WHEN WE GOT BEHIND THE ACFT AFTER THE INITIAL DSNT CLRNC CONFUSION. IF AT ANY TIME I WOULD HAVE TAKEN A STEP BACK, RELAXED AND PRIORITIZED, VERIFIED, BRIEFED, LISTENED AND CLOSELY MONITORED THE FLT, THE ENTIRE VERY BAD FLT COULD HAVE BEEN UNEVENTFUL.
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.