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|
Attributes | |
ACN | 175415 |
Time | |
Date | 199104 |
Day | Wed |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : sjc |
State Reference | CA |
Altitude | msl bound lower : 12000 msl bound upper : 12300 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : liz |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | climbout : initial |
Route In Use | departure sid : sid enroute airway : oak |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 8000 flight time type : 5000 |
ASRS Report | 175415 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance |
Independent Detector | other controllera other flight crewa |
Resolutory Action | none taken : insufficient time |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
After receipt and readback of clearance (which was monitored by captain) dialed in transponder code. Set 2305 instead of assigned code of 4306, because when I wrote the clearance down. We were cleared to FL230 5 mins after takeoff. I did not leave a space between '230' and '5,' so it looked like the 4 digit code. The captain and I discussed the loupe 7 SID and admonished each other to be careful due to a recent company bulletin discussing the need for vigilance on the loupe 7 departure at sjc. During final items of takeoff checklist, the second officer queried 'transponder?' and I answered, 'code set, on,' after checking the code with the clearance which was sitting on the center console. I made the same mistake of looking at '2305' instead of the proper code. After takeoff, departure told us to check the squawk and I discovered my error. On a 120 degree heading, controller cleared us to 23000', 'cross sjc VOR at 12000' and resume the loupe 7 departure. Comply with all restrictions.' there was no confusion on my part as to what the controller wanted us to do. I purposely set in 12000' on altitude warn indicator instead of our final cleared altitude of 23000' to ensure we complied with the SID. Passing through 10000', captain (PF) said, 'we are cleared to 23000', right?' as I was responding 'yes,' he reached up and set 23000' in altitude warn indicator. Passing about 11800', I said, 'we have to cross the VOR at 12000'.' he pushed the nose over, topped out at 12300' on my altimeter while we were still 4 mi from on top of sjc. He expeditiously descended to 12000'. The controller cleared us, 'climb unrestricted to FL230.' he obviously was was watching us and caught the altitude excursion. Lessons learned: 1) departure controller was excellent. He was on top of this screw up the entire time and in no way contributed to the problem. His instructions were specific and left no doubt as to what was expected of us. 2) I have revised my clearance shorthand to preclude an occurrence of mistaking altitudes for squawks. 3) my preoccupation with the squawk mistake detracted from my ability to monitor the PF. 4) altitude warning indicator should not be set by PF (as per our company procedures). 5) murphy's law is alive and well.
Original NASA ASRS Text
Title: ACR FLT CREW SETS WRONG SQUAWK IN TRANSPONDER THEN RESETS ALT WARNING #S. ALT DEVIATION.
Narrative: AFTER RECEIPT AND READBACK OF CLRNC (WHICH WAS MONITORED BY CAPT) DIALED IN XPONDER CODE. SET 2305 INSTEAD OF ASSIGNED CODE OF 4306, BECAUSE WHEN I WROTE THE CLRNC DOWN. WE WERE CLRED TO FL230 5 MINS AFTER TKOF. I DID NOT LEAVE A SPACE BTWN '230' AND '5,' SO IT LOOKED LIKE THE 4 DIGIT CODE. THE CAPT AND I DISCUSSED THE LOUPE 7 SID AND ADMONISHED EACH OTHER TO BE CAREFUL DUE TO A RECENT COMPANY BULLETIN DISCUSSING THE NEED FOR VIGILANCE ON THE LOUPE 7 DEP AT SJC. DURING FINAL ITEMS OF TKOF CHKLIST, THE S/O QUERIED 'XPONDER?' AND I ANSWERED, 'CODE SET, ON,' AFTER CHKING THE CODE WITH THE CLRNC WHICH WAS SITTING ON THE CENTER CONSOLE. I MADE THE SAME MISTAKE OF LOOKING AT '2305' INSTEAD OF THE PROPER CODE. AFTER TKOF, DEP TOLD US TO CHK THE SQUAWK AND I DISCOVERED MY ERROR. ON A 120 DEG HDG, CTLR CLRED US TO 23000', 'CROSS SJC VOR AT 12000' AND RESUME THE LOUPE 7 DEP. COMPLY WITH ALL RESTRICTIONS.' THERE WAS NO CONFUSION ON MY PART AS TO WHAT THE CTLR WANTED US TO DO. I PURPOSELY SET IN 12000' ON ALT WARN INDICATOR INSTEAD OF OUR FINAL CLRED ALT OF 23000' TO ENSURE WE COMPLIED WITH THE SID. PASSING THROUGH 10000', CAPT (PF) SAID, 'WE ARE CLRED TO 23000', RIGHT?' AS I WAS RESPONDING 'YES,' HE REACHED UP AND SET 23000' IN ALT WARN INDICATOR. PASSING ABOUT 11800', I SAID, 'WE HAVE TO CROSS THE VOR AT 12000'.' HE PUSHED THE NOSE OVER, TOPPED OUT AT 12300' ON MY ALTIMETER WHILE WE WERE STILL 4 MI FROM ON TOP OF SJC. HE EXPEDITIOUSLY DSNDED TO 12000'. THE CTLR CLRED US, 'CLB UNRESTRICTED TO FL230.' HE OBVIOUSLY WAS WAS WATCHING US AND CAUGHT THE ALT EXCURSION. LESSONS LEARNED: 1) DEP CTLR WAS EXCELLENT. HE WAS ON TOP OF THIS SCREW UP THE ENTIRE TIME AND IN NO WAY CONTRIBUTED TO THE PROB. HIS INSTRUCTIONS WERE SPECIFIC AND LEFT NO DOUBT AS TO WHAT WAS EXPECTED OF US. 2) I HAVE REVISED MY CLRNC SHORTHAND TO PRECLUDE AN OCCURRENCE OF MISTAKING ALTS FOR SQUAWKS. 3) MY PREOCCUPATION WITH THE SQUAWK MISTAKE DETRACTED FROM MY ABILITY TO MONITOR THE PF. 4) ALT WARNING INDICATOR SHOULD NOT BE SET BY PF (AS PER OUR COMPANY PROCS). 5) MURPHY'S LAW IS ALIVE AND WELL.
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.