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|
Attributes | |
ACN | 187281 |
Time | |
Date | 199108 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sha |
State Reference | FO |
Altitude | msl bound lower : 2000 msl bound upper : 5000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : sha |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : initial climbout : intermediate altitude |
Route In Use | departure other enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | observation : company check pilot other personnel other |
Qualification | pilot : atp pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 200 flight time total : 15000 flight time type : 970 |
ASRS Report | 187281 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer observation : company check pilot |
Qualification | pilot : atp pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 150 flight time total : 20000 flight time type : 860 |
ASRS Report | 187174 |
Events | |
Anomaly | non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Climbing through approximately 1500 ft on takeoff, shanghai approach amended our cleared altitude to 600 meters (2000 ft) from our originally assigned altitude of 1500 meters (4900 ft). The departure procedure was to nhw departure (runway 36). When given altitudes in meters, we have to convert them to ft by using a chart. In the process of this conversion the switches that change the ADF's to preset frequencys never got switched to wb after passing cu NDB. The aircraft was being quickly leveled at 2000 ft also a left turn was initiated to an approximately 140 degree heading to 'ball park' the course to wb until wb could be tuned. We were then cleared to 1500 meters (4900 ft) and the altitude was recalculated. The captain was very busy and became confused and said, to keep it simple. He just turned toward the ADF needles as he climbed and leaned up the airplane. He assumed the ADF's had been switched from cu to wb. They had not. Sha approach called and asked our heading (it was 060 degree) and told us to fly the nb NDB. We had just found our error and had started back right to wb. Then they said 'turn left.' considerable confusion existed and the exact position was uncertain. Shortly after we were given a clearance direct to nhw VOR. Our company operations in shanghai called us after takeoff (15000 ft) and advised us that shanghai approach was very upset because we had flown through restr airspace and crossed the approach path to a military report. They also advised later that a report from me to them would be required. I had signed the flight plan and was PIC. A new check pilot was in the copilot's seat and a newly qualifying captain was in the left seat. I was observing from the jumpseat. This is company policy even though FAA requirements had already been completed for the IOE check airman. A qualified check pilot observes a new check pilot for 2 segments to make him 'company qualified.' the newness of the people, all of our confusion, my failure to be able to see the capts instruments, and a failure to switch to inertial navigation and to change the ADF switches all contributed to this incident. Language and altitude conversions were major factors.
Original NASA ASRS Text
Title: CAPT RECEIVING IOE IN L SEAT FLYING. NEW CKP GIVING THE IOE FLYING IN R SEAT. CKP OBSERVING CKP GIVING IOE IN OBSERVER SEAT. COURSE DEV AFTER TKOF ALLOWED ACFT TO ENTER RESTRICTED AREA.
Narrative: CLBING THROUGH APPROX 1500 FT ON TKOF, SHANGHAI APCH AMENDED OUR CLRED ALT TO 600 METERS (2000 FT) FROM OUR ORIGINALLY ASSIGNED ALT OF 1500 METERS (4900 FT). THE DEP PROC WAS TO NHW DEP (RWY 36). WHEN GIVEN ALTS IN METERS, WE HAVE TO CONVERT THEM TO FT BY USING A CHART. IN THE PROCESS OF THIS CONVERSION THE SWITCHES THAT CHANGE THE ADF'S TO PRESET FREQS NEVER GOT SWITCHED TO WB AFTER PASSING CU NDB. THE ACFT WAS BEING QUICKLY LEVELED AT 2000 FT ALSO A L TURN WAS INITIATED TO AN APPROX 140 DEG HDG TO 'BALL PARK' THE COURSE TO WB UNTIL WB COULD BE TUNED. WE WERE THEN CLRED TO 1500 METERS (4900 FT) AND THE ALT WAS RECALCULATED. THE CAPT WAS VERY BUSY AND BECAME CONFUSED AND SAID, TO KEEP IT SIMPLE. HE JUST TURNED TOWARD THE ADF NEEDLES AS HE CLBED AND LEANED UP THE AIRPLANE. HE ASSUMED THE ADF'S HAD BEEN SWITCHED FROM CU TO WB. THEY HAD NOT. SHA APCH CALLED AND ASKED OUR HDG (IT WAS 060 DEG) AND TOLD US TO FLY THE NB NDB. WE HAD JUST FOUND OUR ERROR AND HAD STARTED BACK R TO WB. THEN THEY SAID 'TURN L.' CONSIDERABLE CONFUSION EXISTED AND THE EXACT POS WAS UNCERTAIN. SHORTLY AFTER WE WERE GIVEN A CLRNC DIRECT TO NHW VOR. OUR COMPANY OPS IN SHANGHAI CALLED US AFTER TKOF (15000 FT) AND ADVISED US THAT SHANGHAI APCH WAS VERY UPSET BECAUSE WE HAD FLOWN THROUGH RESTR AIRSPACE AND CROSSED THE APCH PATH TO A MIL RPT. THEY ALSO ADVISED LATER THAT A RPT FROM ME TO THEM WOULD BE REQUIRED. I HAD SIGNED THE FLT PLAN AND WAS PIC. A NEW CHK PLT WAS IN THE COPLT'S SEAT AND A NEWLY QUALIFYING CAPT WAS IN THE L SEAT. I WAS OBSERVING FROM THE JUMPSEAT. THIS IS COMPANY POLICY EVEN THOUGH FAA REQUIREMENTS HAD ALREADY BEEN COMPLETED FOR THE IOE CHK AIRMAN. A QUALIFIED CHK PLT OBSERVES A NEW CHK PLT FOR 2 SEGMENTS TO MAKE HIM 'COMPANY QUALIFIED.' THE NEWNESS OF THE PEOPLE, ALL OF OUR CONFUSION, MY FAILURE TO BE ABLE TO SEE THE CAPTS INSTS, AND A FAILURE TO SWITCH TO INERTIAL NAV AND TO CHANGE THE ADF SWITCHES ALL CONTRIBUTED TO THIS INCIDENT. LANGUAGE AND ALT CONVERSIONS WERE MAJOR FACTORS.
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.