37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 191862 |
Time | |
Date | 199110 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : lhr |
State Reference | FO |
Altitude | msl bound lower : 8900 msl bound upper : 9000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : lhr |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Medium Transport |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : atp pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 140 flight time total : 14000 flight time type : 300 |
ASRS Report | 191862 |
Person 2 | |
Affiliation | company : air carrier |
Function | observation : company check pilot |
Qualification | pilot : atp pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 260 flight time total : 12000 |
ASRS Report | 191350 |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : clearance other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Miss Distance | horizontal : 0 vertical : 850 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We arrived at the holding fix after flying all night from miami in our widebody transport. I was the PF. The PNF was ny check airman giving me my initial atlantic-europe check. ATC vectored us into the pattern. We crossed the fix once, then when outbound we received a clearance of 4 items (I think). 1) 'right turn, return to the fix. 2) operate at 210 KTS. 3) 'descend to FL80.' 4) 'depart the fix on 280.' I started doing these things while the PNF hd some difficulty with the readback. I had started an easy descent (PNF was still sorting out the clearance) when we heard 'traffic, traffic' on the TCASII. There was an amber target right near us at -.9 (900 ft below us). 2 of us on the left saw an mdt about to go under us. The TCASII then said 'monitor vertical speed.' the display showed -.9 for another 10 seconds or so. I then dialed in a positive vertical speed. The PNF dialed in more and reset the altitude knob to 9000 (I had set it at 8000). The PNF then told ATC we were going back to FL90 and asked for a clarification of our assigned altitude and heading. ATC didn't say whether we had erred. More headings and altitudes were assigned and we landed uneventfully. None of us knows for sure if we were actually cleared to leave 9000. I usually listen for altitudes given to other aircraft in a holding stack. It does appear the mdt was descending. Maybe we were cleared to his vacated altitude. I know we were all somewhat fatigued (naturally) by our all night flight (as are several hundred other airmen every morning after eastbound transatlantic flts)! Even when alert and rested I have problems reading back and responding to more than 2 clearance actions given together. The best controllers give you 2 items, wait for your readback, then give you the remainder. As for me, I intend to be more deliberate in taking action, especially altitude until the clearance(south) have been clearly acknowledged. Supplemental information from acn 191599. We were holding over the ock VOR at 9000 ft, waiting to land at london heathrow. ATC instructed us to turn to a 280 degree heading after the VOR for vectors. The right seated pilot read back 080 degree heading. The other copilot on the other jumpseat corrected the right seated pilot, who in turn then read back the appropriate clearance to ATC. The captain, flying, then turned to a 280 heading but dialed in 8000 in the altitude window. (Company procedures require the PNF to operate the altitude window). The aircraft then started a slow descent towards 8000. Shortly thereafter the TCASII alerted us to traffic below us which we could see as a mdt. Nobody, inclusive of myself, said a word about our altitude even though everyone was aware of it. I personally thought that I had missed something that the captain and rest of the crew heard regarding altitude, so I didn't question it. Added to this was the fact that the captain had so deliberately changed the altitude. The aircraft descended to 8400 MSL while the TCASII continued it's alerts. At this point the right seated pilot confirmed with ATC that our altitude assigned was in fact 9000. As a solution, each of the 3 PNF should have questioned the captain.
Original NASA ASRS Text
Title: ACR ON OVERNIGHT OCEANIC FLT IN HOLD PATTERN. CONFUSION REF CLRNC. DSNDS, TCASII RA.
Narrative: WE ARRIVED AT THE HOLDING FIX AFTER FLYING ALL NIGHT FROM MIAMI IN OUR WDB. I WAS THE PF. THE PNF WAS NY CHK AIRMAN GIVING ME MY INITIAL ATLANTIC-EUROPE CHK. ATC VECTORED US INTO THE PATTERN. WE CROSSED THE FIX ONCE, THEN WHEN OUTBOUND WE RECEIVED A CLRNC OF 4 ITEMS (I THINK). 1) 'R TURN, RETURN TO THE FIX. 2) OPERATE AT 210 KTS. 3) 'DSND TO FL80.' 4) 'DEPART THE FIX ON 280.' I STARTED DOING THESE THINGS WHILE THE PNF HD SOME DIFFICULTY WITH THE READBACK. I HAD STARTED AN EASY DSCNT (PNF WAS STILL SORTING OUT THE CLRNC) WHEN WE HEARD 'TFC, TFC' ON THE TCASII. THERE WAS AN AMBER TARGET RIGHT NEAR US AT -.9 (900 FT BELOW US). 2 OF US ON THE L SAW AN MDT ABOUT TO GO UNDER US. THE TCASII THEN SAID 'MONITOR VERT SPD.' THE DISPLAY SHOWED -.9 FOR ANOTHER 10 SECONDS OR SO. I THEN DIALED IN A POSITIVE VERT SPD. THE PNF DIALED IN MORE AND RESET THE ALT KNOB TO 9000 (I HAD SET IT AT 8000). THE PNF THEN TOLD ATC WE WERE GOING BACK TO FL90 AND ASKED FOR A CLARIFICATION OF OUR ASSIGNED ALT AND HDG. ATC DIDN'T SAY WHETHER WE HAD ERRED. MORE HDGS AND ALTS WERE ASSIGNED AND WE LANDED UNEVENTFULLY. NONE OF US KNOWS FOR SURE IF WE WERE ACTUALLY CLRED TO LEAVE 9000. I USUALLY LISTEN FOR ALTS GIVEN TO OTHER ACFT IN A HOLDING STACK. IT DOES APPEAR THE MDT WAS DSNDING. MAYBE WE WERE CLRED TO HIS VACATED ALT. I KNOW WE WERE ALL SOMEWHAT FATIGUED (NATURALLY) BY OUR ALL NIGHT FLT (AS ARE SEVERAL HUNDRED OTHER AIRMEN EVERY MORNING AFTER EBOUND TRANSATLANTIC FLTS)! EVEN WHEN ALERT AND RESTED I HAVE PROBLEMS READING BACK AND RESPONDING TO MORE THAN 2 CLRNC ACTIONS GIVEN TOGETHER. THE BEST CTLRS GIVE YOU 2 ITEMS, WAIT FOR YOUR READBACK, THEN GIVE YOU THE REMAINDER. AS FOR ME, I INTEND TO BE MORE DELIBERATE IN TAKING ACTION, ESPECIALLY ALT UNTIL THE CLRNC(S) HAVE BEEN CLRLY ACKNOWLEDGED. SUPPLEMENTAL INFO FROM ACN 191599. WE WERE HOLDING OVER THE OCK VOR AT 9000 FT, WAITING TO LAND AT LONDON HEATHROW. ATC INSTRUCTED US TO TURN TO A 280 DEG HDG AFTER THE VOR FOR VECTORS. THE R SEATED PLT READ BACK 080 DEG HDG. THE OTHER COPLT ON THE OTHER JUMPSEAT CORRECTED THE R SEATED PLT, WHO IN TURN THEN READ BACK THE APPROPRIATE CLRNC TO ATC. THE CAPT, FLYING, THEN TURNED TO A 280 HDG BUT DIALED IN 8000 IN THE ALT WINDOW. (COMPANY PROCS REQUIRE THE PNF TO OPERATE THE ALT WINDOW). THE ACFT THEN STARTED A SLOW DSCNT TOWARDS 8000. SHORTLY THEREAFTER THE TCASII ALERTED US TO TFC BELOW US WHICH WE COULD SEE AS A MDT. NOBODY, INCLUSIVE OF MYSELF, SAID A WORD ABOUT OUR ALT EVEN THOUGH EVERYONE WAS AWARE OF IT. I PERSONALLY THOUGHT THAT I HAD MISSED SOMETHING THAT THE CAPT AND REST OF THE CREW HEARD REGARDING ALT, SO I DIDN'T QUESTION IT. ADDED TO THIS WAS THE FACT THAT THE CAPT HAD SO DELIBERATELY CHANGED THE ALT. THE ACFT DSNDED TO 8400 MSL WHILE THE TCASII CONTINUED IT'S ALERTS. AT THIS POINT THE R SEATED PLT CONFIRMED WITH ATC THAT OUR ALT ASSIGNED WAS IN FACT 9000. AS A SOLUTION, EACH OF THE 3 PNF SHOULD HAVE QUESTIONED THE CAPT.
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.