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|
Attributes | |
ACN | 194740 |
Time | |
Date | 199111 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : iah |
State Reference | TX |
Altitude | msl bound lower : 2000 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : iah tower : phl |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : initial climbout : intermediate altitude |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : atp pilot : instrument |
Experience | flight time last 90 days : 180 flight time total : 20000 flight time type : 2400 |
ASRS Report | 194740 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial |
Experience | flight time last 90 days : 200 flight time total : 4000 flight time type : 1200 |
ASRS Report | 195504 |
Events | |
Anomaly | altitude deviation : undershoot non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Pre-departure clearance was received via printed copy along with flight plan and other flight papers. The course for departure was placed properly. The transponder code was inserted properly, but the departure clearance limit altitude was not transferred to altitude alert window correctly. 2000 ft was placed in the altitude alert window instead of the pre departure clearance message altitude limit of 4000 ft. Discovery: on departure we leveled off at 2000 ft and asked departure control for a higher altitude. Departure control then asked if we knew our departure altitude limit. We then realized something was not correct. Eventually we found the pre departure clearance message in our papers and realized our mistake. No conflict occurred. Contributing factor: hurried cockpit preparation by flight crew due to maintenance personnel having control of aircraft until about 10 mins before departure. Corrective action: I have now selected a place in the cockpit preparation flow where the pre departure clearance message (or radio delivered clearance) will be reviewed by both pilots and critical information set improper windows for departure. Also suggest the pre departure clearance message be reformatted to be more pilot user friendly, namely display the altitude first after the flight number and on a line by itself and with a line space above and below. Supplemental information from acn 195504: pilots (initial heading, altitude and squawk) are buried among other non essential verbiage. Need better format to highlight critical information since readback is no longer required.
Original NASA ASRS Text
Title: ACR MLG ALTDEV UNDERSHOT DURING CLB OUT FROM IAH.
Narrative: PRE-DEP CLRNC WAS RECEIVED VIA PRINTED COPY ALONG WITH FLT PLAN AND OTHER FLT PAPERS. THE COURSE FOR DEP WAS PLACED PROPERLY. THE TRANSPONDER CODE WAS INSERTED PROPERLY, BUT THE DEP CLRNC LIMIT ALT WAS NOT TRANSFERRED TO ALT ALERT WINDOW CORRECTLY. 2000 FT WAS PLACED IN THE ALT ALERT WINDOW INSTEAD OF THE PDC MESSAGE ALT LIMIT OF 4000 FT. DISCOVERY: ON DEP WE LEVELED OFF AT 2000 FT AND ASKED DEP CTL FOR A HIGHER ALT. DEP CTL THEN ASKED IF WE KNEW OUR DEP ALT LIMIT. WE THEN REALIZED SOMETHING WAS NOT CORRECT. EVENTUALLY WE FOUND THE PDC MESSAGE IN OUR PAPERS AND REALIZED OUR MISTAKE. NO CONFLICT OCCURRED. CONTRIBUTING FACTOR: HURRIED COCKPIT PREPARATION BY FLC DUE TO MAINT PERSONNEL HAVING CTL OF ACFT UNTIL ABOUT 10 MINS BEFORE DEP. CORRECTIVE ACTION: I HAVE NOW SELECTED A PLACE IN THE COCKPIT PREPARATION FLOW WHERE THE PDC MESSAGE (OR RADIO DELIVERED CLRNC) WILL BE REVIEWED BY BOTH PLTS AND CRITICAL INFO SET IMPROPER WINDOWS FOR DEP. ALSO SUGGEST THE PDC MESSAGE BE REFORMATTED TO BE MORE PLT USER FRIENDLY, NAMELY DISPLAY THE ALT FIRST AFTER THE FLT NUMBER AND ON A LINE BY ITSELF AND WITH A LINE SPACE ABOVE AND BELOW. SUPPLEMENTAL INFO FROM ACN 195504: PLTS (INITIAL HDG, ALT AND SQUAWK) ARE BURIED AMONG OTHER NON ESSENTIAL VERBIAGE. NEED BETTER FORMAT TO HIGHLIGHT CRITICAL INFO SINCE READBACK IS NO LONGER REQUIRED.
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.