37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 196056 |
Time | |
Date | 199112 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : oak |
State Reference | CA |
Altitude | msl bound lower : 2000 msl bound upper : 2300 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : oak artcc : zbw |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : initial |
Route In Use | departure sid : sid enroute airway : sfo |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : flight engineer pilot : commercial pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 8000 flight time type : 1200 |
ASRS Report | 196056 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 200 flight time total : 15000 flight time type : 500 |
ASRS Report | 196006 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot conflict : airborne less severe non adherence : clearance non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Flight was cleared oakland 4 departure off runway 29. The procedure was discussed twice by the crew using the chart as a reference. Both times the procedure was read as cross the oak 4 DME at or above 2000 ft. Upon handoff to bay departure the controller asked if we were aware of the 4 DME restriction. We answered yes, at or above 2000 ft at 4 DME. He replied no sir the restriction is at or below 2000 ft at 4 DME. Upon further review we discovered our error. On the previous leg from sea-oak the departure procedure called for crossing 5 DME at or above 3000 ft. I guess we both suffered from wishful reading! Supplemental information from acn 196006: after takeoff, we were advised by departure control and observed traffic at 3000 ft crossing over our flight path. I slowed our rate of climb and asked my first officer to verify the crossing restriction but by this time we had cleared the traffic and were leaving 2000 ft. We were questioned by departure control if we were aware of the restriction. There was some distraction during preflight due to a maintenance problem and perhaps because many such restrictions are to 'cross at or above' it was possible to 'misread' what was clearly read! A possible safeguard in this case would have been for the tower to remind departures of the restrictions as they often do when a possible traffic conflict could arise.
Original NASA ASRS Text
Title: FLC MISREADS XING RESTRICTION AS 'AT OR ABOVE' INSTEAD OF 'AT OR BELOW'. ALTDEV.
Narrative: FLT WAS CLRED OAKLAND 4 DEP OFF RWY 29. THE PROC WAS DISCUSSED TWICE BY THE CREW USING THE CHART AS A REF. BOTH TIMES THE PROC WAS READ AS CROSS THE OAK 4 DME AT OR ABOVE 2000 FT. UPON HDOF TO BAY DEP THE CTLR ASKED IF WE WERE AWARE OF THE 4 DME RESTRICTION. WE ANSWERED YES, AT OR ABOVE 2000 FT AT 4 DME. HE REPLIED NO SIR THE RESTRICTION IS AT OR BELOW 2000 FT AT 4 DME. UPON FURTHER REVIEW WE DISCOVERED OUR ERROR. ON THE PREVIOUS LEG FROM SEA-OAK THE DEP PROC CALLED FOR XING 5 DME AT OR ABOVE 3000 FT. I GUESS WE BOTH SUFFERED FROM WISHFUL READING! SUPPLEMENTAL INFO FROM ACN 196006: AFTER TKOF, WE WERE ADVISED BY DEP CTL AND OBSERVED TFC AT 3000 FT XING OVER OUR FLT PATH. I SLOWED OUR RATE OF CLB AND ASKED MY FO TO VERIFY THE XING RESTRICTION BUT BY THIS TIME WE HAD CLRED THE TFC AND WERE LEAVING 2000 FT. WE WERE QUESTIONED BY DEP CTL IF WE WERE AWARE OF THE RESTRICTION. THERE WAS SOME DISTR DURING PREFLT DUE TO A MAINT PROBLEM AND PERHAPS BECAUSE MANY SUCH RESTRICTIONS ARE TO 'CROSS AT OR ABOVE' IT WAS POSSIBLE TO 'MISREAD' WHAT WAS CLRLY READ! A POSSIBLE SAFEGUARD IN THIS CASE WOULD HAVE BEEN FOR THE TWR TO REMIND DEPS OF THE RESTRICTIONS AS THEY OFTEN DO WHEN A POSSIBLE TFC CONFLICT COULD ARISE.
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.