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|
Attributes | |
ACN | 199560 |
Time | |
Date | 199201 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : bna |
State Reference | TN |
Altitude | msl bound lower : 10000 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : bna tower : mht |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
Flight Phase | descent other |
Route In Use | arrival other enroute airway : zme enroute airway : bna |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 192 flight time total : 12322 flight time type : 352 |
ASRS Report | 199560 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : flight engineer pilot : instrument pilot : cfi pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 5800 flight time type : 1200 |
ASRS Report | 199572 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were on 'hee haw' arrival into bna. We were cleared to cross hee haw at either 10000 ft or 11000 at 250 KTS. The arrival calls to expect 11000 at hee haw. My first officer believed we were cleared to 11000 ft and 250 KTS and set same in altitude warning window. I had in my mind that we were cleared to 10000 ft and 250 KTS. I believe I repeated back 10000 ft, but if I did it was missed by my first officer. We were cleared to start our descent late and there was some question if we could make altitude (whichever it was) and speed by hee haw. I was coming down at a high sink rate, 4000 ft 1 min, and high speed, 340 KTS. I guess we both were fixed on making altitude and speed. Me thinking 10000 ft and my first officer 11000 ft. For some reason he did not call '1000 to go' for 11000 ft and I leveled off at 10000 ft and started speed bleed to 250 KTS. At this time my first officer realizes we were at 10000 ft and said we were cleared to 11000 ft. I looked at altitude warning window and finally saw that 11000 ft was set in window. I immediately climbed back to 11000 ft. There was no conflict with other aircraft, ATC turned us over to approach and said nothing about our altitude. I still do not know if we were cleared to 10000 ft or 11000 ft. I cannot explain my failure to catch conflict between my thinking 10000 ft and first officer putting 11000 ft in altitude warning window. (I believe we did not hear altitude warning sound because of loud slipstream noise at 340 KTS.) nor can I explain failure of '1000 to go' mandatory callout. The flight engineer was calling company but there was no real excuse for me or my first officer to miss this call. I have flown for over 30 yrs and have never had an altitude 'bust' until this trip. The only thing I know to do is put more emphasis on crew coordination (altitude callouts) and be more diligent toward my profession. Callback conversation with reporter revealed the following information: reporter stated he had his first 2 altitude busts on this trip and was bothered by that fact. Said he knew the first officer was correct on the crossing restriction, just had a mind block on 10000. Other distrs of the other businesses also were weighing on his thoughts. Cockpit was noisy and coordination just broke down between him and his first officer. Supplemental information from acn 199572: cleared to cross intersection at 11000 and 250 KTS. In the descent the controller asked us to give him 310 KTS until we had to slow. There are several factors which I believe added up to this mistake. The first involves not being to this airport for over a yr and that the 98 percent of the airports I go into regularly have arrival stars being 10000 ft. The other factors include: the captain had during the course of the trip explained that he was working hard to shut down 2 other businesses that were failing and that he felt better being at work because he didn't have to think about them, however, it was the first thing on his mind when he woke up. I am also finally building my house, during a time when that 'warm secure' feeling of a future at my airline continues to be non-existent. The captain had been on the airplane only 1 month but ran the ship by the book and was competent. I personally feel that I'm the best pilot this airline has and hate it when I have an off day.
Original NASA ASRS Text
Title: ACR LGT MISSED XING RESTRICTION AT HEEHAW BY 1000 FT.
Narrative: WE WERE ON 'HEE HAW' ARR INTO BNA. WE WERE CLRED TO CROSS HEE HAW AT EITHER 10000 FT OR 11000 AT 250 KTS. THE ARR CALLS TO EXPECT 11000 AT HEE HAW. MY FO BELIEVED WE WERE CLRED TO 11000 FT AND 250 KTS AND SET SAME IN ALT WARNING WINDOW. I HAD IN MY MIND THAT WE WERE CLRED TO 10000 FT AND 250 KTS. I BELIEVE I REPEATED BACK 10000 FT, BUT IF I DID IT WAS MISSED BY MY FO. WE WERE CLRED TO START OUR DSCNT LATE AND THERE WAS SOME QUESTION IF WE COULD MAKE ALT (WHICHEVER IT WAS) AND SPD BY HEE HAW. I WAS COMING DOWN AT A HIGH SINK RATE, 4000 FT 1 MIN, AND HIGH SPD, 340 KTS. I GUESS WE BOTH WERE FIXED ON MAKING ALT AND SPD. ME THINKING 10000 FT AND MY FO 11000 FT. FOR SOME REASON HE DID NOT CALL '1000 TO GO' FOR 11000 FT AND I LEVELED OFF AT 10000 FT AND STARTED SPD BLEED TO 250 KTS. AT THIS TIME MY FO REALIZES WE WERE AT 10000 FT AND SAID WE WERE CLRED TO 11000 FT. I LOOKED AT ALT WARNING WINDOW AND FINALLY SAW THAT 11000 FT WAS SET IN WINDOW. I IMMEDIATELY CLBED BACK TO 11000 FT. THERE WAS NO CONFLICT WITH OTHER ACFT, ATC TURNED US OVER TO APCH AND SAID NOTHING ABOUT OUR ALT. I STILL DO NOT KNOW IF WE WERE CLRED TO 10000 FT OR 11000 FT. I CANNOT EXPLAIN MY FAILURE TO CATCH CONFLICT BTWN MY THINKING 10000 FT AND FO PUTTING 11000 FT IN ALT WARNING WINDOW. (I BELIEVE WE DID NOT HEAR ALT WARNING SOUND BECAUSE OF LOUD SLIPSTREAM NOISE AT 340 KTS.) NOR CAN I EXPLAIN FAILURE OF '1000 TO GO' MANDATORY CALLOUT. THE FLT ENGINEER WAS CALLING COMPANY BUT THERE WAS NO REAL EXCUSE FOR ME OR MY FO TO MISS THIS CALL. I HAVE FLOWN FOR OVER 30 YRS AND HAVE NEVER HAD AN ALT 'BUST' UNTIL THIS TRIP. THE ONLY THING I KNOW TO DO IS PUT MORE EMPHASIS ON CREW COORD (ALT CALLOUTS) AND BE MORE DILIGENT TOWARD MY PROFESSION. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED HE HAD HIS FIRST 2 ALT BUSTS ON THIS TRIP AND WAS BOTHERED BY THAT FACT. SAID HE KNEW THE FO WAS CORRECT ON THE XING RESTRICTION, JUST HAD A MIND BLOCK ON 10000. OTHER DISTRS OF THE OTHER BUSINESSES ALSO WERE WEIGHING ON HIS THOUGHTS. COCKPIT WAS NOISY AND COORD JUST BROKE DOWN BTWN HIM AND HIS FO. SUPPLEMENTAL INFO FROM ACN 199572: CLRED TO CROSS INTXN AT 11000 AND 250 KTS. IN THE DSCNT THE CTLR ASKED US TO GIVE HIM 310 KTS UNTIL WE HAD TO SLOW. THERE ARE SEVERAL FACTORS WHICH I BELIEVE ADDED UP TO THIS MISTAKE. THE FIRST INVOLVES NOT BEING TO THIS ARPT FOR OVER A YR AND THAT THE 98 PERCENT OF THE ARPTS I GO INTO REGULARLY HAVE ARR STARS BEING 10000 FT. THE OTHER FACTORS INCLUDE: THE CAPT HAD DURING THE COURSE OF THE TRIP EXPLAINED THAT HE WAS WORKING HARD TO SHUT DOWN 2 OTHER BUSINESSES THAT WERE FAILING AND THAT HE FELT BETTER BEING AT WORK BECAUSE HE DIDN'T HAVE TO THINK ABOUT THEM, HOWEVER, IT WAS THE FIRST THING ON HIS MIND WHEN HE WOKE UP. I AM ALSO FINALLY BUILDING MY HOUSE, DURING A TIME WHEN THAT 'WARM SECURE' FEELING OF A FUTURE AT MY AIRLINE CONTINUES TO BE NON-EXISTENT. THE CAPT HAD BEEN ON THE AIRPLANE ONLY 1 MONTH BUT RAN THE SHIP BY THE BOOK AND WAS COMPETENT. I PERSONALLY FEEL THAT I'M THE BEST PLT THIS AIRLINE HAS AND HATE IT WHEN I HAVE AN OFF DAY.
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.