37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 211875 |
Time | |
Date | 199206 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : bsy airport : mia |
State Reference | FL |
Altitude | agl bound lower : 22000 agl bound upper : 24000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zma |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | descent other |
Route In Use | arrival other arrival star : star enroute other |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | cruise other descent other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 98 flight time total : 12000 flight time type : 191 |
ASRS Report | 211875 |
Person 2 | |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude conflict : airborne less severe non adherence : required legal separation non adherence : clearance non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course other |
Consequence | faa : investigated |
Miss Distance | horizontal : 20000 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Situations | |
Publication | Unspecified |
Narrative:
We were subsequently cleared to proceed direct heatt when able, and were cleared a heatt 1 STAR. I do not believe that any altitude was specified at this time. I acknowledged that we were cleared direct heatt when able but do not recall acknowledging the heatt 1 STAR at that time. Sometime later the first officer, who was PF, queried me as to whether the clearance for the heatt 1 STAR also constituted a clearance to 16000 ft. I looked at the restriction box next to heatt intersection on my STAR heatt 1 chart (see attached), noted the highlighted 16000 and 250 KTS for landing east, but being unsure as to whether I had acknowledged the heatt 1 STAR clearance, I asked the first officer to stand by while I verified the clearance. I believe I then asked ATC to confirm we had been cleared a heatt 1 arrival, direct heatt when able. ATC confirmed this clearance and asked if we were able to proceed direct heatt. I believe that I replied in the negative but that we would be able direct heatt once we descended below the overhang and it was at this time that 16000 ft was selected and confirmed on the FCU. There was at least one more query by ATC as to whether we could proceed direct heatt, but I cannot recall if it was prior to, or after the ATC exchanges regarding our descent through FL240. ATC initiated that series of exchanges by calling us as we were descending through approximately FL230. To the best of my recollection, the exchange was as follows. 'Air carrier 1 reclred to FL240.' I looked at the first officer, reached for the FCU altitude select knob, and responded; 'confirm air carrier 1 cleared to FL240?' I believe the response was 'air carrier 2 maintain FL240.' to which I replied, 'confirm air carrier to maintain FL240?' ATC then confirmed 'affirmative, air carrier 1 maintain level 240.' I acknowledged, but before 240 could be selected and pulled, ATC asked us what our present level was. I responded we were just out of level 220. ATC then cleared us to maintain FL220 and further exchanges were made to clarify whether we had received a clearance to an altitude other than FL240. I replied negative and by this time the first officer had rechked his STAR chart and confirmed with me that the 16000 ft was an expected altitude only. ATC expressed the same advice and I acknowledged that descent through FL240 had been our error. I received a phone number to call, phone number, when we got on the ground which I subsequently did. I discussed the incident with the ATC shift supervisor who was reviewing the tapes at that time. He advised me that they would be filing a report and that a NASA ASRS report was required on my part. He asked me if I felt that we had been misled by the controller at any time, and I replied no, not directly and that it appeared to be our misreading of the STAR chart which caused our continued descent and loss of separation with, I believe, an large transport on descent into miami behind us. He advised me that our horizontal separation had been about 3.2 NM when we passed through large transport's altitude. Reviewing the events since the incident, I've asked myself countless times how both of us could have misread the STAR chart and descended through a cleared altitude, particularly since we had discussed the STAR prior to descent and referred to the written text which states: turbojets landing east: expect clearance to cross heatt intersection at 16000 and 250 KTS. Capitals are not mine.
Original NASA ASRS Text
Title: AN ENGLISH SPEAKING FOREIGN LGT AIR CREW DSNDED THROUGH THEIR ASSIGNED ALT ON THE HEATT STAR INTO MIAMI.
Narrative: WE WERE SUBSEQUENTLY CLRED TO PROCEED DIRECT HEATT WHEN ABLE, AND WERE CLRED A HEATT 1 STAR. I DO NOT BELIEVE THAT ANY ALT WAS SPECIFIED AT THIS TIME. I ACKNOWLEDGED THAT WE WERE CLRED DIRECT HEATT WHEN ABLE BUT DO NOT RECALL ACKNOWLEDGING THE HEATT 1 STAR AT THAT TIME. SOMETIME LATER THE FO, WHO WAS PF, QUERIED ME AS TO WHETHER THE CLRNC FOR THE HEATT 1 STAR ALSO CONSTITUTED A CLRNC TO 16000 FT. I LOOKED AT THE RESTRICTION BOX NEXT TO HEATT INTXN ON MY STAR HEATT 1 CHART (SEE ATTACHED), NOTED THE HIGHLIGHTED 16000 AND 250 KTS FOR LNDG E, BUT BEING UNSURE AS TO WHETHER I HAD ACKNOWLEDGED THE HEATT 1 STAR CLRNC, I ASKED THE FO TO STAND BY WHILE I VERIFIED THE CLRNC. I BELIEVE I THEN ASKED ATC TO CONFIRM WE HAD BEEN CLRED A HEATT 1 ARR, DIRECT HEATT WHEN ABLE. ATC CONFIRMED THIS CLRNC AND ASKED IF WE WERE ABLE TO PROCEED DIRECT HEATT. I BELIEVE THAT I REPLIED IN THE NEGATIVE BUT THAT WE WOULD BE ABLE DIRECT HEATT ONCE WE DSNDED BELOW THE OVERHANG AND IT WAS AT THIS TIME THAT 16000 FT WAS SELECTED AND CONFIRMED ON THE FCU. THERE WAS AT LEAST ONE MORE QUERY BY ATC AS TO WHETHER WE COULD PROCEED DIRECT HEATT, BUT I CANNOT RECALL IF IT WAS PRIOR TO, OR AFTER THE ATC EXCHANGES REGARDING OUR DSCNT THROUGH FL240. ATC INITIATED THAT SERIES OF EXCHANGES BY CALLING US AS WE WERE DSNDING THROUGH APPROX FL230. TO THE BEST OF MY RECOLLECTION, THE EXCHANGE WAS AS FOLLOWS. 'ACR 1 RECLRED TO FL240.' I LOOKED AT THE FO, REACHED FOR THE FCU ALT SELECT KNOB, AND RESPONDED; 'CONFIRM ACR 1 CLRED TO FL240?' I BELIEVE THE RESPONSE WAS 'ACR 2 MAINTAIN FL240.' TO WHICH I REPLIED, 'CONFIRM ACR TO MAINTAIN FL240?' ATC THEN CONFIRMED 'AFFIRMATIVE, ACR 1 MAINTAIN LEVEL 240.' I ACKNOWLEDGED, BUT BEFORE 240 COULD BE SELECTED AND PULLED, ATC ASKED US WHAT OUR PRESENT LEVEL WAS. I RESPONDED WE WERE JUST OUT OF LEVEL 220. ATC THEN CLRED US TO MAINTAIN FL220 AND FURTHER EXCHANGES WERE MADE TO CLARIFY WHETHER WE HAD RECEIVED A CLRNC TO AN ALT OTHER THAN FL240. I REPLIED NEGATIVE AND BY THIS TIME THE FO HAD RECHKED HIS STAR CHART AND CONFIRMED WITH ME THAT THE 16000 FT WAS AN EXPECTED ALT ONLY. ATC EXPRESSED THE SAME ADVICE AND I ACKNOWLEDGED THAT DSCNT THROUGH FL240 HAD BEEN OUR ERROR. I RECEIVED A PHONE NUMBER TO CALL, PHONE NUMBER, WHEN WE GOT ON THE GND WHICH I SUBSEQUENTLY DID. I DISCUSSED THE INCIDENT WITH THE ATC SHIFT SUPVR WHO WAS REVIEWING THE TAPES AT THAT TIME. HE ADVISED ME THAT THEY WOULD BE FILING A RPT AND THAT A NASA ASRS RPT WAS REQUIRED ON MY PART. HE ASKED ME IF I FELT THAT WE HAD BEEN MISLED BY THE CTLR AT ANY TIME, AND I REPLIED NO, NOT DIRECTLY AND THAT IT APPEARED TO BE OUR MISREADING OF THE STAR CHART WHICH CAUSED OUR CONTINUED DSCNT AND LOSS OF SEPARATION WITH, I BELIEVE, AN LGT ON DSCNT INTO MIAMI BEHIND US. HE ADVISED ME THAT OUR HORIZ SEPARATION HAD BEEN ABOUT 3.2 NM WHEN WE PASSED THROUGH LGT'S ALT. REVIEWING THE EVENTS SINCE THE INCIDENT, I'VE ASKED MYSELF COUNTLESS TIMES HOW BOTH OF US COULD HAVE MISREAD THE STAR CHART AND DSNDED THROUGH A CLRED ALT, PARTICULARLY SINCE WE HAD DISCUSSED THE STAR PRIOR TO DSCNT AND REFERRED TO THE WRITTEN TEXT WHICH STATES: TURBOJETS LNDG E: EXPECT CLRNC TO CROSS HEATT INTXN AT 16000 AND 250 KTS. CAPITALS ARE NOT MINE.
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.