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|
Attributes | |
ACN | 213932 |
Time | |
Date | 199206 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : ipt |
State Reference | PA |
Altitude | msl bound lower : 27000 msl bound upper : 29000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zny |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Flight Phase | descent other |
Flight Plan | VFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 20 flight time total : 1300 flight time type : 200 |
ASRS Report | 213932 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot conflict : airborne less severe non adherence : required legal separation non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 12000 vertical : 1000 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The flight was proceeding eastbound to ewr on a flight plan via the penns 1 arrival. Clearance was received to descend from cruise FL370 to FL240 and descent was begun. Further clearance was given to cross ipt VOR below FL270. I noted we were close enough to the ipt VOR to think a rapid descent was going to be required and had moved the thrust levers to idle and pitched the aircraft nose down concentrating on rate of descent and airspeed. There was normal bust ATC communication and some cockpit talk. I remember the first officer (PNF) said something like 'we can tell them restrictions don't apply to management pilots' and I wondered what he meant by a comment like that. The relationship had been very amiable this flight. Did he jokingly mean management pilots didn't have to follow rules or was his comment more of a chide that I wasn't doing the descent properly. I think I replied 'yeah, management pilots don't have to make restrictions.' but thinking to myself 'what's he talking about, we're going to cross ipt VOR below FL290 in time.' I don't know why I had the number 290 instead of 270 in my mind and later could not recall what had made me make such an elementary and dangerous mix-up, but FL290 was my mental target to meet the crossing clearance. Realization, and events came together rapidly when we were almost on top of the ipt VOR, and descending at more than 4000 FPM with airspeed next to the barber pole. Through FL290 when ATC queried 'are you going to make below 270?' as the first officer was responding 'no, we're passing 290,' I realized, 'damn, we were supposed to cross at 270, not 290!' ATC responded 'level off 290' to which the first officer promptly responded 'we're descending 4000 FPM.' I had begun to reverse the descent upon hearing the clearance to level. When the controller responded 'continue descent below 270, traffic 280, 12 O'clock.' I increased rate of descent again as we spotted the traffic off the nose crossing right to left. We advised ATC we had the traffic and would pass well clear. We reported passing FL270 below and clear. There is uneasy irony about this event because my primary management responsibility at my company is flight safety! I have spent considerable time and effort over the past couple of years promoting altitude awareness in publications and recommendations for procedure and practices. When I have the opportunity to fly, I take care in following the procedures and practices I know are appropriate to awareness, such as being sure to acknowledge the PNF's setting of the altitude alerter in response to ATC altitude changes. I have mentally reviewed this event over and over again but cannot remember anything that would have caused me to think '290' vs '270.' as far as corrective actions, I plan to use this event to examine techniques of awareness specifically for crossing limitations and intermediate altitude restrictions during climb and descent. In retrospect, I should not have accepted a descent clearance that was so close to performance limits. In particular, with a 100 KT tailwind.
Original NASA ASRS Text
Title: CARGO WDB FLC MISSES THE XING RESTRICTION. CREATES LTSS.
Narrative: THE FLT WAS PROCEEDING EBOUND TO EWR ON A FLT PLAN VIA THE PENNS 1 ARR. CLRNC WAS RECEIVED TO DSND FROM CRUISE FL370 TO FL240 AND DSCNT WAS BEGUN. FURTHER CLRNC WAS GIVEN TO CROSS IPT VOR BELOW FL270. I NOTED WE WERE CLOSE ENOUGH TO THE IPT VOR TO THINK A RAPID DSCNT WAS GOING TO BE REQUIRED AND HAD MOVED THE THRUST LEVERS TO IDLE AND PITCHED THE ACFT NOSE DOWN CONCENTRATING ON RATE OF DSCNT AND AIRSPD. THERE WAS NORMAL BUST ATC COM AND SOME COCKPIT TALK. I REMEMBER THE FO (PNF) SAID SOMETHING LIKE 'WE CAN TELL THEM RESTRICTIONS DON'T APPLY TO MGMNT PLTS' AND I WONDERED WHAT HE MEANT BY A COMMENT LIKE THAT. THE RELATIONSHIP HAD BEEN VERY AMIABLE THIS FLT. DID HE JOKINGLY MEAN MGMNT PLTS DIDN'T HAVE TO FOLLOW RULES OR WAS HIS COMMENT MORE OF A CHIDE THAT I WASN'T DOING THE DSCNT PROPERLY. I THINK I REPLIED 'YEAH, MGMNT PLTS DON'T HAVE TO MAKE RESTRICTIONS.' BUT THINKING TO MYSELF 'WHAT'S HE TALKING ABOUT, WE'RE GOING TO CROSS IPT VOR BELOW FL290 IN TIME.' I DON'T KNOW WHY I HAD THE NUMBER 290 INSTEAD OF 270 IN MY MIND AND LATER COULD NOT RECALL WHAT HAD MADE ME MAKE SUCH AN ELEMENTARY AND DANGEROUS MIX-UP, BUT FL290 WAS MY MENTAL TARGET TO MEET THE XING CLRNC. REALIZATION, AND EVENTS CAME TOGETHER RAPIDLY WHEN WE WERE ALMOST ON TOP OF THE IPT VOR, AND DSNDING AT MORE THAN 4000 FPM WITH AIRSPD NEXT TO THE BARBER POLE. THROUGH FL290 WHEN ATC QUERIED 'ARE YOU GOING TO MAKE BELOW 270?' AS THE FO WAS RESPONDING 'NO, WE'RE PASSING 290,' I REALIZED, 'DAMN, WE WERE SUPPOSED TO CROSS AT 270, NOT 290!' ATC RESPONDED 'LEVEL OFF 290' TO WHICH THE FO PROMPTLY RESPONDED 'WE'RE DSNDING 4000 FPM.' I HAD BEGUN TO REVERSE THE DSCNT UPON HEARING THE CLRNC TO LEVEL. WHEN THE CTLR RESPONDED 'CONTINUE DSCNT BELOW 270, TFC 280, 12 O'CLOCK.' I INCREASED RATE OF DSCNT AGAIN AS WE SPOTTED THE TFC OFF THE NOSE XING R TO L. WE ADVISED ATC WE HAD THE TFC AND WOULD PASS WELL CLR. WE RPTED PASSING FL270 BELOW AND CLR. THERE IS UNEASY IRONY ABOUT THIS EVENT BECAUSE MY PRIMARY MGMNT RESPONSIBILITY AT MY COMPANY IS FLT SAFETY! I HAVE SPENT CONSIDERABLE TIME AND EFFORT OVER THE PAST COUPLE OF YEARS PROMOTING ALT AWARENESS IN PUBLICATIONS AND RECOMMENDATIONS FOR PROC AND PRACTICES. WHEN I HAVE THE OPPORTUNITY TO FLY, I TAKE CARE IN FOLLOWING THE PROCS AND PRACTICES I KNOW ARE APPROPRIATE TO AWARENESS, SUCH AS BEING SURE TO ACKNOWLEDGE THE PNF'S SETTING OF THE ALT ALERTER IN RESPONSE TO ATC ALT CHANGES. I HAVE MENTALLY REVIEWED THIS EVENT OVER AND OVER AGAIN BUT CANNOT REMEMBER ANYTHING THAT WOULD HAVE CAUSED ME TO THINK '290' VS '270.' AS FAR AS CORRECTIVE ACTIONS, I PLAN TO USE THIS EVENT TO EXAMINE TECHNIQUES OF AWARENESS SPECIFICALLY FOR XING LIMITATIONS AND INTERMEDIATE ALT RESTRICTIONS DURING CLB AND DSCNT. IN RETROSPECT, I SHOULD NOT HAVE ACCEPTED A DSCNT CLRNC THAT WAS SO CLOSE TO PERFORMANCE LIMITS. IN PARTICULAR, WITH A 100 KT TAILWIND.
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.