37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 214034 |
Time | |
Date | 199206 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : aml |
State Reference | VA |
Altitude | msl bound lower : 7400 msl bound upper : 8000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : dca tower : ama |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent other |
Route In Use | enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | government : faa |
Function | controller : approach |
Qualification | controller : radar |
Experience | controller military : 5 controller radar : 10 |
ASRS Report | 214034 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 11000 flight time type : 2500 |
ASRS Report | 214036 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude 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 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Operational Error Pilot Deviation |
Narrative:
This report concerns a fundamental breakdown of a system of checks and balances already in existance. The following concerns an altitude deviation and a missed readback by me. Typical afternoon shift working approach control into dca. Although I didn't consider workload to be anything less than moderate, review shows heavy. Made a transmission for air carrier X to descend and maintain 6000, hear air carrier Y make what I think to be initial call after handoff from iad approach. Experience told me that quite possibly air carrier Y may have misconstrued the descent as his. Had to specifically restate the descent to air carrier X being very specific talking to air carrier X. Case of too many things to do and not enough time to do it all so you prioritize in your mind what comes first. In this case air carrier X required #1 priority due to traffic. My scan is on air carrier Y data block, the mode C shows air carrier Y observed descending below assigned altitude (8000 in this case). Before I can correct this situation air carrier Y keys the microphone and asks for verification that descent to 6000 (altitude assigned air carrier X) was for him. Immediately I say negative and give him 8000 but the aircraft was shown by radar dump to have descended to 7400 ft, at the scope I believe I observed altitude to be 7100 at the lowest. Pilot tells me that he read back 6000 to which subsequent review of tape substantiates loud and clear. I missed the readback. All my planes were on the same frequency so I can't contribute it to congestion on several frequencys. Position were combined and it was warranted. Several things disturb me about this. #1 is that I missed a very clear readback from the wrong airplane. My focus was so intent on descending that for some reason all else got blocked out in my mind, but only for a split second. The business we're in makes things happen fast. Supplemental information from acn 214036: both captain and I heard approach control clearance from 8000 to 6000 ft. Captain read back descent clearance to 6000 ft, began descent when another aircraft with similar call sign called approach to confirm descent clearance. Some scattered cumulo nimbus in area, some deviating, and control becoming rather loaded up. Captain queried our descent clearance and we were told to maintain 8000 ft and that he was too busy to respond to our 'erroneous readback.' stopped descent at 7500 ft and climbed back to 8000 ft.
Original NASA ASRS Text
Title: ACR Y UNAUTHORIZED DSCNT FROM ASSIGNED ALT BECAUSE OF SIMILAR NUMBERS.
Narrative: THIS RPT CONCERNS A FUNDAMENTAL BREAKDOWN OF A SYS OF CHKS AND BALS ALREADY IN EXISTANCE. THE FOLLOWING CONCERNS AN ALTDEV AND A MISSED READBACK BY ME. TYPICAL AFTERNOON SHIFT WORKING APCH CTL INTO DCA. ALTHOUGH I DIDN'T CONSIDER WORKLOAD TO BE ANYTHING LESS THAN MODERATE, REVIEW SHOWS HVY. MADE A XMISSION FOR ACR X TO DSND AND MAINTAIN 6000, HEAR ACR Y MAKE WHAT I THINK TO BE INITIAL CALL AFTER HDOF FROM IAD APCH. EXPERIENCE TOLD ME THAT QUITE POSSIBLY ACR Y MAY HAVE MISCONSTRUED THE DSCNT AS HIS. HAD TO SPECIFICALLY RESTATE THE DSCNT TO ACR X BEING VERY SPECIFIC TALKING TO ACR X. CASE OF TOO MANY THINGS TO DO AND NOT ENOUGH TIME TO DO IT ALL SO YOU PRIORITIZE IN YOUR MIND WHAT COMES FIRST. IN THIS CASE ACR X REQUIRED #1 PRIORITY DUE TO TFC. MY SCAN IS ON ACR Y DATA BLOCK, THE MODE C SHOWS ACR Y OBSERVED DSNDING BELOW ASSIGNED ALT (8000 IN THIS CASE). BEFORE I CAN CORRECT THIS SITUATION ACR Y KEYS THE MICROPHONE AND ASKS FOR VERIFICATION THAT DSCNT TO 6000 (ALT ASSIGNED ACR X) WAS FOR HIM. IMMEDIATELY I SAY NEGATIVE AND GIVE HIM 8000 BUT THE ACFT WAS SHOWN BY RADAR DUMP TO HAVE DSNDED TO 7400 FT, AT THE SCOPE I BELIEVE I OBSERVED ALT TO BE 7100 AT THE LOWEST. PLT TELLS ME THAT HE READ BACK 6000 TO WHICH SUBSEQUENT REVIEW OF TAPE SUBSTANTIATES LOUD AND CLR. I MISSED THE READBACK. ALL MY PLANES WERE ON THE SAME FREQ SO I CAN'T CONTRIBUTE IT TO CONGESTION ON SEVERAL FREQS. POS WERE COMBINED AND IT WAS WARRANTED. SEVERAL THINGS DISTURB ME ABOUT THIS. #1 IS THAT I MISSED A VERY CLR READBACK FROM THE WRONG AIRPLANE. MY FOCUS WAS SO INTENT ON DSNDING THAT FOR SOME REASON ALL ELSE GOT BLOCKED OUT IN MY MIND, BUT ONLY FOR A SPLIT SECOND. THE BUSINESS WE'RE IN MAKES THINGS HAPPEN FAST. SUPPLEMENTAL INFO FROM ACN 214036: BOTH CAPT AND I HEARD APCH CTL CLRNC FROM 8000 TO 6000 FT. CAPT READ BACK DSCNT CLRNC TO 6000 FT, BEGAN DSCNT WHEN ANOTHER ACFT WITH SIMILAR CALL SIGN CALLED APCH TO CONFIRM DSCNT CLRNC. SOME SCATTERED CUMULO NIMBUS IN AREA, SOME DEVIATING, AND CTL BECOMING RATHER LOADED UP. CAPT QUERIED OUR DSCNT CLRNC AND WE WERE TOLD TO MAINTAIN 8000 FT AND THAT HE WAS TOO BUSY TO RESPOND TO OUR 'ERRONEOUS READBACK.' STOPPED DSCNT AT 7500 FT AND CLBED BACK TO 8000 FT.
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.