37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 218531 |
Time | |
Date | 199208 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : sfo |
State Reference | CA |
Altitude | msl bound lower : 11350 msl bound upper : 12000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
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 airway : oak |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 12000 flight time type : 1000 |
ASRS Report | 218531 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera other flight crewa |
Resolutory Action | flight crew : became reoriented flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were on the golden gate 3 arrival for sjc. The arrival (STAR) advises to expect to cross lestr intersection (6 DME northwest of sfo) at 12000 ft. The captain had entered this as our bod (bottom of descent) in the pms. We were cleared for our descent in steps. Bay approach finally cleared us to cross 6 northwest of sfo at 12000. I was operating the radios and read back 'cross 6 northwest of 12000,' then set the altitude in the alerter window and said '12000 set and armed.' the captain (PF) had the autoplt on. When we received the 12000 ft clearance, I noticed he made an entry in the pms, but as I was working the radio and setting the altitude I didn't see what he entered. About 25 northwest of the VOR I noticed we were well ahead of the normal profile. We were passing 15000 ft and the captain had selected a vertical speed descent of 3000 FPM or more. I checked the pms descent profile which said we were going to be about 7 or 8 mi long on the descent. By my calculations we were going to be at least 15 mi early (short) on arrival at 12000 ft. I remarked to the captain that the pms was confused or screwed up about the descent, because we were going to be very short the captain did not respond to my comment and seemed absorbed in monitoring the descent, constantly tweaking the rate of descent wheel. Now I was a little confused, wondering if I was wrong. I doublechked the altitude alerter to be sure 12000 was set and armed, which it was. I knew the autoplt would capture the armed altitude. As we passed 13000 ft I stated '1 to go.' as we approached 12000 ft I was closely monitoring the autoplt control panel and the captain's actions as I was not sure what he was going to do. He was once again tweaking the rate of descent wheel and I thought he was beginning the level off in an attempt to smooth the altitude capture. At 12300 ft the altitude arm light went out, because the captain inadvertently cancelled it by moving the rate of descent wheel just as it tried to capture the altitude. I immediately called out '12000 ft -- level off!' the captain spun the descent knob up and then after a short hesitation pushed 'altitude hold.' the aircraft passed through 12000 ft, descending to 11350 ft before climbing back up to 12000 ft as the captain used the rod wheel to climb and I rearmed 12000 ft in the alerter window. Approach called at that time and asked us to confirm level at 12000 ft, which we did. Once we were established at 12000 ft the captain said he had thought we were to cross 6 northwest of sfo at 6000 ft. Somehow he had got the numbers mixed up, even though the STAR clearly depicts 12000 ft. I'm sure several factors contributed to this incident. ATC using DME as a crossing fix instead of the intersection name. The more numbers in a clearance the more chance for confusion. Captain's lack of familiarity with the arrival. He admitted he prefers not to fly to the bay area and tries to bid around it and had not flown this STAR in quite a while. I should have been more aggressive in questioning what were inconsistancies in our rate of descent and the information in the pms when compared to our clearance. I should have insisted on some form of response or acknowledgement from the captain when I noticed we were well ahead of profile and at the '1000 above' call out. As it was, he was apparently so wrapped up in getting down, because he thought we were going to be high, that he didn't really hear what I was saying. Our company has a good cockpit resource management course, but all it takes is a moment or 2 of self doubt or confusion and the opportunity to clarify the situation is past.
Original NASA ASRS Text
Title: ALTDEV ALT OVERSHOT IN DSCNT.
Narrative: WE WERE ON THE GOLDEN GATE 3 ARR FOR SJC. THE ARR (STAR) ADVISES TO EXPECT TO CROSS LESTR INTXN (6 DME NW OF SFO) AT 12000 FT. THE CAPT HAD ENTERED THIS AS OUR BOD (BOTTOM OF DSCNT) IN THE PMS. WE WERE CLRED FOR OUR DSCNT IN STEPS. BAY APCH FINALLY CLRED US TO CROSS 6 NW OF SFO AT 12000. I WAS OPERATING THE RADIOS AND READ BACK 'CROSS 6 NW OF 12000,' THEN SET THE ALT IN THE ALERTER WINDOW AND SAID '12000 SET AND ARMED.' THE CAPT (PF) HAD THE AUTOPLT ON. WHEN WE RECEIVED THE 12000 FT CLRNC, I NOTICED HE MADE AN ENTRY IN THE PMS, BUT AS I WAS WORKING THE RADIO AND SETTING THE ALT I DIDN'T SEE WHAT HE ENTERED. ABOUT 25 NW OF THE VOR I NOTICED WE WERE WELL AHEAD OF THE NORMAL PROFILE. WE WERE PASSING 15000 FT AND THE CAPT HAD SELECTED A VERT SPD DSCNT OF 3000 FPM OR MORE. I CHKED THE PMS DSCNT PROFILE WHICH SAID WE WERE GOING TO BE ABOUT 7 OR 8 MI LONG ON THE DSCNT. BY MY CALCULATIONS WE WERE GOING TO BE AT LEAST 15 MI EARLY (SHORT) ON ARR AT 12000 FT. I REMARKED TO THE CAPT THAT THE PMS WAS CONFUSED OR SCREWED UP ABOUT THE DSCNT, BECAUSE WE WERE GOING TO BE VERY SHORT THE CAPT DID NOT RESPOND TO MY COMMENT AND SEEMED ABSORBED IN MONITORING THE DSCNT, CONSTANTLY TWEAKING THE RATE OF DSCNT WHEEL. NOW I WAS A LITTLE CONFUSED, WONDERING IF I WAS WRONG. I DOUBLECHKED THE ALT ALERTER TO BE SURE 12000 WAS SET AND ARMED, WHICH IT WAS. I KNEW THE AUTOPLT WOULD CAPTURE THE ARMED ALT. AS WE PASSED 13000 FT I STATED '1 TO GO.' AS WE APCHED 12000 FT I WAS CLOSELY MONITORING THE AUTOPLT CTL PANEL AND THE CAPT'S ACTIONS AS I WAS NOT SURE WHAT HE WAS GOING TO DO. HE WAS ONCE AGAIN TWEAKING THE RATE OF DSCNT WHEEL AND I THOUGHT HE WAS BEGINNING THE LEVEL OFF IN AN ATTEMPT TO SMOOTH THE ALT CAPTURE. AT 12300 FT THE ALT ARM LIGHT WENT OUT, BECAUSE THE CAPT INADVERTENTLY CANCELLED IT BY MOVING THE RATE OF DSCNT WHEEL JUST AS IT TRIED TO CAPTURE THE ALT. I IMMEDIATELY CALLED OUT '12000 FT -- LEVEL OFF!' THE CAPT SPUN THE DSCNT KNOB UP AND THEN AFTER A SHORT HESITATION PUSHED 'ALT HOLD.' THE ACFT PASSED THROUGH 12000 FT, DSNDING TO 11350 FT BEFORE CLBING BACK UP TO 12000 FT AS THE CAPT USED THE ROD WHEEL TO CLB AND I REARMED 12000 FT IN THE ALERTER WINDOW. APCH CALLED AT THAT TIME AND ASKED US TO CONFIRM LEVEL AT 12000 FT, WHICH WE DID. ONCE WE WERE ESTABLISHED AT 12000 FT THE CAPT SAID HE HAD THOUGHT WE WERE TO CROSS 6 NW OF SFO AT 6000 FT. SOMEHOW HE HAD GOT THE NUMBERS MIXED UP, EVEN THOUGH THE STAR CLRLY DEPICTS 12000 FT. I'M SURE SEVERAL FACTORS CONTRIBUTED TO THIS INCIDENT. ATC USING DME AS A XING FIX INSTEAD OF THE INTXN NAME. THE MORE NUMBERS IN A CLRNC THE MORE CHANCE FOR CONFUSION. CAPT'S LACK OF FAMILIARITY WITH THE ARR. HE ADMITTED HE PREFERS NOT TO FLY TO THE BAY AREA AND TRIES TO BID AROUND IT AND HAD NOT FLOWN THIS STAR IN QUITE A WHILE. I SHOULD HAVE BEEN MORE AGGRESSIVE IN QUESTIONING WHAT WERE INCONSISTANCIES IN OUR RATE OF DSCNT AND THE INFO IN THE PMS WHEN COMPARED TO OUR CLRNC. I SHOULD HAVE INSISTED ON SOME FORM OF RESPONSE OR ACKNOWLEDGEMENT FROM THE CAPT WHEN I NOTICED WE WERE WELL AHEAD OF PROFILE AND AT THE '1000 ABOVE' CALL OUT. AS IT WAS, HE WAS APPARENTLY SO WRAPPED UP IN GETTING DOWN, BECAUSE HE THOUGHT WE WERE GOING TO BE HIGH, THAT HE DIDN'T REALLY HEAR WHAT I WAS SAYING. OUR COMPANY HAS A GOOD COCKPIT RESOURCE MGMNT COURSE, BUT ALL IT TAKES IS A MOMENT OR 2 OF SELF DOUBT OR CONFUSION AND THE OPPORTUNITY TO CLARIFY THE SITUATION IS PAST.
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.