37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 232284 |
Time | |
Date | 199301 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : fxe |
State Reference | FL |
Altitude | msl bound lower : 3000 msl bound upper : 3500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : mia tower : fxe |
Operator | general aviation : corporate |
Make Model Name | Small Transport, Low Wing, 2 Turboprop Eng |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 70 flight time total : 3500 flight time type : 20 |
ASRS Report | 232284 |
Person 2 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | other |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
ATC Facility | procedure or policy : unspecified |
Narrative:
Received IFR clearance from fxe clearance delivery. Readback following clearance: 'radar vectors jet route 85, homme intersection, direct lbv VOR, bridge 2 arrival, 14000, 119.7.' controller stated he did not hear departure control frequency, so I repeated it '119.7.' he replied, 'readback correct.' prior to departure captain questioned assigned altitude of 14000. I indicated that that was what was assigned by the controller which seemed to satisfy his curiosity. After departure from fxe and subsequently trying to establish initial contact with miami departure informed miami that 'we were out of 3500 for 14000.' miami's reply was 'what made you think that you could climb to 14000, maintain 3000.' my reply to the controller was that we had readback the altitude instruction to the previous controller. Fortunately we were VMC at the time and it appeared as though there were no separation violations at the time. However, this situation simply shows how human communication can definitely be the weakest link in the chain of safe aircraft control. In retrospect several 'weak links' can be identified. Departure instructions are read with such speed that at times one wonders if there is a contest between the controller and pilot to see who can say the information faster. Both parties take pride in being able to receive and give information both accurately and quickly, and at times vital information is lost through either the speed or volume in which information is exchanged. In this particular circumstance the format in which I readback the departure clearance was the 'fast and dirty' approach where you readback the 'numbers' and drop the words associated with the numbers. I feel this method is too fast for the controller to adequately ensure that the numbers are a complete and accurate clearance. Also unique to this situation was a phone call between the captain and the controller who issued the clearance, upon our arrival. The captain says that the controller implicitly felt that the SID altitude restriction of 2000 ft applied in this situation without him having issued the SID as part of the IFR clearance. According to the captain the controller routinely does this because he feels that a large number of pilots do not possess a copy of the textual description of the SID. Again, this information is second-hand by way of a phone conversation which I was not a part of. However, I was a player in the actual occurrence of this specific situation, and I must say that if in fact this is the interpretation of the ATC controller involved (implicitly issuing sids without stating so) that this is a gross error on his part. Not to get sidetracked on the issue of laying blame, I feel that a remedy to this situation would include that pilots use a readback format which does not delete 'the words' from the 'numbers' during their readback of IFR clrncs.
Original NASA ASRS Text
Title: RPTR CLAIMS CLRNC DELIVERY DID NOT INCLUDE THE SID IN HIS CLRNC BUT EXPECTED HIM TO MAINTAIN 3000 FT.
Narrative: RECEIVED IFR CLRNC FROM FXE CLRNC DELIVERY. READBACK FOLLOWING CLRNC: 'RADAR VECTORS JET RTE 85, HOMME INTXN, DIRECT LBV VOR, BRIDGE 2 ARR, 14000, 119.7.' CTLR STATED HE DID NOT HEAR DEP CTL FREQ, SO I REPEATED IT '119.7.' HE REPLIED, 'READBACK CORRECT.' PRIOR TO DEP CAPT QUESTIONED ASSIGNED ALT OF 14000. I INDICATED THAT THAT WAS WHAT WAS ASSIGNED BY THE CTLR WHICH SEEMED TO SATISFY HIS CURIOSITY. AFTER DEP FROM FXE AND SUBSEQUENTLY TRYING TO ESTABLISH INITIAL CONTACT WITH MIAMI DEP INFORMED MIAMI THAT 'WE WERE OUT OF 3500 FOR 14000.' MIAMI'S REPLY WAS 'WHAT MADE YOU THINK THAT YOU COULD CLB TO 14000, MAINTAIN 3000.' MY REPLY TO THE CTLR WAS THAT WE HAD READBACK THE ALT INSTRUCTION TO THE PREVIOUS CTLR. FORTUNATELY WE WERE VMC AT THE TIME AND IT APPEARED AS THOUGH THERE WERE NO SEPARATION VIOLATIONS AT THE TIME. HOWEVER, THIS SIT SIMPLY SHOWS HOW HUMAN COM CAN DEFINITELY BE THE WEAKEST LINK IN THE CHAIN OF SAFE ACFT CTL. IN RETROSPECT SEVERAL 'WEAK LINKS' CAN BE IDENTIFIED. DEP INSTRUCTIONS ARE READ WITH SUCH SPD THAT AT TIMES ONE WONDERS IF THERE IS A CONTEST BTWN THE CTLR AND PLT TO SEE WHO CAN SAY THE INFO FASTER. BOTH PARTIES TAKE PRIDE IN BEING ABLE TO RECEIVE AND GIVE INFO BOTH ACCURATELY AND QUICKLY, AND AT TIMES VITAL INFO IS LOST THROUGH EITHER THE SPD OR VOLUME IN WHICH INFO IS EXCHANGED. IN THIS PARTICULAR CIRCUMSTANCE THE FORMAT IN WHICH I READBACK THE DEP CLRNC WAS THE 'FAST AND DIRTY' APCH WHERE YOU READBACK THE 'NUMBERS' AND DROP THE WORDS ASSOCIATED WITH THE NUMBERS. I FEEL THIS METHOD IS TOO FAST FOR THE CTLR TO ADEQUATELY ENSURE THAT THE NUMBERS ARE A COMPLETE AND ACCURATE CLRNC. ALSO UNIQUE TO THIS SIT WAS A PHONE CALL BTWN THE CAPT AND THE CTLR WHO ISSUED THE CLRNC, UPON OUR ARR. THE CAPT SAYS THAT THE CTLR IMPLICITLY FELT THAT THE SID ALT RESTRICTION OF 2000 FT APPLIED IN THIS SIT WITHOUT HIM HAVING ISSUED THE SID AS PART OF THE IFR CLRNC. ACCORDING TO THE CAPT THE CTLR ROUTINELY DOES THIS BECAUSE HE FEELS THAT A LARGE NUMBER OF PLTS DO NOT POSSESS A COPY OF THE TEXTUAL DESCRIPTION OF THE SID. AGAIN, THIS INFO IS SECOND-HAND BY WAY OF A PHONE CONVERSATION WHICH I WAS NOT A PART OF. HOWEVER, I WAS A PLAYER IN THE ACTUAL OCCURRENCE OF THIS SPECIFIC SIT, AND I MUST SAY THAT IF IN FACT THIS IS THE INTERPRETATION OF THE ATC CTLR INVOLVED (IMPLICITLY ISSUING SIDS WITHOUT STATING SO) THAT THIS IS A GROSS ERROR ON HIS PART. NOT TO GET SIDETRACKED ON THE ISSUE OF LAYING BLAME, I FEEL THAT A REMEDY TO THIS SIT WOULD INCLUDE THAT PLTS USE A READBACK FORMAT WHICH DOES NOT DELETE 'THE WORDS' FROM THE 'NUMBERS' DURING THEIR READBACK OF IFR CLRNCS.
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.