37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 241575 |
Time | |
Date | 199305 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ewr |
State Reference | NJ |
Altitude | msl bound lower : 2500 msl bound upper : 3500 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90 |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : initial |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 8200 flight time type : 3800 |
ASRS Report | 241575 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Departing ewr for mci on runway 22 SID. Initial altitude is published at 5000 ft. Pre-departure clearance is printed at gate relieving clearance deliver frequency congestion. A noise abatement test departure is in effect at ewr for 90 days changing the turn point from 3 DME to a close in 2 DME. At times, altitude is changed from 5000 ft 2500 ft. The only place this can be noted is on the pre-departure clearance. Well, the printout was not very good, ground control, and tower were extremely busy requiring increased radio vigilance along with getting all other duties done, and once we were cleared for takeoff, departure was so busy we could not check in with him until 6 NM south of the airport (unusual) and climbing through 3500 ft to level at 5000 ft. Normally, we are talking to departure control at 1000-1200 ft on handoff from tower. Well, you guessed it, our initial climb altitude was 2500, not 5000, we missed it, couldn't' confirm it with anyone and finally talked to departure control at 3500 ft! 2500 was supposedly on the pre-departure clearance, but the printing was so poor it was difficult to really determine. Departure queried us as to our clearance and my heart skipped 2 beats. Departure informed us our initial was 2500, not 5000 as we thought, and then told us our excursion was 'no problem' and issued us further climb to 10000 and 330 degree heading for vectors. Contributing factors: poor printing on pre-departure clearance. Test noise abatement concerns (tight turns). Excessively busy ground, tower, and departure frequencys. Change from the normal procedure. Mixing procedures is not a good idea. The 'test' is only done 'sometimes.' corrective action: not to place blame (some is mine), but anytime a published SID is altered i.e., altitude/heading/etc, ground or tower should be required to confirm initial altitude or, better yet, the more restrictive clearance during takeoff clearance, would really be the ideal time. This would virtually eliminate this type of occurrence and result in a safer operation. The last thing a professional pilot wants to hear is 'what altitude are you at?' or where are you going?' embarrassing? Yes. Avoidable? Yes. Catastrophic?
Original NASA ASRS Text
Title: MLG UNABLE TO READ PRE-DEP CLRNC DUE TO POOR PRINTING. EXCEEDS ALT ASSIGNED.
Narrative: DEPARTING EWR FOR MCI ON RWY 22 SID. INITIAL ALT IS PUBLISHED AT 5000 FT. PRE-DEP CLRNC IS PRINTED AT GATE RELIEVING CLRNC DELIVER FREQ CONGESTION. A NOISE ABATEMENT TEST DEP IS IN EFFECT AT EWR FOR 90 DAYS CHANGING THE TURN POINT FROM 3 DME TO A CLOSE IN 2 DME. AT TIMES, ALT IS CHANGED FROM 5000 FT 2500 FT. THE ONLY PLACE THIS CAN BE NOTED IS ON THE PRE-DEP CLRNC. WELL, THE PRINTOUT WAS NOT VERY GOOD, GND CTL, AND TWR WERE EXTREMELY BUSY REQUIRING INCREASED RADIO VIGILANCE ALONG WITH GETTING ALL OTHER DUTIES DONE, AND ONCE WE WERE CLRED FOR TKOF, DEP WAS SO BUSY WE COULD NOT CHK IN WITH HIM UNTIL 6 NM S OF THE ARPT (UNUSUAL) AND CLBING THROUGH 3500 FT TO LEVEL AT 5000 FT. NORMALLY, WE ARE TALKING TO DEP CTL AT 1000-1200 FT ON HDOF FROM TWR. WELL, YOU GUESSED IT, OUR INITIAL CLB ALT WAS 2500, NOT 5000, WE MISSED IT, COULDN'T' CONFIRM IT WITH ANYONE AND FINALLY TALKED TO DEP CTL AT 3500 FT! 2500 WAS SUPPOSEDLY ON THE PRE-DEP CLRNC, BUT THE PRINTING WAS SO POOR IT WAS DIFFICULT TO REALLY DETERMINE. DEP QUERIED US AS TO OUR CLRNC AND MY HEART SKIPPED 2 BEATS. DEP INFORMED US OUR INITIAL WAS 2500, NOT 5000 AS WE THOUGHT, AND THEN TOLD US OUR EXCURSION WAS 'NO PROB' AND ISSUED US FURTHER CLB TO 10000 AND 330 DEG HDG FOR VECTORS. CONTRIBUTING FACTORS: POOR PRINTING ON PRE-DEP CLRNC. TEST NOISE ABATEMENT CONCERNS (TIGHT TURNS). EXCESSIVELY BUSY GND, TWR, AND DEP FREQS. CHANGE FROM THE NORMAL PROC. MIXING PROCS IS NOT A GOOD IDEA. THE 'TEST' IS ONLY DONE 'SOMETIMES.' CORRECTIVE ACTION: NOT TO PLACE BLAME (SOME IS MINE), BUT ANYTIME A PUBLISHED SID IS ALTERED I.E., ALT/HDG/ETC, GND OR TWR SHOULD BE REQUIRED TO CONFIRM INITIAL ALT OR, BETTER YET, THE MORE RESTRICTIVE CLRNC DURING TKOF CLRNC, WOULD REALLY BE THE IDEAL TIME. THIS WOULD VIRTUALLY ELIMINATE THIS TYPE OF OCCURRENCE AND RESULT IN A SAFER OP. THE LAST THING A PROFESSIONAL PLT WANTS TO HEAR IS 'WHAT ALT ARE YOU AT?' OR WHERE ARE YOU GOING?' EMBARRASSING? YES. AVOIDABLE? YES. CATASTROPHIC?
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.