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|
Attributes | |
ACN | 251857 |
Time | |
Date | 199309 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : egll |
State Reference | FO |
Altitude | msl bound lower : 31000 msl bound upper : 35000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : einn artcc : egtt artcc : eggx |
Operator | common carrier : air carrier |
Make Model Name | Widebody, Low Wing, 4 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | enroute : atlantic enroute : direct enroute : other oceanic |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : commercial pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 140 flight time total : 15000 flight time type : 3000 |
ASRS Report | 251857 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : second officer |
Qualification | pilot : instrument pilot : atp pilot : cfi pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 150 flight time total : 12000 flight time type : 900 |
ASRS Report | 251470 |
Events | |
Anomaly | altitude deviation : crossing restriction not met non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Consequence | faa : investigated |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were cruising at FL280 after departing london, england, bound for washington, dc. The captain said he was going to be off the radio #1 and on #2 to receive the oceanic clearance from shannon. I took over the communications with london and made several voice communication with london as we were being vectored. At some point the captain said 'tell them you want FL310.' I got the clearance to climb and began to climb to FL310. I could see that the captain was re-inserting waypoints on the INS and asked if we had gotten a different routing. He replied yes we now have track 'H.' the captain had the track message in his hand as he was loading the new waypoints. This is nothing that doesn't happen from time to time and many times we can't get the requested altitude so I figured FL310 was the crossing altitude since the captain had told me to ask for it with london. A few mins later london cleared us direct to 54N 15W and I asked the captain where he had loaded 5415. He said in 6 so I went present position to waypoint 6. The captain said he was 'back' so I assumed he was on the radio #1 again. There was some discussion with the engineer about an oven door that was stuck closed and if he should go back and help open it. This could have distracted the captain and me because I never heard a handoff from london to shannon control. Approaching 15W, the SELCAL went off and it was shanwick telling us to contact shannon on 127.9 VHF. We attempted several times but the frequency was so congested we could not make contact. By that time we had arrived at 15W which was our new oceanic control point at FL310. In reality we had been cleared to make the crossing at FL350. Since we had not gotten the handoff to shannon from frequency 133.6 to 127.9 we were not cleared to climb to FL350. We called shanwick back on HF and gave our position report for 15W told them we were at FL310 and were unable shannon on VHF 127.9 we crossed 15W at XA39Z. At XA47Z shanwick called back and said shannon control request to know why we did not work shannon ATC on 132.15. The captain replied that we never got the frequency change. For the next few mins, the captain tried to contact shannon on the frequency 127.9 but could not establish contact for a climb clearance. We could hear other people talking but could not make contact ourselves. Now we were approaching 20W at FL310 and realized that we were not going to get through. Shanwick called again on HF and cleared us to climb to FL350 and be level FL350 by 30W. 4 mins later, shanwick called back on HF and asked why we had not complied with our oceanic clearance, to which the captain replied that we were never cleared out of FL310. 5 mins later, shanwick called back with a message that shannon control had been trying to contact us on VHF including 121.5 and that some sort of reporting action will be taken. Lesson: make sure that all of the crew know the oceanic clearance. My policy in the future will be to have the clearance read back aloud by the crew member receiving the clearance to all the crew so that all the crew are aware of the clearance. Also, on 3-MAN aircraft, the third pilot will monitor the receiving of the clearance with the pilot actually calling for the clearance. I should have made inquiry into the clearance and who we were talking to. As soon as you receive the oceanic clearance, ask for the crossing altitude from the controling agency. Supplemental information from acn 251470: after receiving the oceanic clearance, the captain asked me if we could make FL350. I said we were too heavy at that time and would be able in a few mins. Then, ATC cleared the first officer direct to our oceanic entry point. A few mins later, a cabin crew member called with a galley oven problem. I was concerned about the oven overheating so notified the captain and requested to go take a look at the oven in the lower aft galley. Consequently, I was absent from the cockpit during most of the time of this event.
Original NASA ASRS Text
Title: ALTDEV ALT UNDERSHOT IN ACR WDB FAILURE TO MAKE ALT XING RESTRICTION.
Narrative: WE WERE CRUISING AT FL280 AFTER DEPARTING LONDON, ENGLAND, BOUND FOR WASHINGTON, DC. THE CAPT SAID HE WAS GOING TO BE OFF THE RADIO #1 AND ON #2 TO RECEIVE THE OCEANIC CLRNC FROM SHANNON. I TOOK OVER THE COMS WITH LONDON AND MADE SEVERAL VOICE COM WITH LONDON AS WE WERE BEING VECTORED. AT SOME POINT THE CAPT SAID 'TELL THEM YOU WANT FL310.' I GOT THE CLRNC TO CLB AND BEGAN TO CLB TO FL310. I COULD SEE THAT THE CAPT WAS RE-INSERTING WAYPOINTS ON THE INS AND ASKED IF WE HAD GOTTEN A DIFFERENT ROUTING. HE REPLIED YES WE NOW HAVE TRACK 'H.' THE CAPT HAD THE TRACK MESSAGE IN HIS HAND AS HE WAS LOADING THE NEW WAYPOINTS. THIS IS NOTHING THAT DOESN'T HAPPEN FROM TIME TO TIME AND MANY TIMES WE CAN'T GET THE REQUESTED ALT SO I FIGURED FL310 WAS THE XING ALT SINCE THE CAPT HAD TOLD ME TO ASK FOR IT WITH LONDON. A FEW MINS LATER LONDON CLRED US DIRECT TO 54N 15W AND I ASKED THE CAPT WHERE HE HAD LOADED 5415. HE SAID IN 6 SO I WENT PRESENT POS TO WAYPOINT 6. THE CAPT SAID HE WAS 'BACK' SO I ASSUMED HE WAS ON THE RADIO #1 AGAIN. THERE WAS SOME DISCUSSION WITH THE ENGINEER ABOUT AN OVEN DOOR THAT WAS STUCK CLOSED AND IF HE SHOULD GO BACK AND HELP OPEN IT. THIS COULD HAVE DISTRACTED THE CAPT AND ME BECAUSE I NEVER HEARD A HDOF FROM LONDON TO SHANNON CTL. APCHING 15W, THE SELCAL WENT OFF AND IT WAS SHANWICK TELLING US TO CONTACT SHANNON ON 127.9 VHF. WE ATTEMPTED SEVERAL TIMES BUT THE FREQ WAS SO CONGESTED WE COULD NOT MAKE CONTACT. BY THAT TIME WE HAD ARRIVED AT 15W WHICH WAS OUR NEW OCEANIC CTL POINT AT FL310. IN REALITY WE HAD BEEN CLRED TO MAKE THE XING AT FL350. SINCE WE HAD NOT GOTTEN THE HDOF TO SHANNON FROM FREQ 133.6 TO 127.9 WE WERE NOT CLRED TO CLB TO FL350. WE CALLED SHANWICK BACK ON HF AND GAVE OUR POS RPT FOR 15W TOLD THEM WE WERE AT FL310 AND WERE UNABLE SHANNON ON VHF 127.9 WE CROSSED 15W AT XA39Z. AT XA47Z SHANWICK CALLED BACK AND SAID SHANNON CTL REQUEST TO KNOW WHY WE DID NOT WORK SHANNON ATC ON 132.15. THE CAPT REPLIED THAT WE NEVER GOT THE FREQ CHANGE. FOR THE NEXT FEW MINS, THE CAPT TRIED TO CONTACT SHANNON ON THE FREQ 127.9 BUT COULD NOT ESTABLISH CONTACT FOR A CLB CLRNC. WE COULD HEAR OTHER PEOPLE TALKING BUT COULD NOT MAKE CONTACT OURSELVES. NOW WE WERE APCHING 20W AT FL310 AND REALIZED THAT WE WERE NOT GOING TO GET THROUGH. SHANWICK CALLED AGAIN ON HF AND CLRED US TO CLB TO FL350 AND BE LEVEL FL350 BY 30W. 4 MINS LATER, SHANWICK CALLED BACK ON HF AND ASKED WHY WE HAD NOT COMPLIED WITH OUR OCEANIC CLRNC, TO WHICH THE CAPT REPLIED THAT WE WERE NEVER CLRED OUT OF FL310. 5 MINS LATER, SHANWICK CALLED BACK WITH A MESSAGE THAT SHANNON CTL HAD BEEN TRYING TO CONTACT US ON VHF INCLUDING 121.5 AND THAT SOME SORT OF RPTING ACTION WILL BE TAKEN. LESSON: MAKE SURE THAT ALL OF THE CREW KNOW THE OCEANIC CLRNC. MY POLICY IN THE FUTURE WILL BE TO HAVE THE CLRNC READ BACK ALOUD BY THE CREW MEMBER RECEIVING THE CLRNC TO ALL THE CREW SO THAT ALL THE CREW ARE AWARE OF THE CLRNC. ALSO, ON 3-MAN ACFT, THE THIRD PLT WILL MONITOR THE RECEIVING OF THE CLRNC WITH THE PLT ACTUALLY CALLING FOR THE CLRNC. I SHOULD HAVE MADE INQUIRY INTO THE CLRNC AND WHO WE WERE TALKING TO. AS SOON AS YOU RECEIVE THE OCEANIC CLRNC, ASK FOR THE XING ALT FROM THE CTLING AGENCY. SUPPLEMENTAL INFO FROM ACN 251470: AFTER RECEIVING THE OCEANIC CLRNC, THE CAPT ASKED ME IF WE COULD MAKE FL350. I SAID WE WERE TOO HVY AT THAT TIME AND WOULD BE ABLE IN A FEW MINS. THEN, ATC CLRED THE FO DIRECT TO OUR OCEANIC ENTRY POINT. A FEW MINS LATER, A CABIN CREW MEMBER CALLED WITH A GALLEY OVEN PROB. I WAS CONCERNED ABOUT THE OVEN OVERHEATING SO NOTIFIED THE CAPT AND REQUESTED TO GO TAKE A LOOK AT THE OVEN IN THE LOWER AFT GALLEY. CONSEQUENTLY, I WAS ABSENT FROM THE COCKPIT DURING MOST OF THE TIME OF THIS EVENT.
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.