37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 253696 |
Time | |
Date | 199310 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : bwz |
State Reference | NJ |
Altitude | msl bound lower : 7000 msl bound upper : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | descent other |
Route In Use | arrival other enroute airway : n90 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 230 flight time total : 9000 flight time type : 2500 |
ASRS Report | 253696 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : undershoot altitude deviation : crossing restriction not met non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | flight crew : became reoriented |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While descending into ewr, on the 'williamsport 1' arrival. Controller gave us clearance to cross 'sweet' intersection at 7000. It had been a long day with an AM15 check-in. By now, it was PM00 eastern and we were both feeling the effects of fatigue. The captain set 7000 in the altitude window and programmed the FMC to be at 'sweet' at 7000. I did not see if VNAV was active or if the instructions to the FMC had been executed because I had returned my gaze to the outside. 3 mi from 'sweet' the controller was about to hand us off when he asked us if we would be able to make our crossing restriction. It was only then that we realized we were still at 10000 and had not descended. In the resulting admission that we couldn't make it, and the confusion regarding why, the controller angrily informed us he had issued the clearance 30 mi back and instructed us to turn right out of the flow, then abruptly changed his instructions by turning us left and handing us off to the next controller. By this time we were passing 7500 ft in our descent and no further comment was made. While we continued to wonder why the descent did not occur as programmed, it was obvious that we had both failed to monitor the descent as we should have. Workload was not high. All the necessary company calls, approach review, etc, had been completed. Fatigue and a reduced sense of vigilance due to the time of arrival in the new york area were significant contributing factors in this instance. Lesson learned: it is especially under the above circumstances that vigilance must be maintained.
Original NASA ASRS Text
Title: ACR MISSES XING RESTRICTION. FATIGUE CLAIMED.
Narrative: WHILE DSNDING INTO EWR, ON THE 'WILLIAMSPORT 1' ARR. CTLR GAVE US CLRNC TO CROSS 'SWEET' INTXN AT 7000. IT HAD BEEN A LONG DAY WITH AN AM15 CHK-IN. BY NOW, IT WAS PM00 EASTERN AND WE WERE BOTH FEELING THE EFFECTS OF FATIGUE. THE CAPT SET 7000 IN THE ALT WINDOW AND PROGRAMMED THE FMC TO BE AT 'SWEET' AT 7000. I DID NOT SEE IF VNAV WAS ACTIVE OR IF THE INSTRUCTIONS TO THE FMC HAD BEEN EXECUTED BECAUSE I HAD RETURNED MY GAZE TO THE OUTSIDE. 3 MI FROM 'SWEET' THE CTLR WAS ABOUT TO HAND US OFF WHEN HE ASKED US IF WE WOULD BE ABLE TO MAKE OUR XING RESTRICTION. IT WAS ONLY THEN THAT WE REALIZED WE WERE STILL AT 10000 AND HAD NOT DSNDED. IN THE RESULTING ADMISSION THAT WE COULDN'T MAKE IT, AND THE CONFUSION REGARDING WHY, THE CTLR ANGRILY INFORMED US HE HAD ISSUED THE CLRNC 30 MI BACK AND INSTRUCTED US TO TURN R OUT OF THE FLOW, THEN ABRUPTLY CHANGED HIS INSTRUCTIONS BY TURNING US L AND HANDING US OFF TO THE NEXT CTLR. BY THIS TIME WE WERE PASSING 7500 FT IN OUR DSCNT AND NO FURTHER COMMENT WAS MADE. WHILE WE CONTINUED TO WONDER WHY THE DSCNT DID NOT OCCUR AS PROGRAMMED, IT WAS OBVIOUS THAT WE HAD BOTH FAILED TO MONITOR THE DSCNT AS WE SHOULD HAVE. WORKLOAD WAS NOT HIGH. ALL THE NECESSARY COMPANY CALLS, APCH REVIEW, ETC, HAD BEEN COMPLETED. FATIGUE AND A REDUCED SENSE OF VIGILANCE DUE TO THE TIME OF ARR IN THE NEW YORK AREA WERE SIGNIFICANT CONTRIBUTING FACTORS IN THIS INSTANCE. LESSON LEARNED: IT IS ESPECIALLY UNDER THE ABOVE CIRCUMSTANCES THAT VIGILANCE MUST BE MAINTAINED.
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.