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37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
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Attributes | |
ACN | 276147 |
Time | |
Date | 199407 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : svo |
State Reference | FO |
Altitude | msl bound lower : 1660 msl bound upper : 5920 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : mkjk |
Operator | common carrier : air carrier |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : takeoff climbout : initial climbout : intermediate altitude |
Route In Use | departure sid : sid enroute airway : svo |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 50 flight time total : 15000 flight time type : 600 |
ASRS Report | 276147 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot altitude deviation : undershoot non adherence : published procedure non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to assigned altitude flight crew : became reoriented |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were assigned a 'buzharovo 25 delta (AR25D) departure from moscow. Initial altitude 500 meters. QFE, contact departure at 400 meters, transition altitude (ht) 900 meters, QFE 736 MM on 982 millibars. Above information broadcast on ATIS. The departure calls for a maximum climb gradient to the MM, then a right 90 degree turn, followed by a left 90 degree turn in 5 mi. There is an additional 600 meter minimum altitude requirement at the 'left 90 degree' turn. On climb out, I busted 2 altitude assignments. I make no excuses. I do, however, wish to bring this situation to light in hopes that a conflict involving the safety of aircraft is avoided. 3 items combined to create this unwanted situation: 1) QFE used in moscow (I always used qnh). 2) millibars for altitude (I always used ft). 3) difficulty understanding controllers. Events: 1) initial leveloff at 500 meters, 1660 ft. 2) assigned (during leveloff) 1200 meters, 3940 ft. During the turn, leveloff, frequency change, new altitude assignment and climb, we missed the 900 millibar transition to qne 29.92. 3) leveling at 1200 meters we were assigned 1800 meters, 5900 ft. 4) leveled at 5900 ft, set qne. We were at approximately 6900 ft. 5) assigned new altitude of 3600 meters, 3900 meters, 8600 meters without problems. Note: had we changed altimeters to 29.92 at 900 meters during climb, we would have gone from 2960 ft at 982m6 to 3880 ft at 29.92 headquarters climbing at approximately 2500 FPM to an altitude of 3940 ft (1200 meters). We were assigned a flight level 60 ft above the transition altitude -- with a 1000 ft altimeter change! I am more concerned on how to avoid this situation than I am over the fact that I encountered or caused it to occur. Noise abatement should not take priority over safety! The departure plate makes reference to ICAO annex 16 chapter 2.3 (noise abatement) as if I carried this in my flight kit! We were obviously not allowed to fly the noise abatement profile for our aircraft! ATC should never assign leveloffs at 500, 1200, 1800, 3600, 3900, 8600 meters, 1660, 3940, 5920, 11820, 12800, 28220 ft with a transition altitude of 900 meters. We are operating high performance aircraft with advanced/automated cockpits in an environment that forces us to abandon automation and revert to hand flown ADF airways. Brief, brief, brief! This is where I failed to prepare myself and my crew, and why I accept responsibility for the 2 altitude busts. I did not brief the QFE to qne altitude or the 1000 ft change we could expect! The entire event happened very quickly. At no time was the aircraft in jeopardy. Altitude changes came in rapid fire sequence. I doubt that anyone was aware of the busts. It was only upon review that we became aware of our mistakes. Yet, had there been another aircraft involved, it could be tragic. As long as the aircraft and the system we operate in are not compatible, then we as pilots must make it work. We must prepare ourselves and our crew.
Original NASA ASRS Text
Title: ACFT DEVIATES FROM 2 ASSIGNED ALTS DURING CLBOUT FROM MOSCOW, RUSSIA ARPT. LOW TRANSITION ALT AND QNE ALTIMETER SETTINGS ARE NEW TO PIC.
Narrative: WE WERE ASSIGNED A 'BUZHAROVO 25 DELTA (AR25D) DEP FROM MOSCOW. INITIAL ALT 500 METERS. QFE, CONTACT DEP AT 400 METERS, TRANSITION ALT (HT) 900 METERS, QFE 736 MM ON 982 MILLIBARS. ABOVE INFO BROADCAST ON ATIS. THE DEP CALLS FOR A MAX CLB GRADIENT TO THE MM, THEN A R 90 DEG TURN, FOLLOWED BY A L 90 DEG TURN IN 5 MI. THERE IS AN ADDITIONAL 600 METER MINIMUM ALT REQUIREMENT AT THE 'L 90 DEG' TURN. ON CLBOUT, I BUSTED 2 ALT ASSIGNMENTS. I MAKE NO EXCUSES. I DO, HOWEVER, WISH TO BRING THIS SIT TO LIGHT IN HOPES THAT A CONFLICT INVOLVING THE SAFETY OF ACFT IS AVOIDED. 3 ITEMS COMBINED TO CREATE THIS UNWANTED SIT: 1) QFE USED IN MOSCOW (I ALWAYS USED QNH). 2) MILLIBARS FOR ALT (I ALWAYS USED FT). 3) DIFFICULTY UNDERSTANDING CTLRS. EVENTS: 1) INITIAL LEVELOFF AT 500 METERS, 1660 FT. 2) ASSIGNED (DURING LEVELOFF) 1200 METERS, 3940 FT. DURING THE TURN, LEVELOFF, FREQ CHANGE, NEW ALT ASSIGNMENT AND CLB, WE MISSED THE 900 MILLIBAR TRANSITION TO QNE 29.92. 3) LEVELING AT 1200 METERS WE WERE ASSIGNED 1800 METERS, 5900 FT. 4) LEVELED AT 5900 FT, SET QNE. WE WERE AT APPROX 6900 FT. 5) ASSIGNED NEW ALT OF 3600 METERS, 3900 METERS, 8600 METERS WITHOUT PROBS. NOTE: HAD WE CHANGED ALTIMETERS TO 29.92 AT 900 METERS DURING CLB, WE WOULD HAVE GONE FROM 2960 FT AT 982M6 TO 3880 FT AT 29.92 HQ CLBING AT APPROX 2500 FPM TO AN ALT OF 3940 FT (1200 METERS). WE WERE ASSIGNED A FLT LEVEL 60 FT ABOVE THE TRANSITION ALT -- WITH A 1000 FT ALTIMETER CHANGE! I AM MORE CONCERNED ON HOW TO AVOID THIS SIT THAN I AM OVER THE FACT THAT I ENCOUNTERED OR CAUSED IT TO OCCUR. NOISE ABATEMENT SHOULD NOT TAKE PRIORITY OVER SAFETY! THE DEP PLATE MAKES REF TO ICAO ANNEX 16 CHAPTER 2.3 (NOISE ABATEMENT) AS IF I CARRIED THIS IN MY FLT KIT! WE WERE OBVIOUSLY NOT ALLOWED TO FLY THE NOISE ABATEMENT PROFILE FOR OUR ACFT! ATC SHOULD NEVER ASSIGN LEVELOFFS AT 500, 1200, 1800, 3600, 3900, 8600 METERS, 1660, 3940, 5920, 11820, 12800, 28220 FT WITH A TRANSITION ALT OF 900 METERS. WE ARE OPERATING HIGH PERFORMANCE ACFT WITH ADVANCED/AUTOMATED COCKPITS IN AN ENVIRONMENT THAT FORCES US TO ABANDON AUTOMATION AND REVERT TO HAND FLOWN ADF AIRWAYS. BRIEF, BRIEF, BRIEF! THIS IS WHERE I FAILED TO PREPARE MYSELF AND MY CREW, AND WHY I ACCEPT RESPONSIBILITY FOR THE 2 ALT BUSTS. I DID NOT BRIEF THE QFE TO QNE ALT OR THE 1000 FT CHANGE WE COULD EXPECT! THE ENTIRE EVENT HAPPENED VERY QUICKLY. AT NO TIME WAS THE ACFT IN JEOPARDY. ALT CHANGES CAME IN RAPID FIRE SEQUENCE. I DOUBT THAT ANYONE WAS AWARE OF THE BUSTS. IT WAS ONLY UPON REVIEW THAT WE BECAME AWARE OF OUR MISTAKES. YET, HAD THERE BEEN ANOTHER ACFT INVOLVED, IT COULD BE TRAGIC. AS LONG AS THE ACFT AND THE SYS WE OPERATE IN ARE NOT COMPATIBLE, THEN WE AS PLTS MUST MAKE IT WORK. WE MUST PREPARE OURSELVES AND OUR CREW.
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.