37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 278791 |
Time | |
Date | 199407 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : fak |
State Reference | VA |
Altitude | agl bound lower : 27000 agl bound upper : 33000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | cruise other |
Route In Use | enroute : direct |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 210 flight time total : 16000 flight time type : 1700 |
ASRS Report | 278791 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 12000 flight time type : 1400 |
ASRS Report | 278794 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : clearance 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:
Tpa-iad FL330 received clearance to cross 85 south fak at FL270. First officer (PF) entered 65 mi into FMC. I (captain PNF) did not double check. About time we were to start descent, controller asked if we had received above clearance. I replied affirmative and the controller replied 'you missed it.' we started down and were handed off to next sector where controller told us there was no conflicting traffic. Contributing factors: 2 hour delay at tpa acct local WX. Numerous deviations acct WX in north fl and south GA. Many international connections aboard. PNF busy coordinating with flight attendant with iad airborne gate controller. This greatly reduced PNF backup/support role. This put PF into PNF duties. PF got ATIS and long list of NOTAMS including runway 1R of questionable legality. This workload saturation, combined with lack of double check by PNF, resulted in human error. In retrospect, I (captain and PNF) should have told flight attendant to forget connections. I effectively failed to prioritize although it was not a conscious decision. Further complication: because first officer, PF was an excellent and thorough pilot, I allowed my backup xchk to slip. Air carrier constantly preaches 'fly the plane first.' however, I tend to consider that in the lower altitude structure and/or involving irregularities. That admonition is now reinforced for all aspects of this environment. Finally, this is a function of 2 pilot versus 3 pilot workload. Had a flight engine been involved with misconnect details, I am confident this would not have occurred. For the future, passenger service will be a casualty of 2 pilot crews.
Original NASA ASRS Text
Title: ALT XING RESTR NOT MET.
Narrative: TPA-IAD FL330 RECEIVED CLRNC TO CROSS 85 S FAK AT FL270. FO (PF) ENTERED 65 MI INTO FMC. I (CAPT PNF) DID NOT DOUBLE CHK. ABOUT TIME WE WERE TO START DSCNT, CTLR ASKED IF WE HAD RECEIVED ABOVE CLRNC. I REPLIED AFFIRMATIVE AND THE CTLR REPLIED 'YOU MISSED IT.' WE STARTED DOWN AND WERE HANDED OFF TO NEXT SECTOR WHERE CTLR TOLD US THERE WAS NO CONFLICTING TFC. CONTRIBUTING FACTORS: 2 HR DELAY AT TPA ACCT LCL WX. NUMEROUS DEVS ACCT WX IN N FL AND S GA. MANY INTL CONNECTIONS ABOARD. PNF BUSY COORDINATING WITH FLT ATTENDANT WITH IAD AIRBORNE GATE CTLR. THIS GREATLY REDUCED PNF BACKUP/SUPPORT ROLE. THIS PUT PF INTO PNF DUTIES. PF GOT ATIS AND LONG LIST OF NOTAMS INCLUDING RWY 1R OF QUESTIONABLE LEGALITY. THIS WORKLOAD SATURATION, COMBINED WITH LACK OF DOUBLE CHK BY PNF, RESULTED IN HUMAN ERROR. IN RETROSPECT, I (CAPT AND PNF) SHOULD HAVE TOLD FLT ATTENDANT TO FORGET CONNECTIONS. I EFFECTIVELY FAILED TO PRIORITIZE ALTHOUGH IT WAS NOT A CONSCIOUS DECISION. FURTHER COMPLICATION: BECAUSE FO, PF WAS AN EXCELLENT AND THOROUGH PLT, I ALLOWED MY BACKUP XCHK TO SLIP. ACR CONSTANTLY PREACHES 'FLY THE PLANE FIRST.' HOWEVER, I TEND TO CONSIDER THAT IN THE LOWER ALT STRUCTURE AND/OR INVOLVING IRREGULARITIES. THAT ADMONITION IS NOW REINFORCED FOR ALL ASPECTS OF THIS ENVIRONMENT. FINALLY, THIS IS A FUNCTION OF 2 PLT VERSUS 3 PLT WORKLOAD. HAD A FLT ENG BEEN INVOLVED WITH MISCONNECT DETAILS, I AM CONFIDENT THIS WOULD NOT HAVE OCCURRED. FOR THE FUTURE, PAX SVC WILL BE A CASUALTY OF 2 PLT CREWS.
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.