37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 289705 |
Time | |
Date | 199411 |
Day | Mon |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : den |
State Reference | CO |
Altitude | msl bound lower : 13000 msl bound upper : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | descent other |
Route In Use | arrival : profile descent arrival other enroute airway : den |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 7200 flight time type : 600 |
ASRS Report | 289705 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Air carrier X on the descent into den and assigned to cross shrew at 17000 ft. We were then cleared for the profile descent and told to contact den approach. I told the captain I was setting 11000 ft in the MCP since the FMS was preprogrammed to cross shrew at 17000 ft. He agreed. I contacted den approach. They asked if we were on the profile descent. I responded affirmative, profile descent down to 11000 ft. There was no response, although approach control was not busy -- at least on this frequency. As we descended through about 13200 ft the controller advised that the profile descent called for us to stop at 14000 ft. At this point we were descending through 13000 ft. The controller advised us to climb back and maintain 13000 ft. We complied. I looked down at the profile descent plate and discovered my error. I had misread the plate. Coming in from the southwest required us to stop at 14000 ft, coming in from the southeast over kiowa required a descent to 11000 ft. The whole problem started with me misreading the plate. The captain had a chance to catch the mistake but was distracted with other duties. The approach controller had a chance to intervene when I said 'affirmative, profile descent down to 11000 ft,' but did not catch it. This kind of incident could be easy to avoid. Instead of giving a clearance for the profile descent, ATC should give a clearance to the altitude required by the profile. A simple 'cleared for profile descent, maintain 14000 ft' would preclude any chance of misreading the plate.
Original NASA ASRS Text
Title: ACR X ALTDEV DSCNT BELOW ASSIGNED ALT ON PROFILE DSCNT.
Narrative: ACR X ON THE DSCNT INTO DEN AND ASSIGNED TO CROSS SHREW AT 17000 FT. WE WERE THEN CLRED FOR THE PROFILE DSCNT AND TOLD TO CONTACT DEN APCH. I TOLD THE CAPT I WAS SETTING 11000 FT IN THE MCP SINCE THE FMS WAS PREPROGRAMMED TO CROSS SHREW AT 17000 FT. HE AGREED. I CONTACTED DEN APCH. THEY ASKED IF WE WERE ON THE PROFILE DSCNT. I RESPONDED AFFIRMATIVE, PROFILE DSCNT DOWN TO 11000 FT. THERE WAS NO RESPONSE, ALTHOUGH APCH CTL WAS NOT BUSY -- AT LEAST ON THIS FREQ. AS WE DSNDED THROUGH ABOUT 13200 FT THE CTLR ADVISED THAT THE PROFILE DSCNT CALLED FOR US TO STOP AT 14000 FT. AT THIS POINT WE WERE DSNDING THROUGH 13000 FT. THE CTLR ADVISED US TO CLB BACK AND MAINTAIN 13000 FT. WE COMPLIED. I LOOKED DOWN AT THE PROFILE DSCNT PLATE AND DISCOVERED MY ERROR. I HAD MISREAD THE PLATE. COMING IN FROM THE SW REQUIRED US TO STOP AT 14000 FT, COMING IN FROM THE SE OVER KIOWA REQUIRED A DSCNT TO 11000 FT. THE WHOLE PROB STARTED WITH ME MISREADING THE PLATE. THE CAPT HAD A CHANCE TO CATCH THE MISTAKE BUT WAS DISTRACTED WITH OTHER DUTIES. THE APCH CTLR HAD A CHANCE TO INTERVENE WHEN I SAID 'AFFIRMATIVE, PROFILE DSCNT DOWN TO 11000 FT,' BUT DID NOT CATCH IT. THIS KIND OF INCIDENT COULD BE EASY TO AVOID. INSTEAD OF GIVING A CLRNC FOR THE PROFILE DSCNT, ATC SHOULD GIVE A CLRNC TO THE ALT REQUIRED BY THE PROFILE. A SIMPLE 'CLRED FOR PROFILE DSCNT, MAINTAIN 14000 FT' WOULD PRECLUDE ANY CHANCE OF MISREADING THE PLATE.
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.