37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 294358 |
Time | |
Date | 199501 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : bae airport : mke |
State Reference | WI |
Altitude | msl bound lower : 10000 msl bound upper : 15000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zau |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | descent other |
Route In Use | enroute : direct enroute airway : zau |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : flight engineer pilot : atp pilot : commercial |
Experience | flight time last 90 days : 180 flight time total : 20000 flight time type : 1800 |
ASRS Report | 294358 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : flight engineer pilot : instrument |
Experience | flight time last 90 days : 120 flight time total : 7000 flight time type : 1200 |
ASRS Report | 294478 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance none taken : unable |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Clearance was to cross 15 DME wnw of bae VOR at 10000 ft MSL. I have done this at least 100 times in past 20 yrs. Always the same clearance, in fact I briefed crew in advance what the clearance would be. As bae VOR was not in our flight plan or INS (delco carousel) and we were cleared to the VOR, and only 75 mi from it, I did not load it in INS but went direct with the NAVAID raw data. I went present, position direct to the mke airport on the INS. So now, I have cockpit and instrument lights dim, and the INS distance to go is brighter than the VOR DME readout. I planned descent to make restr, but due to my 'diminished' mental capabilities (read complacency), I used the INS distance vice VOR DME. About 20 DME bae (clearance 5 mi to go) and 15000 ft MSL, I finally woke up to what has happening. We called ZAU and he said to do the best we could. We were advised of no traffic conflict. Cause of error was mental (complacency) all instrument and DME reading were correct-I used the wrong information displayed and naturally came up with the wrong solution. Supplemental information from acn #294478: a contributing factor was the fact that the first officer and so were in the military together, and were spending too much time telling old stories, and not enough time monitoring the descent. Even though we were above 10000 ft, the crossing restr was critical enough that we should all have been paying more attention. High reliance on INS on a regular basis led us to leave VOR DME out of our scan.
Original NASA ASRS Text
Title: ALTDEV DURING A NIGHT OP.
Narrative: CLRNC WAS TO CROSS 15 DME WNW OF BAE VOR AT 10000 FT MSL. I HAVE DONE THIS AT LEAST 100 TIMES IN PAST 20 YRS. ALWAYS THE SAME CLRNC, IN FACT I BRIEFED CREW IN ADVANCE WHAT THE CLRNC WOULD BE. AS BAE VOR WAS NOT IN OUR FLT PLAN OR INS (DELCO CAROUSEL) AND WE WERE CLRED TO THE VOR, AND ONLY 75 MI FROM IT, I DID NOT LOAD IT IN INS BUT WENT DIRECT WITH THE NAVAID RAW DATA. I WENT PRESENT, POS DIRECT TO THE MKE ARPT ON THE INS. SO NOW, I HAVE COCKPIT AND INST LIGHTS DIM, AND THE INS DISTANCE TO GO IS BRIGHTER THAN THE VOR DME READOUT. I PLANNED DSCNT TO MAKE RESTR, BUT DUE TO MY 'DIMINISHED' MENTAL CAPABILITIES (READ COMPLACENCY), I USED THE INS DISTANCE VICE VOR DME. ABOUT 20 DME BAE (CLRNC 5 MI TO GO) AND 15000 FT MSL, I FINALLY WOKE UP TO WHAT HAS HAPPENING. WE CALLED ZAU AND HE SAID TO DO THE BEST WE COULD. WE WERE ADVISED OF NO TFC CONFLICT. CAUSE OF ERROR WAS MENTAL (COMPLACENCY) ALL INST AND DME READING WERE CORRECT-I USED THE WRONG INFO DISPLAYED AND NATURALLY CAME UP WITH THE WRONG SOLUTION. SUPPLEMENTAL INFO FROM ACN #294478: A CONTRIBUTING FACTOR WAS THE FACT THAT THE FO AND SO WERE IN THE MILITARY TOGETHER, AND WERE SPENDING TOO MUCH TIME TELLING OLD STORIES, AND NOT ENOUGH TIME MONITORING THE DSCNT. EVEN THOUGH WE WERE ABOVE 10000 FT, THE XING RESTR WAS CRITICAL ENOUGH THAT WE SHOULD ALL HAVE BEEN PAYING MORE ATTN. HIGH RELIANCE ON INS ON A REGULAR BASIS LED US TO LEAVE VOR DME OUT OF OUR SCAN.
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.