37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 299508 |
Time | |
Date | 199503 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ewr |
State Reference | NJ |
Altitude | msl bound lower : 2500 msl bound upper : 3200 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : ewr tower : mia |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : commercial pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 13000 flight time type : 1400 |
ASRS Report | 299508 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : undershoot conflict : airborne less severe non adherence : clearance other spatial deviation |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : took evasive action other |
Consequence | Other |
Miss Distance | horizontal : 2000 vertical : 600 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Our flight was cleared for a SID off runway 22. It required us to turn to a 190 degree heading after takeoff for 3 NM and then turn back to a 220 degree heading for vectors to assigned routing. The pictorial SID directed us to climb to 5000 ft, but ATC clearance modified that to a 2500 ft level off. The departure SID uses the active ILS DME to identify the 3 NM fix to commence the turn to a 220 degree heading. In order to receive the ILS DME in our aircraft, the frequency has to be dialed in on the common ILS head and then the 'approach mode' has to be selected on the EFIS control panel located directly in front of the pilot. The ILS DME will then be displayed in the lower l-hand corner of the primary flight display (pfd). When this was done, I noticed that the DME was not displayed. The first officer and I discussed this situation at the gate. We tried to display the DME on both sides, but to no avail. I the opted to put the 3 NM fix into the FMS. I briefed the SID to the first officer, talking through the procedures I was going to follow. I then put the 3 NM fix into the FMS using the airport identifier, bearing and distance. Somehow, in reading and discussing the SID at the gate I flipped- flopped in my mind that the 220 degree heading was to come first. Therefore, it was entered into the FMS incorrectly. The 'pbd' in the FMS was discussed with my first officer, and he did not detect the error while viewing his navigation display (nd). My first officer is relatively new in the aircraft, but I consider him to be extremely capable pilot and very attentive in performing his duties. We performed our takeoff and I maintained a 220 degree heading although 190 degree heading was predialed in on the fmp. I was manually flying the aircraft with the autothrottles engaged (light weight takeoff). At about 2 NM to go to the turn point, the first officer asked me if I wanted the new heading to be selected (190 degree heading predialed). I said, 'yes,' but I was still locked on to flying a 220 degree heading. Everything was happening fast with the airplane rapidly approaching our 2500 ft level off and also changing to departure control at the same time. The first officer was preoccupied with monitoring the level off and switching frequencys. So, the first officer did not pickup on me not turning to 190 degree heading. While beginning my level off and thinking now I have to turn, departure controller then clears us to a 230 degree heading and 6000 ft. The first officer acknowledges and reconfigures the fmp. I am now reoriented to a visual search of the airspace ahead of the airplane. Suddenly, the previous aircraft departure, whose destination was to the northwest, is now within my windscreen view and, in my estimation, I am heading on a collision course. I immediately stopped the climb and then realized that might not be enough. I then began a push over at about 3200 ft to a lower altitude, approximately 2500 ft. The TCASII was set only to the TA position per our flight operating manual. We received a TA alert at about the same time I began my evasive action. The departure controller realized we were on a collision course. The controller immediately ordered a heading change (voice stressed) to a 180 degree heading. We complied immediately before answering. We then informed the ATC controller we had the other aircraft in sight. When the controller heard the transmission, the voice became more normal. At that time, we then continued our climb to 6000 ft. Retrospect, I can see all the human errors of my crew and of the ATC controller, and not one of us picking up on it until it was almost too late. You can practice the best cockpit resources management techniques, but that will not save you if you do not have your brain engaged. This incident was a culmination of errors that could have led to a very serious accident. Very fortunately, I was doing 1 thing right, and that was, I maintained my visual scan during VMC conditions.
Original NASA ASRS Text
Title: CAPT OF AN MLG FAILED TO TURN AFTER TKOF TO ASSIGNED HDG AND THEN SUBSEQUENTLY OVERSHOT CLB ALT RESULTING IN A CONFLICT WITH ANOTHER ACFT.
Narrative: OUR FLT WAS CLRED FOR A SID OFF RWY 22. IT REQUIRED US TO TURN TO A 190 DEG HDG AFTER TKOF FOR 3 NM AND THEN TURN BACK TO A 220 DEG HDG FOR VECTORS TO ASSIGNED ROUTING. THE PICTORIAL SID DIRECTED US TO CLB TO 5000 FT, BUT ATC CLRNC MODIFIED THAT TO A 2500 FT LEVEL OFF. THE DEP SID USES THE ACTIVE ILS DME TO IDENT THE 3 NM FIX TO COMMENCE THE TURN TO A 220 DEG HDG. IN ORDER TO RECEIVE THE ILS DME IN OUR ACFT, THE FREQ HAS TO BE DIALED IN ON THE COMMON ILS HEAD AND THEN THE 'APCH MODE' HAS TO BE SELECTED ON THE EFIS CTL PANEL LOCATED DIRECTLY IN FRONT OF THE PLT. THE ILS DME WILL THEN BE DISPLAYED IN THE LOWER L-HAND CORNER OF THE PRIMARY FLT DISPLAY (PFD). WHEN THIS WAS DONE, I NOTICED THAT THE DME WAS NOT DISPLAYED. THE FO AND I DISCUSSED THIS SIT AT THE GATE. WE TRIED TO DISPLAY THE DME ON BOTH SIDES, BUT TO NO AVAIL. I THE OPTED TO PUT THE 3 NM FIX INTO THE FMS. I BRIEFED THE SID TO THE FO, TALKING THROUGH THE PROCS I WAS GOING TO FOLLOW. I THEN PUT THE 3 NM FIX INTO THE FMS USING THE ARPT IDENTIFIER, BEARING AND DISTANCE. SOMEHOW, IN READING AND DISCUSSING THE SID AT THE GATE I FLIPPED- FLOPPED IN MY MIND THAT THE 220 DEG HDG WAS TO COME FIRST. THEREFORE, IT WAS ENTERED INTO THE FMS INCORRECTLY. THE 'PBD' IN THE FMS WAS DISCUSSED WITH MY FO, AND HE DID NOT DETECT THE ERROR WHILE VIEWING HIS NAV DISPLAY (ND). MY FO IS RELATIVELY NEW IN THE ACFT, BUT I CONSIDER HIM TO BE EXTREMELY CAPABLE PLT AND VERY ATTENTIVE IN PERFORMING HIS DUTIES. WE PERFORMED OUR TKOF AND I MAINTAINED A 220 DEG HDG ALTHOUGH 190 DEG HDG WAS PREDIALED IN ON THE FMP. I WAS MANUALLY FLYING THE ACFT WITH THE AUTOTHROTTLES ENGAGED (LIGHT WT TKOF). AT ABOUT 2 NM TO GO TO THE TURN POINT, THE FO ASKED ME IF I WANTED THE NEW HDG TO BE SELECTED (190 DEG HDG PREDIALED). I SAID, 'YES,' BUT I WAS STILL LOCKED ON TO FLYING A 220 DEG HDG. EVERYTHING WAS HAPPENING FAST WITH THE AIRPLANE RAPIDLY APCHING OUR 2500 FT LEVEL OFF AND ALSO CHANGING TO DEP CTL AT THE SAME TIME. THE FO WAS PREOCCUPIED WITH MONITORING THE LEVEL OFF AND SWITCHING FREQS. SO, THE FO DID NOT PICKUP ON ME NOT TURNING TO 190 DEG HDG. WHILE BEGINNING MY LEVEL OFF AND THINKING NOW I HAVE TO TURN, DEP CTLR THEN CLRS US TO A 230 DEG HDG AND 6000 FT. THE FO ACKNOWLEDGES AND RECONFIGURES THE FMP. I AM NOW REORIENTED TO A VISUAL SEARCH OF THE AIRSPACE AHEAD OF THE AIRPLANE. SUDDENLY, THE PREVIOUS ACFT DEP, WHOSE DEST WAS TO THE NW, IS NOW WITHIN MY WINDSCREEN VIEW AND, IN MY ESTIMATION, I AM HDG ON A COLLISION COURSE. I IMMEDIATELY STOPPED THE CLB AND THEN REALIZED THAT MIGHT NOT BE ENOUGH. I THEN BEGAN A PUSH OVER AT ABOUT 3200 FT TO A LOWER ALT, APPROX 2500 FT. THE TCASII WAS SET ONLY TO THE TA POS PER OUR FLT OPERATING MANUAL. WE RECEIVED A TA ALERT AT ABOUT THE SAME TIME I BEGAN MY EVASIVE ACTION. THE DEP CTLR REALIZED WE WERE ON A COLLISION COURSE. THE CTLR IMMEDIATELY ORDERED A HDG CHANGE (VOICE STRESSED) TO A 180 DEG HDG. WE COMPLIED IMMEDIATELY BEFORE ANSWERING. WE THEN INFORMED THE ATC CTLR WE HAD THE OTHER ACFT IN SIGHT. WHEN THE CTLR HEARD THE XMISSION, THE VOICE BECAME MORE NORMAL. AT THAT TIME, WE THEN CONTINUED OUR CLB TO 6000 FT. RETROSPECT, I CAN SEE ALL THE HUMAN ERRORS OF MY CREW AND OF THE ATC CTLR, AND NOT ONE OF US PICKING UP ON IT UNTIL IT WAS ALMOST TOO LATE. YOU CAN PRACTICE THE BEST COCKPIT RESOURCES MGMNT TECHNIQUES, BUT THAT WILL NOT SAVE YOU IF YOU DO NOT HAVE YOUR BRAIN ENGAGED. THIS INCIDENT WAS A CULMINATION OF ERRORS THAT COULD HAVE LED TO A VERY SERIOUS ACCIDENT. VERY FORTUNATELY, I WAS DOING 1 THING RIGHT, AND THAT WAS, I MAINTAINED MY VISUAL SCAN DURING VMC CONDITIONS.
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.