37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 320590 |
Time | |
Date | 199511 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : slc |
State Reference | UT |
Altitude | msl bound lower : 15000 msl bound upper : 16000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
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 other arrival star : star enroute airway : zlc |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 180 flight time total : 11500 flight time type : 1700 |
ASRS Report | 320590 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The spane 1 is a new arrival at the slc airport. It became effective nov/xx/95 and coincided with the opening of the new runway 34L/16R. I read the arrival several times to make sure I understood it. Each time, I somehow missed the expect 11000 ft at fairfield (ffu), after the cross at 16000 ft at spane. I even programmed the FMS with 11000 ft at ffu. After spane, I continued the descent until ZLC called and asked about our altitude (15000 ft and descending), and told us to level at 15000 ft while he called approach control. There was no conflict and ZLC switched us over to approach control. Approach then cleared us to intercept localizer for runway 34R and descend to 11000 ft. The remainder of the flight was uneventful. Well, I never thought I'd make a mistake like this! From my perspective the 3 largest contributing factors: 1) I did not realize it at the time, but I had a mindset that this arrival was going to finally give us a good descent into slc. I thought 'yeah, that 11000 ft over ffu is going to work great.' 2) as a part of the above mindset, I looked at the spane 1 as more of a profile descent which it is not. 3) having 'expect' altitudes (2 different ones: 11000 ft and 15000 ft) after 'cross at' altitudes (2 different ones: 16000 ft and 19000 ft) contributes to the problem. The phrasing 'expect to cross at...' is a real problem if you miss the 'expect.' please just use 'expect 11000 ft,' not 'expect to cross at 11000 ft,' especially if it's coming after a hard (cross at) altitude.
Original NASA ASRS Text
Title: IN ANTICIPATION OF CONTINUED DSCNT, FLC OF AN LGT FAILED TO MAINTAIN A XING ALT.
Narrative: THE SPANE 1 IS A NEW ARR AT THE SLC ARPT. IT BECAME EFFECTIVE NOV/XX/95 AND COINCIDED WITH THE OPENING OF THE NEW RWY 34L/16R. I READ THE ARR SEVERAL TIMES TO MAKE SURE I UNDERSTOOD IT. EACH TIME, I SOMEHOW MISSED THE EXPECT 11000 FT AT FAIRFIELD (FFU), AFTER THE CROSS AT 16000 FT AT SPANE. I EVEN PROGRAMMED THE FMS WITH 11000 FT AT FFU. AFTER SPANE, I CONTINUED THE DSCNT UNTIL ZLC CALLED AND ASKED ABOUT OUR ALT (15000 FT AND DSNDING), AND TOLD US TO LEVEL AT 15000 FT WHILE HE CALLED APCH CTL. THERE WAS NO CONFLICT AND ZLC SWITCHED US OVER TO APCH CTL. APCH THEN CLRED US TO INTERCEPT LOC FOR RWY 34R AND DSND TO 11000 FT. THE REMAINDER OF THE FLT WAS UNEVENTFUL. WELL, I NEVER THOUGHT I'D MAKE A MISTAKE LIKE THIS! FROM MY PERSPECTIVE THE 3 LARGEST CONTRIBUTING FACTORS: 1) I DID NOT REALIZE IT AT THE TIME, BUT I HAD A MINDSET THAT THIS ARR WAS GOING TO FINALLY GIVE US A GOOD DSCNT INTO SLC. I THOUGHT 'YEAH, THAT 11000 FT OVER FFU IS GOING TO WORK GREAT.' 2) AS A PART OF THE ABOVE MINDSET, I LOOKED AT THE SPANE 1 AS MORE OF A PROFILE DSCNT WHICH IT IS NOT. 3) HAVING 'EXPECT' ALTS (2 DIFFERENT ONES: 11000 FT AND 15000 FT) AFTER 'CROSS AT' ALTS (2 DIFFERENT ONES: 16000 FT AND 19000 FT) CONTRIBUTES TO THE PROB. THE PHRASING 'EXPECT TO CROSS AT...' IS A REAL PROB IF YOU MISS THE 'EXPECT.' PLEASE JUST USE 'EXPECT 11000 FT,' NOT 'EXPECT TO CROSS AT 11000 FT,' ESPECIALLY IF IT'S COMING AFTER A HARD (CROSS AT) ALT.
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.