37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 344040 |
Time | |
Date | 199608 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : msp |
State Reference | MN |
Altitude | msl bound lower : 5000 msl bound upper : 7300 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : msp |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude climbout : takeoff ground : preflight |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 19000 flight time type : 1700 |
ASRS Report | 344040 |
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 other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : became reoriented |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Flew inbound overnight, crews pre departure clearance outbound. We were given a 30 min report, because of short layover night before. When we arrived at operations computers and paperwork were messed up. As crew went to aircraft we were already feeling rushed. I did my preflight and then started my cockpit setup. I saw the pre departure clearance clearance laying on the pedestal and assumed captain had obtained it. The first mistake. I checked it for altitude and routing, but only looked for O'neil VOR, which was on our routing. (As bad luck would have it, we were going to denver, inbound crew, from night before, had come from denver). The captain also checked the pre departure clearance and stated later, that he assumed I had obtained it. Neither one of us ever checked it for flight number or date. I even checked the SID page for altitude and radio frequencys, but my head was so up and locked, I still didn't get or pick up on the obvious clues to help me sort it all out. Off we went, wbound, runway heading with 10000 ft in the altitude window instead of 5000 ft as was printed on SID. We of course couldn't get departure control because we had the wrong radio frequency set up and wrong transponder code. When we got it sorted out we were out of 7300 ft headed for 10000 ft. Msp immediately cleared us to 17000 ft and of course asked us to call them when we got to denver. There is a simple solution to this problem, but many subtle matters got us into the box. Our company SOP's require us, both pilots individually, to check all of the pre departure clearance or both listen to a radio clearance. As an additional back up I believe our company should add at the end of our blocks checklist a requirement to remove all paperwork from cockpit and trash it! Other things that contributed to this situation for me: 1) being rushed, 2) being tired, short layover combined with noise, poor night's sleep, 3) personal matters on my mind, my mother's health, and 4) I had been on a diet for over a month and possibly improper nutrition, while flying. In any case no professional pilot would end up doing this without several very unusual factors working against them. Murphy won this round!!
Original NASA ASRS Text
Title: ALTDEV EXCURSION FROM ASSIGNED. WRONG SID USED IN USE OF PDC PROCS. ACFT UNABLE TO ESTABLISH RADIO CONTACT WITH DEP CTL.
Narrative: FLEW INBOUND OVERNIGHT, CREWS PDC OUTBOUND. WE WERE GIVEN A 30 MIN RPT, BECAUSE OF SHORT LAYOVER NIGHT BEFORE. WHEN WE ARRIVED AT OPS COMPUTERS AND PAPERWORK WERE MESSED UP. AS CREW WENT TO ACFT WE WERE ALREADY FEELING RUSHED. I DID MY PREFLT AND THEN STARTED MY COCKPIT SETUP. I SAW THE PDC CLRNC LAYING ON THE PEDESTAL AND ASSUMED CAPT HAD OBTAINED IT. THE FIRST MISTAKE. I CHKED IT FOR ALT AND ROUTING, BUT ONLY LOOKED FOR O'NEIL VOR, WHICH WAS ON OUR ROUTING. (AS BAD LUCK WOULD HAVE IT, WE WERE GOING TO DENVER, INBOUND CREW, FROM NIGHT BEFORE, HAD COME FROM DENVER). THE CAPT ALSO CHKED THE PDC AND STATED LATER, THAT HE ASSUMED I HAD OBTAINED IT. NEITHER ONE OF US EVER CHKED IT FOR FLT NUMBER OR DATE. I EVEN CHKED THE SID PAGE FOR ALT AND RADIO FREQS, BUT MY HEAD WAS SO UP AND LOCKED, I STILL DIDN'T GET OR PICK UP ON THE OBVIOUS CLUES TO HELP ME SORT IT ALL OUT. OFF WE WENT, WBOUND, RWY HDG WITH 10000 FT IN THE ALT WINDOW INSTEAD OF 5000 FT AS WAS PRINTED ON SID. WE OF COURSE COULDN'T GET DEP CTL BECAUSE WE HAD THE WRONG RADIO FREQ SET UP AND WRONG XPONDER CODE. WHEN WE GOT IT SORTED OUT WE WERE OUT OF 7300 FT HEADED FOR 10000 FT. MSP IMMEDIATELY CLRED US TO 17000 FT AND OF COURSE ASKED US TO CALL THEM WHEN WE GOT TO DENVER. THERE IS A SIMPLE SOLUTION TO THIS PROB, BUT MANY SUBTLE MATTERS GOT US INTO THE BOX. OUR COMPANY SOP'S REQUIRE US, BOTH PLTS INDIVIDUALLY, TO CHK ALL OF THE PDC OR BOTH LISTEN TO A RADIO CLRNC. AS AN ADDITIONAL BACK UP I BELIEVE OUR COMPANY SHOULD ADD AT THE END OF OUR BLOCKS CHKLIST A REQUIREMENT TO REMOVE ALL PAPERWORK FROM COCKPIT AND TRASH IT! OTHER THINGS THAT CONTRIBUTED TO THIS SIT FOR ME: 1) BEING RUSHED, 2) BEING TIRED, SHORT LAYOVER COMBINED WITH NOISE, POOR NIGHT'S SLEEP, 3) PERSONAL MATTERS ON MY MIND, MY MOTHER'S HEALTH, AND 4) I HAD BEEN ON A DIET FOR OVER A MONTH AND POSSIBLY IMPROPER NUTRITION, WHILE FLYING. IN ANY CASE NO PROFESSIONAL PLT WOULD END UP DOING THIS WITHOUT SEVERAL VERY UNUSUAL FACTORS WORKING AGAINST THEM. MURPHY WON THIS ROUND!!
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.