37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 348280 |
Time | |
Date | 199609 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : ewr |
State Reference | NJ |
Altitude | msl bound lower : 3000 msl bound upper : 3000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : n90 tower : dtw |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : initial |
Route In Use | 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 : 210 flight time total : 14000 flight time type : 3000 |
ASRS Report | 348280 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 200 flight time total : 10000 flight time type : 1500 |
ASRS Report | 348052 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : far non adherence : published procedure non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Altitude alert set to 3000 ft. Discussed 3000 ft initial leveloff and engine failure procedure prior to takeoff. PNF announced leaving 1000 ft climbing to 3000 ft on first contact with departure control. It wasn't until leveling at 3000 ft and controller advised cleared only to 2500 ft that we noticed deviation, and immediately descended to 2500 ft. Ewr 5 departure indicates 2500 ft for runway 4L/right, in small print and pre departure clearance. 3000 ft set in altitude alert was left from previous approach. This was a fairly quick turn around and neither crew member did a detailed review of the SID. I concentrated on the course to be flown which included an immediate turn after departure and then a 90 degree turn at 4 mi, and a low level initial attitude. There were numerous opportunities to catch this deviation before it happened, both inside the cockpit and out (ATC). Suggestions: 1) more vigilant review of SID. 2) bold lettering of altitudes on SID just like on stars. 3) enhanced hearback. 4) eliminate low altitude initial leveloff that is combined with numerous turns and nonstandard engine failure procedure.
Original NASA ASRS Text
Title: B737-300 ON EWR 3 DEP FAILED TO SET ALT ALERT TO 2500 FT. HAD LEFT 3000 FT IN THE ALERTER FROM THE ARR SEQUENCE. BRIEFING WAS CONCENTRATING ON THE ENG OUT PROC VERSUS CHKING THE SID.
Narrative: ALT ALERT SET TO 3000 FT. DISCUSSED 3000 FT INITIAL LEVELOFF AND ENG FAILURE PROC PRIOR TO TKOF. PNF ANNOUNCED LEAVING 1000 FT CLBING TO 3000 FT ON FIRST CONTACT WITH DEP CTL. IT WASN'T UNTIL LEVELING AT 3000 FT AND CTLR ADVISED CLRED ONLY TO 2500 FT THAT WE NOTICED DEV, AND IMMEDIATELY DSNDED TO 2500 FT. EWR 5 DEP INDICATES 2500 FT FOR RWY 4L/R, IN SMALL PRINT AND PDC. 3000 FT SET IN ALT ALERT WAS LEFT FROM PREVIOUS APCH. THIS WAS A FAIRLY QUICK TURN AROUND AND NEITHER CREW MEMBER DID A DETAILED REVIEW OF THE SID. I CONCENTRATED ON THE COURSE TO BE FLOWN WHICH INCLUDED AN IMMEDIATE TURN AFTER DEP AND THEN A 90 DEG TURN AT 4 MI, AND A LOW LEVEL INITIAL ATTITUDE. THERE WERE NUMEROUS OPPORTUNITIES TO CATCH THIS DEV BEFORE IT HAPPENED, BOTH INSIDE THE COCKPIT AND OUT (ATC). SUGGESTIONS: 1) MORE VIGILANT REVIEW OF SID. 2) BOLD LETTERING OF ALTS ON SID JUST LIKE ON STARS. 3) ENHANCED HEARBACK. 4) ELIMINATE LOW ALT INITIAL LEVELOFF THAT IS COMBINED WITH NUMEROUS TURNS AND NONSTANDARD ENG FAILURE PROC.
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.