37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 352919 |
Time | |
Date | 199611 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : ont |
State Reference | CA |
Altitude | msl bound lower : 4000 msl bound upper : 5000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : ont |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Super 80 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
ASRS Report | 352919 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 352920 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot non adherence : clearance non adherence : published procedure other anomaly other |
Independent Detector | other flight crewa |
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:
Pre departure clearance clearance was prado 5 departure maintain 7000 ft. Tower cleared us for takeoff runway 26R. At approximately 1000 ft AGL with no tower contact or handoff to socal departure, we continued on runway heading. Both the captain and I thought we had heard fly runway heading but didn't feel extremely confident about it. We switched to departure and questioned the heading. Socal acknowledged radar contact and said we should be turning toward pdz VOR. I was hand flying the aircraft in IMC conditions and immediately initiated a hard turn back toward the VOR and continued the climb to level at the 4000 ft 6 DME crossing restr. This had been an extremely busy couple of mins since takeoff with the low ceiling and visibility, noise abatement climb profile and the inter cockpit confusion resulting from no contact with tower after takeoff. As a result of these distractions I realized I had leveled off at 4000 ft on my altimeter and 5000 ft MSL. We had been too busy to reset altimeters in the climb and because field elevation is 984 ft all altimeter needles were aligned at 12 O'clock position. When we briefed the departure at the gate we set the altitude selector at 7000 ft resulting no warning for the error I made. The heavy workload and confusion were definitely factors but I felt confident as a result of a thorough pre-departure briefing. What I will do differently in the future is always set altitude select to crossing altitudes on a SID just as I would on an approach. Also confirm departure instructions with tower prior to takeoff roll.
Original NASA ASRS Text
Title: MD80S ACFT CLRED FOR SID DEP, FLC CONFUSED ON PROC TO FOLLOW EXPECTING CTLR TO TELL THEM WHAT TO DO. ACFT LEVELED 1000 FT LOW DUE TO ACR PROC OF SETTING 1 ALTIMETER TO QNH AND 1 TO QNE. ALSO, CLRNC HAD BEEN RECEIVED TO 7000 FT AND FLC FAILED TO SET INTERMEDIATE RESTR ALTS IN ALT ALERT.
Narrative: PDC CLRNC WAS PRADO 5 DEP MAINTAIN 7000 FT. TWR CLRED US FOR TKOF RWY 26R. AT APPROX 1000 FT AGL WITH NO TWR CONTACT OR HDOF TO SOCAL DEP, WE CONTINUED ON RWY HEADING. BOTH THE CAPT AND I THOUGHT WE HAD HEARD FLY RWY HEADING BUT DIDN'T FEEL EXTREMELY CONFIDENT ABOUT IT. WE SWITCHED TO DEP AND QUESTIONED THE HEADING. SOCAL ACKNOWLEDGED RADAR CONTACT AND SAID WE SHOULD BE TURNING TOWARD PDZ VOR. I WAS HAND FLYING THE ACFT IN IMC CONDITIONS AND IMMEDIATELY INITIATED A HARD TURN BACK TOWARD THE VOR AND CONTINUED THE CLB TO LEVEL AT THE 4000 FT 6 DME XING RESTR. THIS HAD BEEN AN EXTREMELY BUSY COUPLE OF MINS SINCE TKOF WITH THE LOW CEILING AND VISIBILITY, NOISE ABATEMENT CLB PROFILE AND THE INTER COCKPIT CONFUSION RESULTING FROM NO CONTACT WITH TWR AFTER TKOF. AS A RESULT OF THESE DISTRACTIONS I REALIZED I HAD LEVELED OFF AT 4000 FT ON MY ALTIMETER AND 5000 FT MSL. WE HAD BEEN TOO BUSY TO RESET ALTIMETERS IN THE CLB AND BECAUSE FIELD ELEVATION IS 984 FT ALL ALTIMETER NEEDLES WERE ALIGNED AT 12 O'CLOCK POS. WHEN WE BRIEFED THE DEP AT THE GATE WE SET THE ALT SELECTOR AT 7000 FT RESULTING NO WARNING FOR THE ERROR I MADE. THE HVY WORKLOAD AND CONFUSION WERE DEFINITELY FACTORS BUT I FELT CONFIDENT AS A RESULT OF A THOROUGH PRE-DEP BRIEFING. WHAT I WILL DO DIFFERENTLY IN THE FUTURE IS ALWAYS SET ALT SELECT TO XING ALTS ON A SID JUST AS I WOULD ON AN APCH. ALSO CONFIRM DEP INSTRUCTIONS WITH TWR PRIOR TO TKOF ROLL.
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.