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|
Attributes | |
ACN | 359230 |
Time | |
Date | 199701 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sac |
State Reference | CA |
Altitude | msl bound lower : 20000 msl bound upper : 22000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | artcc : zoa |
Operator | general aviation : corporate |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | Part 91 |
Navigation In Use | Other Other |
Flight Phase | cruise other descent other |
Route In Use | arrival other enroute : on vectors |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : instrument pilot : commercial pilot : cfi |
Experience | flight time last 90 days : 42 flight time total : 5350 flight time type : 80 |
ASRS Report | 359230 |
Person 2 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : instrument pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 52 flight time total : 2954 flight time type : 80 |
ASRS Report | 359233 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : published procedure non adherence : far non adherence : clearance other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other controllera |
Resolutory Action | controller : issued new clearance flight crew : took evasive action |
Consequence | Other |
Miss Distance | horizontal : 5140 vertical : 5000 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation Operational Deviation |
Narrative:
We were on a part 91 flight to our destination. The purpose of our flight was a return trip after successfully passing a far 135.297, 135.299 flight check with an FAA inspector. I was flying as first officer on this leg of our flight. Our aircraft was cleared direct to our destination and to climb and maintain FL220. When approaching the destination area we asked for lower altitude. The center controller advised us to turn left to 250 degrees and maintain FL220. The controller additionally reported opposite direction traffic that I reported we had in sight. The following events took place next. I began running the descent checklist, and was proceeding to set up the aircraft for the instrument approach to our destination. As I looked up to the flight instruments I noticed our aircraft was descending from FL220 with FL200 set into the altitude select. I asked the captain if we were cleared to FL200 and the captain replied yes. Our aircraft had the traffic on TCASII and we also had visual contact with the traffic. The controller asked us what altitude we were at, and I replied level at FL200. After clearing the traffic, we were instructed to turn right on course and issued a descent clearance to 14000 ft, our aircraft landed and we immediately telephoned the center ATC manager to discuss the situation. I believe that several factors were involved with this situation that included a breakdown of CRM. We, as a crew, were very fatigued after completing 2 separate chkrides in actual WX conditions that included some 9 actual IFR/IMC approachs. Our crew was by no means unsafe, but simply tired. The lesson our crew learned reaffirms the necessity for CRM and to confirm critical instructions such as altitudes and headings, etc. Supplemental information from acn 359233: departing for the return flight home, the flight crew received an IFR clearance: direct (310 degrees), climb and maintain FL220. The WX was clear (50 NM) above the fog layer. Ete was 30 mins. At 40 NM to destination airport, the flight crew realized that we had not been handed off to ZOA (the ARTCC for the area). After contact with ATC was finally established, the PNF requested a lower altitude for the descent. The aircraft was still level at FL220 and now only 25 NM from the destination airport. ATC apologized for the discrepancy and issued a delay vector, left turn 250 degrees, and in my (the PF) opinion, heard a descent clearance to and maintain FL200. The descent and vector by ATC placed the aircraft into oncoming traffic (B737) climbing through FL200.
Original NASA ASRS Text
Title: POTENTIAL CONFLICT. LTT IN ALTDEV ALT EXCURSION. OPPOSITE DIRECTION CLBING TFC.
Narrative: WE WERE ON A PART 91 FLT TO OUR DEST. THE PURPOSE OF OUR FLT WAS A RETURN TRIP AFTER SUCCESSFULLY PASSING A FAR 135.297, 135.299 FLT CHK WITH AN FAA INSPECTOR. I WAS FLYING AS FO ON THIS LEG OF OUR FLT. OUR ACFT WAS CLRED DIRECT TO OUR DEST AND TO CLB AND MAINTAIN FL220. WHEN APCHING THE DEST AREA WE ASKED FOR LOWER ALT. THE CTR CTLR ADVISED US TO TURN L TO 250 DEGS AND MAINTAIN FL220. THE CTLR ADDITIONALLY RPTED OPPOSITE DIRECTION TFC THAT I RPTED WE HAD IN SIGHT. THE FOLLOWING EVENTS TOOK PLACE NEXT. I BEGAN RUNNING THE DSCNT CHKLIST, AND WAS PROCEEDING TO SET UP THE ACFT FOR THE INST APCH TO OUR DEST. AS I LOOKED UP TO THE FLT INSTS I NOTICED OUR ACFT WAS DSNDING FROM FL220 WITH FL200 SET INTO THE ALT SELECT. I ASKED THE CAPT IF WE WERE CLRED TO FL200 AND THE CAPT REPLIED YES. OUR ACFT HAD THE TFC ON TCASII AND WE ALSO HAD VISUAL CONTACT WITH THE TFC. THE CTLR ASKED US WHAT ALT WE WERE AT, AND I REPLIED LEVEL AT FL200. AFTER CLRING THE TFC, WE WERE INSTRUCTED TO TURN R ON COURSE AND ISSUED A DSCNT CLRNC TO 14000 FT, OUR ACFT LANDED AND WE IMMEDIATELY TELEPHONED THE CTR ATC MGR TO DISCUSS THE SIT. I BELIEVE THAT SEVERAL FACTORS WERE INVOLVED WITH THIS SIT THAT INCLUDED A BREAKDOWN OF CRM. WE, AS A CREW, WERE VERY FATIGUED AFTER COMPLETING 2 SEPARATE CHKRIDES IN ACTUAL WX CONDITIONS THAT INCLUDED SOME 9 ACTUAL IFR/IMC APCHS. OUR CREW WAS BY NO MEANS UNSAFE, BUT SIMPLY TIRED. THE LESSON OUR CREW LEARNED REAFFIRMS THE NECESSITY FOR CRM AND TO CONFIRM CRITICAL INSTRUCTIONS SUCH AS ALTS AND HDGS, ETC. SUPPLEMENTAL INFO FROM ACN 359233: DEPARTING FOR THE RETURN FLT HOME, THE FLC RECEIVED AN IFR CLRNC: DIRECT (310 DEGS), CLB AND MAINTAIN FL220. THE WX WAS CLR (50 NM) ABOVE THE FOG LAYER. ETE WAS 30 MINS. AT 40 NM TO DEST ARPT, THE FLC REALIZED THAT WE HAD NOT BEEN HANDED OFF TO ZOA (THE ARTCC FOR THE AREA). AFTER CONTACT WITH ATC WAS FINALLY ESTABLISHED, THE PNF REQUESTED A LOWER ALT FOR THE DSCNT. THE ACFT WAS STILL LEVEL AT FL220 AND NOW ONLY 25 NM FROM THE DEST ARPT. ATC APOLOGIZED FOR THE DISCREPANCY AND ISSUED A DELAY VECTOR, L TURN 250 DEGS, AND IN MY (THE PF) OPINION, HEARD A DSCNT CLRNC TO AND MAINTAIN FL200. THE DSCNT AND VECTOR BY ATC PLACED THE ACFT INTO ONCOMING TFC (B737) CLBING THROUGH FL200.
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.