37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 362470 |
Time | |
Date | 199703 |
Day | Wed |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | atc facility : bwz airport : ewr |
State Reference | NJ |
Altitude | msl bound lower : 8700 msl bound upper : 9000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : n90 tracon : pbi |
Operator | common carrier : air carrier |
Make Model Name | DC-10 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | cruise other |
Route In Use | enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : commercial pilot : flight engineer pilot : atp pilot : private |
Experience | flight time last 90 days : 100 flight time total : 15000 flight time type : 1500 |
ASRS Report | 362470 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : private pilot : cfi pilot : commercial pilot : flight engineer |
Experience | flight time last 90 days : 60 flight time total : 10000 flight time type : 350 |
ASRS Report | 362303 |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : far non adherence : published procedure |
Independent Detector | other controllera other flight crewa |
Resolutory Action | 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:
Level flight at 9000 ft MSL in terminal area. I was captain, first officer was flying. Our flight number was abc. Aircraft about 6-8 mi ahead, same company, similar flight number (abd). ATC cleared flight abd to 3000 ft. I was trying to tune and identify localizer and NDB for approach. I looked up and saw first officer had vacated 9000 ft as he said to me 'set 3000 ft in altitude alerter.' at this time we were descending through about 8700 ft. Just then ATC called and said 'abc maintain 9000 ft.' I immediately directed first officer to climb as rapidly as possible back to 9000 ft. I never heard a clearance to 3000 ft. First officer said he did. So didn't. Because first officer began descent without anyone acknowledging a descent clearance, we never gave ATC a chance to tell us that the call was for abd. We have a very specific procedure to follow regarding setting the altitude alerter, but the procedure takes 2 people and must be followed correctly for it to prevent this type of incident. When the PF 'shoots from the hip' and begins a descent without following the procedure, without an acknowledgement call to ATC with a readback, he's taking 2 other crew members out of the loop. Contributing factors: 1) similar call signs. Our company has similar calls signs into and out of most hubs. 2) fatigue. Left oak at XA00 local/arrival ewr XF30. Previous rest in oak XA00-XN00. Previous duty period ewr- oak XA30 local to XA00 local (7 hours 30 mins duty). 3) first officer fairly new in DC10 and fairly new as first officer. 4) first officer ex-military fighter pilot. Used to 'doing his own thing' -- not really used to utilizing a full crew. 5) brand new so pretty much 'out of the loop.'
Original NASA ASRS Text
Title: DC10 CARGO MAINTAINING 9000 FT. FO, PF, COPIED CLRNC TO DSND TO 3000 FT FOR A SIMILAR COMPANY CALL SIGN. CTLR QUERIED ALT AT SAME TIME CAPT QUESTIONED THE DSCNT. RETURNED TO ALT, NO CONFLICT.
Narrative: LEVEL FLT AT 9000 FT MSL IN TERMINAL AREA. I WAS CAPT, FO WAS FLYING. OUR FLT NUMBER WAS ABC. ACFT ABOUT 6-8 MI AHEAD, SAME COMPANY, SIMILAR FLT NUMBER (ABD). ATC CLRED FLT ABD TO 3000 FT. I WAS TRYING TO TUNE AND IDENT LOC AND NDB FOR APCH. I LOOKED UP AND SAW FO HAD VACATED 9000 FT AS HE SAID TO ME 'SET 3000 FT IN ALT ALERTER.' AT THIS TIME WE WERE DSNDING THROUGH ABOUT 8700 FT. JUST THEN ATC CALLED AND SAID 'ABC MAINTAIN 9000 FT.' I IMMEDIATELY DIRECTED FO TO CLB AS RAPIDLY AS POSSIBLE BACK TO 9000 FT. I NEVER HEARD A CLRNC TO 3000 FT. FO SAID HE DID. SO DIDN'T. BECAUSE FO BEGAN DSCNT WITHOUT ANYONE ACKNOWLEDGING A DSCNT CLRNC, WE NEVER GAVE ATC A CHANCE TO TELL US THAT THE CALL WAS FOR ABD. WE HAVE A VERY SPECIFIC PROC TO FOLLOW REGARDING SETTING THE ALT ALERTER, BUT THE PROC TAKES 2 PEOPLE AND MUST BE FOLLOWED CORRECTLY FOR IT TO PREVENT THIS TYPE OF INCIDENT. WHEN THE PF 'SHOOTS FROM THE HIP' AND BEGINS A DSCNT WITHOUT FOLLOWING THE PROC, WITHOUT AN ACKNOWLEDGEMENT CALL TO ATC WITH A READBACK, HE'S TAKING 2 OTHER CREW MEMBERS OUT OF THE LOOP. CONTRIBUTING FACTORS: 1) SIMILAR CALL SIGNS. OUR COMPANY HAS SIMILAR CALLS SIGNS INTO AND OUT OF MOST HUBS. 2) FATIGUE. LEFT OAK AT XA00 LCL/ARR EWR XF30. PREVIOUS REST IN OAK XA00-XN00. PREVIOUS DUTY PERIOD EWR- OAK XA30 LCL TO XA00 LCL (7 HRS 30 MINS DUTY). 3) FO FAIRLY NEW IN DC10 AND FAIRLY NEW AS FO. 4) FO EX-MIL FIGHTER PLT. USED TO 'DOING HIS OWN THING' -- NOT REALLY USED TO UTILIZING A FULL CREW. 5) BRAND NEW SO PRETTY MUCH 'OUT OF THE LOOP.'
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.