37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 374336 |
Time | |
Date | 199707 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | atc facility : ltn airport : lut |
State Reference | FO |
Altitude | msl bound lower : 4000 msl bound upper : 6000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : lut |
Operator | general aviation : corporate |
Make Model Name | Gulfstream IV |
Operating Under FAR Part | Part 91 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Operating Under FAR Part | other : unknown |
Flight Plan | IFR |
Person 1 | |
Affiliation | Other |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 12000 flight time type : 1200 |
ASRS Report | 374336 |
Person 2 | |
Affiliation | Other |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 59 flight time total : 10585 flight time type : 335 |
ASRS Report | 374340 |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : crossing restriction not met conflict : airborne less severe non adherence : required legal separation non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Miss Distance | vertical : 850 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Just before holding point C1 I was issued a clearance and read back we were cleared daventry 1B. Ground said contact tower. I briefed the PF and I read the clearance from left to right, ie, at D20 dty 6000 ft D25 above 4500 ft D30 dty above 3500 ft and at D24 lon at or above 4000 ft, and I read the rest of the SID to the PF. My eyes read above and when I got to D24 lon it was at or below and not above. I put 6000 ft in the altitude select because that was the highest altitude on the SID. I selected the SID on the FMS and reviewed it to compare with the SID and it was correct. I contacted the tower for takeoff. We were cleared onto the runway and back track into position on runway 26. As we completed the turn the tower cleared us for takeoff. At 500 ft AGL the PF engaged the LNAV but VNAV was not selected inadvertently which caused the autoplt to fly to 6000 ft immediately and not level off at 4000 ft as required by the SID. The PF called for the after takeoff checklist and I was completing it when the controller called and asked what altitude we were at and I looked up from doing the checklist and replied that we were at 6000 ft. He said the SID said we were to be at 4000 ft per the SID and I said the SID said 'at or above.' he asked me to read the SID again, only to find out from the navigation display that we had not in fact passed the D24 lon 015 degree radial point yet and the SID actually said 'at or below.' I responded that he was correct and he told us to descend to 4000 ft. (The PF was already descending prior to his command.) he said I was involved in a near miss and he was filing a report with london control. The TCASII never had a RA nor indicated an aircraft near us. The controller did say an aircraft passed overhead at FL70 and we were at 6000 ft on a qnh of 1020 millibars.
Original NASA ASRS Text
Title: FLC OF A GULFSTREAM, G4, OVERSHOT ASSIGNED CLB ALT XING RESTR ON A SID DEP RESULTING IN LTSS WITH ANOTHER ACFT.
Narrative: JUST BEFORE HOLDING POINT C1 I WAS ISSUED A CLRNC AND READ BACK WE WERE CLRED DAVENTRY 1B. GND SAID CONTACT TWR. I BRIEFED THE PF AND I READ THE CLRNC FROM L TO R, IE, AT D20 DTY 6000 FT D25 ABOVE 4500 FT D30 DTY ABOVE 3500 FT AND AT D24 LON AT OR ABOVE 4000 FT, AND I READ THE REST OF THE SID TO THE PF. MY EYES READ ABOVE AND WHEN I GOT TO D24 LON IT WAS AT OR BELOW AND NOT ABOVE. I PUT 6000 FT IN THE ALT SELECT BECAUSE THAT WAS THE HIGHEST ALT ON THE SID. I SELECTED THE SID ON THE FMS AND REVIEWED IT TO COMPARE WITH THE SID AND IT WAS CORRECT. I CONTACTED THE TWR FOR TKOF. WE WERE CLRED ONTO THE RWY AND BACK TRACK INTO POS ON RWY 26. AS WE COMPLETED THE TURN THE TWR CLRED US FOR TKOF. AT 500 FT AGL THE PF ENGAGED THE LNAV BUT VNAV WAS NOT SELECTED INADVERTENTLY WHICH CAUSED THE AUTOPLT TO FLY TO 6000 FT IMMEDIATELY AND NOT LEVEL OFF AT 4000 FT AS REQUIRED BY THE SID. THE PF CALLED FOR THE AFTER TKOF CHKLIST AND I WAS COMPLETING IT WHEN THE CTLR CALLED AND ASKED WHAT ALT WE WERE AT AND I LOOKED UP FROM DOING THE CHKLIST AND REPLIED THAT WE WERE AT 6000 FT. HE SAID THE SID SAID WE WERE TO BE AT 4000 FT PER THE SID AND I SAID THE SID SAID 'AT OR ABOVE.' HE ASKED ME TO READ THE SID AGAIN, ONLY TO FIND OUT FROM THE NAV DISPLAY THAT WE HAD NOT IN FACT PASSED THE D24 LON 015 DEG RADIAL POINT YET AND THE SID ACTUALLY SAID 'AT OR BELOW.' I RESPONDED THAT HE WAS CORRECT AND HE TOLD US TO DSND TO 4000 FT. (THE PF WAS ALREADY DSNDING PRIOR TO HIS COMMAND.) HE SAID I WAS INVOLVED IN A NEAR MISS AND HE WAS FILING A RPT WITH LONDON CTL. THE TCASII NEVER HAD A RA NOR INDICATED AN ACFT NEAR US. THE CTLR DID SAY AN ACFT PASSED OVERHEAD AT FL70 AND WE WERE AT 6000 FT ON A QNH OF 1020 MILLIBARS.
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.