37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 380396 |
Time | |
Date | 199709 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : ywt |
State Reference | ON |
Altitude | msl bound lower : 13000 msl bound upper : 13000 |
Environment | |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : czyz |
Operator | common carrier : air carrier |
Make Model Name | MD-80 Super 80 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other |
Flight Phase | descent other |
Route In Use | arrival : profile descent arrival other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 380396 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
ASRS Report | 380560 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | other controllera |
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:
Prior to descent into yyz pulled up ACARS WX and winds favored a runway 6L or runway 6R approach. Pulled out descent profile runways 6L/right and reviewed it with first officer. During descent controller gave us runway 24 profile descent and it didn't register so I failed to change arrival page. So instead of being southwest of ywt between 14000 ft and 12000 ft we should have been at ywt between 17000 ft and 13000 ft. Descending through 13000 ft center said cleared to 11000 ft and that was profile runway 24 descent. His subtle hint made us realize our mistake. He made no other comments and TCASII showed no conflicts. We quickly changed and flew the runway 24 profile descent from there. Our preplanning set us up for this mistake, plus the fact I have been in there 3 previous times recently -- all to runway 6 arrs. This is also one of the few (the only one I could find) with different arrs to different runways on separate pages. Possibly adding a warning statement on the commercial chart under notes or a caution heading on the profile under special procedures to emphasize these different arrival pages for each runway, as opposed to different named approachs that we are used to, might help someone else from a similar mistake. I will definitely be aware of their separate arrs from now on.
Original NASA ASRS Text
Title: AN ACR MD80 FLC USED THE WRONG PROFILE DSCNT INTO YYZ AND CROSSED A DSCNT FIX TOO LOW. THE ARTCC CTLR GENTLY CORRECTED THEM. THE FLC COMPLAIN ABOUT THE USE OF RWY SPECIFIC PROFILES, ON DIFFERENT PAGES, FOR THE SAME APCH NAME.
Narrative: PRIOR TO DSCNT INTO YYZ PULLED UP ACARS WX AND WINDS FAVORED A RWY 6L OR RWY 6R APCH. PULLED OUT DSCNT PROFILE RWYS 6L/R AND REVIEWED IT WITH FO. DURING DSCNT CTLR GAVE US RWY 24 PROFILE DSCNT AND IT DIDN'T REGISTER SO I FAILED TO CHANGE ARR PAGE. SO INSTEAD OF BEING SW OF YWT BTWN 14000 FT AND 12000 FT WE SHOULD HAVE BEEN AT YWT BTWN 17000 FT AND 13000 FT. DSNDING THROUGH 13000 FT CTR SAID CLRED TO 11000 FT AND THAT WAS PROFILE RWY 24 DSCNT. HIS SUBTLE HINT MADE US REALIZE OUR MISTAKE. HE MADE NO OTHER COMMENTS AND TCASII SHOWED NO CONFLICTS. WE QUICKLY CHANGED AND FLEW THE RWY 24 PROFILE DSCNT FROM THERE. OUR PREPLANNING SET US UP FOR THIS MISTAKE, PLUS THE FACT I HAVE BEEN IN THERE 3 PREVIOUS TIMES RECENTLY -- ALL TO RWY 6 ARRS. THIS IS ALSO ONE OF THE FEW (THE ONLY ONE I COULD FIND) WITH DIFFERENT ARRS TO DIFFERENT RWYS ON SEPARATE PAGES. POSSIBLY ADDING A WARNING STATEMENT ON THE COMMERCIAL CHART UNDER NOTES OR A CAUTION HDG ON THE PROFILE UNDER SPECIAL PROCS TO EMPHASIZE THESE DIFFERENT ARR PAGES FOR EACH RWY, AS OPPOSED TO DIFFERENT NAMED APCHS THAT WE ARE USED TO, MIGHT HELP SOMEONE ELSE FROM A SIMILAR MISTAKE. I WILL DEFINITELY BE AWARE OF THEIR SEPARATE ARRS FROM NOW ON.
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.