37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 395150 |
Time | |
Date | 199802 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : brv |
State Reference | VA |
Altitude | msl bound lower : 10000 msl bound upper : 11000 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tower : apf |
Operator | common carrier : air carrier |
Make Model Name | B737-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise other descent other |
Route In Use | arrival other arrival star : star enroute airway : zdc |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : flight engineer |
ASRS Report | 395150 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : cfi pilot : atp |
ASRS Report | 395084 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Intra Facility Coordination Failure other |
Narrative:
While on coatt 3 arrival into iad we were told to expect falko at 10000 ft and 250 KTS. We were at FL190. Frequency change issued by ZDC, captain flying aircraft. First officer attempted to check in on new frequency. No answer. Went back to old frequency and asked for new frequency. Switched and checked in. At this time we were approximately 15 NM south of falko. Issued clearance to cross falko at 10000 ft and 250 KTS. 11100 was dialed into window to initially begin descent. Noticed we were close to falko, descent rate increased to 4000-5000 FPM. At this point 11000 was dialed into window and we crossed falko at 11000 ft, 250 KTS. Bottom line: late clearance assignment to cross falko 10000 ft, 250 KTS. Frequency swap during descent with unsuccessful check in. Extremely high workload event where first officer was unable to adequately monitor captain and captain made mistake of 11000 ft vice 10000 ft. The late altitude clearance assignment combined with multiple aircraft talking to center when we changed over significantly contributing to event. Event occurred on 4TH day of 4 day trip worth 25 hours block time on duty at event = approximately 8 hours. Supplemental information from acn 395084: first officer attempted to check in on new frequency. No answer initially then was told wrong frequency, return to original where we were told the frequency was for someone else. After a few more mi, when we had already begun to slow down for the pending descent and we were approximately 15 NM south of falko. Center issued a clearance to cross falko at 10000 ft and 250 KTS. Immediately following the descent clearance, center issued another frequency change and the first officer switched frequencys, checked in, got a valid altimeter setting and ran the descent checklist. At this point first officer noticed 11100 ft in the altitude window and reset it 11000 ft thinking it was just missed by 100 ft instead of 1100 ft. The most significant factor was the late clearance to descend and the subsequent frequency change which resulted in a slam dunk descent and an extremely high workload environment within a compressed time frame and distance. Next time, I won't accept such a rushed clearance.
Original NASA ASRS Text
Title: B737-200 ACFT ON STAR WAS ISSUED A FREQ CHANGE THAT WAS INCORRECT, SO FLC WENT BACK TO PREVIOUS FREQ AND WAS ISSUED CORRECT ONE. WHEN CHKING IN THEY WERE CLRED TO CROSS INTXN 15 MI AWAY REQUIRING A DSCNT OF 9000 FT AND SLOW TO 250 KTS. LATE CLRNC AND INCREASED WORKLOAD TO MAKE XING CONTRIBUTED TO FLC NOT MAKING RESTR, PLUS THE ALT WINDOW HAD BEEN SET INCORRECTLY.
Narrative: WHILE ON COATT 3 ARR INTO IAD WE WERE TOLD TO EXPECT FALKO AT 10000 FT AND 250 KTS. WE WERE AT FL190. FREQ CHANGE ISSUED BY ZDC, CAPT FLYING ACFT. FO ATTEMPTED TO CHK IN ON NEW FREQ. NO ANSWER. WENT BACK TO OLD FREQ AND ASKED FOR NEW FREQ. SWITCHED AND CHKED IN. AT THIS TIME WE WERE APPROX 15 NM S OF FALKO. ISSUED CLRNC TO CROSS FALKO AT 10000 FT AND 250 KTS. 11100 WAS DIALED INTO WINDOW TO INITIALLY BEGIN DSCNT. NOTICED WE WERE CLOSE TO FALKO, DSCNT RATE INCREASED TO 4000-5000 FPM. AT THIS POINT 11000 WAS DIALED INTO WINDOW AND WE CROSSED FALKO AT 11000 FT, 250 KTS. BOTTOM LINE: LATE CLRNC ASSIGNMENT TO CROSS FALKO 10000 FT, 250 KTS. FREQ SWAP DURING DSCNT WITH UNSUCCESSFUL CHK IN. EXTREMELY HIGH WORKLOAD EVENT WHERE FO WAS UNABLE TO ADEQUATELY MONITOR CAPT AND CAPT MADE MISTAKE OF 11000 FT VICE 10000 FT. THE LATE ALT CLRNC ASSIGNMENT COMBINED WITH MULTIPLE ACFT TALKING TO CTR WHEN WE CHANGED OVER SIGNIFICANTLY CONTRIBUTING TO EVENT. EVENT OCCURRED ON 4TH DAY OF 4 DAY TRIP WORTH 25 HRS BLOCK TIME ON DUTY AT EVENT = APPROX 8 HRS. SUPPLEMENTAL INFO FROM ACN 395084: FO ATTEMPTED TO CHK IN ON NEW FREQ. NO ANSWER INITIALLY THEN WAS TOLD WRONG FREQ, RETURN TO ORIGINAL WHERE WE WERE TOLD THE FREQ WAS FOR SOMEONE ELSE. AFTER A FEW MORE MI, WHEN WE HAD ALREADY BEGUN TO SLOW DOWN FOR THE PENDING DSCNT AND WE WERE APPROX 15 NM S OF FALKO. CTR ISSUED A CLRNC TO CROSS FALKO AT 10000 FT AND 250 KTS. IMMEDIATELY FOLLOWING THE DSCNT CLRNC, CTR ISSUED ANOTHER FREQ CHANGE AND THE FO SWITCHED FREQS, CHKED IN, GOT A VALID ALTIMETER SETTING AND RAN THE DSCNT CHKLIST. AT THIS POINT FO NOTICED 11100 FT IN THE ALT WINDOW AND RESET IT 11000 FT THINKING IT WAS JUST MISSED BY 100 FT INSTEAD OF 1100 FT. THE MOST SIGNIFICANT FACTOR WAS THE LATE CLRNC TO DSND AND THE SUBSEQUENT FREQ CHANGE WHICH RESULTED IN A SLAM DUNK DSCNT AND AN EXTREMELY HIGH WORKLOAD ENVIRONMENT WITHIN A COMPRESSED TIME FRAME AND DISTANCE. NEXT TIME, I WON'T ACCEPT SUCH A RUSHED CLRNC.
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.