Narrative:

Air carrier X departed jfk for nrt at XA22 jul/xa/98. Later, we landed at new chitose airport (sapporo) after diverting from our redispatch fix due to insufficient fuel. This resulted from a very inaccurate wind forecast as the basis of our flight plan. After refueling, flight planning, and reinitializing the INS's to continue to nrt, we departed cts at XD02. Our filed flight plan was 'SID che dct goc R211 kasmi dct rjaa' (nrt). Therefore, I created waypoints at che, goc, etc. When we received our ATC clearance, it was 'air carrier X, cleared to nrt airport, tobby 4 departure to tobby, after tobby flight plan route, maintain FL390.' I looked at the departure procedure page, then the airport diagram (10-9) because neither the first officer nor I had been to cts before. The first officer stared at the SID page on his yoke for an unusually long time, and the so waited patiently to review the takeoff card, and his calculations with us. Finally, I reached over to his chart, showed him the route we would fly, and explained that I would use radio navigation until we were past tobby, because we had not created a waypoint at tobby. He cited the climb restrs and asked what to set in the altitude alert window. I explained that since all the restrs were 'at or above,' we should set FL390 (our clearance flight level). He set FL390. During pushback and engine start, we experienced a hot start on #3 engine. Since the first officer had let go of the start lever and the starter valve was closed at 50% N2, I shut down the engine just below the start limit egt. After starting the other engines, #3 was successfully restarted. Normally, the first officer would detect the hot start. The apparent departure procedure confusion and the fact that the first officer had briefed us that he drove to jfk many hours before the flight because he couldn't sleep and that he had only 2 trips in the last 6 months and we better watch him, began to raise 'red flags' (an airline crew management term). I became very deliberate, doublechking all SOP's and checklists during taxi and before takeoff. (Unfortunately, I never went back to thoroughly review the SID.) after an ICAO takeoff, I flew the departure route, and the first officer announced passage and compliance with restrs at D6 che and D11 che (see charts). Subsequently, departure control transmitted 'air carrier X, maintain 11000 ft.' there was alarm in his voice, so I began an aggressive pushover, checked TCASII which showed no traffic within 40 NM, then looked outside. Simultaneously, the first officer replied, 'air carrier X leaving 11400 ft for 11000 ft.' then, departure said, 'maintain 12000 ft.' a little while later, departure queried us 'air carrier X, are you aware of restr at (sounded like eleven) thousand?' I looked at the SID, and found the 'at or below restr at D27 che.' I was about to tell the first officer to tell him we see it but had not noticed it before, when he transmitted 'we were cleared to FL390!' departure soon cleared us direct to goc, climb and maintain FL390. Some possible factors which contributed to our error were: 1) fatigue: the first officer had been up over 24 hours and was clearly tired. I didn't feel tired, but perhaps our struggle to make nrt nonstop and the diversion into an unfamiliar airport with a full B747 took its toll. 2) the SID chart shows 4 tracks, all 185 degree courses, that could easily be 1. If the final crossing restr was depicted on the same side of the track as the others, I'm sure we wouldn't have missed it. Finally, distances are shown that cannot be measured in-flight, either by DME or INS from the NDB (ch). Superfluous information and poor layout made the chart less readable than it could be. 3) a clearance at takeoff to 'comply with restrs,' which we did receive and 'maintain 10000 ft' which we did not, would have prevented the situation in spite of our oversight. Supplemental information from acn 408836: our assigned departure was changed several times, finally receiving the tobby 4 departure, which calls for a restr to cross the 185 degree radial at or below 10000 ft MSL (at 27 NM). We were not aware of this, even though we had read the departure. We were cleared to 39000 ft, but climbing through 11400 ft, ATC asked if we were aware of the restr and told us to maintain 12000 ft. When cleared to 39000 ft, ATC did advise us to comply with all restrs. The biggest reasons for this deviation were 1) lack of attention to the departure, and 2) fatigue brought on by the long trip across the pacific and another leg to tokyo.

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Original NASA ASRS Text

Title: B747 CREW HAD AN ALT BUST ON CLBOUT FROM RJCC ON THE TOBBY 4 DEP.

Narrative: ACR X DEPARTED JFK FOR NRT AT XA22 JUL/XA/98. LATER, WE LANDED AT NEW CHITOSE ARPT (SAPPORO) AFTER DIVERTING FROM OUR REDISPATCH FIX DUE TO INSUFFICIENT FUEL. THIS RESULTED FROM A VERY INACCURATE WIND FORECAST AS THE BASIS OF OUR FLT PLAN. AFTER REFUELING, FLT PLANNING, AND REINITIALIZING THE INS'S TO CONTINUE TO NRT, WE DEPARTED CTS AT XD02. OUR FILED FLT PLAN WAS 'SID CHE DCT GOC R211 KASMI DCT RJAA' (NRT). THEREFORE, I CREATED WAYPOINTS AT CHE, GOC, ETC. WHEN WE RECEIVED OUR ATC CLRNC, IT WAS 'ACR X, CLRED TO NRT ARPT, TOBBY 4 DEP TO TOBBY, AFTER TOBBY FLT PLAN RTE, MAINTAIN FL390.' I LOOKED AT THE DEP PROC PAGE, THEN THE ARPT DIAGRAM (10-9) BECAUSE NEITHER THE FO NOR I HAD BEEN TO CTS BEFORE. THE FO STARED AT THE SID PAGE ON HIS YOKE FOR AN UNUSUALLY LONG TIME, AND THE SO WAITED PATIENTLY TO REVIEW THE TKOF CARD, AND HIS CALCULATIONS WITH US. FINALLY, I REACHED OVER TO HIS CHART, SHOWED HIM THE RTE WE WOULD FLY, AND EXPLAINED THAT I WOULD USE RADIO NAV UNTIL WE WERE PAST TOBBY, BECAUSE WE HAD NOT CREATED A WAYPOINT AT TOBBY. HE CITED THE CLB RESTRS AND ASKED WHAT TO SET IN THE ALT ALERT WINDOW. I EXPLAINED THAT SINCE ALL THE RESTRS WERE 'AT OR ABOVE,' WE SHOULD SET FL390 (OUR CLRNC FLT LEVEL). HE SET FL390. DURING PUSHBACK AND ENG START, WE EXPERIENCED A HOT START ON #3 ENG. SINCE THE FO HAD LET GO OF THE START LEVER AND THE STARTER VALVE WAS CLOSED AT 50% N2, I SHUT DOWN THE ENG JUST BELOW THE START LIMIT EGT. AFTER STARTING THE OTHER ENGS, #3 WAS SUCCESSFULLY RESTARTED. NORMALLY, THE FO WOULD DETECT THE HOT START. THE APPARENT DEP PROC CONFUSION AND THE FACT THAT THE FO HAD BRIEFED US THAT HE DROVE TO JFK MANY HRS BEFORE THE FLT BECAUSE HE COULDN'T SLEEP AND THAT HE HAD ONLY 2 TRIPS IN THE LAST 6 MONTHS AND WE BETTER WATCH HIM, BEGAN TO RAISE 'RED FLAGS' (AN AIRLINE CREW MGMNT TERM). I BECAME VERY DELIBERATE, DOUBLECHKING ALL SOP'S AND CHKLISTS DURING TAXI AND BEFORE TKOF. (UNFORTUNATELY, I NEVER WENT BACK TO THOROUGHLY REVIEW THE SID.) AFTER AN ICAO TKOF, I FLEW THE DEP RTE, AND THE FO ANNOUNCED PASSAGE AND COMPLIANCE WITH RESTRS AT D6 CHE AND D11 CHE (SEE CHARTS). SUBSEQUENTLY, DEP CTL XMITTED 'ACR X, MAINTAIN 11000 FT.' THERE WAS ALARM IN HIS VOICE, SO I BEGAN AN AGGRESSIVE PUSHOVER, CHKED TCASII WHICH SHOWED NO TFC WITHIN 40 NM, THEN LOOKED OUTSIDE. SIMULTANEOUSLY, THE FO REPLIED, 'ACR X LEAVING 11400 FT FOR 11000 FT.' THEN, DEP SAID, 'MAINTAIN 12000 FT.' A LITTLE WHILE LATER, DEP QUERIED US 'ACR X, ARE YOU AWARE OF RESTR AT (SOUNDED LIKE ELEVEN) THOUSAND?' I LOOKED AT THE SID, AND FOUND THE 'AT OR BELOW RESTR AT D27 CHE.' I WAS ABOUT TO TELL THE FO TO TELL HIM WE SEE IT BUT HAD NOT NOTICED IT BEFORE, WHEN HE XMITTED 'WE WERE CLRED TO FL390!' DEP SOON CLRED US DIRECT TO GOC, CLB AND MAINTAIN FL390. SOME POSSIBLE FACTORS WHICH CONTRIBUTED TO OUR ERROR WERE: 1) FATIGUE: THE FO HAD BEEN UP OVER 24 HRS AND WAS CLRLY TIRED. I DIDN'T FEEL TIRED, BUT PERHAPS OUR STRUGGLE TO MAKE NRT NONSTOP AND THE DIVERSION INTO AN UNFAMILIAR ARPT WITH A FULL B747 TOOK ITS TOLL. 2) THE SID CHART SHOWS 4 TRACKS, ALL 185 DEG COURSES, THAT COULD EASILY BE 1. IF THE FINAL XING RESTR WAS DEPICTED ON THE SAME SIDE OF THE TRACK AS THE OTHERS, I'M SURE WE WOULDN'T HAVE MISSED IT. FINALLY, DISTANCES ARE SHOWN THAT CANNOT BE MEASURED INFLT, EITHER BY DME OR INS FROM THE NDB (CH). SUPERFLUOUS INFO AND POOR LAYOUT MADE THE CHART LESS READABLE THAN IT COULD BE. 3) A CLRNC AT TKOF TO 'COMPLY WITH RESTRS,' WHICH WE DID RECEIVE AND 'MAINTAIN 10000 FT' WHICH WE DID NOT, WOULD HAVE PREVENTED THE SIT IN SPITE OF OUR OVERSIGHT. SUPPLEMENTAL INFO FROM ACN 408836: OUR ASSIGNED DEP WAS CHANGED SEVERAL TIMES, FINALLY RECEIVING THE TOBBY 4 DEP, WHICH CALLS FOR A RESTR TO CROSS THE 185 DEG RADIAL AT OR BELOW 10000 FT MSL (AT 27 NM). WE WERE NOT AWARE OF THIS, EVEN THOUGH WE HAD READ THE DEP. WE WERE CLRED TO 39000 FT, BUT CLBING THROUGH 11400 FT, ATC ASKED IF WE WERE AWARE OF THE RESTR AND TOLD US TO MAINTAIN 12000 FT. WHEN CLRED TO 39000 FT, ATC DID ADVISE US TO COMPLY WITH ALL RESTRS. THE BIGGEST REASONS FOR THIS DEV WERE 1) LACK OF ATTN TO THE DEP, AND 2) FATIGUE BROUGHT ON BY THE LONG TRIP ACROSS THE PACIFIC AND ANOTHER LEG TO TOKYO.

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.