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Attributes | |
ACN | 412831 |
Time | |
Date | 199809 |
Day | Tue |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : hnl |
State Reference | HI |
Altitude | msl bound lower : 32000 msl bound upper : 33000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : nzzo tower : ind |
Operator | common carrier : air carrier |
Make Model Name | B747-400 |
Operating Under FAR Part | Part 121 |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | enroute : pacific |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : flight engineer pilot : atp |
Experience | flight time last 90 days : 185 flight time total : 20000 flight time type : 3250 |
ASRS Report | 412831 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : instrument pilot : atp pilot : cfi pilot : commercial |
Experience | flight time last 90 days : 135 flight time total : 8550 flight time type : 3035 |
ASRS Report | 413062 |
Events | |
Anomaly | non adherence : clearance other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : unspecified other flight crewa |
Resolutory Action | flight crew : became reoriented flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
En route syd-sfo in block altitude FL310-FL330, at FL320 at approximately XA00Z, received fans clearance 'climb to FL330 by XB15Z report level FL330.' first officer and I agreed, as PNF I accepted. At approximately XA55Z, I checked our altitude, thought we were at FL330 and sent fans message that we were level at FL330. I asked the first officer if he wanted a block FL330-FL350. He thought we were too heavy to climb yet. I said I would request it to have when we needed, fans request was denied. Shift time was XB18Z. I gave a briefing which included we were at FL330 and unable block altitude FL330-FL350. Relief pilots stated we were still at FL320. I told them to climb immediately to FL330 then send fans message reporting level at FL330 at approximately XB25Z which they did. It was the middle of the night for me, at the end of my shift and I was tired. I was convinced we were at FL330. Most of the fans deviations I have heard about have involved conditional clrncs. I feel it is a mistake to use them and I will refuse to use them in the future and tell my relief pilots they can't accept them as well. If I am unable to climb immediately, I will refuse the clearance and request a descent to a lower altitude then request climb to a higher altitude at a later time. Callback conversation with reporter revealed the following information: reporter participated in the structured fans callback program. Reporter was intent in having all the cleared altitudes complied with for the relief flight crew, who was about to replace them at the flight controls. He doesn't know why he concentrated on looking at the MCP altitude select and not the official altitude on the altimeters. He reports he felt very fatigued, which is why he wasn't xchking all the instrumentation as it should have been done. He was careful to brief the flight crew members who were to assume command about the clearance, but no one looked at the altimeters until the relief flight crew were in the seats and set up. The relief flight crew saw the error, called the captain out of the rest area, and he commanded an immediate climb to proper altitude. This reporter captain likes the cpdlc, but dislikes the conditional clrncs, the ambiguous clrncs, and the multi-page clearance. Supplemental information from acn 413062: close to the end of our flying shift we received a clearance to climb and maintain FL330 by XB15Z. Our response was to reset the MCP altitude to FL330 and discuss when we would climb from FL320 to FL330 (previous clearance was a block FL310- FL330). I, the first officer (PF), departed the cockpit. Upon my return, the captain informed me that he had reported level FL330. I responded by pointing to the altitude on the MCP and reiterating that we were at our new altitude. I thought that I had verified the actual altitude but, due to the distraction of crew change activities, didn't catch the altitude variance. The flight was off our cleared altitude by 1000 ft for about 15 mins and no TCASII alerts were received during that time. Contributing factors included 'conditional' time related climb clearance, fatigue, and crew change activities. Callback conversation with reporter revealed the following information: reporter participated in the structured callback fans program. Reporter had left the flight deck for a short while. When he returned, the captain told him that a fans report had been sent, informing ATC that they were at FL330. When the reporter looked at the MCP altitude he read FL330, but is not certain what else he looked at to verify they were at FL330. He was also fatigued and knows he was not 'sharp,' at xchking all the different altimeters to verify their exact altitude. Reporter likes the cpdlc very much, but dislikes the conditional clrncs, and multi-page clrncs. It would be reporter's suggestion to issue conditional clrncs with a latitude/longitude position so it could be entered into the aircraft's LNAV. Supplemental information from acn 413462: I feel these provisional clrncs are contributing to many altdevs using cpdlc. We should not be given clrncs that are not to be acted on for up to 1 hour out or 400 or 500 mi away. This is common practice in the pacific using cpdlc.
Original NASA ASRS Text
Title: A B747-400 FLC MISREADS THE ALT AND SENDS BY CPDLC THAT THEY ARE LEVEL AT ASSIGNED ALT WHEN IN REALITY THEY ARE FLYING 1000 FT LOWER.
Narrative: ENRTE SYD-SFO IN BLOCK ALT FL310-FL330, AT FL320 AT APPROX XA00Z, RECEIVED FANS CLRNC 'CLB TO FL330 BY XB15Z RPT LEVEL FL330.' FO AND I AGREED, AS PNF I ACCEPTED. AT APPROX XA55Z, I CHKED OUR ALT, THOUGHT WE WERE AT FL330 AND SENT FANS MESSAGE THAT WE WERE LEVEL AT FL330. I ASKED THE FO IF HE WANTED A BLOCK FL330-FL350. HE THOUGHT WE WERE TOO HVY TO CLB YET. I SAID I WOULD REQUEST IT TO HAVE WHEN WE NEEDED, FANS REQUEST WAS DENIED. SHIFT TIME WAS XB18Z. I GAVE A BRIEFING WHICH INCLUDED WE WERE AT FL330 AND UNABLE BLOCK ALT FL330-FL350. RELIEF PLTS STATED WE WERE STILL AT FL320. I TOLD THEM TO CLB IMMEDIATELY TO FL330 THEN SEND FANS MESSAGE RPTING LEVEL AT FL330 AT APPROX XB25Z WHICH THEY DID. IT WAS THE MIDDLE OF THE NIGHT FOR ME, AT THE END OF MY SHIFT AND I WAS TIRED. I WAS CONVINCED WE WERE AT FL330. MOST OF THE FANS DEVS I HAVE HEARD ABOUT HAVE INVOLVED CONDITIONAL CLRNCS. I FEEL IT IS A MISTAKE TO USE THEM AND I WILL REFUSE TO USE THEM IN THE FUTURE AND TELL MY RELIEF PLTS THEY CAN'T ACCEPT THEM AS WELL. IF I AM UNABLE TO CLB IMMEDIATELY, I WILL REFUSE THE CLRNC AND REQUEST A DSCNT TO A LOWER ALT THEN REQUEST CLB TO A HIGHER ALT AT A LATER TIME. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR PARTICIPATED IN THE STRUCTURED FANS CALLBACK PROGRAM. RPTR WAS INTENT IN HAVING ALL THE CLRED ALTS COMPLIED WITH FOR THE RELIEF FLC, WHO WAS ABOUT TO REPLACE THEM AT THE FLT CTLS. HE DOESN'T KNOW WHY HE CONCENTRATED ON LOOKING AT THE MCP ALT SELECT AND NOT THE OFFICIAL ALT ON THE ALTIMETERS. HE RPTS HE FELT VERY FATIGUED, WHICH IS WHY HE WASN'T XCHKING ALL THE INSTRUMENTATION AS IT SHOULD HAVE BEEN DONE. HE WAS CAREFUL TO BRIEF THE FLC MEMBERS WHO WERE TO ASSUME COMMAND ABOUT THE CLRNC, BUT NO ONE LOOKED AT THE ALTIMETERS UNTIL THE RELIEF FLC WERE IN THE SEATS AND SET UP. THE RELIEF FLC SAW THE ERROR, CALLED THE CAPT OUT OF THE REST AREA, AND HE COMMANDED AN IMMEDIATE CLB TO PROPER ALT. THIS RPTR CAPT LIKES THE CPDLC, BUT DISLIKES THE CONDITIONAL CLRNCS, THE AMBIGUOUS CLRNCS, AND THE MULTI-PAGE CLRNC. SUPPLEMENTAL INFO FROM ACN 413062: CLOSE TO THE END OF OUR FLYING SHIFT WE RECEIVED A CLRNC TO CLB AND MAINTAIN FL330 BY XB15Z. OUR RESPONSE WAS TO RESET THE MCP ALT TO FL330 AND DISCUSS WHEN WE WOULD CLB FROM FL320 TO FL330 (PREVIOUS CLRNC WAS A BLOCK FL310- FL330). I, THE FO (PF), DEPARTED THE COCKPIT. UPON MY RETURN, THE CAPT INFORMED ME THAT HE HAD RPTED LEVEL FL330. I RESPONDED BY POINTING TO THE ALT ON THE MCP AND REITERATING THAT WE WERE AT OUR NEW ALT. I THOUGHT THAT I HAD VERIFIED THE ACTUAL ALT BUT, DUE TO THE DISTR OF CREW CHANGE ACTIVITIES, DIDN'T CATCH THE ALT VARIANCE. THE FLT WAS OFF OUR CLRED ALT BY 1000 FT FOR ABOUT 15 MINS AND NO TCASII ALERTS WERE RECEIVED DURING THAT TIME. CONTRIBUTING FACTORS INCLUDED 'CONDITIONAL' TIME RELATED CLB CLRNC, FATIGUE, AND CREW CHANGE ACTIVITIES. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR PARTICIPATED IN THE STRUCTURED CALLBACK FANS PROGRAM. RPTR HAD LEFT THE FLT DECK FOR A SHORT WHILE. WHEN HE RETURNED, THE CAPT TOLD HIM THAT A FANS RPT HAD BEEN SENT, INFORMING ATC THAT THEY WERE AT FL330. WHEN THE RPTR LOOKED AT THE MCP ALT HE READ FL330, BUT IS NOT CERTAIN WHAT ELSE HE LOOKED AT TO VERIFY THEY WERE AT FL330. HE WAS ALSO FATIGUED AND KNOWS HE WAS NOT 'SHARP,' AT XCHKING ALL THE DIFFERENT ALTIMETERS TO VERIFY THEIR EXACT ALT. RPTR LIKES THE CPDLC VERY MUCH, BUT DISLIKES THE CONDITIONAL CLRNCS, AND MULTI-PAGE CLRNCS. IT WOULD BE RPTR'S SUGGESTION TO ISSUE CONDITIONAL CLRNCS WITH A LATITUDE/LONGITUDE POS SO IT COULD BE ENTERED INTO THE ACFT'S LNAV. SUPPLEMENTAL INFO FROM ACN 413462: I FEEL THESE PROVISIONAL CLRNCS ARE CONTRIBUTING TO MANY ALTDEVS USING CPDLC. WE SHOULD NOT BE GIVEN CLRNCS THAT ARE NOT TO BE ACTED ON FOR UP TO 1 HR OUT OR 400 OR 500 MI AWAY. THIS IS COMMON PRACTICE IN THE PACIFIC USING CPDLC.
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.