37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 429589 |
Time | |
Date | 199902 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : rbv.vortac |
State Reference | NJ |
Altitude | msl single value : 11000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Embraer Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | cruise : holding |
Route In Use | arrival : holding pattern |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : atp pilot : cfi |
Experience | flight time last 90 days : 125 flight time total : 3300 flight time type : 125 |
ASRS Report | 429589 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : cfi |
Experience | flight time last 90 days : 200 flight time total : 2200 flight time type : 200 |
ASRS Report | 429521 |
Events | |
Anomaly | conflict : airborne critical inflight encounter : vfr in imc non adherence : published procedure |
Independent Detector | atc equipment : conflict alert aircraft equipment : tcas other controllera |
Resolutory Action | controller : issued alert flight crew : became reoriented flight crew : took evasive action |
Supplementary | |
Problem Areas | Flight Crew Human Performance Company |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We had received a descent clearance to cross holey intersection at 11000 ft and, while descending, received further clearance that rbv VOR was our new clearance limit and to hold as published. I looked at the arrival plate and immediately misread it seeing the published hold at holey intersection. When the first officer reported us entering the hold, the controller caught my mistake and provided directions to us and others nearby that prevented any further problems. Contributing factors: it was our last leg of a 3 day trip that was plagued by delays. Earlier in the day, after holding for 40 mins en route to clt, nc, we diverted to gso, nc. The first officer was anxious to catch a flight home at the end of our trip and was on the radio checking flight schedules with the company while I was busy screwing up. The hold depicted at robbinsville VOR is drawn over some other elements of the arrival which creates a cluttered diagram. I guess if I had listened more closely I would have known to look for it. Fixes: listen more closely to radio communications when PF. Review clearance amendments more carefully with first officer. Callback conversation with reporter revealed the following information: the PIC reporter stated in the callback that maybe he was in a hurry to arrive at ewr. That it ws the end of a long day, the first officer was not in the loop with him when he received his holding instructions, and that he was to begin his vacation starting the next day. This reporter also stated that his company had a 'green on green' policy -- a policy where a waiver had been established allowing inexperienced pilots to be paired together, and that this policy had expired. This reporter was not aware of any further investigation or action on the part of the FAA.
Original NASA ASRS Text
Title: ACR FLC FLYING EMB145 ENRTE TO EWR DEVIATED FROM ATC INSTRUCTIONS TO HOLD AS PUBLISHED AT RBV VORTAC ON THE ROBBINSVILLE 1 ARR WITH SUBSEQUENT TCASII RA AND ATC INTERVENTION.
Narrative: WE HAD RECEIVED A DSCNT CLRNC TO CROSS HOLEY INTXN AT 11000 FT AND, WHILE DSNDING, RECEIVED FURTHER CLRNC THAT RBV VOR WAS OUR NEW CLRNC LIMIT AND TO HOLD AS PUBLISHED. I LOOKED AT THE ARR PLATE AND IMMEDIATELY MISREAD IT SEEING THE PUBLISHED HOLD AT HOLEY INTXN. WHEN THE FO RPTED US ENTERING THE HOLD, THE CTLR CAUGHT MY MISTAKE AND PROVIDED DIRECTIONS TO US AND OTHERS NEARBY THAT PREVENTED ANY FURTHER PROBS. CONTRIBUTING FACTORS: IT WAS OUR LAST LEG OF A 3 DAY TRIP THAT WAS PLAGUED BY DELAYS. EARLIER IN THE DAY, AFTER HOLDING FOR 40 MINS ENRTE TO CLT, NC, WE DIVERTED TO GSO, NC. THE FO WAS ANXIOUS TO CATCH A FLT HOME AT THE END OF OUR TRIP AND WAS ON THE RADIO CHKING FLT SCHEDULES WITH THE COMPANY WHILE I WAS BUSY SCREWING UP. THE HOLD DEPICTED AT ROBBINSVILLE VOR IS DRAWN OVER SOME OTHER ELEMENTS OF THE ARR WHICH CREATES A CLUTTERED DIAGRAM. I GUESS IF I HAD LISTENED MORE CLOSELY I WOULD HAVE KNOWN TO LOOK FOR IT. FIXES: LISTEN MORE CLOSELY TO RADIO COMS WHEN PF. REVIEW CLRNC AMENDMENTS MORE CAREFULLY WITH FO. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE PIC RPTR STATED IN THE CALLBACK THAT MAYBE HE WAS IN A HURRY TO ARRIVE AT EWR. THAT IT WS THE END OF A LONG DAY, THE FO WAS NOT IN THE LOOP WITH HIM WHEN HE RECEIVED HIS HOLDING INSTRUCTIONS, AND THAT HE WAS TO BEGIN HIS VACATION STARTING THE NEXT DAY. THIS RPTR ALSO STATED THAT HIS COMPANY HAD A 'GREEN ON GREEN' POLICY -- A POLICY WHERE A WAIVER HAD BEEN ESTABLISHED ALLOWING INEXPERIENCED PLTS TO BE PAIRED TOGETHER, AND THAT THIS POLICY HAD EXPIRED. THIS RPTR WAS NOT AWARE OF ANY FURTHER INVESTIGATION OR ACTION ON THE PART OF THE FAA.
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.