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|
Attributes | |
ACN | 436267 |
Time | |
Date | 199905 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sjc.airport |
State Reference | CA |
Altitude | msl single value : 5000 |
Environment | |
Flight Conditions | Mixed |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : o90.tracon tower : lax.tower |
Operator | common carrier : charter |
Make Model Name | Learjet 31 |
Operating Under FAR Part | Part 135 |
Navigation In Use | other other vortac |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure : noise abatement departure sid : loupe9 |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : o90.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737 Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : loupe9 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : charter |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 115 flight time total : 4259 flight time type : 494 |
ASRS Report | 436267 |
Person 2 | |
Affiliation | company : charter |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 65 flight time total : 2765 flight time type : 17 |
ASRS Report | 436561 |
Events | |
Anomaly | conflict : airborne critical non adherence : clearance non adherence : published procedure other spatial deviation |
Independent Detector | atc equipment other atc equipment : radar aircraft equipment : tcas other controllera other flight crewa other flight crewb |
Resolutory Action | controller : issued new clearance controller : separated traffic flight crew : took evasive action |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 500 vertical : 1000 |
Supplementary | |
Problem Areas | Environmental Factor Flight Crew Human Performance Airspace Structure |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The flight originated as a charter from bfi (seattle boeing field) to sjc (san jose) to las (las vegas) for an overnight stop on may/mon/99. We would then return via reverse routing on may/sun/99. I filed all the return flight plans at approximately AB50 am on may/sun/99 at las vegas. The problem occurred on the leg from sjc to bfi. I filed the danville one departure out of sjc anticipating a runway 12 departure. I chose that departure due to arriving and departing on runway 12 the previous day and figured they'd be on the same runway. My copilot picked up the clearance and said that we'd been cleared the loupe nine departure, and that it was just runway heading for vectors. I failed to verify that piece of information but programmed the loupe nine departure in the FMS. Once on departure, we passed the sjc VOR and the FMS sequenced to the next point, which was dyblo. I figured that we'd get a right turn on course and was anticipating that when ATC told us to turn right immediately to a heading of 120 degrees using best rate for traffic. I commenced the turn and found myself confused. We saw the airliner come out of the clouds in a climb and had good separation. The controller asked us our heading as we passed 060 degrees and we answered 060 degrees. That got his attention and he gave us further right to 130 degrees. At that point, my copilot realized that we had neglected to perform the proper instrument departure procedure. That procedure had us turning to 120 degrees at 1.8 DME and completing the turn within 4 NM of the sjc VOR. ATC then told us to climb and maintain 12000 ft and told us to proceed direct the sjc VOR. Shortly thereafter, we were given direct rbl (red bluff). The rest of the flight was uneventful. I contacted ATC at the end of the flight and we talked about what had happened. I told them that I hadn't verified my copilot's understanding of the departure procedure and the FMS seemed to corroborate his interpretation during the departure. He explained that TCASII in the airliner had prevented 'losing separation.' I apologized for the foul up. We did have the copilot's instrumentation set up for raw data (ie, sjc 339 degree radial), but obviously we didn't use the 120 degree heading. The copilot I had on this trip is very new with our company. He has been done with training for about 2 weeks and has a total of 37 hours in learjets, with 17 hours in the lear 31A. I forget sometimes what it is to be a new guy. I probably didn't adjust my pacing to keep him from feeling overwhelmed with checklists and procedures, thus contributing to the misinterp of the departure procedure. I had loaded the proper departure in the FMS, but when it passed the VOR, it figured we were outbound for the second time and sequenced down track. My assessment of my own performance has led me to the following conclusions: we are never in such a hurry, that we can't take the time to verify where we're going and what ATC expects of us. As a good captain, I really need to watch out for my new coplts and give them the time to learn and cope with the demands of charter flying. The FMS will try to kill you. Don't let it. Supplemental information from acn 436561: the captain was navigating off of the FMS and I was using the VOR (raw data) and had it set up for the 339 degree outbound of sjc. We noticed a B737 coming out of the clouds in a climb. The controller informed us to call him when we landed at boeing field. I should have got my head out of the checklist and should have been more proactive with what was happening. When the captain was loading the FMS I should have taken a min to make sure we knew what was going on after takeoff. As a new first officer I need to let a captain know when I need a min so I'm up with what is going on. The most important thing is their need to be a good communication in the cockpit so there is no confusion on any part of the flight.
Original NASA ASRS Text
Title: A LEAR 31 PIC DOES NOT FOLLOW THE LOUPE 9 DEP PROC OUT OF SJC AND HAS AN ENCOUNTER WITH A B737 ON DEP.
Narrative: THE FLT ORIGINATED AS A CHARTER FROM BFI (SEATTLE BOEING FIELD) TO SJC (SAN JOSE) TO LAS (LAS VEGAS) FOR AN OVERNIGHT STOP ON MAY/MON/99. WE WOULD THEN RETURN VIA REVERSE ROUTING ON MAY/SUN/99. I FILED ALL THE RETURN FLT PLANS AT APPROX AB50 AM ON MAY/SUN/99 AT LAS VEGAS. THE PROB OCCURRED ON THE LEG FROM SJC TO BFI. I FILED THE DANVILLE ONE DEP OUT OF SJC ANTICIPATING A RWY 12 DEP. I CHOSE THAT DEP DUE TO ARRIVING AND DEPARTING ON RWY 12 THE PREVIOUS DAY AND FIGURED THEY'D BE ON THE SAME RWY. MY COPLT PICKED UP THE CLRNC AND SAID THAT WE'D BEEN CLRED THE LOUPE NINE DEP, AND THAT IT WAS JUST RWY HEADING FOR VECTORS. I FAILED TO VERIFY THAT PIECE OF INFO BUT PROGRAMMED THE LOUPE NINE DEP IN THE FMS. ONCE ON DEP, WE PASSED THE SJC VOR AND THE FMS SEQUENCED TO THE NEXT POINT, WHICH WAS DYBLO. I FIGURED THAT WE'D GET A R TURN ON COURSE AND WAS ANTICIPATING THAT WHEN ATC TOLD US TO TURN R IMMEDIATELY TO A HDG OF 120 DEGS USING BEST RATE FOR TFC. I COMMENCED THE TURN AND FOUND MYSELF CONFUSED. WE SAW THE AIRLINER COME OUT OF THE CLOUDS IN A CLB AND HAD GOOD SEPARATION. THE CTLR ASKED US OUR HEADING AS WE PASSED 060 DEGS AND WE ANSWERED 060 DEGS. THAT GOT HIS ATTN AND HE GAVE US FURTHER R TO 130 DEGS. AT THAT POINT, MY COPLT REALIZED THAT WE HAD NEGLECTED TO PERFORM THE PROPER INST DEP PROC. THAT PROC HAD US TURNING TO 120 DEGS AT 1.8 DME AND COMPLETING THE TURN WITHIN 4 NM OF THE SJC VOR. ATC THEN TOLD US TO CLB AND MAINTAIN 12000 FT AND TOLD US TO PROCEED DIRECT THE SJC VOR. SHORTLY THEREAFTER, WE WERE GIVEN DIRECT RBL (RED BLUFF). THE REST OF THE FLT WAS UNEVENTFUL. I CONTACTED ATC AT THE END OF THE FLT AND WE TALKED ABOUT WHAT HAD HAPPENED. I TOLD THEM THAT I HADN'T VERIFIED MY COPLT'S UNDERSTANDING OF THE DEP PROC AND THE FMS SEEMED TO CORROBORATE HIS INTERP DURING THE DEP. HE EXPLAINED THAT TCASII IN THE AIRLINER HAD PREVENTED 'LOSING SEPARATION.' I APOLOGIZED FOR THE FOUL UP. WE DID HAVE THE COPLT'S INSTRUMENTATION SET UP FOR RAW DATA (IE, SJC 339 DEG RADIAL), BUT OBVIOUSLY WE DIDN'T USE THE 120 DEG HDG. THE COPLT I HAD ON THIS TRIP IS VERY NEW WITH OUR COMPANY. HE HAS BEEN DONE WITH TRAINING FOR ABOUT 2 WKS AND HAS A TOTAL OF 37 HRS IN LEARJETS, WITH 17 HRS IN THE LEAR 31A. I FORGET SOMETIMES WHAT IT IS TO BE A NEW GUY. I PROBABLY DIDN'T ADJUST MY PACING TO KEEP HIM FROM FEELING OVERWHELMED WITH CHKLISTS AND PROCS, THUS CONTRIBUTING TO THE MISINTERP OF THE DEP PROC. I HAD LOADED THE PROPER DEP IN THE FMS, BUT WHEN IT PASSED THE VOR, IT FIGURED WE WERE OUTBOUND FOR THE SECOND TIME AND SEQUENCED DOWN TRACK. MY ASSESSMENT OF MY OWN PERFORMANCE HAS LED ME TO THE FOLLOWING CONCLUSIONS: WE ARE NEVER IN SUCH A HURRY, THAT WE CAN'T TAKE THE TIME TO VERIFY WHERE WE'RE GOING AND WHAT ATC EXPECTS OF US. AS A GOOD CAPT, I REALLY NEED TO WATCH OUT FOR MY NEW COPLTS AND GIVE THEM THE TIME TO LEARN AND COPE WITH THE DEMANDS OF CHARTER FLYING. THE FMS WILL TRY TO KILL YOU. DON'T LET IT. SUPPLEMENTAL INFO FROM ACN 436561: THE CAPT WAS NAVING OFF OF THE FMS AND I WAS USING THE VOR (RAW DATA) AND HAD IT SET UP FOR THE 339 DEG OUTBOUND OF SJC. WE NOTICED A B737 COMING OUT OF THE CLOUDS IN A CLB. THE CTLR INFORMED US TO CALL HIM WHEN WE LANDED AT BOEING FIELD. I SHOULD HAVE GOT MY HEAD OUT OF THE CHKLIST AND SHOULD HAVE BEEN MORE PROACTIVE WITH WHAT WAS HAPPENING. WHEN THE CAPT WAS LOADING THE FMS I SHOULD HAVE TAKEN A MIN TO MAKE SURE WE KNEW WHAT WAS GOING ON AFTER TKOF. AS A NEW FO I NEED TO LET A CAPT KNOW WHEN I NEED A MIN SO I'M UP WITH WHAT IS GOING ON. THE MOST IMPORTANT THING IS THEIR NEED TO BE A GOOD COM IN THE COCKPIT SO THERE IS NO CONFUSION ON ANY PART OF THE FLT.
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.