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|
Attributes | |
ACN | 441865 |
Time | |
Date | 199907 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : svzm.airport |
State Reference | FO |
Altitude | msl single value : 4700 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : svzm.artcc |
Operator | common carrier : air carrier |
Make Model Name | Large Transport, Low Wing, 2 Turbojet Eng |
Operating Under FAR Part | Part 121 |
Navigation In Use | other vortac |
Flight Phase | climbout : initial |
Route In Use | departure sid : darpa 2 |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : svzm.artcc |
Make Model Name | DC-9 Undifferentiated or Other Model |
Flight Phase | descent : approach |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp pilot : commercial pilot : flight engineer pilot : instrument pilot : private pilot : multi engine |
Experience | flight time last 90 days : 100 flight time total : 4000 flight time type : 400 |
ASRS Report | 441865 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 10000 flight time type : 300 |
ASRS Report | 441866 |
Events | |
Anomaly | conflict : airborne less severe non adherence : clearance other spatial deviation |
Independent Detector | aircraft equipment : tcas other controllera other flight crewa other flight crewb |
Resolutory Action | flight crew : returned to intended or assigned course none taken : anomaly accepted |
Miss Distance | horizontal : 9000 vertical : 300 |
Supplementary | |
Problem Areas | ATC Facility ATC Human Performance Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
ATC clearance cleared af-jfk, darpa 2 departure runway 9, expect FL290. Tower contact: change climb out, intercept 040 degree radial outbound, climb/maintain 4000 ft. First officer (PNF) clarified with readback 2 times, tower cleared into position and hold after traffic, cleared for takeoff contact departure. Normal takeoff. Followed darpa 2 SID procedures initially. First officer and captain both had raw data displayed. Upon contact with departure, controller gave clearance to climb to FL290. Then captain and first officer noticed flying through 25 degree radial and immediately verbalized and made correction back to 040 degree radial at approximately 10 DME and 3000 ft MSL. Svzm control informed crew we were flying through 22 degree radial -- first officer acknowledged. Aircraft was clean and approximately 4000 ft climb out -- TCASII warning and both pilots verbalized visual contact with DC9 at approximately 11 O'clock, 5000 ft opposite direction. We were already correcting to 040 degree radial and closest separation was approximately at 4700 ft, 1-2 mi lateral, 300 ft vertical. Neither tower nor departure passed any information regarding traffic either before, during, or after TCASII visual contact svzm. Control did not acknowledge any other deviations other than aircraft deviation laterally from 040 degree radial (approximately 2 mi north). Problem: primary language used by svzm tower/control is spanish. They only use english with united states registered aircraft. English is spoken poorly which leads to several readbacks causing confusion and clogged radio frequency communications. NOTAMS and SID information advise crews to maintain 4000 ft until darpa or first departure fix, neither NOTAMS nor SID advise clearly of required altitude if vectored/cleared off SID. Controller gave clearance to climb to FL290 -- never indicated to maintain 4000 ft darpa and then cleared to climb to flight level. Crew read back 'understand cleared to climb FL290.' control never acknowledged altitude deviation. Tower/departure never gave traffic report before, during, or after loss of separation. Crew deviated from clearance by flying through 040 degree radial by approximately 2 mi north before correcting. Solutions suggested: continued emphasis/training with controllers of importance of using english as primary -- leads to better situational awareness for all parties on frequency. United states registered aircraft would continue to request absolute clearance understanding. NOTAMS should clearly state importance of absolutely maintaining 4000 ft to darpa or first departure fix, even if vectored/cleared off of SID. Commercial chart SID (attached) should clearly state importance of maintaining 4000 ft to darpa even if cleared to climb early to flight level. FMC database should also reflect accordingly. Controllers should be trained to underscore clearance clarification by giving clearance to climb to flight level after darpa, but maintain 4000 ft. When departure clearance is changed for traffic, control must pass traffic information to pilots immediately with appropriate updates on climb out. Crew was not vigilant in intercepting 040 degree radial as cleared and did not immediately acknowledge lateral deviation when it occurred. Crew should have more thoroughly briefed and understood 4000 ft altitude restr before accepting departure. Altitude clrncs, clrncs off SID without TA's and crew lateral deviation created a 'trap' (loss of separation) which was avoided by crew visual acquisition of traffic and TCASII advisories.
Original NASA ASRS Text
Title: RPTR'S ACFT X STRAYED OFF SID. AS THEY WERE CORRECTING, THEIR TCASII WAS ACTIVATED BY ACFT Y.
Narrative: ATC CLRNC CLRED AF-JFK, DARPA 2 DEP RWY 9, EXPECT FL290. TWR CONTACT: CHANGE CLBOUT, INTERCEPT 040 DEG RADIAL OUTBOUND, CLB/MAINTAIN 4000 FT. FO (PNF) CLARIFIED WITH READBACK 2 TIMES, TWR CLRED INTO POS AND HOLD AFTER TFC, CLRED FOR TKOF CONTACT DEP. NORMAL TKOF. FOLLOWED DARPA 2 SID PROCS INITIALLY. FO AND CAPT BOTH HAD RAW DATA DISPLAYED. UPON CONTACT WITH DEP, CTLR GAVE CLRNC TO CLB TO FL290. THEN CAPT AND FO NOTICED FLYING THROUGH 25 DEG RADIAL AND IMMEDIATELY VERBALIZED AND MADE CORRECTION BACK TO 040 DEG RADIAL AT APPROX 10 DME AND 3000 FT MSL. SVZM CTL INFORMED CREW WE WERE FLYING THROUGH 22 DEG RADIAL -- FO ACKNOWLEDGED. ACFT WAS CLEAN AND APPROX 4000 FT CLBOUT -- TCASII WARNING AND BOTH PLTS VERBALIZED VISUAL CONTACT WITH DC9 AT APPROX 11 O'CLOCK, 5000 FT OPPOSITE DIRECTION. WE WERE ALREADY CORRECTING TO 040 DEG RADIAL AND CLOSEST SEPARATION WAS APPROX AT 4700 FT, 1-2 MI LATERAL, 300 FT VERT. NEITHER TWR NOR DEP PASSED ANY INFO REGARDING TFC EITHER BEFORE, DURING, OR AFTER TCASII VISUAL CONTACT SVZM. CTL DID NOT ACKNOWLEDGE ANY OTHER DEVS OTHER THAN ACFT DEV LATERALLY FROM 040 DEG RADIAL (APPROX 2 MI N). PROB: PRIMARY LANGUAGE USED BY SVZM TWR/CTL IS SPANISH. THEY ONLY USE ENGLISH WITH UNITED STATES REGISTERED ACFT. ENGLISH IS SPOKEN POORLY WHICH LEADS TO SEVERAL READBACKS CAUSING CONFUSION AND CLOGGED RADIO FREQ COMS. NOTAMS AND SID INFO ADVISE CREWS TO MAINTAIN 4000 FT UNTIL DARPA OR FIRST DEP FIX, NEITHER NOTAMS NOR SID ADVISE CLRLY OF REQUIRED ALT IF VECTORED/CLRED OFF SID. CTLR GAVE CLRNC TO CLB TO FL290 -- NEVER INDICATED TO MAINTAIN 4000 FT DARPA AND THEN CLRED TO CLB TO FLT LEVEL. CREW READ BACK 'UNDERSTAND CLRED TO CLB FL290.' CTL NEVER ACKNOWLEDGED ALTDEV. TWR/DEP NEVER GAVE TFC RPT BEFORE, DURING, OR AFTER LOSS OF SEPARATION. CREW DEVIATED FROM CLRNC BY FLYING THROUGH 040 DEG RADIAL BY APPROX 2 MI N BEFORE CORRECTING. SOLUTIONS SUGGESTED: CONTINUED EMPHASIS/TRAINING WITH CTLRS OF IMPORTANCE OF USING ENGLISH AS PRIMARY -- LEADS TO BETTER SITUATIONAL AWARENESS FOR ALL PARTIES ON FREQ. UNITED STATES REGISTERED ACFT WOULD CONTINUE TO REQUEST ABSOLUTE CLRNC UNDERSTANDING. NOTAMS SHOULD CLRLY STATE IMPORTANCE OF ABSOLUTELY MAINTAINING 4000 FT TO DARPA OR FIRST DEP FIX, EVEN IF VECTORED/CLRED OFF OF SID. COMMERCIAL CHART SID (ATTACHED) SHOULD CLRLY STATE IMPORTANCE OF MAINTAINING 4000 FT TO DARPA EVEN IF CLRED TO CLB EARLY TO FLT LEVEL. FMC DATABASE SHOULD ALSO REFLECT ACCORDINGLY. CTLRS SHOULD BE TRAINED TO UNDERSCORE CLRNC CLARIFICATION BY GIVING CLRNC TO CLB TO FLT LEVEL AFTER DARPA, BUT MAINTAIN 4000 FT. WHEN DEP CLRNC IS CHANGED FOR TFC, CTL MUST PASS TFC INFO TO PLTS IMMEDIATELY WITH APPROPRIATE UPDATES ON CLBOUT. CREW WAS NOT VIGILANT IN INTERCEPTING 040 DEG RADIAL AS CLRED AND DID NOT IMMEDIATELY ACKNOWLEDGE LATERAL DEV WHEN IT OCCURRED. CREW SHOULD HAVE MORE THOROUGHLY BRIEFED AND UNDERSTOOD 4000 FT ALT RESTR BEFORE ACCEPTING DEP. ALT CLRNCS, CLRNCS OFF SID WITHOUT TA'S AND CREW LATERAL DEV CREATED A 'TRAP' (LOSS OF SEPARATION) WHICH WAS AVOIDED BY CREW VISUAL ACQUISITION OF TFC AND TCASII ADVISORIES.
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.