37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 454570 |
Time | |
Date | 199910 |
Day | Fri |
Place | |
State Reference | MD |
Altitude | msl bound lower : 15000 msl bound upper : 17000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zdc.artcc |
Operator | common carrier : air carrier |
Make Model Name | Light Transport, Low Wing, 2 Turboprop Eng |
Operating Under FAR Part | Part 135 |
Navigation In Use | other |
Flight Phase | descent : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 250 flight time total : 3000 flight time type : 500 |
ASRS Report | 454570 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 5000 |
ASRS Report | 453550 |
Events | |
Anomaly | altitude deviation : crossing restriction not met non adherence : clearance |
Independent Detector | other controllera other flight crewa |
Resolutory Action | none taken : insufficient time |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were given the following by ATC: 'cross pxt at 15000 ft.' we were at FL210. I was PNF. I said to PF, '15 at patuxent, 15 set' and set 15000 ft in altitude in autoplt. I also said this to ATC, 'cross pxt at 15000 ft.' the PF then began our descent. A few mins later, I looked at FMS. It showed that our descent was going to meet the crossing restr. The captain called for approach checks, which I started. Some time passed, then ATC said 'say altitude.' I responded that we were at 17000 ft descending. ATC then reminded us that we were supposed to have been at pxt at 15000 ft. We were now 10 mi past pxt. The captain initiated a 3000 FPM descent to get down to 15000 ft. In retrospect, I'm aware that although I repeated what ATC told us about the crossing restr to the PF he didn't hear or understand. He responded saying '15 checks' which is standard for our company, but I should have made sure he knew. I said, '15 at pxt, 15 set.' and he said '15 checks.' I should have then asked him, 'and 15 at pxt?' now I always say it all. This was a failure for the PF to hear and understand an ATC instruction and the PNF's readback. Also, the PNF (me) should have verified the PF knew and understood the complete ATC instruction. Supplemental information from acn 453550: en route from tys to phl on oct/xa/99, we missed a crossing restr by approximately 500 ft. We were descending from altitude and were told to cross pxt VOR at 15000 ft. The restr was given and the first officer read it back but apparently the captain didn't hear the pxt at 15000 ft restr. Both pilots commute for work and fatigue may have played a factor, also a breakdown in communication between flight crew members. Although the 'show time' wasn't until XA35, both pilots had started their day at least 7 hours prior. Also the first officer's inexperience, being employed less than 6 months, may have played a factor. Possibly not verifying the restr due to thinking the apt understood. Also, automation complacency may have played a factor. Both pilots had verified that the descent was initiated and afterwards the first officer even reverified that the crossing green arc was definitely on or before pxt, on the FMS. After the controller notified us that we were not going to make the restr, the captain noticed that the FMS had 'latched' to an airspeed of 248 KTS and the captain had set the vertical flight lvl change mode at 260 KIAS in the autoplt. If the first officer had put in the 15000 ft at pxt in the FMS and the airspeed had been previously set at 248 KIAS in the FMS, this may have slowed the descent. Also, the crew's preoccupation of the crew preparing for holding at phl may have led to improper monitoring of the FMS and autoplt.
Original NASA ASRS Text
Title: ACR CREW MISSES XING RESTR.
Narrative: WE WERE GIVEN THE FOLLOWING BY ATC: 'CROSS PXT AT 15000 FT.' WE WERE AT FL210. I WAS PNF. I SAID TO PF, '15 AT PATUXENT, 15 SET' AND SET 15000 FT IN ALT IN AUTOPLT. I ALSO SAID THIS TO ATC, 'CROSS PXT AT 15000 FT.' THE PF THEN BEGAN OUR DSCNT. A FEW MINS LATER, I LOOKED AT FMS. IT SHOWED THAT OUR DSCNT WAS GOING TO MEET THE XING RESTR. THE CAPT CALLED FOR APCH CHKS, WHICH I STARTED. SOME TIME PASSED, THEN ATC SAID 'SAY ALT.' I RESPONDED THAT WE WERE AT 17000 FT DSNDING. ATC THEN REMINDED US THAT WE WERE SUPPOSED TO HAVE BEEN AT PXT AT 15000 FT. WE WERE NOW 10 MI PAST PXT. THE CAPT INITIATED A 3000 FPM DSCNT TO GET DOWN TO 15000 FT. IN RETROSPECT, I'M AWARE THAT ALTHOUGH I REPEATED WHAT ATC TOLD US ABOUT THE XING RESTR TO THE PF HE DIDN'T HEAR OR UNDERSTAND. HE RESPONDED SAYING '15 CHKS' WHICH IS STANDARD FOR OUR COMPANY, BUT I SHOULD HAVE MADE SURE HE KNEW. I SAID, '15 AT PXT, 15 SET.' AND HE SAID '15 CHKS.' I SHOULD HAVE THEN ASKED HIM, 'AND 15 AT PXT?' NOW I ALWAYS SAY IT ALL. THIS WAS A FAILURE FOR THE PF TO HEAR AND UNDERSTAND AN ATC INSTRUCTION AND THE PNF'S READBACK. ALSO, THE PNF (ME) SHOULD HAVE VERIFIED THE PF KNEW AND UNDERSTOOD THE COMPLETE ATC INSTRUCTION. SUPPLEMENTAL INFO FROM ACN 453550: ENRTE FROM TYS TO PHL ON OCT/XA/99, WE MISSED A XING RESTR BY APPROX 500 FT. WE WERE DSNDING FROM ALT AND WERE TOLD TO CROSS PXT VOR AT 15000 FT. THE RESTR WAS GIVEN AND THE FO READ IT BACK BUT APPARENTLY THE CAPT DIDN'T HEAR THE PXT AT 15000 FT RESTR. BOTH PLTS COMMUTE FOR WORK AND FATIGUE MAY HAVE PLAYED A FACTOR, ALSO A BREAKDOWN IN COM BTWN FLC MEMBERS. ALTHOUGH THE 'SHOW TIME' WASN'T UNTIL XA35, BOTH PLTS HAD STARTED THEIR DAY AT LEAST 7 HRS PRIOR. ALSO THE FO'S INEXPERIENCE, BEING EMPLOYED LESS THAN 6 MONTHS, MAY HAVE PLAYED A FACTOR. POSSIBLY NOT VERIFYING THE RESTR DUE TO THINKING THE APT UNDERSTOOD. ALSO, AUTOMATION COMPLACENCY MAY HAVE PLAYED A FACTOR. BOTH PLTS HAD VERIFIED THAT THE DSCNT WAS INITIATED AND AFTERWARDS THE FO EVEN REVERIFIED THAT THE XING GREEN ARC WAS DEFINITELY ON OR BEFORE PXT, ON THE FMS. AFTER THE CTLR NOTIFIED US THAT WE WERE NOT GOING TO MAKE THE RESTR, THE CAPT NOTICED THAT THE FMS HAD 'LATCHED' TO AN AIRSPD OF 248 KTS AND THE CAPT HAD SET THE VERT FLT LVL CHANGE MODE AT 260 KIAS IN THE AUTOPLT. IF THE FO HAD PUT IN THE 15000 FT AT PXT IN THE FMS AND THE AIRSPD HAD BEEN PREVIOUSLY SET AT 248 KIAS IN THE FMS, THIS MAY HAVE SLOWED THE DSCNT. ALSO, THE CREW'S PREOCCUPATION OF THE CREW PREPARING FOR HOLDING AT PHL MAY HAVE LED TO IMPROPER MONITORING OF THE FMS AND AUTOPLT.
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.