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|
Attributes | |
ACN | 455970 |
Time | |
Date | 199911 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
State Reference | FO |
Altitude | msl bound lower : 6000 msl bound upper : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : egpx.artcc tower : egph.tower |
Operator | common carrier : air carrier |
Make Model Name | B727-200 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other ndb |
Flight Phase | climbout : vacating altitude |
Route In Use | departure sid : dcs 2c |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : atp pilot : cfi pilot : flight engineer |
Experience | flight time last 90 days : 67 flight time total : 2700 flight time type : 441 |
ASRS Report | 455970 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : published procedure other anomaly other |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued advisory none taken : detected after the fact |
Consequence | faa : investigated |
Supplementary | |
Problem Areas | Flight Crew Human Performance ATC Human Performance Chart Or Publication Environmental Factor |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Prior to pushback, the captain and I briefed our flight planned departure, the talla 5C (tla 5C) SID. We set an altitude of 6000 ft in the annunciator. After pushback and during the taxi, edinburgh gave us our clearance containing a different departure, the dean cross 2C (dcs 2C) SID with no comment on crossing altitude restrs. After completing the taxi checklist, we got out the dcs 2C SID and briefed it. This time we missed a warning box limiting our climb to 6000 ft until further cleared by ATC. Instead we concentrated on altitude limits noted along the route of flight and in the routing and altitude box at the bottom of the plate. The altitude limits read 'cross uw lctr (ith 4.5 DME) at 6000 ft, D44 trn (D19 ith) at or above FL100.' based on this we revised our altitude limit to FL100. We followed standard company takeoff and noise abatement departure procedures. At the transition altitude of 6000 ft, we set 1013 millibars. At about FL80 edinburgh tower asked if we were still with him. We answered affirmative since we had not received a call to contact scottish control. Edinburgh tower said that he had already instructed us once to contact scottish and asked us to do so immediately. We complied with this. If there was an earlier call, we had not heard or acknowledged it and edinburgh tower never questioned our failure to read back his first transmission. We contacted scottish control immediately and were informed by him that we had exceeded a 6000 ft climb restr. We reviewed our plates again and did not see this climb limit, only the FL100 limit. At this point we felt we had complied with the SID, asked scottish control for his phone number and said we would call him once we landed at east midlands (egnx). On the ground in east midlands, the captain and I reviewed the dcs 2C SID again. This time we saw the altitude warning box. I called scottish control to explain what had happened, and we discussed why there is a limiting altitude. At this point I was informed that an altitude deviation report would have to be filed. We also discussed the failure to establish radio contact. I said that we had never received a call from edinburgh tower to contact scottish control. Scottish control said that we were the second aircraft that night which edinburgh tower had failed to hand off. Summary; failure to observe an altitude warning box on the departure plate caused us to believe that we had a higher climb limit. A timely handover to scottish control by edinburgh tower would have prevented this problem from occurring. Chain of events: 1) receiving the clearance during taxi. 2) getting a different SID from the one filed. 3) failure to see the altitude warning box. Contributing factors: 1) failure of edinburgh tower to hand us off in a timely manner. 2) confusing chart layout. Instructions along the route of flight and at the foot of the plate in the altitude box suggest FL100 is the final cleared altitude. Corrective actions: 1) issue the SID clearance before taxi. 2) include the 6000 ft limit in the clearance. 3) include instructions to contact scottish control after takeoff or above a specified altitude if no contact from edinburgh tower. 4) rewrite the departure plate to emphasize the 6000 ft climb limit. 5) change the FL100 limit to read 'D44 trn (D19 ith) at or above FL100 when cleared by ATC.' human performance considerations: perceptions, judgement, decisions -- based on our flight planned SID we originally had set 6000 ft as a climb limit. The new clearance came during the busy taxi period. The result was insufficient study of the departure plate. 2) our perception of a new climb limit was reinforced by several references to it on the plate. Actions or inactions -- 1) as PNF, I should have spent more time studying the SID so I could back up the PF. 2) I should have been more aware that edinburgh tower had not handed us off. Factors affecting the quality of human performance -- 1) it was the last leg of a busy week. I was looking forward to finishing. 2) poor lighting in the cockpit, confusing chart layout and a change of SID during taxi while finishing checklists combined to distract me from my proper duties.
Original NASA ASRS Text
Title: A CARGO 727-200 FLC EXPERIENCES AN ALT EXCURSION DURING THEIR REVISED SID DEP PROC FROM EDINBURGH, EGPH, FO.
Narrative: PRIOR TO PUSHBACK, THE CAPT AND I BRIEFED OUR FLT PLANNED DEP, THE TALLA 5C (TLA 5C) SID. WE SET AN ALT OF 6000 FT IN THE ANNUNCIATOR. AFTER PUSHBACK AND DURING THE TAXI, EDINBURGH GAVE US OUR CLRNC CONTAINING A DIFFERENT DEP, THE DEAN CROSS 2C (DCS 2C) SID WITH NO COMMENT ON XING ALT RESTRS. AFTER COMPLETING THE TAXI CHKLIST, WE GOT OUT THE DCS 2C SID AND BRIEFED IT. THIS TIME WE MISSED A WARNING BOX LIMITING OUR CLB TO 6000 FT UNTIL FURTHER CLRED BY ATC. INSTEAD WE CONCENTRATED ON ALT LIMITS NOTED ALONG THE RTE OF FLT AND IN THE ROUTING AND ALT BOX AT THE BOTTOM OF THE PLATE. THE ALT LIMITS READ 'CROSS UW LCTR (ITH 4.5 DME) AT 6000 FT, D44 TRN (D19 ITH) AT OR ABOVE FL100.' BASED ON THIS WE REVISED OUR ALT LIMIT TO FL100. WE FOLLOWED STANDARD COMPANY TKOF AND NOISE ABATEMENT DEP PROCS. AT THE TRANSITION ALT OF 6000 FT, WE SET 1013 MILLIBARS. AT ABOUT FL80 EDINBURGH TWR ASKED IF WE WERE STILL WITH HIM. WE ANSWERED AFFIRMATIVE SINCE WE HAD NOT RECEIVED A CALL TO CONTACT SCOTTISH CTL. EDINBURGH TWR SAID THAT HE HAD ALREADY INSTRUCTED US ONCE TO CONTACT SCOTTISH AND ASKED US TO DO SO IMMEDIATELY. WE COMPLIED WITH THIS. IF THERE WAS AN EARLIER CALL, WE HAD NOT HEARD OR ACKNOWLEDGED IT AND EDINBURGH TWR NEVER QUESTIONED OUR FAILURE TO READ BACK HIS FIRST XMISSION. WE CONTACTED SCOTTISH CTL IMMEDIATELY AND WERE INFORMED BY HIM THAT WE HAD EXCEEDED A 6000 FT CLB RESTR. WE REVIEWED OUR PLATES AGAIN AND DID NOT SEE THIS CLB LIMIT, ONLY THE FL100 LIMIT. AT THIS POINT WE FELT WE HAD COMPLIED WITH THE SID, ASKED SCOTTISH CTL FOR HIS PHONE NUMBER AND SAID WE WOULD CALL HIM ONCE WE LANDED AT EAST MIDLANDS (EGNX). ON THE GND IN EAST MIDLANDS, THE CAPT AND I REVIEWED THE DCS 2C SID AGAIN. THIS TIME WE SAW THE ALT WARNING BOX. I CALLED SCOTTISH CTL TO EXPLAIN WHAT HAD HAPPENED, AND WE DISCUSSED WHY THERE IS A LIMITING ALT. AT THIS POINT I WAS INFORMED THAT AN ALTDEV RPT WOULD HAVE TO BE FILED. WE ALSO DISCUSSED THE FAILURE TO ESTABLISH RADIO CONTACT. I SAID THAT WE HAD NEVER RECEIVED A CALL FROM EDINBURGH TWR TO CONTACT SCOTTISH CTL. SCOTTISH CTL SAID THAT WE WERE THE SECOND ACFT THAT NIGHT WHICH EDINBURGH TWR HAD FAILED TO HAND OFF. SUMMARY; FAILURE TO OBSERVE AN ALT WARNING BOX ON THE DEP PLATE CAUSED US TO BELIEVE THAT WE HAD A HIGHER CLB LIMIT. A TIMELY HANDOVER TO SCOTTISH CTL BY EDINBURGH TWR WOULD HAVE PREVENTED THIS PROB FROM OCCURRING. CHAIN OF EVENTS: 1) RECEIVING THE CLRNC DURING TAXI. 2) GETTING A DIFFERENT SID FROM THE ONE FILED. 3) FAILURE TO SEE THE ALT WARNING BOX. CONTRIBUTING FACTORS: 1) FAILURE OF EDINBURGH TWR TO HAND US OFF IN A TIMELY MANNER. 2) CONFUSING CHART LAYOUT. INSTRUCTIONS ALONG THE RTE OF FLT AND AT THE FOOT OF THE PLATE IN THE ALT BOX SUGGEST FL100 IS THE FINAL CLRED ALT. CORRECTIVE ACTIONS: 1) ISSUE THE SID CLRNC BEFORE TAXI. 2) INCLUDE THE 6000 FT LIMIT IN THE CLRNC. 3) INCLUDE INSTRUCTIONS TO CONTACT SCOTTISH CTL AFTER TKOF OR ABOVE A SPECIFIED ALT IF NO CONTACT FROM EDINBURGH TWR. 4) REWRITE THE DEP PLATE TO EMPHASIZE THE 6000 FT CLB LIMIT. 5) CHANGE THE FL100 LIMIT TO READ 'D44 TRN (D19 ITH) AT OR ABOVE FL100 WHEN CLRED BY ATC.' HUMAN PERFORMANCE CONSIDERATIONS: PERCEPTIONS, JUDGEMENT, DECISIONS -- BASED ON OUR FLT PLANNED SID WE ORIGINALLY HAD SET 6000 FT AS A CLB LIMIT. THE NEW CLRNC CAME DURING THE BUSY TAXI PERIOD. THE RESULT WAS INSUFFICIENT STUDY OF THE DEP PLATE. 2) OUR PERCEPTION OF A NEW CLB LIMIT WAS REINFORCED BY SEVERAL REFS TO IT ON THE PLATE. ACTIONS OR INACTIONS -- 1) AS PNF, I SHOULD HAVE SPENT MORE TIME STUDYING THE SID SO I COULD BACK UP THE PF. 2) I SHOULD HAVE BEEN MORE AWARE THAT EDINBURGH TWR HAD NOT HANDED US OFF. FACTORS AFFECTING THE QUALITY OF HUMAN PERFORMANCE -- 1) IT WAS THE LAST LEG OF A BUSY WK. I WAS LOOKING FORWARD TO FINISHING. 2) POOR LIGHTING IN THE COCKPIT, CONFUSING CHART LAYOUT AND A CHANGE OF SID DURING TAXI WHILE FINISHING CHKLISTS COMBINED TO DISTRACT ME FROM MY PROPER DUTIES.
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.