37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 456552 |
Time | |
Date | 199912 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
State Reference | CO |
Altitude | msl bound lower : 3000 msl bound upper : 13000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Snow |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | A320 |
Operating Under FAR Part | Part 121 |
Flight Phase | descent : intermediate altitude descent : vacating altitude |
Route In Use | arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : instrument pilot : cfi pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 18000 flight time type : 600 |
ASRS Report | 456552 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument pilot : multi engine |
Events | |
Anomaly | conflict : ground critical non adherence : clearance non adherence : company policies non adherence : published procedure non adherence : far other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance controller : issued alert |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Aircraft level at 13000 ft. Clearance given again to maintain 13000 ft. I heard 3000 ft and looked at altitude. Since aircraft was already at 13000 ft I thought the clearance was 3000 ft and started down. I was preoccupied with the first officer in trying to figure the difference in the approach in the commercial chart versus the approach in the database. Both crew members were in a heavy workload and both missed the correct clearance. I knew den was 5000 ft, but before I stopped, the controller asked our altitude. It was 11000 ft and he said that would be all right. We maintained 11000 ft and continued on vectors for the approach and landed. Factors: 1) both pilots fairly new in glass cockpit. 2) late hour and WX -- fatigue with heavy cockpit load. 3) unfamiliar with den airport and approachs and procedures. 4) pilots did not confirm altitude change with each other. Company policy and procedures followed to the letter would probably have caught the mistake. Lessons: 1) one pilot must always fly the airplane. 2) never get too preoccupied inside aircraft with glass panel. 3) always confirm altitude clearance with other pilot. If unsure, ask controller for verification.
Original NASA ASRS Text
Title: EA32 CREW SET 3000 FT IN ALT SELECT WHEN DSNDING TO A 5431 FT ARPT.
Narrative: ACFT LEVEL AT 13000 FT. CLRNC GIVEN AGAIN TO MAINTAIN 13000 FT. I HEARD 3000 FT AND LOOKED AT ALT. SINCE ACFT WAS ALREADY AT 13000 FT I THOUGHT THE CLRNC WAS 3000 FT AND STARTED DOWN. I WAS PREOCCUPIED WITH THE FO IN TRYING TO FIGURE THE DIFFERENCE IN THE APCH IN THE COMMERCIAL CHART VERSUS THE APCH IN THE DATABASE. BOTH CREW MEMBERS WERE IN A HVY WORKLOAD AND BOTH MISSED THE CORRECT CLRNC. I KNEW DEN WAS 5000 FT, BUT BEFORE I STOPPED, THE CTLR ASKED OUR ALT. IT WAS 11000 FT AND HE SAID THAT WOULD BE ALL RIGHT. WE MAINTAINED 11000 FT AND CONTINUED ON VECTORS FOR THE APCH AND LANDED. FACTORS: 1) BOTH PLTS FAIRLY NEW IN GLASS COCKPIT. 2) LATE HR AND WX -- FATIGUE WITH HVY COCKPIT LOAD. 3) UNFAMILIAR WITH DEN ARPT AND APCHS AND PROCS. 4) PLTS DID NOT CONFIRM ALT CHANGE WITH EACH OTHER. COMPANY POLICY AND PROCS FOLLOWED TO THE LETTER WOULD PROBABLY HAVE CAUGHT THE MISTAKE. LESSONS: 1) ONE PLT MUST ALWAYS FLY THE AIRPLANE. 2) NEVER GET TOO PREOCCUPIED INSIDE ACFT WITH GLASS PANEL. 3) ALWAYS CONFIRM ALT CLRNC WITH OTHER PLT. IF UNSURE, ASK CTLR FOR VERIFICATION.
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.