37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 491580 |
Time | |
Date | 200011 |
Day | Sat |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : iad.airport |
State Reference | VA |
Altitude | msl bound lower : 3000 msl bound upper : 4000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : iad.tracon |
Operator | general aviation : personal |
Make Model Name | Citation I/SP |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : vacating altitude |
Route In Use | departure sid : capitol 4 |
Flight Plan | IFR |
Person 1 | |
Affiliation | other |
Function | flight crew : single pilot |
Qualification | pilot : atp |
Experience | flight time last 90 days : 50 flight time total : 8964 flight time type : 2700 |
ASRS Report | 491580 |
Person 2 | |
Affiliation | government : faa |
Function | controller : departure |
Qualification | controller : radar |
Events | |
Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance non adherence : far other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued alert none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The aircraft (a citation 501) was flown to the clearance altitude of 4000 ft called for by the capitol 4 departure procedure for iad airport. Unfortunately, this procedure had recently been replaced by the capital 5 procedure, which calls for maintaining 3000 ft. The pilot had not noticed the update in the commercial IFR SID plate, nor compared the procedure name on the departure plate to that specified in the verbal clearance (ie, carelessness). The error was noticed by the departure controller after the pilot established initial contact. The mistake was immediately recognized by the pilot, and acknowledged, with an apology. One contributing factor was the inability to make initial contact with the departure controller, due to the controller's lengthy conversation with another aircraft which was apparently lost, or in a place other than that expected by the controller, and coincidentally the ability of the citation to reach the initial departure altitude faster than normal due to light takeoff weight (10000 pounds). A call of 'climbing to 4000 ft' might otherwise have been challenged by the departure controller before the aircraft climbed through the 3000 ft level. Suggestion: this type of error might be decreased if the entire procedure name was changed at the time of any significant change to the actual procedure (rather than just incrementing the procedure index number, or perhaps have the procedure receive a new name consisting of 5 randomly generated letters (eg, 'ylcrf') each time the procedure is changed.
Original NASA ASRS Text
Title: C501 PLT HAD ALT OVERSHOOT IN IAD CLASS B AIRSPACE.
Narrative: THE ACFT (A CITATION 501) WAS FLOWN TO THE CLRNC ALT OF 4000 FT CALLED FOR BY THE CAPITOL 4 DEP PROC FOR IAD ARPT. UNFORTUNATELY, THIS PROC HAD RECENTLY BEEN REPLACED BY THE CAPITAL 5 PROC, WHICH CALLS FOR MAINTAINING 3000 FT. THE PLT HAD NOT NOTICED THE UPDATE IN THE COMMERCIAL IFR SID PLATE, NOR COMPARED THE PROC NAME ON THE DEP PLATE TO THAT SPECIFIED IN THE VERBAL CLRNC (IE, CARELESSNESS). THE ERROR WAS NOTICED BY THE DEP CTLR AFTER THE PLT ESTABLISHED INITIAL CONTACT. THE MISTAKE WAS IMMEDIATELY RECOGNIZED BY THE PLT, AND ACKNOWLEDGED, WITH AN APOLOGY. ONE CONTRIBUTING FACTOR WAS THE INABILITY TO MAKE INITIAL CONTACT WITH THE DEP CTLR, DUE TO THE CTLR'S LENGTHY CONVERSATION WITH ANOTHER ACFT WHICH WAS APPARENTLY LOST, OR IN A PLACE OTHER THAN THAT EXPECTED BY THE CTLR, AND COINCIDENTALLY THE ABILITY OF THE CITATION TO REACH THE INITIAL DEP ALT FASTER THAN NORMAL DUE TO LIGHT TKOF WT (10000 LBS). A CALL OF 'CLBING TO 4000 FT' MIGHT OTHERWISE HAVE BEEN CHALLENGED BY THE DEP CTLR BEFORE THE ACFT CLBED THROUGH THE 3000 FT LEVEL. SUGGESTION: THIS TYPE OF ERROR MIGHT BE DECREASED IF THE ENTIRE PROC NAME WAS CHANGED AT THE TIME OF ANY SIGNIFICANT CHANGE TO THE ACTUAL PROC (RATHER THAN JUST INCREMENTING THE PROC INDEX NUMBER, OR PERHAPS HAVE THE PROC RECEIVE A NEW NAME CONSISTING OF 5 RANDOMLY GENERATED LETTERS (EG, 'YLCRF') EACH TIME THE PROC IS CHANGED.
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.