37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 495162 |
Time | |
Date | 200012 |
Day | Sun |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : slc.airport |
State Reference | UT |
Altitude | msl bound lower : 7300 msl bound upper : 9000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : s56.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 34r other |
Flight Phase | descent : approach |
Route In Use | approach : instrument precision |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 5000 flight time type : 1500 |
ASRS Report | 495162 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 11500 flight time type : 2500 |
ASRS Report | 495338 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : published procedure |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : returned to original clearance |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
ATC cleared us to cross plage at or above 9000 ft and cleared us for the ILS runway 34R approach. After crossing plage at 9000 ft, I verbalized to the captain that the next altitude we were cleared to on the approach was 7100 ft. He dialed in 7100 ft on the MCP and started down. The next fix after plage is scoer at 7100 ft. The normal altitude at plage is 10500 ft, but ATC may authorize 9000 ft. I had looked at the approach plate and thought that we were passing scoer since we were already at 9000 ft. Hence, I thought the next altitude should be 7100 ft. We should have been maintaining 9000 ft until scoer. Instead we started out of 9000 ft just after passing plage and arrived at about 7700 ft just prior to scoer. It was at this point that the captain realized our mistake. The said 'uh oh' and leveled off until scoer. He said that we should not have started down yet. I understood him and realized that we had screwed up. In the chain of events: 1) ATC cleared us to 9000 ft instead of 10500 ft to start the approach. 2) I looked at the next altitude on the approach after 9000 ft and saw 7100 ft. I did this without verifying which fix was next. 3) I verbalized 7100 ft to the captain which caused him to think we should start down. I feel like a dummy for making such a simple and obvious mistake, but in retrospect, I could see how it could happen to any pilot given just a momentary loss of positional awareness. Other factors: only my second time to slc and last time was several months earlier. Captain also had not been there recently. Other note: ATC never mentioned the early start of descent. I'm not sure why. We were visual and perhaps he was thinking along those lines in which case altitude was our choice.
Original NASA ASRS Text
Title: B733 FLC OVERSHOT MANDATORY XING ALTS ON SLC ILS RWY 34R APCH.
Narrative: ATC CLRED US TO CROSS PLAGE AT OR ABOVE 9000 FT AND CLRED US FOR THE ILS RWY 34R APCH. AFTER XING PLAGE AT 9000 FT, I VERBALIZED TO THE CAPT THAT THE NEXT ALT WE WERE CLRED TO ON THE APCH WAS 7100 FT. HE DIALED IN 7100 FT ON THE MCP AND STARTED DOWN. THE NEXT FIX AFTER PLAGE IS SCOER AT 7100 FT. THE NORMAL ALT AT PLAGE IS 10500 FT, BUT ATC MAY AUTHORIZE 9000 FT. I HAD LOOKED AT THE APCH PLATE AND THOUGHT THAT WE WERE PASSING SCOER SINCE WE WERE ALREADY AT 9000 FT. HENCE, I THOUGHT THE NEXT ALT SHOULD BE 7100 FT. WE SHOULD HAVE BEEN MAINTAINING 9000 FT UNTIL SCOER. INSTEAD WE STARTED OUT OF 9000 FT JUST AFTER PASSING PLAGE AND ARRIVED AT ABOUT 7700 FT JUST PRIOR TO SCOER. IT WAS AT THIS POINT THAT THE CAPT REALIZED OUR MISTAKE. THE SAID 'UH OH' AND LEVELED OFF UNTIL SCOER. HE SAID THAT WE SHOULD NOT HAVE STARTED DOWN YET. I UNDERSTOOD HIM AND REALIZED THAT WE HAD SCREWED UP. IN THE CHAIN OF EVENTS: 1) ATC CLRED US TO 9000 FT INSTEAD OF 10500 FT TO START THE APCH. 2) I LOOKED AT THE NEXT ALT ON THE APCH AFTER 9000 FT AND SAW 7100 FT. I DID THIS WITHOUT VERIFYING WHICH FIX WAS NEXT. 3) I VERBALIZED 7100 FT TO THE CAPT WHICH CAUSED HIM TO THINK WE SHOULD START DOWN. I FEEL LIKE A DUMMY FOR MAKING SUCH A SIMPLE AND OBVIOUS MISTAKE, BUT IN RETROSPECT, I COULD SEE HOW IT COULD HAPPEN TO ANY PLT GIVEN JUST A MOMENTARY LOSS OF POSITIONAL AWARENESS. OTHER FACTORS: ONLY MY SECOND TIME TO SLC AND LAST TIME WAS SEVERAL MONTHS EARLIER. CAPT ALSO HAD NOT BEEN THERE RECENTLY. OTHER NOTE: ATC NEVER MENTIONED THE EARLY START OF DSCNT. I'M NOT SURE WHY. WE WERE VISUAL AND PERHAPS HE WAS THINKING ALONG THOSE LINES IN WHICH CASE ALT WAS OUR CHOICE.
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.