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|
Attributes | |
ACN | 499190 |
Time | |
Date | 200101 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : luk.airport |
State Reference | OH |
Altitude | msl bound lower : 2500 msl bound upper : 4000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Snow |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : cvg.tracon |
Operator | general aviation : corporate |
Make Model Name | IAI1125 (Astra) |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : vacating altitude climbout : intermediate altitude |
Route In Use | departure : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 30 flight time total : 6050 flight time type : 30 |
ASRS Report | 499190 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 75 flight time total : 3100 flight time type : 150 |
ASRS Report | 499207 |
Events | |
Anomaly | altitude deviation : overshoot inflight encounter : weather inflight encounter other non adherence : clearance other anomaly other |
Independent Detector | other controllera |
Resolutory Action | controller : issued alert controller : issued new clearance |
Consequence | other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Weather Company |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
This flight was the return trip of what had been a fairly routine 3-DAY trip from hillsboro, or, to cincinnati/lunken and return. We were scheduled to depart at XB00 on friday afternoon. It was approximately XA15 when my copilot went out to the aircraft and copied the clearance. I left to pick up the catering and was gone approximately 45 mins. Upon returning I queried my copilot as to the clearance. He seemed to be unsure as to some of the fixes in the clearance, so I encouraged him to grab the charts and locate those points so that we would not be hunting for them while in the air. He did find the fixes and explained the routing to me. XB30 came and went and it became apparent that we were going to be departing much later than previously scheduled. My copilot continued to ensure that our clearance would not be dropped out of the system. Our passenger finally arrived approximately XE30. I went out to the aircraft and started the right engine to warm up the aircraft and also used this time to load the flight plan into the FMC while the copilot finished loading the luggage, passenger, and catering. I found what I believed to be the copilot's clearance. I copied as much of the clearance into the box as I could interpretation from his note pad and waited for him to join me in the cockpit before loading the rest of the clearance. I found the transponder code, dialed it in and left it at that. When the copilot joined me he deciphered the rest of the clearance fixes and we were able to then finish programming the boxes. Because of the snow on the taxiway, a good share of my attention was given to ensuring safe taxiing and verifying taxi clrncs across the runways that we had to cross. My copilot was performing the taxi checks and when he came to the altitude verification, he stated 4000 ft. That got my attention as we usually get 2500 ft for an initial altitude. I verified that the clearance was 4000 ft. He looked at his note pad and assured me that 4000 ft was correct. We did not lower the flaps until taking the runway, as I wanted to prevent any contamination of the flaps prior to takeoff. I briefed the departure procedure and the nonstandard procedures as we were going to leave the gear and the flaps extended for a longer than usual time to clear any residual slush off of them prior to retraction. Climbing through 2000 ft, the tower handed us off to cincinnati approach. The copilot was unable to reach approach control on the frequency he had dialed in which happened to be the portland approach frequency. He finally reached approach control as we were climbing through about 3000 ft. Altitude clarification was made as we passed through 3500 ft. During the inquiry about altitude clrncs, the controller verified a different squawk from what was set in the box, which I then noticed had been changed from what I had set in earlier. The controller also stated that we had been cleared to 2500 ft. My copilot stated that the clearance was to 4000 ft. At this point the controller cleared us to maintain 4000 ft and that the tower had no recollection of clearing us to 4000 ft. Nothing else was said about the altitude deviation between the controller and us. My copilot seemed very perplexed as to how he could have made that kind of mistake until he realized that he had looked at the old clearance from our departure out of hillsboro. My copilot had done the same thing that many of us had done -- leaving old clrncs lying around. I believe there are several things that we can do to prevent this happening again: 1) old notes and clrncs need to be disposed of after each flight. 2) verification between clrncs and departure procedures on approach plates if there is a discrepancy. 3) if there is any doubt or question as to a clearance, ask for verification. Controllers tend to be intimidating when asked to verify clrncs which at times obstructs open communication between them and pilots. This may have been a classic example. Earlier in the day, my copilot had asked the tower controller to keep our clearance in the system, as we did not know when we were going to depart. My copilot called them once again a couple hours later to verify that they still had our clearance. The controller responded in a rather perturbed way that 'yes, they still had it like I said I would.' now, my copilot really would rather not talk to thisguy unless absolutely necessary. This creates an atmosphere where there is a reluctance to ask for verifications and ask questions when there are doubts. Supplemental information from acn 499207: the WX had been snowing so the captain and I were keeping the plane clean while waiting for our passenger. Our passenger arrived and the captain started #2 engine and began preparing for the flight, while I loaded catering and helped with the passenger. Prior to taxi, captain asked that I verify the route of the clearance that he had entered into the computer. Then we began to taxi to runway 21L and started completing our taxi check. During the taxi check, I read the clearance to the captain in an abbreviated format instead of the entire clearance. All normal readbacks occurred. We were then cleared for takeoff and to fly runway heading. After switching to departure, the controller asked why we were at 4000 ft MSL, only cleared to 2500 ft MSL. What was our clearance. I read back 4000 ft MSL. He then told us to remain at 4000 ft MSL and turn 5 degrees right. This is when I discovered that I was using an old clearance and I had made a mistake. Departure then switched us over to center and the flight proceeded as normal. To my knowledge, there were no separation problems. Both the captain and myself have discussed this situation with our company's chief pilot and we are having meetings to change procedures our flight department uses regarding how the crew reads and understands clrncs.
Original NASA ASRS Text
Title: ASTRA CREW HAD ALT OVERSHOOT IN CVG CLASS B AIRSPACE.
Narrative: THIS FLT WAS THE RETURN TRIP OF WHAT HAD BEEN A FAIRLY ROUTINE 3-DAY TRIP FROM HILLSBORO, OR, TO CINCINNATI/LUNKEN AND RETURN. WE WERE SCHEDULED TO DEPART AT XB00 ON FRIDAY AFTERNOON. IT WAS APPROX XA15 WHEN MY COPLT WENT OUT TO THE ACFT AND COPIED THE CLRNC. I LEFT TO PICK UP THE CATERING AND WAS GONE APPROX 45 MINS. UPON RETURNING I QUERIED MY COPLT AS TO THE CLRNC. HE SEEMED TO BE UNSURE AS TO SOME OF THE FIXES IN THE CLRNC, SO I ENCOURAGED HIM TO GRAB THE CHARTS AND LOCATE THOSE POINTS SO THAT WE WOULD NOT BE HUNTING FOR THEM WHILE IN THE AIR. HE DID FIND THE FIXES AND EXPLAINED THE ROUTING TO ME. XB30 CAME AND WENT AND IT BECAME APPARENT THAT WE WERE GOING TO BE DEPARTING MUCH LATER THAN PREVIOUSLY SCHEDULED. MY COPLT CONTINUED TO ENSURE THAT OUR CLRNC WOULD NOT BE DROPPED OUT OF THE SYS. OUR PAX FINALLY ARRIVED APPROX XE30. I WENT OUT TO THE ACFT AND STARTED THE R ENG TO WARM UP THE ACFT AND ALSO USED THIS TIME TO LOAD THE FLT PLAN INTO THE FMC WHILE THE COPLT FINISHED LOADING THE LUGGAGE, PAX, AND CATERING. I FOUND WHAT I BELIEVED TO BE THE COPLT'S CLRNC. I COPIED AS MUCH OF THE CLRNC INTO THE BOX AS I COULD INTERP FROM HIS NOTE PAD AND WAITED FOR HIM TO JOIN ME IN THE COCKPIT BEFORE LOADING THE REST OF THE CLRNC. I FOUND THE XPONDER CODE, DIALED IT IN AND LEFT IT AT THAT. WHEN THE COPLT JOINED ME HE DECIPHERED THE REST OF THE CLRNC FIXES AND WE WERE ABLE TO THEN FINISH PROGRAMMING THE BOXES. BECAUSE OF THE SNOW ON THE TXWY, A GOOD SHARE OF MY ATTN WAS GIVEN TO ENSURING SAFE TAXIING AND VERIFYING TAXI CLRNCS ACROSS THE RWYS THAT WE HAD TO CROSS. MY COPLT WAS PERFORMING THE TAXI CHKS AND WHEN HE CAME TO THE ALT VERIFICATION, HE STATED 4000 FT. THAT GOT MY ATTN AS WE USUALLY GET 2500 FT FOR AN INITIAL ALT. I VERIFIED THAT THE CLRNC WAS 4000 FT. HE LOOKED AT HIS NOTE PAD AND ASSURED ME THAT 4000 FT WAS CORRECT. WE DID NOT LOWER THE FLAPS UNTIL TAKING THE RWY, AS I WANTED TO PREVENT ANY CONTAMINATION OF THE FLAPS PRIOR TO TKOF. I BRIEFED THE DEP PROC AND THE NONSTANDARD PROCS AS WE WERE GOING TO LEAVE THE GEAR AND THE FLAPS EXTENDED FOR A LONGER THAN USUAL TIME TO CLR ANY RESIDUAL SLUSH OFF OF THEM PRIOR TO RETRACTION. CLBING THROUGH 2000 FT, THE TWR HANDED US OFF TO CINCINNATI APCH. THE COPLT WAS UNABLE TO REACH APCH CTL ON THE FREQ HE HAD DIALED IN WHICH HAPPENED TO BE THE PORTLAND APCH FREQ. HE FINALLY REACHED APCH CTL AS WE WERE CLBING THROUGH ABOUT 3000 FT. ALT CLARIFICATION WAS MADE AS WE PASSED THROUGH 3500 FT. DURING THE INQUIRY ABOUT ALT CLRNCS, THE CTLR VERIFIED A DIFFERENT SQUAWK FROM WHAT WAS SET IN THE BOX, WHICH I THEN NOTICED HAD BEEN CHANGED FROM WHAT I HAD SET IN EARLIER. THE CTLR ALSO STATED THAT WE HAD BEEN CLRED TO 2500 FT. MY COPLT STATED THAT THE CLRNC WAS TO 4000 FT. AT THIS POINT THE CTLR CLRED US TO MAINTAIN 4000 FT AND THAT THE TWR HAD NO RECOLLECTION OF CLRING US TO 4000 FT. NOTHING ELSE WAS SAID ABOUT THE ALTDEV BTWN THE CTLR AND US. MY COPLT SEEMED VERY PERPLEXED AS TO HOW HE COULD HAVE MADE THAT KIND OF MISTAKE UNTIL HE REALIZED THAT HE HAD LOOKED AT THE OLD CLRNC FROM OUR DEP OUT OF HILLSBORO. MY COPLT HAD DONE THE SAME THING THAT MANY OF US HAD DONE -- LEAVING OLD CLRNCS LYING AROUND. I BELIEVE THERE ARE SEVERAL THINGS THAT WE CAN DO TO PREVENT THIS HAPPENING AGAIN: 1) OLD NOTES AND CLRNCS NEED TO BE DISPOSED OF AFTER EACH FLT. 2) VERIFICATION BTWN CLRNCS AND DEP PROCS ON APCH PLATES IF THERE IS A DISCREPANCY. 3) IF THERE IS ANY DOUBT OR QUESTION AS TO A CLRNC, ASK FOR VERIFICATION. CTLRS TEND TO BE INTIMIDATING WHEN ASKED TO VERIFY CLRNCS WHICH AT TIMES OBSTRUCTS OPEN COM BTWN THEM AND PLTS. THIS MAY HAVE BEEN A CLASSIC EXAMPLE. EARLIER IN THE DAY, MY COPLT HAD ASKED THE TWR CTLR TO KEEP OUR CLRNC IN THE SYS, AS WE DID NOT KNOW WHEN WE WERE GOING TO DEPART. MY COPLT CALLED THEM ONCE AGAIN A COUPLE HRS LATER TO VERIFY THAT THEY STILL HAD OUR CLRNC. THE CTLR RESPONDED IN A RATHER PERTURBED WAY THAT 'YES, THEY STILL HAD IT LIKE I SAID I WOULD.' NOW, MY COPLT REALLY WOULD RATHER NOT TALK TO THISGUY UNLESS ABSOLUTELY NECESSARY. THIS CREATES AN ATMOSPHERE WHERE THERE IS A RELUCTANCE TO ASK FOR VERIFICATIONS AND ASK QUESTIONS WHEN THERE ARE DOUBTS. SUPPLEMENTAL INFO FROM ACN 499207: THE WX HAD BEEN SNOWING SO THE CAPT AND I WERE KEEPING THE PLANE CLEAN WHILE WAITING FOR OUR PAX. OUR PAX ARRIVED AND THE CAPT STARTED #2 ENG AND BEGAN PREPARING FOR THE FLT, WHILE I LOADED CATERING AND HELPED WITH THE PAX. PRIOR TO TAXI, CAPT ASKED THAT I VERIFY THE RTE OF THE CLRNC THAT HE HAD ENTERED INTO THE COMPUTER. THEN WE BEGAN TO TAXI TO RWY 21L AND STARTED COMPLETING OUR TAXI CHK. DURING THE TAXI CHK, I READ THE CLRNC TO THE CAPT IN AN ABBREVIATED FORMAT INSTEAD OF THE ENTIRE CLRNC. ALL NORMAL READBACKS OCCURRED. WE WERE THEN CLRED FOR TKOF AND TO FLY RWY HDG. AFTER SWITCHING TO DEP, THE CTLR ASKED WHY WE WERE AT 4000 FT MSL, ONLY CLRED TO 2500 FT MSL. WHAT WAS OUR CLRNC. I READ BACK 4000 FT MSL. HE THEN TOLD US TO REMAIN AT 4000 FT MSL AND TURN 5 DEGS R. THIS IS WHEN I DISCOVERED THAT I WAS USING AN OLD CLRNC AND I HAD MADE A MISTAKE. DEP THEN SWITCHED US OVER TO CTR AND THE FLT PROCEEDED AS NORMAL. TO MY KNOWLEDGE, THERE WERE NO SEPARATION PROBS. BOTH THE CAPT AND MYSELF HAVE DISCUSSED THIS SIT WITH OUR COMPANY'S CHIEF PLT AND WE ARE HAVING MEETINGS TO CHANGE PROCS OUR FLT DEPT USES REGARDING HOW THE CREW READS AND UNDERSTANDS CLRNCS.
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.