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|
Attributes | |
ACN | 514370 |
Time | |
Date | 200106 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | navaid : ign.vor |
State Reference | NY |
Altitude | msl bound lower : 19000 msl bound upper : 29000 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zmp.artcc |
Operator | common carrier : air carrier |
Make Model Name | B747-400 |
Flight Phase | descent : approach |
Route In Use | arrival star : n/s |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : multi engine pilot : commercial pilot : atp pilot : instrument |
Experience | flight time last 90 days : 85 flight time total : 14000 flight time type : 85 |
ASRS Report | 514370 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance |
Resolutory Action | controller : issued new clearance flight crew : returned to assigned altitude |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
This incident involves 3 pilots: the flying captain (me), my copilot, and a relief captain. We were nearing the end of a 12 hour 17 min flight to jfk when we had an altitude deviation. After being cleared direct ign and while at cruise altitude, I left the cockpit for the lav and to talk to the lead flight attendant. The relief captain was in the cockpit at that time and sat in the captain's seat while I was gone. That way, no one had to wear an oxygen mask. When I returned he was trying to build, with some difficulty, a waypoint 35 mi this side of ign. I sat in the observer's seat while he was doing this and watched. After he got the point built, I told him to enter our clearance altitude. When he did, the computed descent path showed us to be very high. He next told center that the only way we would make that crossing restr was if we did a 360 degree turn. Center responded with 'do the best you can.' I then reoccupied the left seat as the PF and speed intervened to increase the rate of descent. As I started to look over the situation, I began to feel uneasy about what was happening and the clearance that I was told that we had received. I thought, if possible, that the relief captain or my copilot had misunderstood the point where we were to cross at FL190. I asked center if they meant for us to cross 35 mi this side of ign or the other side. Center then asked what our current altitude was and then almost simultaneously told us to immediately stop our descent. I was then told that we had been cleared to FL290, not FL190. We were then given a clearance to FL270 and were told that there had been no loss of separation. I was out of the cockpit when the original clearance was received. My copilot said that he wrote down FL190 and read back FL190 as the clearance altitude. I don't know if the relief captain heard the original clearance. It is possible that he didn't put on the head phones when he occupied the left seat as he was only going to situation there temporarily while I went to the lav. He and I have both flown over 30 yrs in the airline service plus a few yrs in the navy. Some observations: 1) when a pilot tells a controller that the only way he or she can make a crossing restr is to do a 360 degree turn, then something is wrong somewhere and should be looked into. 2) in a multi-crewed situation, if you are going to temporarily relieve another crew member you should be fully prepared to assume the duties of the seat you are occupying. 3) if you have the certain 'feeling' or something just doesn't seem quite right then start asking questions.
Original NASA ASRS Text
Title: B747 FLT CREW HAS ALTDEV DURING DSCNT INTO JFK.
Narrative: THIS INCIDENT INVOLVES 3 PLTS: THE FLYING CAPT (ME), MY COPLT, AND A RELIEF CAPT. WE WERE NEARING THE END OF A 12 HR 17 MIN FLT TO JFK WHEN WE HAD AN ALTDEV. AFTER BEING CLRED DIRECT IGN AND WHILE AT CRUISE ALT, I LEFT THE COCKPIT FOR THE LAV AND TO TALK TO THE LEAD FLT ATTENDANT. THE RELIEF CAPT WAS IN THE COCKPIT AT THAT TIME AND SAT IN THE CAPT'S SEAT WHILE I WAS GONE. THAT WAY, NO ONE HAD TO WEAR AN OXYGEN MASK. WHEN I RETURNED HE WAS TRYING TO BUILD, WITH SOME DIFFICULTY, A WAYPOINT 35 MI THIS SIDE OF IGN. I SAT IN THE OBSERVER'S SEAT WHILE HE WAS DOING THIS AND WATCHED. AFTER HE GOT THE POINT BUILT, I TOLD HIM TO ENTER OUR CLRNC ALT. WHEN HE DID, THE COMPUTED DSCNT PATH SHOWED US TO BE VERY HIGH. HE NEXT TOLD CTR THAT THE ONLY WAY WE WOULD MAKE THAT XING RESTR WAS IF WE DID A 360 DEG TURN. CTR RESPONDED WITH 'DO THE BEST YOU CAN.' I THEN REOCCUPIED THE L SEAT AS THE PF AND SPD INTERVENED TO INCREASE THE RATE OF DSCNT. AS I STARTED TO LOOK OVER THE SIT, I BEGAN TO FEEL UNEASY ABOUT WHAT WAS HAPPENING AND THE CLRNC THAT I WAS TOLD THAT WE HAD RECEIVED. I THOUGHT, IF POSSIBLE, THAT THE RELIEF CAPT OR MY COPLT HAD MISUNDERSTOOD THE POINT WHERE WE WERE TO CROSS AT FL190. I ASKED CTR IF THEY MEANT FOR US TO CROSS 35 MI THIS SIDE OF IGN OR THE OTHER SIDE. CTR THEN ASKED WHAT OUR CURRENT ALT WAS AND THEN ALMOST SIMULTANEOUSLY TOLD US TO IMMEDIATELY STOP OUR DSCNT. I WAS THEN TOLD THAT WE HAD BEEN CLRED TO FL290, NOT FL190. WE WERE THEN GIVEN A CLRNC TO FL270 AND WERE TOLD THAT THERE HAD BEEN NO LOSS OF SEPARATION. I WAS OUT OF THE COCKPIT WHEN THE ORIGINAL CLRNC WAS RECEIVED. MY COPLT SAID THAT HE WROTE DOWN FL190 AND READ BACK FL190 AS THE CLRNC ALT. I DON'T KNOW IF THE RELIEF CAPT HEARD THE ORIGINAL CLRNC. IT IS POSSIBLE THAT HE DIDN'T PUT ON THE HEAD PHONES WHEN HE OCCUPIED THE L SEAT AS HE WAS ONLY GOING TO SIT THERE TEMPORARILY WHILE I WENT TO THE LAV. HE AND I HAVE BOTH FLOWN OVER 30 YRS IN THE AIRLINE SVC PLUS A FEW YRS IN THE NAVY. SOME OBSERVATIONS: 1) WHEN A PLT TELLS A CTLR THAT THE ONLY WAY HE OR SHE CAN MAKE A XING RESTR IS TO DO A 360 DEG TURN, THEN SOMETHING IS WRONG SOMEWHERE AND SHOULD BE LOOKED INTO. 2) IN A MULTI-CREWED SIT, IF YOU ARE GOING TO TEMPORARILY RELIEVE ANOTHER CREW MEMBER YOU SHOULD BE FULLY PREPARED TO ASSUME THE DUTIES OF THE SEAT YOU ARE OCCUPYING. 3) IF YOU HAVE THE CERTAIN 'FEELING' OR SOMETHING JUST DOESN'T SEEM QUITE RIGHT THEN START ASKING QUESTIONS.
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.