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|
Attributes | |
ACN | 530938 |
Time | |
Date | 200111 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | intersection : misen |
State Reference | CA |
Altitude | msl bound lower : 24000 msl bound upper : 29000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zla.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : approach |
Route In Use | arrival star : skebr 1 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 200 flight time total : 6000 flight time type : 4000 |
ASRS Report | 530938 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : commercial |
Experience | flight time last 90 days : 33 flight time total : 7000 flight time type : 3000 |
ASRS Report | 530937 |
Events | |
Anomaly | altitude deviation : undershoot altitude deviation : crossing restriction not met non adherence : company policies non adherence : clearance non adherence : far non adherence : published procedure other anomaly other |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued alert none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Approaching dagett on the pamona six departure out of ontario, we were given a clearance from FL290 to descend to FL250 to expect FL240 at misen intersection on the skebr one arrival into las vegas. The PNF read the clearance back correctly and the PF repeated the readback. Both pilots attended to some paperwork (logbook entries) from departure after the communication with ATC. After reviewing the skebr one arrival illustration and the FMC profile, both which read 'misen FL240 mim,' the PF understood at or above FL240 at misen, rather than the hard altitude assigned. As the PF began his descent, ATC questioned our profile and the misunderstanding became apparent. We were too high to make the restriction. Some contributing factors that lead to the error include the very short duration of the flight with both pilots attending to their logbooks rather than the descent profile. New RNAV procedures were in effect which were relatively new to the crew. In addition the daggett VOR was inoperative, so the familiar pattern of establishing situation awareness was unavailable. ATC made little differentiation between the illustrated profile and the altitude assigned. Lessons learned include: pay attention to the new arrivals into las, both flcs and ATC are new to the procedures. The standard cues for situation awareness are no longer displayed, pay attention. Don't get distracted on the short flts as a flight crew. ATC could make more of an effort to differentiate descent profiles, especially when procedures are new. Both crewmembers should better manage FMC and back each other up.
Original NASA ASRS Text
Title: B737-300 CREW DID NOT COMPLY WITH AN ISSUED CROSSING RESTRICTION ON THE SKEBR 1 STAR INTO LAS.
Narrative: APCHING DAGETT ON THE PAMONA SIX DEP OUT OF ONTARIO, WE WERE GIVEN A CLRNC FROM FL290 TO DSND TO FL250 TO EXPECT FL240 AT MISEN INTXN ON THE SKEBR ONE ARRIVAL INTO LAS VEGAS. THE PNF READ THE CLRNC BACK CORRECTLY AND THE PF REPEATED THE READBACK. BOTH PLTS ATTENDED TO SOME PAPERWORK (LOGBOOK ENTRIES) FROM DEP AFTER THE COM WITH ATC. AFTER REVIEWING THE SKEBR ONE ARRIVAL ILLUSTRATION AND THE FMC PROFILE, BOTH WHICH READ 'MISEN FL240 MIM,' THE PF UNDERSTOOD AT OR ABOVE FL240 AT MISEN, RATHER THAN THE HARD ALT ASSIGNED. AS THE PF BEGAN HIS DSCNT, ATC QUESTIONED OUR PROFILE AND THE MISUNDERSTANDING BECAME APPARENT. WE WERE TOO HIGH TO MAKE THE RESTRICTION. SOME CONTRIBUTING FACTORS THAT LEAD TO THE ERROR INCLUDE THE VERY SHORT DURATION OF THE FLT WITH BOTH PLTS ATTENDING TO THEIR LOGBOOKS RATHER THAN THE DSCNT PROFILE. NEW RNAV PROCS WERE IN EFFECT WHICH WERE RELATIVELY NEW TO THE CREW. IN ADDITION THE DAGGETT VOR WAS INOP, SO THE FAMILIAR PATTERN OF ESTABLISHING SIT AWARENESS WAS UNAVAILABLE. ATC MADE LITTLE DIFFERENTIATION BETWEEN THE ILLUSTRATED PROFILE AND THE ALT ASSIGNED. LESSONS LEARNED INCLUDE: PAY ATTENTION TO THE NEW ARRIVALS INTO LAS, BOTH FLCS AND ATC ARE NEW TO THE PROCS. THE STD CUES FOR SIT AWARENESS ARE NO LONGER DISPLAYED, PAY ATTENTION. DON'T GET DISTRACTED ON THE SHORT FLTS AS A FLC. ATC COULD MAKE MORE OF AN EFFORT TO DIFFERENTIATE DSCNT PROFILES, ESPECIALLY WHEN PROCS ARE NEW. BOTH CREWMEMBERS SHOULD BETTER MANAGE FMC AND BACK EACH OTHER UP.
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.