37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 537525 |
Time | |
Date | 200202 |
Day | Thu |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | intersection : l1z10 |
State Reference | WV |
Altitude | msl single value : 27000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zob.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : vacating altitude |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : multi engine pilot : cfi pilot : instrument pilot : commercial |
Experience | flight time last 90 days : 225 flight time total : 17000 flight time type : 14000 |
ASRS Report | 537525 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : undershoot non adherence : company policies non adherence : clearance other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact none taken : unable |
Consequence | Other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Environmental Factor ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Flight from buf to bwi. Cruise flight at FL270. I was flying, the first officer on radios. First officer received a clearance to cross lizio intersection at FL250. I never heard the transmission. As the aircraft began a turn at lizio, the first officer said we needed to descend. This was my first knowledge of the clearance issued by ATC. I immediately descended to FL250. There appeared to be no loss of any separation or conflicts with other aircraft. This incident occurred because of the first officer's failure to carry out with the company's required procedures. The procedure states that the PNF reads back the clearance to ATC and resets the altitude alerter to the new altitude. The PF is to verbally restate the new altitude and verify the altitude alerter is set correctly. The PNF is to continue querying until he has received a verbal acknowledgement from the PF. I never acknowledged the clearance because I never heard it. The first officer did not complete this very important part of the procedure assuming I heard it. Assumptions: we all know the little ditty about them -- in aviation they can be fatal.
Original NASA ASRS Text
Title: A B737-700 PIC COMPLAINS OF THE LACK OF COORD COM FROM HIS FO DURING AN ALTDEV, ALT XING RESTR NOT MET, AT LIZIO INTXN, WV.
Narrative: FLT FROM BUF TO BWI. CRUISE FLT AT FL270. I WAS FLYING, THE FO ON RADIOS. FO RECEIVED A CLRNC TO CROSS LIZIO INTXN AT FL250. I NEVER HEARD THE XMISSION. AS THE ACFT BEGAN A TURN AT LIZIO, THE FO SAID WE NEEDED TO DSND. THIS WAS MY FIRST KNOWLEDGE OF THE CLRNC ISSUED BY ATC. I IMMEDIATELY DSNDED TO FL250. THERE APPEARED TO BE NO LOSS OF ANY SEPARATION OR CONFLICTS WITH OTHER ACFT. THIS INCIDENT OCCURRED BECAUSE OF THE FO'S FAILURE TO CARRY OUT WITH THE COMPANY'S REQUIRED PROCS. THE PROC STATES THAT THE PNF READS BACK THE CLRNC TO ATC AND RESETS THE ALT ALERTER TO THE NEW ALT. THE PF IS TO VERBALLY RESTATE THE NEW ALT AND VERIFY THE ALT ALERTER IS SET CORRECTLY. THE PNF IS TO CONTINUE QUERYING UNTIL HE HAS RECEIVED A VERBAL ACKNOWLEDGEMENT FROM THE PF. I NEVER ACKNOWLEDGED THE CLRNC BECAUSE I NEVER HEARD IT. THE FO DID NOT COMPLETE THIS VERY IMPORTANT PART OF THE PROC ASSUMING I HEARD IT. ASSUMPTIONS: WE ALL KNOW THE LITTLE DITTY ABOUT THEM -- IN AVIATION THEY CAN BE FATAL.
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.