Narrative:

Confusion occurred during descent and setup of flight director MCP following issue of multipart course/descent clearance being issued by slc TRACON arrival controller. Review of tapes following phone call to TRACON revealed clearance read 'descend and maintain 14000 ft depart the ogden VOR heading 130 degrees and intercept the runway 16L localizer.' tape review further revealed that PNF in fact read back the entire clearance something like '14000 ft, depart ogden heading 130 degrees and intercept the runway 16L localizer.' what actually happened in the cockpit during the setup of the MCP was the captain, was PF, set the heading per company fom. The first officer was in the process of twisting the altitude set knob to set the alb and was distraction when the captain very confidently, very emphatically and very unmistakably read back 13000 ft in intercockpit communication. PNF, first officer, was very busily multitasking verifying the localizer frequency, front course, heading set while still in the process of simultaneously setting the altitude setting on the MCP and first officer went on to set 13000 ft in the MCP. There was a call from TRACON very shortly after, the clearance call 'caution fuel dumping...13000 ft...ogden VOR,' which seemed very close to our location. Perhaps the 130 degree heading caused the slip by the PF and the misheard 14000 ft versus 13000 ft, eg, '130' and '13000.' pilots were relatively experienced with the airplane and company operations procedures. It was the first leg of the day so fatigue wasn't a big issue and we were well rested and seemed to be getting along well. My impression of the captain was he flew the airplane very well and was a 'good guy' to work with, so I had very high confidence in our ability to stay out of trouble. Analysis/corrective action: my technique, learned from other capts, is: PF shouldn't ever intercockpit read back the perceived altitude clearance limit until the PNF has completed the setting of the altitude window on the MCP. This readback, especially when done very confidently/emphatically has a powerful effect of influencing the PNF in setting the MCP to set a wrong altitude. I always ask for verification of assigned altitude when there is the slightest doubt, but the manner in which the captain read back the altitude '13000 ft!' influenced me strongly. Problem would not have likely occurred if the clearance hadn't been multipart, somewhat complex and the cockpit workload tasking relatively heavy at the moment and certainly the captain reading back the wrong altitude in a busy scenario was key to the error chain. The captain observed in his analysis that his technique in this particular case wasn't in keeping with both our philosophy of setting the altitude window before intercockpit readback by PF.

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Original NASA ASRS Text

Title: MLG CREW DSNDED 1000 FT BELOW THE CLRED ALT DSNDING ON THE BEARR STAR INTO SLC.

Narrative: CONFUSION OCCURRED DURING DSCNT AND SETUP OF FLT DIRECTOR MCP FOLLOWING ISSUE OF MULTIPART COURSE/DSCNT CLRNC BEING ISSUED BY SLC TRACON ARR CTLR. REVIEW OF TAPES FOLLOWING PHONE CALL TO TRACON REVEALED CLRNC READ 'DSND AND MAINTAIN 14000 FT DEPART THE OGDEN VOR HDG 130 DEGS AND INTERCEPT THE RWY 16L LOC.' TAPE REVIEW FURTHER REVEALED THAT PNF IN FACT READ BACK THE ENTIRE CLRNC SOMETHING LIKE '14000 FT, DEPART OGDEN HDG 130 DEGS AND INTERCEPT THE RWY 16L LOC.' WHAT ACTUALLY HAPPENED IN THE COCKPIT DURING THE SETUP OF THE MCP WAS THE CAPT, WAS PF, SET THE HDG PER COMPANY FOM. THE FO WAS IN THE PROCESS OF TWISTING THE ALT SET KNOB TO SET THE ALB AND WAS DISTR WHEN THE CAPT VERY CONFIDENTLY, VERY EMPHATICALLY AND VERY UNMISTAKABLY READ BACK 13000 FT IN INTERCOCKPIT COM. PNF, FO, WAS VERY BUSILY MULTITASKING VERIFYING THE LOC FREQ, FRONT COURSE, HDG SET WHILE STILL IN THE PROCESS OF SIMULTANEOUSLY SETTING THE ALT SETTING ON THE MCP AND FO WENT ON TO SET 13000 FT IN THE MCP. THERE WAS A CALL FROM TRACON VERY SHORTLY AFTER, THE CLRNC CALL 'CAUTION FUEL DUMPING...13000 FT...OGDEN VOR,' WHICH SEEMED VERY CLOSE TO OUR LOCATION. PERHAPS THE 130 DEG HDG CAUSED THE SLIP BY THE PF AND THE MISHEARD 14000 FT VERSUS 13000 FT, EG, '130' AND '13000.' PLTS WERE RELATIVELY EXPERIENCED WITH THE AIRPLANE AND COMPANY OPS PROCS. IT WAS THE FIRST LEG OF THE DAY SO FATIGUE WASN'T A BIG ISSUE AND WE WERE WELL RESTED AND SEEMED TO BE GETTING ALONG WELL. MY IMPRESSION OF THE CAPT WAS HE FLEW THE AIRPLANE VERY WELL AND WAS A 'GOOD GUY' TO WORK WITH, SO I HAD VERY HIGH CONFIDENCE IN OUR ABILITY TO STAY OUT OF TROUBLE. ANALYSIS/CORRECTIVE ACTION: MY TECHNIQUE, LEARNED FROM OTHER CAPTS, IS: PF SHOULDN'T EVER INTERCOCKPIT READ BACK THE PERCEIVED ALT CLRNC LIMIT UNTIL THE PNF HAS COMPLETED THE SETTING OF THE ALT WINDOW ON THE MCP. THIS READBACK, ESPECIALLY WHEN DONE VERY CONFIDENTLY/EMPHATICALLY HAS A POWERFUL EFFECT OF INFLUENCING THE PNF IN SETTING THE MCP TO SET A WRONG ALT. I ALWAYS ASK FOR VERIFICATION OF ASSIGNED ALT WHEN THERE IS THE SLIGHTEST DOUBT, BUT THE MANNER IN WHICH THE CAPT READ BACK THE ALT '13000 FT!' INFLUENCED ME STRONGLY. PROB WOULD NOT HAVE LIKELY OCCURRED IF THE CLRNC HADN'T BEEN MULTIPART, SOMEWHAT COMPLEX AND THE COCKPIT WORKLOAD TASKING RELATIVELY HVY AT THE MOMENT AND CERTAINLY THE CAPT READING BACK THE WRONG ALT IN A BUSY SCENARIO WAS KEY TO THE ERROR CHAIN. THE CAPT OBSERVED IN HIS ANALYSIS THAT HIS TECHNIQUE IN THIS PARTICULAR CASE WASN'T IN KEEPING WITH BOTH OUR PHILOSOPHY OF SETTING THE ALT WINDOW BEFORE INTERCOCKPIT READBACK BY PF.

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.