37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 540528 |
Time | |
Date | 200202 |
Day | Wed |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : bos.airport |
State Reference | MA |
Altitude | msl bound lower : 1800 msl bound upper : 2300 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Snow |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : a90.tracon tower : bos.tower |
Operator | common carrier : air carrier |
Make Model Name | B737-800 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : logan 2 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 60 flight time total : 12700 |
ASRS Report | 540528 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : flight engineer pilot : cfi pilot : atp |
Experience | flight time last 90 days : 110 flight time total : 6778 flight time type : 230 |
ASRS Report | 539376 |
Events | |
Anomaly | non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : became reoriented |
Supplementary | |
Problem Areas | ATC Human Performance Flight Crew Human Performance Environmental Factor Company |
Primary Problem | ATC Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Takeoff and initial departure normal. Prior to 2 DME, checked in with departure control, 'climbing 1800 ft for 5000 ft.' SID turn required at 2 DME to 315 degrees. ATC responded, 'maintain 3000 ft.' both copilot and I exclaimed and started to pitch over to keep from busting 3000 ft and set new altitude in the MCP. ATC then came back after I queried them on the 3000 ft clearance with a corrected clearance altitude of 6000 ft. The first officer then smoothly transitioned from leveling off back to climb -- both of us relieved we didn't bust the altitude. A few mins later, ATC requested heading 040 degrees and then we remembered we never made the 2 DME heading change to 315 degrees. Due to the multiple altitude clrncs given at the 2 DME (which required immediate reaction of both pilots) the turn at 2 DME was missed. Supplemental information from acn 539376: when the weight and data arrived from the gate agent we found we couldn't use runway 27, which meant we had to change the departure. We were assigned the logan 2 departure and runway 33L. Changed the FMS and rebriefed the departure. There was a considerable departure delay due to poor WX and heavy traffic. We had to watch our minimum fuel for takeoff, so we taxied out on 1 engine. Started the second engine in plenty of time but the takeoff clearance was a bit of a surprise and the before takeoff checklist (which includes a pretkof brief on headings, altitudes, and airspeed restrs) was rushed, ie, I said the words, but didn't think about it carefully. The PNF during this whole time is changing flap settings, MCP panel setting, radios, etc. Pretty busy. Biggest reason for the deviation was the distraction of a low altitude hold down during a very busy phase of flight. Was a bit rushed on pretkof which didn't allow a thorough review of the departure, after a long situation waiting to take off. Probably need to slow down. Overall, yes we messed up, but we fell into a trap.
Original NASA ASRS Text
Title: HDG TRACK DEV ON DEP PROC WHEN THE CREW IS DISTR BY A LAST MIN ALT CHANGE DEPARTING RWY 33L AT BOS, MA.
Narrative: TKOF AND INITIAL DEP NORMAL. PRIOR TO 2 DME, CHKED IN WITH DEP CTL, 'CLBING 1800 FT FOR 5000 FT.' SID TURN REQUIRED AT 2 DME TO 315 DEGS. ATC RESPONDED, 'MAINTAIN 3000 FT.' BOTH COPLT AND I EXCLAIMED AND STARTED TO PITCH OVER TO KEEP FROM BUSTING 3000 FT AND SET NEW ALT IN THE MCP. ATC THEN CAME BACK AFTER I QUERIED THEM ON THE 3000 FT CLRNC WITH A CORRECTED CLRNC ALT OF 6000 FT. THE FO THEN SMOOTHLY TRANSITIONED FROM LEVELING OFF BACK TO CLB -- BOTH OF US RELIEVED WE DIDN'T BUST THE ALT. A FEW MINS LATER, ATC REQUESTED HDG 040 DEGS AND THEN WE REMEMBERED WE NEVER MADE THE 2 DME HDG CHANGE TO 315 DEGS. DUE TO THE MULTIPLE ALT CLRNCS GIVEN AT THE 2 DME (WHICH REQUIRED IMMEDIATE REACTION OF BOTH PLTS) THE TURN AT 2 DME WAS MISSED. SUPPLEMENTAL INFO FROM ACN 539376: WHEN THE WT AND DATA ARRIVED FROM THE GATE AGENT WE FOUND WE COULDN'T USE RWY 27, WHICH MEANT WE HAD TO CHANGE THE DEP. WE WERE ASSIGNED THE LOGAN 2 DEP AND RWY 33L. CHANGED THE FMS AND REBRIEFED THE DEP. THERE WAS A CONSIDERABLE DEP DELAY DUE TO POOR WX AND HVY TFC. WE HAD TO WATCH OUR MINIMUM FUEL FOR TKOF, SO WE TAXIED OUT ON 1 ENG. STARTED THE SECOND ENG IN PLENTY OF TIME BUT THE TKOF CLRNC WAS A BIT OF A SURPRISE AND THE BEFORE TKOF CHKLIST (WHICH INCLUDES A PRETKOF BRIEF ON HDGS, ALTS, AND AIRSPD RESTRS) WAS RUSHED, IE, I SAID THE WORDS, BUT DIDN'T THINK ABOUT IT CAREFULLY. THE PNF DURING THIS WHOLE TIME IS CHANGING FLAP SETTINGS, MCP PANEL SETTING, RADIOS, ETC. PRETTY BUSY. BIGGEST REASON FOR THE DEV WAS THE DISTR OF A LOW ALT HOLD DOWN DURING A VERY BUSY PHASE OF FLT. WAS A BIT RUSHED ON PRETKOF WHICH DIDN'T ALLOW A THOROUGH REVIEW OF THE DEP, AFTER A LONG SIT WAITING TO TAKE OFF. PROBABLY NEED TO SLOW DOWN. OVERALL, YES WE MESSED UP, BUT WE FELL INTO A TRAP.
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.