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|
Attributes | |
ACN | 541886 |
Time | |
Date | 200203 |
Day | Fri |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : rjbb.airport |
State Reference | FO |
Altitude | msl bound lower : 16000 msl bound upper : 16500 |
Environment | |
Flight Conditions | IMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Gulfstream IV |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : tomo two |
Flight Plan | IFR |
Aircraft 2 | |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 125 flight time total : 13.375 flight time type : 1900 |
ASRS Report | 541886 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | conflict : airborne less severe non adherence : published procedure non adherence : required legal separation |
Independent Detector | atc equipment other atc equipment : radar other controllera other controllerb other flight crewa other flight crewb other other : 3 |
Resolutory Action | controller : issued advisory controller : separated traffic flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | ATC Human Performance Flight Crew Human Performance |
Primary Problem | ATC Human Performance |
Narrative:
We were cleared to depart kansai international airport, osaka, japan, on the tomo 2 departure to maintain 11000 ft. Between tomo VOR (tme) and goboh VOR (gbe) we were cleared to climb to FL200 by kansai departure. Transition altitude was 14000 ft. Passing 16000 ft, departure advised us of traffic at 2 O'clock position at 17000 ft. I was the PIC, flying in the right seat, performing pilot monitoring duties. The cockpit crew consisted of the PF and a relief pilot in the jump seat, all 3 being ATP and type rated in the aircraft and all 3 monitoring communications with noise attenuating headsets. To the TA I responded that we were passing 16000 ft for FL200 and were IMC. Immediately, a different voice than the one that had been working our departure came on the frequency advising us to maintain 16000 ft. I responded that we were at 16500 ft descending to 16000 ft. The controller then made some editorial comments that sounded to us like he was trying to tell us that we had not been cleared to FL200 but only to 16000 ft. The language barrier prevented us from fully understanding the extra comments by the controller. We continued at 16000 ft until reclred to a higher altitude and handed off to tokyo control. In reviewing the episode, all 3 crew members clearly heard and understood that we had been cleared to FL200. None of us were sure what the controller was trying to impart to us after the incident. Anytime there is an abnormal incident or threat to safety, the circumstances must be reviewed and lessons learned idented. Quite frankly, we could not see anything that we did wrong. However, the incident did reinforce the strength of our company SOP's and practices. First was the use of noise concealing headsets, which afforded the best possible communications when flying in an environment where english is the second language. Secondly, strict SOP requiring that the pilot monitoring read back the clearance in its entirety and set the altitude selector to the new altitude, leaving his finger on the altitude selector and repeating the altitude and the PF checking his EFIS readout for the stated altitude and repeating the altitude and only then commencing the change to the new altitude. Though it is not company SOP, the inclusion of a qualified third crew member, if assigned to the flight, in the jump seat to monitor the flight during takeoff and landing phases of flight is invaluable. Finally, this incident points up the importance of using communications to all aircraft in the area to maintain special orientation and awareness of the environment around the aircraft.
Original NASA ASRS Text
Title: GIV SP CREW ON DEP OFF RJBB CLBING TO A STATED ALT OF FL200 WHICH IS ABRUPTLY AMENDED TO 16000 FT.
Narrative: WE WERE CLRED TO DEPART KANSAI INTL ARPT, OSAKA, JAPAN, ON THE TOMO 2 DEP TO MAINTAIN 11000 FT. BTWN TOMO VOR (TME) AND GOBOH VOR (GBE) WE WERE CLRED TO CLB TO FL200 BY KANSAI DEP. TRANSITION ALT WAS 14000 FT. PASSING 16000 FT, DEP ADVISED US OF TFC AT 2 O'CLOCK POS AT 17000 FT. I WAS THE PIC, FLYING IN THE R SEAT, PERFORMING PLT MONITORING DUTIES. THE COCKPIT CREW CONSISTED OF THE PF AND A RELIEF PLT IN THE JUMP SEAT, ALL 3 BEING ATP AND TYPE RATED IN THE ACFT AND ALL 3 MONITORING COMS WITH NOISE ATTENUATING HEADSETS. TO THE TA I RESPONDED THAT WE WERE PASSING 16000 FT FOR FL200 AND WERE IMC. IMMEDIATELY, A DIFFERENT VOICE THAN THE ONE THAT HAD BEEN WORKING OUR DEP CAME ON THE FREQ ADVISING US TO MAINTAIN 16000 FT. I RESPONDED THAT WE WERE AT 16500 FT DSNDING TO 16000 FT. THE CTLR THEN MADE SOME EDITORIAL COMMENTS THAT SOUNDED TO US LIKE HE WAS TRYING TO TELL US THAT WE HAD NOT BEEN CLRED TO FL200 BUT ONLY TO 16000 FT. THE LANGUAGE BARRIER PREVENTED US FROM FULLY UNDERSTANDING THE EXTRA COMMENTS BY THE CTLR. WE CONTINUED AT 16000 FT UNTIL RECLRED TO A HIGHER ALT AND HANDED OFF TO TOKYO CTL. IN REVIEWING THE EPISODE, ALL 3 CREW MEMBERS CLRLY HEARD AND UNDERSTOOD THAT WE HAD BEEN CLRED TO FL200. NONE OF US WERE SURE WHAT THE CTLR WAS TRYING TO IMPART TO US AFTER THE INCIDENT. ANYTIME THERE IS AN ABNORMAL INCIDENT OR THREAT TO SAFETY, THE CIRCUMSTANCES MUST BE REVIEWED AND LESSONS LEARNED IDENTED. QUITE FRANKLY, WE COULD NOT SEE ANYTHING THAT WE DID WRONG. HOWEVER, THE INCIDENT DID REINFORCE THE STRENGTH OF OUR COMPANY SOP'S AND PRACTICES. FIRST WAS THE USE OF NOISE CONCEALING HEADSETS, WHICH AFFORDED THE BEST POSSIBLE COMS WHEN FLYING IN AN ENVIRONMENT WHERE ENGLISH IS THE SECOND LANGUAGE. SECONDLY, STRICT SOP REQUIRING THAT THE PLT MONITORING READ BACK THE CLRNC IN ITS ENTIRETY AND SET THE ALT SELECTOR TO THE NEW ALT, LEAVING HIS FINGER ON THE ALT SELECTOR AND REPEATING THE ALT AND THE PF CHKING HIS EFIS READOUT FOR THE STATED ALT AND REPEATING THE ALT AND ONLY THEN COMMENCING THE CHANGE TO THE NEW ALT. THOUGH IT IS NOT COMPANY SOP, THE INCLUSION OF A QUALIFIED THIRD CREW MEMBER, IF ASSIGNED TO THE FLT, IN THE JUMP SEAT TO MONITOR THE FLT DURING TKOF AND LNDG PHASES OF FLT IS INVALUABLE. FINALLY, THIS INCIDENT POINTS UP THE IMPORTANCE OF USING COMS TO ALL ACFT IN THE AREA TO MAINTAIN SPECIAL ORIENTATION AND AWARENESS OF THE ENVIRONMENT AROUND THE ACFT.
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.