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|
Attributes | |
ACN | 575523 |
Time | |
Date | 200303 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | navaid : lvz.vortac |
State Reference | PA |
Altitude | msl bound lower : 27000 msl bound upper : 29000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zny.artcc |
Operator | general aviation : corporate |
Make Model Name | Citation V |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | descent : approach |
Route In Use | arrival star : wilkes barre |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | artcc : zny.artcc |
Operator | common carrier : air carrier |
Make Model Name | Regional Jet CL65, Undifferentiated or Other Model |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | cruise : level |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : instrument pilot : commercial pilot : cfi pilot : atp |
Experience | flight time last 90 days : 60 flight time total : 3100 flight time type : 600 |
ASRS Report | 575523 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 50 flight time total : 16300 flight time type : 5500 |
ASRS Report | 576535 |
Events | |
Anomaly | altitude deviation : overshoot conflict : airborne less severe non adherence : required legal separation non adherence : published procedure non adherence : clearance non adherence : company policies other anomaly other |
Independent Detector | atc equipment other atc equipment : mode c aircraft equipment : tcas other controllera |
Resolutory Action | none taken : detected after the fact |
Miss Distance | horizontal : 13800 vertical : 700 |
Supplementary | |
Problem Areas | Environmental Factor Airspace Structure ATC Human Performance Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
The captain was the PF and I was the PNF. We were level at FL410 and were proceeding direct to the lvz VOR. We were given a crossing restr at lvz at FL180. After the PF initiated the descent, I picked up the destination airport ATIS on communication #2. After switching back to communication #1, the PF advised me that we were now turning to a heading for the descent and that he was increasing his rate of descent. A few seconds later, ATC reclred us direct to the lvz VOR. Shortly after this we received an alert on TCASII (TA mode), but I was having difficulty interpreting the TCASII display. I scanned outside but did not see any aircraft. The PF asked me to switch to TA/RA mode. Shortly thereafter the PF began to shallow his descent and eventfully leveled off at approximately FL270. ATC asked if we were level at FL290. The altitude alerter was still set at FL180. We later determined that while I was obtaining the ATIS, the PF received and acknowledged an amended clearance consisting of a heading and a descent to FL290. He did not immediately set the altitude alerter when he received the amended clearance and forgot about it. I believe the failure of the PF to immediately record the amended altitude clearance on the altitude alerter caused this event. Normally the PNF sets the altitude alerter unless he is busy using the other communication radio for non ATC related communication. In this case, the PF assumes all duties including setting the alerter. I believe the contributing factors included the inability of the PF to keep the amended altitude clearance in short term memory, fatigue associated with an XA30 am departure, lack of familiarity with some of the TCASII displays/messages, and the possibility my TCASII/ivsi display may have still been dimmed from earlier in the flight. The immediate corrective actions during the event included reducing and eventually stopping the descent. The actions taken after the flight involved discussing the event with management, including what occurred, why it occurred, and how to prevent it. Also, I will be spending some time with the TCASII pilot's guide. Supplemental information from acn 576535: contributing factors: mis-prioritizing the right handed tasks, autoplt pitch, autoplt heading and altitude alert. Using the TCASII for traffic awareness only and relying on ATC for separation. TCASII in RA mode would have given more time to prevent the conflict. Should have reacted much more rapidly to the numbers that we saw on the TCASII. Tried to use visual separation techniques in positive control airspace.
Original NASA ASRS Text
Title: POTENTIAL CONFLICT OCCURS BTWN 2 ACFT WHEN ONE DSNDS THROUGH THE ALT OF WBOUND TFC AT FL280, 50 NM NW OF LVZ VOR, PA.
Narrative: THE CAPT WAS THE PF AND I WAS THE PNF. WE WERE LEVEL AT FL410 AND WERE PROCEEDING DIRECT TO THE LVZ VOR. WE WERE GIVEN A XING RESTR AT LVZ AT FL180. AFTER THE PF INITIATED THE DSCNT, I PICKED UP THE DEST ARPT ATIS ON COM #2. AFTER SWITCHING BACK TO COM #1, THE PF ADVISED ME THAT WE WERE NOW TURNING TO A HEADING FOR THE DSCNT AND THAT HE WAS INCREASING HIS RATE OF DSCNT. A FEW SECONDS LATER, ATC RECLRED US DIRECT TO THE LVZ VOR. SHORTLY AFTER THIS WE RECEIVED AN ALERT ON TCASII (TA MODE), BUT I WAS HAVING DIFFICULTY INTERPRETING THE TCASII DISPLAY. I SCANNED OUTSIDE BUT DID NOT SEE ANY ACFT. THE PF ASKED ME TO SWITCH TO TA/RA MODE. SHORTLY THEREAFTER THE PF BEGAN TO SHALLOW HIS DSCNT AND EVENTFULLY LEVELED OFF AT APPROX FL270. ATC ASKED IF WE WERE LEVEL AT FL290. THE ALT ALERTER WAS STILL SET AT FL180. WE LATER DETERMINED THAT WHILE I WAS OBTAINING THE ATIS, THE PF RECEIVED AND ACKNOWLEDGED AN AMENDED CLRNC CONSISTING OF A HEADING AND A DSCNT TO FL290. HE DID NOT IMMEDIATELY SET THE ALT ALERTER WHEN HE RECEIVED THE AMENDED CLRNC AND FORGOT ABOUT IT. I BELIEVE THE FAILURE OF THE PF TO IMMEDIATELY RECORD THE AMENDED ALT CLRNC ON THE ALT ALERTER CAUSED THIS EVENT. NORMALLY THE PNF SETS THE ALT ALERTER UNLESS HE IS BUSY USING THE OTHER COM RADIO FOR NON ATC RELATED COM. IN THIS CASE, THE PF ASSUMES ALL DUTIES INCLUDING SETTING THE ALERTER. I BELIEVE THE CONTRIBUTING FACTORS INCLUDED THE INABILITY OF THE PF TO KEEP THE AMENDED ALT CLRNC IN SHORT TERM MEMORY, FATIGUE ASSOCIATED WITH AN XA30 AM DEP, LACK OF FAMILIARITY WITH SOME OF THE TCASII DISPLAYS/MESSAGES, AND THE POSSIBILITY MY TCASII/IVSI DISPLAY MAY HAVE STILL BEEN DIMMED FROM EARLIER IN THE FLT. THE IMMEDIATE CORRECTIVE ACTIONS DURING THE EVENT INCLUDED REDUCING AND EVENTUALLY STOPPING THE DSCNT. THE ACTIONS TAKEN AFTER THE FLT INVOLVED DISCUSSING THE EVENT WITH MGMNT, INCLUDING WHAT OCCURRED, WHY IT OCCURRED, AND HOW TO PREVENT IT. ALSO, I WILL BE SPENDING SOME TIME WITH THE TCASII PLT'S GUIDE. SUPPLEMENTAL INFO FROM ACN 576535: CONTRIBUTING FACTORS: MIS-PRIORITIZING THE R HANDED TASKS, AUTOPLT PITCH, AUTOPLT HEADING AND ALT ALERT. USING THE TCASII FOR TFC AWARENESS ONLY AND RELYING ON ATC FOR SEPARATION. TCASII IN RA MODE WOULD HAVE GIVEN MORE TIME TO PREVENT THE CONFLICT. SHOULD HAVE REACTED MUCH MORE RAPIDLY TO THE NUMBERS THAT WE SAW ON THE TCASII. TRIED TO USE VISUAL SEPARATION TECHNIQUES IN POSITIVE CTL AIRSPACE.
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.