37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 598640 |
Time | |
Date | 200311 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : oak.airport |
State Reference | CA |
Altitude | msl bound lower : 2100 msl bound upper : 3000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain Turbulence |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : nct.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | ils localizer & glide slope : 295 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 255 flight time total : 20000 flight time type : 10000 |
ASRS Report | 598640 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure other anomaly other other spatial deviation |
Independent Detector | aircraft equipment : gpws other flight crewa |
Resolutory Action | controller : issued new clearance flight crew : took evasive action |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | ATC Human Performance Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were being vectored to runway 11 at oak. We were at 4000 ft on downwind to the ILS to runway 11 northeast of the field. We thought the controller said descend to 2100 ft. We were about abeam the OM for the approach. The first officer read back 2100 ft and I started to descend to 2100 ft. The minimum altitude for that area is about 3800 ft, but we were about to turn toward the FAF and we were under his control. At 2100 ft we received a 'terrain, terrain, pull up.' I immediately executed a climb and was climbing through 3000 ft when the controller asked us to confirm that we were at '3100 ft.' we told him that we were leveling off from a climb from 2100 ft and we understood that he had given us a descent to 2100 ft and had read that back to him. He told us to turn and descend to 2000 ft until localizer intercept and then intercept the GS at 1800 ft. Approach and landing was uneventful. This controller talked with a speech impediment and when he spoke fast it was difficult to understand him. Why he didn't correct us when we read back the wrong altitude, I don't know. He was busy. After we had our problem, he did slow his speech down and it was easier to understand. I should have questioned him further on the 2100 ft instruction because it was an odd altitude with that minimum sector altitude. Callback conversation with reporter revealed the following information: captain said that he waited a bit too long to challenge the descent clearance, especially knowing that he was heading for higher terrain. By the time it bothered him sufficiently to question ATC, the reporter advised the GPWS was alarming. The other principle problem was the controller's speech rate. It was very fast and appeared to have an impediment. After the controller questioned the flight crew's descent altitude, and the captain's challenge response, the controller's speech rate slowed down sufficiently to be understood.
Original NASA ASRS Text
Title: ON N DOWNWIND VECTOR TO OAK ILS RWY 11 BY NCT APCH CTL, A B737-300 FLT CREW READ BACK INCORRECT DSCNT ALT RESULTING IN A GPWS ALERT CLB.
Narrative: WE WERE BEING VECTORED TO RWY 11 AT OAK. WE WERE AT 4000 FT ON DOWNWIND TO THE ILS TO RWY 11 NE OF THE FIELD. WE THOUGHT THE CTLR SAID DSND TO 2100 FT. WE WERE ABOUT ABEAM THE OM FOR THE APCH. THE FO READ BACK 2100 FT AND I STARTED TO DSND TO 2100 FT. THE MINIMUM ALT FOR THAT AREA IS ABOUT 3800 FT, BUT WE WERE ABOUT TO TURN TOWARD THE FAF AND WE WERE UNDER HIS CTL. AT 2100 FT WE RECEIVED A 'TERRAIN, TERRAIN, PULL UP.' I IMMEDIATELY EXECUTED A CLB AND WAS CLBING THROUGH 3000 FT WHEN THE CTLR ASKED US TO CONFIRM THAT WE WERE AT '3100 FT.' WE TOLD HIM THAT WE WERE LEVELING OFF FROM A CLB FROM 2100 FT AND WE UNDERSTOOD THAT HE HAD GIVEN US A DSCNT TO 2100 FT AND HAD READ THAT BACK TO HIM. HE TOLD US TO TURN AND DSND TO 2000 FT UNTIL LOC INTERCEPT AND THEN INTERCEPT THE GS AT 1800 FT. APCH AND LNDG WAS UNEVENTFUL. THIS CTLR TALKED WITH A SPEECH IMPEDIMENT AND WHEN HE SPOKE FAST IT WAS DIFFICULT TO UNDERSTAND HIM. WHY HE DIDN'T CORRECT US WHEN WE READ BACK THE WRONG ALT, I DON'T KNOW. HE WAS BUSY. AFTER WE HAD OUR PROB, HE DID SLOW HIS SPEECH DOWN AND IT WAS EASIER TO UNDERSTAND. I SHOULD HAVE QUESTIONED HIM FURTHER ON THE 2100 FT INSTRUCTION BECAUSE IT WAS AN ODD ALT WITH THAT MINIMUM SECTOR ALT. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: CAPT SAID THAT HE WAITED A BIT TOO LONG TO CHALLENGE THE DSCNT CLRNC, ESPECIALLY KNOWING THAT HE WAS HEADING FOR HIGHER TERRAIN. BY THE TIME IT BOTHERED HIM SUFFICIENTLY TO QUESTION ATC, THE RPTR ADVISED THE GPWS WAS ALARMING. THE OTHER PRINCIPLE PROB WAS THE CTLR'S SPEECH RATE. IT WAS VERY FAST AND APPEARED TO HAVE AN IMPEDIMENT. AFTER THE CTLR QUESTIONED THE FLT CREW'S DSCNT ALT, AND THE CAPT'S CHALLENGE RESPONSE, THE CTLR'S SPEECH RATE SLOWED DOWN SUFFICIENTLY TO BE UNDERSTOOD.
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.