37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 599271 |
Time | |
Date | 200311 |
Day | Fri |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | intersection : roppr |
State Reference | NV |
Altitude | msl bound lower : 7000 msl bound upper : 8000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude climbout : initial |
Route In Use | departure sid : boach |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Experience | flight time last 90 days : 120 flight time total : 13000 flight time type : 8000 |
ASRS Report | 599271 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 230 flight time total : 7200 flight time type : 1847 |
ASRS Report | 599272 |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : crossing restriction not met non adherence : clearance non adherence : published procedure |
Independent Detector | atc equipment other atc equipment : radar other controllera |
Resolutory Action | controller : issued advisory other |
Supplementary | |
Problem Areas | Flight Crew Human Performance Chart Or Publication ATC Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Departure was briefed at gate and 7000 ft set in the MCP. After takeoff, first officer stated altitude cleared to was FL190 and pointed to his clearance and changed it to FL190. Checked in with departure and stated climbing to FL190. Departure controller rogered and reported radar contact. Nothing else was said until he advised air carrier that in the future the crossing at roppr was 7000 ft or below. At that time, we were already above 7000 ft and he then told us the same. The first officer stated to the controller that he thought we were cleared to FL190. At that time, they requested we call upon arrival. The departure is a new procedure and falls under the normal rules of a SID. Reviewing the situation, it was obvious that the 7000 ft hold down applied. However, as the airspace around las has been changing for the past couple of yrs, arrs and departures have been published and used that have various altitudes depicted. The normal procedures in las for me have been none of the altitudes have been used. The controllers have been using their own altitudes and, therefore, we have been conditioned to not key on the published altitudes. During our return to las, we flew the kepec.KEPEC1 arrival and the only altitude that was as published was clarr at 13000 ft, 250 KTS. Even misen was a hard altitude versus the at or above. When these altitudes are routinely disregarded, it sets the stage for disregarding one the controller wants. A preconditioned event. Additionally, the hold down fix roppr is 13.5 mi from the departure runway. Commercial chart does not include altitudes in the written verbal portion of the SID anymore. You must track the departure with your finger and try to find each above or below restr. The controller made no effort to ensure that we complied with the SID. During our later flight, the departure controller stated to either comply with the restrs or the restrs are canceled, and an unrestr climb was approved. I went through the altitude without checking again from departure controller and they watched. If the arrival/departure procedures always used the altitudes, like lax, I would think there would not be as many problems as switching back and forth. These come across as experimental departures/arrs that aren't working. Once standardized, I would hope what is published is flown each time. If VNAV was engaged, even without autothrottles, the aircraft would have leveled off unless you made one more effort to delete the restr. We have forced the autoplt LNAV departure and fly partially automated. Maybe we need to totally automate the departure since doing half of the process doesn't always work. It seems that with the autoplt flying, we are along for the ride instead of actually being in control like flying the flight director or track data. Trying to ensure that it goes where it is supposed to, takes some of the workload that otherwise night see some of these less apparent mistakes. We should have caught the altitude at the gate and questioned clearance delivery. The aircraft directly ahead, from a different company, did exactly the same thing, which would indicate that something isn't depicted correctly or communicated as to what the controllers really want the pilots to fly. The controller on the aircraft after ours re-confirmed their crossing altitude at roppr. I feel we were a test, and we failed. The WX packet had a comment about the altitudes, but used an abbreviation of 'aob.' I looked at the plate and processed that as 'at or above,' not 'at or below' and noted that at our light weight, we would have no problem exceeding each of those fixes. I hope ATC can settle on a set of SID/stars at las and not be changing often. We will be much more aware and will ask more questions when operating in their environment. Supplemental information from acn 599272: due to early departure, did not question climb up to FL190. More importantly did not receive the 'comply with restrs' caveat included in the warning note in our WX package from dispatch to cross roppr intersection 'aob' 7000 ft. Since we did not receive the 'comply with restrs' that our company had told us to expect, we believed we were cleared to FL190. Causes: 1) no warning issued by any controller. 2) pilot unfamiliarity with boach 1 RNAV departure. 3) time of day/traffic volume. Prevention: 1) if any controller had advised us to 'comply with restrs,' this event would not have happened.
Original NASA ASRS Text
Title: B737-700 FLT CREW OVERSHOT NEW IMPLEMENTED LAS RNAV BOACH SID. FO QUESTIONS CTLR LACK OF 'INVOLVEMENT' BY NOT ADVISING AS EXPECTED IN COMPANY BRIEF TO 'COMPLY WITH SID ALT RESTRS.'
Narrative: DEP WAS BRIEFED AT GATE AND 7000 FT SET IN THE MCP. AFTER TKOF, FO STATED ALT CLRED TO WAS FL190 AND POINTED TO HIS CLRNC AND CHANGED IT TO FL190. CHKED IN WITH DEP AND STATED CLBING TO FL190. DEP CTLR ROGERED AND RPTED RADAR CONTACT. NOTHING ELSE WAS SAID UNTIL HE ADVISED ACR THAT IN THE FUTURE THE XING AT ROPPR WAS 7000 FT OR BELOW. AT THAT TIME, WE WERE ALREADY ABOVE 7000 FT AND HE THEN TOLD US THE SAME. THE FO STATED TO THE CTLR THAT HE THOUGHT WE WERE CLRED TO FL190. AT THAT TIME, THEY REQUESTED WE CALL UPON ARR. THE DEP IS A NEW PROC AND FALLS UNDER THE NORMAL RULES OF A SID. REVIEWING THE SIT, IT WAS OBVIOUS THAT THE 7000 FT HOLD DOWN APPLIED. HOWEVER, AS THE AIRSPACE AROUND LAS HAS BEEN CHANGING FOR THE PAST COUPLE OF YRS, ARRS AND DEPS HAVE BEEN PUBLISHED AND USED THAT HAVE VARIOUS ALTS DEPICTED. THE NORMAL PROCS IN LAS FOR ME HAVE BEEN NONE OF THE ALTS HAVE BEEN USED. THE CTLRS HAVE BEEN USING THEIR OWN ALTS AND, THEREFORE, WE HAVE BEEN CONDITIONED TO NOT KEY ON THE PUBLISHED ALTS. DURING OUR RETURN TO LAS, WE FLEW THE KEPEC.KEPEC1 ARR AND THE ONLY ALT THAT WAS AS PUBLISHED WAS CLARR AT 13000 FT, 250 KTS. EVEN MISEN WAS A HARD ALT VERSUS THE AT OR ABOVE. WHEN THESE ALTS ARE ROUTINELY DISREGARDED, IT SETS THE STAGE FOR DISREGARDING ONE THE CTLR WANTS. A PRECONDITIONED EVENT. ADDITIONALLY, THE HOLD DOWN FIX ROPPR IS 13.5 MI FROM THE DEP RWY. COMMERCIAL CHART DOES NOT INCLUDE ALTS IN THE WRITTEN VERBAL PORTION OF THE SID ANYMORE. YOU MUST TRACK THE DEP WITH YOUR FINGER AND TRY TO FIND EACH ABOVE OR BELOW RESTR. THE CTLR MADE NO EFFORT TO ENSURE THAT WE COMPLIED WITH THE SID. DURING OUR LATER FLT, THE DEP CTLR STATED TO EITHER COMPLY WITH THE RESTRS OR THE RESTRS ARE CANCELED, AND AN UNRESTR CLB WAS APPROVED. I WENT THROUGH THE ALT WITHOUT CHKING AGAIN FROM DEP CTLR AND THEY WATCHED. IF THE ARR/DEP PROCS ALWAYS USED THE ALTS, LIKE LAX, I WOULD THINK THERE WOULD NOT BE AS MANY PROBS AS SWITCHING BACK AND FORTH. THESE COME ACROSS AS EXPERIMENTAL DEPS/ARRS THAT AREN'T WORKING. ONCE STANDARDIZED, I WOULD HOPE WHAT IS PUBLISHED IS FLOWN EACH TIME. IF VNAV WAS ENGAGED, EVEN WITHOUT AUTOTHROTTLES, THE ACFT WOULD HAVE LEVELED OFF UNLESS YOU MADE ONE MORE EFFORT TO DELETE THE RESTR. WE HAVE FORCED THE AUTOPLT LNAV DEP AND FLY PARTIALLY AUTOMATED. MAYBE WE NEED TO TOTALLY AUTOMATE THE DEP SINCE DOING HALF OF THE PROCESS DOESN'T ALWAYS WORK. IT SEEMS THAT WITH THE AUTOPLT FLYING, WE ARE ALONG FOR THE RIDE INSTEAD OF ACTUALLY BEING IN CTL LIKE FLYING THE FLT DIRECTOR OR TRACK DATA. TRYING TO ENSURE THAT IT GOES WHERE IT IS SUPPOSED TO, TAKES SOME OF THE WORKLOAD THAT OTHERWISE NIGHT SEE SOME OF THESE LESS APPARENT MISTAKES. WE SHOULD HAVE CAUGHT THE ALT AT THE GATE AND QUESTIONED CLRNC DELIVERY. THE ACFT DIRECTLY AHEAD, FROM A DIFFERENT COMPANY, DID EXACTLY THE SAME THING, WHICH WOULD INDICATE THAT SOMETHING ISN'T DEPICTED CORRECTLY OR COMMUNICATED AS TO WHAT THE CTLRS REALLY WANT THE PLTS TO FLY. THE CTLR ON THE ACFT AFTER OURS RE-CONFIRMED THEIR XING ALT AT ROPPR. I FEEL WE WERE A TEST, AND WE FAILED. THE WX PACKET HAD A COMMENT ABOUT THE ALTS, BUT USED AN ABBREVIATION OF 'AOB.' I LOOKED AT THE PLATE AND PROCESSED THAT AS 'AT OR ABOVE,' NOT 'AT OR BELOW' AND NOTED THAT AT OUR LIGHT WT, WE WOULD HAVE NO PROB EXCEEDING EACH OF THOSE FIXES. I HOPE ATC CAN SETTLE ON A SET OF SID/STARS AT LAS AND NOT BE CHANGING OFTEN. WE WILL BE MUCH MORE AWARE AND WILL ASK MORE QUESTIONS WHEN OPERATING IN THEIR ENVIRONMENT. SUPPLEMENTAL INFO FROM ACN 599272: DUE TO EARLY DEP, DID NOT QUESTION CLB UP TO FL190. MORE IMPORTANTLY DID NOT RECEIVE THE 'COMPLY WITH RESTRS' CAVEAT INCLUDED IN THE WARNING NOTE IN OUR WX PACKAGE FROM DISPATCH TO CROSS ROPPR INTXN 'AOB' 7000 FT. SINCE WE DID NOT RECEIVE THE 'COMPLY WITH RESTRS' THAT OUR COMPANY HAD TOLD US TO EXPECT, WE BELIEVED WE WERE CLRED TO FL190. CAUSES: 1) NO WARNING ISSUED BY ANY CTLR. 2) PLT UNFAMILIARITY WITH BOACH 1 RNAV DEP. 3) TIME OF DAY/TFC VOLUME. PREVENTION: 1) IF ANY CTLR HAD ADVISED US TO 'COMPLY WITH RESTRS,' THIS EVENT WOULD NOT HAVE HAPPENED.
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.