37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 600689 |
Time | |
Date | 200311 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | intersection : tarrk |
State Reference | NV |
Altitude | msl bound lower : 11000 msl bound upper : 16000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Plan | IFR |
Aircraft 2 | |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : shead |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : instrument pilot : multi engine pilot : commercial |
Experience | flight time last 90 days : 230 flight time total : 7000 flight time type : 2000 |
ASRS Report | 600689 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time total : 22000 |
ASRS Report | 600690 |
Events | |
Anomaly | altitude deviation : crossing restriction not met non adherence : published procedure non adherence : clearance |
Independent Detector | other controllera other flight crewa other flight crewb |
Resolutory Action | none taken : anomaly accepted |
Consequence | faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
While departing las on the shead SID, departure control cleared us to 'maintain FL190 comply with restr.' the captain and I had both read and discussed the read before flies concerning altdevs on las departures, so we left the altitude select set to 7000 ft until crossing roppr. The altitude was then set to FL190 and the climb continued. Upon crossing tarrk, dp control asked for our altitude, which was 16000 ft, and then informed us of a crossing restr of 11000 ft at tarrk. I feel 2 factors contributed primarily to this deviation: 1) although we both read and were aware of the possibility of misunderstandings, all the attention has been centered on the initial 7000 ft restrs on these departures with barely a passing mention of other restrs. So naturally our attention focused on the 7000 ft restr and missed the other. 2) this type of procedure is unique and even the phraseology differs from that of the similar RNAV stars. I have never seen or flown a SID with crossing restrs like those on the shead. When cleared to descend via a STAR, you are told just that 'descend via the (such and such) arrival.' while on the departure, we are told to climb to the final altitude. The bottom-line is that even being aware of possible confusion, we both missed this restr on the departure chart. Certainly neither of us will misinterpret this type of notation, but others may fall into the same trap. Perhaps an advisory circular or similar type of training document is warranted when procedures change appreciably like this.
Original NASA ASRS Text
Title: B737 DEP FROM LAS IS DIRECTED TO CLB WITH RESTRS BUT FAILS TO COMPLY WITH SUBSEQUENT ALT XING REQUIREMENT.
Narrative: WHILE DEPARTING LAS ON THE SHEAD SID, DEP CTL CLRED US TO 'MAINTAIN FL190 COMPLY WITH RESTR.' THE CAPT AND I HAD BOTH READ AND DISCUSSED THE READ BEFORE FLIES CONCERNING ALTDEVS ON LAS DEPS, SO WE LEFT THE ALT SELECT SET TO 7000 FT UNTIL XING ROPPR. THE ALT WAS THEN SET TO FL190 AND THE CLB CONTINUED. UPON XING TARRK, DP CTL ASKED FOR OUR ALT, WHICH WAS 16000 FT, AND THEN INFORMED US OF A XING RESTR OF 11000 FT AT TARRK. I FEEL 2 FACTORS CONTRIBUTED PRIMARILY TO THIS DEV: 1) ALTHOUGH WE BOTH READ AND WERE AWARE OF THE POSSIBILITY OF MISUNDERSTANDINGS, ALL THE ATTN HAS BEEN CTRED ON THE INITIAL 7000 FT RESTRS ON THESE DEPS WITH BARELY A PASSING MENTION OF OTHER RESTRS. SO NATURALLY OUR ATTN FOCUSED ON THE 7000 FT RESTR AND MISSED THE OTHER. 2) THIS TYPE OF PROC IS UNIQUE AND EVEN THE PHRASEOLOGY DIFFERS FROM THAT OF THE SIMILAR RNAV STARS. I HAVE NEVER SEEN OR FLOWN A SID WITH XING RESTRS LIKE THOSE ON THE SHEAD. WHEN CLRED TO DSND VIA A STAR, YOU ARE TOLD JUST THAT 'DSND VIA THE (SUCH AND SUCH) ARR.' WHILE ON THE DEP, WE ARE TOLD TO CLB TO THE FINAL ALT. THE BOTTOM-LINE IS THAT EVEN BEING AWARE OF POSSIBLE CONFUSION, WE BOTH MISSED THIS RESTR ON THE DEP CHART. CERTAINLY NEITHER OF US WILL MISINTERPRET THIS TYPE OF NOTATION, BUT OTHERS MAY FALL INTO THE SAME TRAP. PERHAPS AN ADVISORY CIRCULAR OR SIMILAR TYPE OF TRAINING DOCUMENT IS WARRANTED WHEN PROCS CHANGE APPRECIABLY LIKE THIS.
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.