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Attributes | |
ACN | 600976 |
Time | |
Date | 200311 |
Day | Fri |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | msl bound lower : 9000 msl bound upper : 11200 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-700 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : shead one |
Flight Plan | IFR |
Aircraft 2 | |
Controlling Facilities | tracon : l30.tracon |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
ASRS Report | 600976 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
ASRS Report | 600975 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot non adherence : clearance non adherence : published procedure |
Independent Detector | atc equipment other atc equipment : radar other flight crewa |
Resolutory Action | controller : issued alert flight crew : overrode automation flight crew : returned to original clearance |
Consequence | faa : assigned or threatened penalties faa : investigated faa : reviewed incident with flight crew |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was hand flying the shead RNAV 1 departure out of las vegas at night from runway 25R. We were given the clearance by departure control to 'climb to FL190, comply with shead RNAV 1 departure altitude crossing restrs.' I verified with the captain our next crossing restr altitude at roppr at or below 7000 ft, which we complied with. Passing roppr, I then verified with the captain our crossing restr altitude of mddog at 9000 ft, which we also complied with. We were now tracking to the tarkk waypoint in LNAV and VNAV speed climbing at approximately 4000 FPM. At approximately 11200 ft, las vegas departure instructed us to descend immediately to 11000 ft for opposite traffic, which we had in sight. At about the same time departure control gave their instructions, the flight director transitioned from VNAV speed to VNAV path as we crossed over the tarkk waypoint. Tarkk waypoint has a crossing restr of 11000 ft and I immediately descended down to 11000 ft. Although I briefed this RNAV departure on the ground with the captain, including waypoint names and crossing restrs, I neglected to verify the crossing restr at tarkk after we passed mddog while I was hand flying the climb out. There are multiple crossing restr altitudes on the shead RNAV 1 departure. And as a result, for future purposes, I will fly this procedure with the autoplt engaged to reduce the workload associated with this RNAV departure and keep a careful watch on the flight director. Supplemental information from acn 600975: I, as the PNF, made a complete readback of that, as well as all other clrncs. As we climbed through 10000 ft MSL, I called 10000 ft for 11000 ft, 1000 ft to go, and proceeded to complete the 'out of 10000 ft' flow. I then looked back through the HUD display as we were now approaching tarrk, and noticed that we were just now climbing through 11000 ft, whereupon I placed my hands on the yoke control and pushed the control forward to arrest our climb, and at the same time told the first officer to stop the climb. At this moment, ATC instructed us to descend and maintain 11000 ft. First officer exclaimed, 'oh shoot, I'm sorry, I was flying on the flight director and following the commands.' we were given a telephone number and instructed to call this number for 'possible ATC violation.' I considered whether the flight directors had misbehaved, but was satisfied that this is something that I see very often. Our final conclusion was that perhaps he should have begun leveloff, against the commands of the flight director, as he crosschecked the instruments and saw that we were approaching the required leveloff altitude. Las departure control stated that they had noticed many altitude problems since the procedure had been designed and suggested that all RNAV arrival and departure procedures be flown by the autoplt, rather than by hand flying in hopes of avoiding this situation in the future. In reflection, I feel that the autoplt could have provided a better, and safer, departure than hand flying.
Original NASA ASRS Text
Title: B737-700 FLT CREW HAND FLY LAS SHEAD RNAV SID, OVERSHOOT SID XING RESTR, REALIZING THE SAME TIME AS L30 DEP CTLR ALERTS THE FLT CREW TO THE OVERSHOOT TO RETURN TO 11000 FT XING RESTR.
Narrative: I WAS HAND FLYING THE SHEAD RNAV 1 DEP OUT OF LAS VEGAS AT NIGHT FROM RWY 25R. WE WERE GIVEN THE CLRNC BY DEP CTL TO 'CLB TO FL190, COMPLY WITH SHEAD RNAV 1 DEP ALT XING RESTRS.' I VERIFIED WITH THE CAPT OUR NEXT XING RESTR ALT AT ROPPR AT OR BELOW 7000 FT, WHICH WE COMPLIED WITH. PASSING ROPPR, I THEN VERIFIED WITH THE CAPT OUR XING RESTR ALT OF MDDOG AT 9000 FT, WHICH WE ALSO COMPLIED WITH. WE WERE NOW TRACKING TO THE TARKK WAYPOINT IN LNAV AND VNAV SPD CLBING AT APPROX 4000 FPM. AT APPROX 11200 FT, LAS VEGAS DEP INSTRUCTED US TO DSND IMMEDIATELY TO 11000 FT FOR OPPOSITE TFC, WHICH WE HAD IN SIGHT. AT ABOUT THE SAME TIME DEP CTL GAVE THEIR INSTRUCTIONS, THE FLT DIRECTOR TRANSITIONED FROM VNAV SPD TO VNAV PATH AS WE CROSSED OVER THE TARKK WAYPOINT. TARKK WAYPOINT HAS A XING RESTR OF 11000 FT AND I IMMEDIATELY DSNDED DOWN TO 11000 FT. ALTHOUGH I BRIEFED THIS RNAV DEP ON THE GND WITH THE CAPT, INCLUDING WAYPOINT NAMES AND XING RESTRS, I NEGLECTED TO VERIFY THE XING RESTR AT TARKK AFTER WE PASSED MDDOG WHILE I WAS HAND FLYING THE CLBOUT. THERE ARE MULTIPLE XING RESTR ALTS ON THE SHEAD RNAV 1 DEP. AND AS A RESULT, FOR FUTURE PURPOSES, I WILL FLY THIS PROC WITH THE AUTOPLT ENGAGED TO REDUCE THE WORKLOAD ASSOCIATED WITH THIS RNAV DEP AND KEEP A CAREFUL WATCH ON THE FLT DIRECTOR. SUPPLEMENTAL INFO FROM ACN 600975: I, AS THE PNF, MADE A COMPLETE READBACK OF THAT, AS WELL AS ALL OTHER CLRNCS. AS WE CLBED THROUGH 10000 FT MSL, I CALLED 10000 FT FOR 11000 FT, 1000 FT TO GO, AND PROCEEDED TO COMPLETE THE 'OUT OF 10000 FT' FLOW. I THEN LOOKED BACK THROUGH THE HUD DISPLAY AS WE WERE NOW APCHING TARRK, AND NOTICED THAT WE WERE JUST NOW CLBING THROUGH 11000 FT, WHEREUPON I PLACED MY HANDS ON THE YOKE CTL AND PUSHED THE CTL FORWARD TO ARREST OUR CLB, AND AT THE SAME TIME TOLD THE FO TO STOP THE CLB. AT THIS MOMENT, ATC INSTRUCTED US TO DSND AND MAINTAIN 11000 FT. FO EXCLAIMED, 'OH SHOOT, I'M SORRY, I WAS FLYING ON THE FLT DIRECTOR AND FOLLOWING THE COMMANDS.' WE WERE GIVEN A TELEPHONE NUMBER AND INSTRUCTED TO CALL THIS NUMBER FOR 'POSSIBLE ATC VIOLATION.' I CONSIDERED WHETHER THE FLT DIRECTORS HAD MISBEHAVED, BUT WAS SATISFIED THAT THIS IS SOMETHING THAT I SEE VERY OFTEN. OUR FINAL CONCLUSION WAS THAT PERHAPS HE SHOULD HAVE BEGUN LEVELOFF, AGAINST THE COMMANDS OF THE FLT DIRECTOR, AS HE XCHKED THE INSTS AND SAW THAT WE WERE APCHING THE REQUIRED LEVELOFF ALT. LAS DEP CTL STATED THAT THEY HAD NOTICED MANY ALT PROBS SINCE THE PROC HAD BEEN DESIGNED AND SUGGESTED THAT ALL RNAV ARR AND DEP PROCS BE FLOWN BY THE AUTOPLT, RATHER THAN BY HAND FLYING IN HOPES OF AVOIDING THIS SIT IN THE FUTURE. IN REFLECTION, I FEEL THAT THE AUTOPLT COULD HAVE PROVIDED A BETTER, AND SAFER, DEP THAN HAND FLYING.
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.