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|
Attributes | |
ACN | 614643 |
Time | |
Date | 200404 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : las.airport |
State Reference | NV |
Altitude | msl bound lower : 11000 msl bound upper : 12500 |
Environment | |
Flight Conditions | VMC |
Weather Elements | Thunderstorm Turbulence |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude climbout : initial |
Route In Use | departure sid : shead |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : multi engine pilot : commercial pilot : instrument |
Experience | flight time last 90 days : 150 flight time total : 12000 flight time type : 500 |
ASRS Report | 614643 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 180 flight time total : 25000 flight time type : 8000 |
ASRS Report | 614305 |
Events | |
Anomaly | aircraft equipment problem : critical altitude deviation : crossing restriction not met altitude deviation : overshoot inflight encounter : turbulence non adherence : clearance non adherence : published procedure |
Independent Detector | other flight crewa |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | FAA Aircraft Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Situations | |
Chart | sid : shead rnav |
Narrative:
On the shead departure out of las, we were level at 9000 ft at mddog, per the departure. We were next given a climb to FL190 and began to climb. Somehow we missed the crossing restr at tarrk (at 11000 ft) and we believe we may have passed the waypoint at a higher altitude than charted. Next crossing restr was shead at or above 14000 ft and the climb page set for climb power, temporarily tarrk waypoint was overlooked in the climb. Upon reflecting on the procedure and to prevent the same thing from happening, when given a climb clearance, I will read back the altitude and 'climb restr' to mentally make a note of any lower crossing altitude restrs. Also, I think that with previous operations in las, I have mentally accustomed myself to the unrestr climbs that were frequently given. We were using single FMS operations at the time in a -300 which I realize takes a lot more xchking than in a -700 with dual FMS and the glass picture. The departure was reviewed by both of us on preflight brief, but between the turbulence distraction and assumption of a higher altitude, a crossing restr was missed. I think that by changing my readback phraseology, I can prevent this from happening again. Supplemental information from acn 614305: I don't know if we busted 'tarrk at 11000 ft,' which was the restriction. The reason we don't know this is because the FMC was on the climb page. I really think that doing the RNAV departure and arrivals with one FMC is like driving your car in the rain without windshield wipers (at least in the B737-300/500).
Original NASA ASRS Text
Title: FLT CREW OF B737-300 ON SHEAD RNAV DEP FROM LAS FAILS TO MEET 11000 FT XING RESTR AT MDDOG.
Narrative: ON THE SHEAD DEP OUT OF LAS, WE WERE LEVEL AT 9000 FT AT MDDOG, PER THE DEP. WE WERE NEXT GIVEN A CLB TO FL190 AND BEGAN TO CLB. SOMEHOW WE MISSED THE XING RESTR AT TARRK (AT 11000 FT) AND WE BELIEVE WE MAY HAVE PASSED THE WAYPOINT AT A HIGHER ALT THAN CHARTED. NEXT XING RESTR WAS SHEAD AT OR ABOVE 14000 FT AND THE CLB PAGE SET FOR CLB PWR, TEMPORARILY TARRK WAYPOINT WAS OVERLOOKED IN THE CLB. UPON REFLECTING ON THE PROC AND TO PREVENT THE SAME THING FROM HAPPENING, WHEN GIVEN A CLB CLRNC, I WILL READ BACK THE ALT AND 'CLB RESTR' TO MENTALLY MAKE A NOTE OF ANY LOWER XING ALT RESTRS. ALSO, I THINK THAT WITH PREVIOUS OPS IN LAS, I HAVE MENTALLY ACCUSTOMED MYSELF TO THE UNRESTR CLBS THAT WERE FREQUENTLY GIVEN. WE WERE USING SINGLE FMS OPS AT THE TIME IN A -300 WHICH I REALIZE TAKES A LOT MORE XCHKING THAN IN A -700 WITH DUAL FMS AND THE GLASS PICTURE. THE DEP WAS REVIEWED BY BOTH OF US ON PREFLT BRIEF, BUT BTWN THE TURB DISTR AND ASSUMPTION OF A HIGHER ALT, A XING RESTR WAS MISSED. I THINK THAT BY CHANGING MY READBACK PHRASEOLOGY, I CAN PREVENT THIS FROM HAPPENING AGAIN. SUPPLEMENTAL INFO FROM ACN 614305: I DON'T KNOW IF WE BUSTED 'TARRK AT 11000 FT,' WHICH WAS THE RESTRICTION. THE REASON WE DON'T KNOW THIS IS BECAUSE THE FMC WAS ON THE CLB PAGE. I REALLY THINK THAT DOING THE RNAV DEP AND ARRIVALS WITH ONE FMC IS LIKE DRIVING YOUR CAR IN THE RAIN WITHOUT WINDSHIELD WIPERS (AT LEAST IN THE B737-300/500).
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.