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|
Attributes | |
ACN | 636551 |
Time | |
Date | 200411 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | intersection : roppr |
State Reference | NV |
Altitude | msl bound lower : 7000 msl bound upper : 10500 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Turbulence Rain Windshear |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : l30.tracon tower : las.tower |
Operator | general aviation : corporate |
Make Model Name | Learjet 35 |
Operating Under FAR Part | Part 91 |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : cowby |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 94 flight time total : 14800 flight time type : 3600 |
ASRS Report | 636551 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 110 flight time total : 3600 flight time type : 1210 |
ASRS Report | 636944 |
Events | |
Anomaly | altitude deviation : crossing restriction not met altitude deviation : overshoot inflight encounter : turbulence inflight encounter : weather non adherence : clearance non adherence : published procedure other anomaly other |
Independent Detector | atc equipment other atc equipment : mode c other controllera |
Resolutory Action | controller : issued advisory none taken : insufficient time |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance Weather |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Our departure clearance was the cowby RNAV 1 departure, gallup transition, as filed to maintain FL190. We were instructed to taxi to runway 19R and hold for several mins as they were changing the flow around to runways 19 and 25 departures. There was unusual WX for las vegas with a lot of convective activity in the vicinity. As we taxied out, there was a very active cell north of the airport that was responsible for numerous windshear alerts from the tower. The PNF and I discussed the departure and as he entered it into our GPS, we discovered that our database contained the route for a departure on runway 19L, but not for wy 19R. We determined that the first 2 waypoints would have to be entered manually, with the second entered as we passed over the first. We briefed that he would do the waypoint entry as I flew the airplane. We were #3 for departure behind an MD80 and a B737 on runway 19L. The MD80 started his takeoff and aborted midfield due to windshear alert in the cockpit. As he cleared, there was considerable discussion on tower as to wind conditions, etc. The B737 made an uneventful takeoff and we were in position as he rolled. Still concerned about the WX and windshear, we concentrated on the takeoff. As you can see on the attached copy of the departure, it is only 5.5 NM to the first waypoint. As we cleaned the airplane up, we were already in IMC in choppy cumulus. As we passed jaker, I made the turn to roper as the PNF entered it into the GPS. As we contacted departure, he advised that we were supposed to comply with the restrs and asked if we realized that we were about to bust one several mi ahead (I think he said 2). Looking at the chart, I realized that I had misread the restr at roper as 'at or above' like the next 3 crossing restrs. But by that time we were somewhere between 10000-11000 ft, if I recall, so I continued with the remainder of the procedure. There were no further comments from the controller. I allowed myself to become too focused on one thing -- the potential for windshear on takeoff -- and neglected to give the complicated departure the mental attention it required. Additional factor was the unusual workload imposed by our outdated GPS (soon to be replaced) not having the runway 19R procedure. That required the PNF to deviate from our SOP and concentrate on entering a waypoint during an already high workload phase of flight. When conditions create an undesirably high workload in the cockpit, every effort should be made to change things that can be changed to reduce it. In this case, after discovering the problem in the GPS database, it would have completely changed the workload if I had just declined the RNAV departure and requested a conventional one. It is almost always a combination of factors that combine to create a situation such as this. They key is recognizing this in real time and then taking steps to effectively deal with it. Supplemental information from acn 636944: concerned about windshear alerts, we decided to build up extra airspeed on the runway and then climb at an above average rate. As we departed, everything went as planned and we started up into the bumps and the low level cumulus. Upon approaching the second waypoint, the controller asked us to confirm that we would comply with the restrs at roppr because we were about to bust the altitude requirement. The captain and I then rechked the SID and found that we both had misread the departure. Since this instance, we have slowed down our briefings and become more thorough on our SID review.
Original NASA ASRS Text
Title: ALT OVERSHOT, ALT XING RESTR OVER ROPPR NOT MADE BY AN LR35A FLT CREW ON THE COWBY RNAV 1 DEP FROM LAS.
Narrative: OUR DEP CLRNC WAS THE COWBY RNAV 1 DEP, GALLUP TRANSITION, AS FILED TO MAINTAIN FL190. WE WERE INSTRUCTED TO TAXI TO RWY 19R AND HOLD FOR SEVERAL MINS AS THEY WERE CHANGING THE FLOW AROUND TO RWYS 19 AND 25 DEPS. THERE WAS UNUSUAL WX FOR LAS VEGAS WITH A LOT OF CONVECTIVE ACTIVITY IN THE VICINITY. AS WE TAXIED OUT, THERE WAS A VERY ACTIVE CELL N OF THE ARPT THAT WAS RESPONSIBLE FOR NUMEROUS WINDSHEAR ALERTS FROM THE TWR. THE PNF AND I DISCUSSED THE DEP AND AS HE ENTERED IT INTO OUR GPS, WE DISCOVERED THAT OUR DATABASE CONTAINED THE RTE FOR A DEP ON RWY 19L, BUT NOT FOR WY 19R. WE DETERMINED THAT THE FIRST 2 WAYPOINTS WOULD HAVE TO BE ENTERED MANUALLY, WITH THE SECOND ENTERED AS WE PASSED OVER THE FIRST. WE BRIEFED THAT HE WOULD DO THE WAYPOINT ENTRY AS I FLEW THE AIRPLANE. WE WERE #3 FOR DEP BEHIND AN MD80 AND A B737 ON RWY 19L. THE MD80 STARTED HIS TKOF AND ABORTED MIDFIELD DUE TO WINDSHEAR ALERT IN THE COCKPIT. AS HE CLRED, THERE WAS CONSIDERABLE DISCUSSION ON TWR AS TO WIND CONDITIONS, ETC. THE B737 MADE AN UNEVENTFUL TKOF AND WE WERE IN POS AS HE ROLLED. STILL CONCERNED ABOUT THE WX AND WINDSHEAR, WE CONCENTRATED ON THE TKOF. AS YOU CAN SEE ON THE ATTACHED COPY OF THE DEP, IT IS ONLY 5.5 NM TO THE FIRST WAYPOINT. AS WE CLEANED THE AIRPLANE UP, WE WERE ALREADY IN IMC IN CHOPPY CUMULUS. AS WE PASSED JAKER, I MADE THE TURN TO ROPER AS THE PNF ENTERED IT INTO THE GPS. AS WE CONTACTED DEP, HE ADVISED THAT WE WERE SUPPOSED TO COMPLY WITH THE RESTRS AND ASKED IF WE REALIZED THAT WE WERE ABOUT TO BUST ONE SEVERAL MI AHEAD (I THINK HE SAID 2). LOOKING AT THE CHART, I REALIZED THAT I HAD MISREAD THE RESTR AT ROPER AS 'AT OR ABOVE' LIKE THE NEXT 3 XING RESTRS. BUT BY THAT TIME WE WERE SOMEWHERE BTWN 10000-11000 FT, IF I RECALL, SO I CONTINUED WITH THE REMAINDER OF THE PROC. THERE WERE NO FURTHER COMMENTS FROM THE CTLR. I ALLOWED MYSELF TO BECOME TOO FOCUSED ON ONE THING -- THE POTENTIAL FOR WINDSHEAR ON TKOF -- AND NEGLECTED TO GIVE THE COMPLICATED DEP THE MENTAL ATTN IT REQUIRED. ADDITIONAL FACTOR WAS THE UNUSUAL WORKLOAD IMPOSED BY OUR OUTDATED GPS (SOON TO BE REPLACED) NOT HAVING THE RWY 19R PROC. THAT REQUIRED THE PNF TO DEVIATE FROM OUR SOP AND CONCENTRATE ON ENTERING A WAYPOINT DURING AN ALREADY HIGH WORKLOAD PHASE OF FLT. WHEN CONDITIONS CREATE AN UNDESIRABLY HIGH WORKLOAD IN THE COCKPIT, EVERY EFFORT SHOULD BE MADE TO CHANGE THINGS THAT CAN BE CHANGED TO REDUCE IT. IN THIS CASE, AFTER DISCOVERING THE PROB IN THE GPS DATABASE, IT WOULD HAVE COMPLETELY CHANGED THE WORKLOAD IF I HAD JUST DECLINED THE RNAV DEP AND REQUESTED A CONVENTIONAL ONE. IT IS ALMOST ALWAYS A COMBINATION OF FACTORS THAT COMBINE TO CREATE A SIT SUCH AS THIS. THEY KEY IS RECOGNIZING THIS IN REAL TIME AND THEN TAKING STEPS TO EFFECTIVELY DEAL WITH IT. SUPPLEMENTAL INFO FROM ACN 636944: CONCERNED ABOUT WINDSHEAR ALERTS, WE DECIDED TO BUILD UP EXTRA AIRSPD ON THE RWY AND THEN CLB AT AN ABOVE AVERAGE RATE. AS WE DEPARTED, EVERYTHING WENT AS PLANNED AND WE STARTED UP INTO THE BUMPS AND THE LOW LEVEL CUMULUS. UPON APCHING THE SECOND WAYPOINT, THE CTLR ASKED US TO CONFIRM THAT WE WOULD COMPLY WITH THE RESTRS AT ROPPR BECAUSE WE WERE ABOUT TO BUST THE ALT REQUIREMENT. THE CAPT AND I THEN RECHKED THE SID AND FOUND THAT WE BOTH HAD MISREAD THE DEP. SINCE THIS INSTANCE, WE HAVE SLOWED DOWN OUR BRIEFINGS AND BECOME MORE THOROUGH ON OUR SID REVIEW.
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.