37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 677115 |
Time | |
Date | 200511 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | navaid : yso.vor |
State Reference | ON |
Altitude | msl single value : 10000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : cyyz.tracon |
Operator | common carrier : air carrier |
Make Model Name | MD-11 |
Operating Under FAR Part | Part 121 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 190 flight time total : 18000 flight time type : 2400 |
ASRS Report | 677115 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | altitude deviation : excursion from assigned altitude non adherence : clearance non adherence : far non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | controller : issued advisory controller : issued new clearance |
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:
Our flight plan from frankfurt to toronto did not include a STAR. Approaching toronto; we were given a STAR at the last min. Approach control cleared us for a STAR to runway 6L. We saw all the mandatory crossing limits and based on that; we descended below 10000 ft for our next altitude limit of 3000 ft. This was all in large font and easily readable. Apparently; at the bottom of the page in small font was a statement that all altitudes will be assigned by ATC. We missed that in the rush to manually build the STAR as it was not in the FMS database. I believe the problem was the last min change. We did not have adequate time to thoroughly brief the STAR because of the last min change. Also; the low light conditions played a factor in that; had we manually built this arrival while at cruise with all the cockpit lights full on; we would not have missed the fine print at the bottom of the page. We would have looked at the arrival closely and in good light conditions. Lastly; the controller made it perfectly clear that we were cleared for the arrival and then it was silent -- no further xmissions. There was very little traffic at the time. We looked at the crossing restrs in large font again and then started down. We descended from 10000 ft to 8000 ft before we were instructed to maintain 8000 ft. We slightly shot through 8000 ft but regained 8000 ft before we were told of our altitude deviation. I think the crossing limits should only be in large font if there is an accompanying statement in large font that is nearby stating 'all altitudes assigned by ATC.' we would not have missed that.
Original NASA ASRS Text
Title: AN MD11 RECEIVED AN UNEXPECTED CYYZ STAR AND BEGAN A DSCNT ON THE ROUTING PRIOR TO ATC CLRNC. A STAR NOTE INDICATES ALL ALTS ARE ASSIGNED BY ATC.
Narrative: OUR FLT PLAN FROM FRANKFURT TO TORONTO DID NOT INCLUDE A STAR. APCHING TORONTO; WE WERE GIVEN A STAR AT THE LAST MIN. APCH CTL CLRED US FOR A STAR TO RWY 6L. WE SAW ALL THE MANDATORY XING LIMITS AND BASED ON THAT; WE DSNDED BELOW 10000 FT FOR OUR NEXT ALT LIMIT OF 3000 FT. THIS WAS ALL IN LARGE FONT AND EASILY READABLE. APPARENTLY; AT THE BOTTOM OF THE PAGE IN SMALL FONT WAS A STATEMENT THAT ALL ALTS WILL BE ASSIGNED BY ATC. WE MISSED THAT IN THE RUSH TO MANUALLY BUILD THE STAR AS IT WAS NOT IN THE FMS DATABASE. I BELIEVE THE PROB WAS THE LAST MIN CHANGE. WE DID NOT HAVE ADEQUATE TIME TO THOROUGHLY BRIEF THE STAR BECAUSE OF THE LAST MIN CHANGE. ALSO; THE LOW LIGHT CONDITIONS PLAYED A FACTOR IN THAT; HAD WE MANUALLY BUILT THIS ARR WHILE AT CRUISE WITH ALL THE COCKPIT LIGHTS FULL ON; WE WOULD NOT HAVE MISSED THE FINE PRINT AT THE BOTTOM OF THE PAGE. WE WOULD HAVE LOOKED AT THE ARR CLOSELY AND IN GOOD LIGHT CONDITIONS. LASTLY; THE CTLR MADE IT PERFECTLY CLR THAT WE WERE CLRED FOR THE ARR AND THEN IT WAS SILENT -- NO FURTHER XMISSIONS. THERE WAS VERY LITTLE TFC AT THE TIME. WE LOOKED AT THE XING RESTRS IN LARGE FONT AGAIN AND THEN STARTED DOWN. WE DSNDED FROM 10000 FT TO 8000 FT BEFORE WE WERE INSTRUCTED TO MAINTAIN 8000 FT. WE SLIGHTLY SHOT THROUGH 8000 FT BUT REGAINED 8000 FT BEFORE WE WERE TOLD OF OUR ALTDEV. I THINK THE XING LIMITS SHOULD ONLY BE IN LARGE FONT IF THERE IS AN ACCOMPANYING STATEMENT IN LARGE FONT THAT IS NEARBY STATING 'ALL ALTS ASSIGNED BY ATC.' WE WOULD NOT HAVE MISSED THAT.
Data retrieved from NASA's ASRS site as of January 2009 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.