37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 714663 |
Time | |
Date | 200610 |
Place | |
Locale Reference | airport : apa.airport |
State Reference | CO |
Altitude | msl single value : 9000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : d01.tracon |
Operator | general aviation : corporate |
Make Model Name | Continental (Bombardier) |
Operating Under FAR Part | Part 91 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : rocki |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 150 flight time total : 27000 flight time type : 400 |
ASRS Report | 714663 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance 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 | Flight Crew Human Performance Chart Or Publication |
Primary Problem | Chart Or Publication |
Air Traffic Incident | Pilot Deviation |
Narrative:
I was the first officer; PNF departing apa to smo. Several factors led to a deviation from assigned altitude on departure from apa. Approximately 30 mins prior to departure I called for clearance to smo. The clearance included a SID; the rockies 4; transition; red table; airways to smo; and departure frequency and transponder code. I was unfamiliar with the first fix on the assigned airway; so prior to a full readback I asked for clarification of the first fix on the assigned airway. I then read back what I had written down. 'Cleared to smo via rockies 4 dbl; J60 hve as filed. Departure frequency XXX.xx squawk XXXX.' I did not have an altitude or heading written down; and I don't remember reading back either. The 'rockies 4' is a den SID which serves several satellite airports. During my cockpit preparation I referred to the SID for both initial altitude and departure frequencys. (I had already been given a different frequency when I wrote down the clearance.) in bold print in the upper left corner of the SID is the instruction to maintain 10000 ft. On closer inspection I should have seen; in fine print; 'airports served -- maintain assigned heading and altitude for vectors.' I briefed the captain that we were cleared via the rockies 4 and to maintain 10000 ft which I set in the altitude alert window in our mode control panel. When I switched radios to tower for takeoff clearance; I referred to the SID for the departure frequency which I didn't notice was different from the one I had written down with our airways clearance. After takeoff when I switched to the departure frequency; it took 2 calls to get a response from the controller. We were climbing through 9000 ft when departure told us to stop the climb and turn left. Asked what altitude we were climbing to; my response was '10000 ft the charted altitude.' ATC advised that we were assigned a lower altitude. ATC later advised us to call denver TRACON and gave us the phone number. I then talked to the supervisor and explained what I thought happened; and he said that fortunately there had been no loss of separation; and no further action would be necessary. Several seemingly minor factors led up to what could have been a tragic accident. First; and most important is the use of one SID; with several possible altitudes for several different airports. It is almost criminal to think that saving a fraction of a penny by not publishing separate charts for separate airports is somehow cost effective. Most of my career (36 yrs) I have been with part 121 air carriers flying to and from high density major airports. I have been programmed to respond to and follow bold print instructions. A rockies 4 SID from centennial airport should be just that -- the centennial rockies 4 departure -- with no other ifs; ands; or buts. Then the bold print 'maintain XXXX ft' would be much clrer and safer. I do not remember reading back any altitude to the clearance delivery controller; and I do not remember reading back any altitude to the tower controller when cleared for takeoff. Somewhere the important altitude information was lost. This would not happen if separate charts were published for each airport in all of the busy high density airport environments. More and more corporate and airline airplanes are using satellite airports. This charting situation is as critical as the runway incursion problems plaguing aviation. Callback conversation with reporter revealed the following information: the reporter commented that the company supplies only a single set of airways charts to the flight crew; adding; the SOP is for the PNF to review the procedure and brief the PF. Reporter suggested this procedure is flawed in that it presupposes that the pilot doing the briefing will make no errors and that the pilot receiving the briefing will not misinterpret it. He felt the process failed to provide redundancy -- in this case independent review of the procedure -- that is a fundamental tenet of aviation safety.
Original NASA ASRS Text
Title: CL30 FLT CREW HAS ALTDEV ON ROCKIES DEP FROM APA.
Narrative: I WAS THE FO; PNF DEPARTING APA TO SMO. SEVERAL FACTORS LED TO A DEV FROM ASSIGNED ALT ON DEP FROM APA. APPROX 30 MINS PRIOR TO DEP I CALLED FOR CLRNC TO SMO. THE CLRNC INCLUDED A SID; THE ROCKIES 4; TRANSITION; RED TABLE; AIRWAYS TO SMO; AND DEP FREQ AND XPONDER CODE. I WAS UNFAMILIAR WITH THE FIRST FIX ON THE ASSIGNED AIRWAY; SO PRIOR TO A FULL READBACK I ASKED FOR CLARIFICATION OF THE FIRST FIX ON THE ASSIGNED AIRWAY. I THEN READ BACK WHAT I HAD WRITTEN DOWN. 'CLRED TO SMO VIA ROCKIES 4 DBL; J60 HVE AS FILED. DEP FREQ XXX.XX SQUAWK XXXX.' I DID NOT HAVE AN ALT OR HDG WRITTEN DOWN; AND I DON'T REMEMBER READING BACK EITHER. THE 'ROCKIES 4' IS A DEN SID WHICH SERVES SEVERAL SATELLITE ARPTS. DURING MY COCKPIT PREPARATION I REFERRED TO THE SID FOR BOTH INITIAL ALT AND DEP FREQS. (I HAD ALREADY BEEN GIVEN A DIFFERENT FREQ WHEN I WROTE DOWN THE CLRNC.) IN BOLD PRINT IN THE UPPER L CORNER OF THE SID IS THE INSTRUCTION TO MAINTAIN 10000 FT. ON CLOSER INSPECTION I SHOULD HAVE SEEN; IN FINE PRINT; 'ARPTS SERVED -- MAINTAIN ASSIGNED HDG AND ALT FOR VECTORS.' I BRIEFED THE CAPT THAT WE WERE CLRED VIA THE ROCKIES 4 AND TO MAINTAIN 10000 FT WHICH I SET IN THE ALT ALERT WINDOW IN OUR MODE CTL PANEL. WHEN I SWITCHED RADIOS TO TWR FOR TKOF CLRNC; I REFERRED TO THE SID FOR THE DEP FREQ WHICH I DIDN'T NOTICE WAS DIFFERENT FROM THE ONE I HAD WRITTEN DOWN WITH OUR AIRWAYS CLRNC. AFTER TKOF WHEN I SWITCHED TO THE DEP FREQ; IT TOOK 2 CALLS TO GET A RESPONSE FROM THE CTLR. WE WERE CLBING THROUGH 9000 FT WHEN DEP TOLD US TO STOP THE CLB AND TURN L. ASKED WHAT ALT WE WERE CLBING TO; MY RESPONSE WAS '10000 FT THE CHARTED ALT.' ATC ADVISED THAT WE WERE ASSIGNED A LOWER ALT. ATC LATER ADVISED US TO CALL DENVER TRACON AND GAVE US THE PHONE NUMBER. I THEN TALKED TO THE SUPVR AND EXPLAINED WHAT I THOUGHT HAPPENED; AND HE SAID THAT FORTUNATELY THERE HAD BEEN NO LOSS OF SEPARATION; AND NO FURTHER ACTION WOULD BE NECESSARY. SEVERAL SEEMINGLY MINOR FACTORS LED UP TO WHAT COULD HAVE BEEN A TRAGIC ACCIDENT. FIRST; AND MOST IMPORTANT IS THE USE OF ONE SID; WITH SEVERAL POSSIBLE ALTS FOR SEVERAL DIFFERENT ARPTS. IT IS ALMOST CRIMINAL TO THINK THAT SAVING A FRACTION OF A PENNY BY NOT PUBLISHING SEPARATE CHARTS FOR SEPARATE ARPTS IS SOMEHOW COST EFFECTIVE. MOST OF MY CAREER (36 YRS) I HAVE BEEN WITH PART 121 AIR CARRIERS FLYING TO AND FROM HIGH DENSITY MAJOR ARPTS. I HAVE BEEN PROGRAMMED TO RESPOND TO AND FOLLOW BOLD PRINT INSTRUCTIONS. A ROCKIES 4 SID FROM CENTENNIAL ARPT SHOULD BE JUST THAT -- THE CENTENNIAL ROCKIES 4 DEP -- WITH NO OTHER IFS; ANDS; OR BUTS. THEN THE BOLD PRINT 'MAINTAIN XXXX FT' WOULD BE MUCH CLRER AND SAFER. I DO NOT REMEMBER READING BACK ANY ALT TO THE CLRNC DELIVERY CTLR; AND I DO NOT REMEMBER READING BACK ANY ALT TO THE TWR CTLR WHEN CLRED FOR TKOF. SOMEWHERE THE IMPORTANT ALT INFO WAS LOST. THIS WOULD NOT HAPPEN IF SEPARATE CHARTS WERE PUBLISHED FOR EACH ARPT IN ALL OF THE BUSY HIGH DENSITY ARPT ENVIRONMENTS. MORE AND MORE CORPORATE AND AIRLINE AIRPLANES ARE USING SATELLITE ARPTS. THIS CHARTING SITUATION IS AS CRITICAL AS THE RWY INCURSION PROBS PLAGUING AVIATION. CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: THE RPTR COMMENTED THAT THE COMPANY SUPPLIES ONLY A SINGLE SET OF AIRWAYS CHARTS TO THE FLT CREW; ADDING; THE SOP IS FOR THE PNF TO REVIEW THE PROC AND BRIEF THE PF. RPTR SUGGESTED THIS PROC IS FLAWED IN THAT IT PRESUPPOSES THAT THE PLT DOING THE BRIEFING WILL MAKE NO ERRORS AND THAT THE PLT RECEIVING THE BRIEFING WILL NOT MISINTERPRET IT. HE FELT THE PROCESS FAILED TO PROVIDE REDUNDANCY -- IN THIS CASE INDEPENDENT REVIEW OF THE PROC -- THAT IS A FUNDAMENTAL TENET OF AVIATION SAFETY.
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.