37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 723072 |
Time | |
Date | 200701 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : ont.airport |
State Reference | CA |
Altitude | msl bound lower : 7000 msl bound upper : 8000 |
Environment | |
Flight Conditions | IMC |
Weather Elements | Rain |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : sct.tracon |
Operator | common carrier : air carrier |
Make Model Name | Commercial Fixed Wing |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : vacating altitude |
Route In Use | departure sid : pom |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 723072 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 90 flight time total : 7000 flight time type : 400 |
ASRS Report | 723070 |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : crossing restriction not met non adherence : clearance non adherence : far non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | 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 |
Situations | |
Chart | star : commercial chart mps 2 pom 7 |
Narrative:
Pre departure clearance clearance: pom 7 departure maintain 14000 ft. Contacted socal departure and were informed to comply with all restr. We were filed for the gorman transition and only saw the 'cross bucck at or above 14000 ft.' the pilot monitoring (first officer) re-checked the SID and again neither pilot saw the restr at pom. Passing 7500 ft we were told to level off. Complied and level off was 8000 ft. Socal asked if we saw the restr and after a further review we found the 7000 ft restr at pom. We were informed there was no loss of separation. We were subsequently cleared to 14000 ft and handed off to center. We have recently started using commercial charts for our operation and these charts do not show crossing restr on the plan view. We both overlooked the restr in the header of the text page of the SID and only saw the restr in the gorman transition. The fact that 3 different sections and two different pages need to be reviewed to fly this procedure was a contributing factor as the other commercial chart very clearly puts the restr on the plan view. Supplemental information from acn 723070: pre departure clearance clearance: pom 7 departure maintain 14000 ft. Contact socal departure frequency 125.5 contact ground crew for push with current ATIS. Classic miss by captain and first officer of a departure altitude restr lower than pre departure clearance altitude clearance. I consider a contributing fact to be the company's recent change of commercial chart company and the need to consult and comprehend multiple pages for a single departure procedure.
Original NASA ASRS Text
Title: A PLT RPTS OVERSHOOTING AN ONT POM 7 SID ALT RESTR BECAUSE THE COMMERCIAL CHART IN USE WAS CONFUSING.
Narrative: PDC CLRNC: POM 7 DEP MAINTAIN 14000 FT. CONTACTED SOCAL DEP AND WERE INFORMED TO COMPLY WITH ALL RESTR. WE WERE FILED FOR THE GORMAN TRANSITION AND ONLY SAW THE 'CROSS BUCCK AT OR ABOVE 14000 FT.' THE PLT MONITORING (FO) RE-CHKED THE SID AND AGAIN NEITHER PLT SAW THE RESTR AT POM. PASSING 7500 FT WE WERE TOLD TO LEVEL OFF. COMPLIED AND LEVEL OFF WAS 8000 FT. SOCAL ASKED IF WE SAW THE RESTR AND AFTER A FURTHER REVIEW WE FOUND THE 7000 FT RESTR AT POM. WE WERE INFORMED THERE WAS NO LOSS OF SEPARATION. WE WERE SUBSEQUENTLY CLRED TO 14000 FT AND HANDED OFF TO CTR. WE HAVE RECENTLY STARTED USING COMMERCIAL CHARTS FOR OUR OP AND THESE CHARTS DO NOT SHOW CROSSING RESTR ON THE PLAN VIEW. WE BOTH OVERLOOKED THE RESTR IN THE HEADER OF THE TEXT PAGE OF THE SID AND ONLY SAW THE RESTR IN THE GORMAN TRANSITION. THE FACT THAT 3 DIFFERENT SECTIONS AND TWO DIFFERENT PAGES NEED TO BE REVIEWED TO FLY THIS PROC WAS A CONTRIBUTING FACTOR AS THE OTHER COMMERCIAL CHART VERY CLRLY PUTS THE RESTR ON THE PLAN VIEW. SUPPLEMENTAL INFO FROM ACN 723070: PDC CLRNC: POM 7 DEP MAINTAIN 14000 FT. CONTACT SOCAL DEP FREQ 125.5 CONTACT GND CREW FOR PUSH WITH CURRENT ATIS. CLASSIC MISS BY CAPT AND FO OF A DEP ALT RESTR LOWER THAN PDC ALT CLRNC. I CONSIDER A CONTRIBUTING FACT TO BE THE COMPANY'S RECENT CHANGE OF COMMERCIAL CHART COMPANY AND THE NEED TO CONSULT AND COMPREHEND MULTIPLE PAGES FOR A SINGLE DEP PROC.
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.