37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 729124 |
Time | |
Date | 200702 |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sea.airport |
State Reference | WA |
Altitude | msl single value : 22200 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zse.artcc |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | descent : vacating altitude |
Route In Use | arrival star : chins 5 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 264 flight time type : 2040 |
ASRS Report | 729124 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Events | |
Anomaly | altitude deviation : crossing restriction not met non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | none taken : insufficient time |
Supplementary | |
Problem Areas | Flight Crew Human Performance Chart Or Publication |
Primary Problem | Flight Crew Human Performance |
Narrative:
While I was off frequency the PF was given a clearance by center to descend via the chins 5 arrival and to cross aubrn at 12000 ft and 250 KTS as depicted. While giving the PA; I noticed the PF talking to center as he dialed 12000 ft into the altitude window on the autoplt. When I returned to the frequency; he told me we were cleared to cross aubrn at 12K/250 KTS but didn't say we were to 'descend via the chins 5 arrival.' he did ask me if I saw any other altitude restrs other than the 12K at aubrn. We both looked at the arrival again. I noticed numerous speed and altitude restrs but for some reason we both failed to notice the 16K restr at raddy when landing south. At this point all I was thinking about was the 12K at aubrn since he hadn't mentioned the phrase 'descend via' and it never occurred to me to ask about it. We began our descent and it was proceeding normally when center asked if we were going to make the restr at raddy. I was confused at this point because she hadn't issued one that I'd heard; and I was still unaware of the 16K restr there. We were approximately 2-3 miles from raddy at that point. I can't remember the exact exchange on the radio but I said something to the effect of 'we weren't given a raddy restr' to which she replied that we were told to 'descend via' and 'we were on top of raddy.' both of us looked at the arrival again and that's when we finally noticed the 16K raddy restr. Center then said 'don't worry about it; we'll work it out here.' she didn't seem mad or upset. The PF and I both realized our error at that point and apologized when she handed us off to sea approach a few moments later. The rest of the approach and landing were uneventful. We discussed what occurred after landing. Our error has several facets. First; was the fact that while off frequency giving my PA; I had not heard center state 'descend via the chins 5...' and the PF didn't mention that to me when I returned to frequency. So crew communication was a factor. Had I known that; I might have made a bigger effort to find any altitude restrs on the arrival among the many printed. He did ask me if I saw any other restrs besides the 12K at aubrn and that should have been my clue about a 'descend via' clearance. The most aggravating thing was when we both finally saw the 16K restr at raddy printed at the far lower left side of the arrival page; underneath numerous other restrs. It seemed so obvious when I finally saw it; yet we both missed it initially. This was in VMC daylight conditions with a low workload. We wondered how tough it would be to notice the restrs at night or with a high workload. For me; I learned to query about descents more carefully when they occur while I'm off frequency and to more carefully review all the various altitude and speed restrs on arrs and departures to see if they apply to our situation. I also need to brief the PNF thoroughly if I'm the PF and get a clearance while the PNF is off frequency; so he can help me prevent those kinds of errors. Finally; as a practical suggestion to help reduce these incidents; why can't some sort of color coding be used on arrival/departure pages to make it easier to scan the page and see applicable restrs among the myriad of other navaids; fixes; routing; dmes and notes. I would suggest putting altitude restrs in red and speed restrs in blue. These colors would help draw the eye to them and mentally filter out less important black colored numbers and words. This would be especially helpful at night. There are many procedures in our route structure with the chins 5 complexity. The mitts 2 arrival into lax is a good example. The human factors that goes into printing them is poor; as evidenced by the two of us completely missing this restr in a day with a VMC low workload environment. Ultimately; it is still our responsibility to make all crossing restrs and our error when we fail to do that. But I think there are a few minor changes that could be made to help pilots do that.
Original NASA ASRS Text
Title: B737-300 CREW MISSES CROSSING RESTR AT RADDY ON THE CHINS 5 ARR TO SEA.
Narrative: WHILE I WAS OFF FREQUENCY THE PF WAS GIVEN A CLRNC BY CENTER TO DESCEND VIA THE CHINS 5 ARR AND TO CROSS AUBRN AT 12000 FT AND 250 KTS AS DEPICTED. WHILE GIVING THE PA; I NOTICED THE PF TALKING TO CENTER AS HE DIALED 12000 FT INTO THE ALT WINDOW ON THE AUTOPLT. WHEN I RETURNED TO THE FREQUENCY; HE TOLD ME WE WERE CLEARED TO CROSS AUBRN AT 12K/250 KTS BUT DIDN'T SAY WE WERE TO 'DESCEND VIA THE CHINS 5 ARR.' HE DID ASK ME IF I SAW ANY OTHER ALT RESTRS OTHER THAN THE 12K AT AUBRN. WE BOTH LOOKED AT THE ARR AGAIN. I NOTICED NUMEROUS SPEED AND ALT RESTRS BUT FOR SOME REASON WE BOTH FAILED TO NOTICE THE 16K RESTR AT RADDY WHEN LNDG S. AT THIS POINT ALL I WAS THINKING ABOUT WAS THE 12K AT AUBRN SINCE HE HADN'T MENTIONED THE PHRASE 'DESCEND VIA' AND IT NEVER OCCURRED TO ME TO ASK ABOUT IT. WE BEGAN OUR DESCENT AND IT WAS PROCEEDING NORMALLY WHEN CENTER ASKED IF WE WERE GOING TO MAKE THE RESTR AT RADDY. I WAS CONFUSED AT THIS POINT BECAUSE SHE HADN'T ISSUED ONE THAT I'D HEARD; AND I WAS STILL UNAWARE OF THE 16K RESTR THERE. WE WERE APPROX 2-3 MILES FROM RADDY AT THAT POINT. I CAN'T REMEMBER THE EXACT EXCHANGE ON THE RADIO BUT I SAID SOMETHING TO THE EFFECT OF 'WE WEREN'T GIVEN A RADDY RESTR' TO WHICH SHE REPLIED THAT WE WERE TOLD TO 'DESCEND VIA' AND 'WE WERE ON TOP OF RADDY.' BOTH OF US LOOKED AT THE ARR AGAIN AND THAT'S WHEN WE FINALLY NOTICED THE 16K RADDY RESTR. CENTER THEN SAID 'DON'T WORRY ABOUT IT; WE'LL WORK IT OUT HERE.' SHE DIDN'T SEEM MAD OR UPSET. THE PF AND I BOTH REALIZED OUR ERROR AT THAT POINT AND APOLOGIZED WHEN SHE HANDED US OFF TO SEA APCH A FEW MOMENTS LATER. THE REST OF THE APCH AND LNDG WERE UNEVENTFUL. WE DISCUSSED WHAT OCCURRED AFTER LNDG. OUR ERROR HAS SEVERAL FACETS. FIRST; WAS THE FACT THAT WHILE OFF FREQUENCY GIVING MY PA; I HAD NOT HEARD CENTER STATE 'DESCEND VIA THE CHINS 5...' AND THE PF DIDN'T MENTION THAT TO ME WHEN I RETURNED TO FREQUENCY. SO CREW COM WAS A FACTOR. HAD I KNOWN THAT; I MIGHT HAVE MADE A BIGGER EFFORT TO FIND ANY ALT RESTRS ON THE ARR AMONG THE MANY PRINTED. HE DID ASK ME IF I SAW ANY OTHER RESTRS BESIDES THE 12K AT AUBRN AND THAT SHOULD HAVE BEEN MY CLUE ABOUT A 'DESCEND VIA' CLRNC. THE MOST AGGRAVATING THING WAS WHEN WE BOTH FINALLY SAW THE 16K RESTR AT RADDY PRINTED AT THE FAR LOWER L SIDE OF THE ARR PAGE; UNDERNEATH NUMEROUS OTHER RESTRS. IT SEEMED SO OBVIOUS WHEN I FINALLY SAW IT; YET WE BOTH MISSED IT INITIALLY. THIS WAS IN VMC DAYLIGHT CONDITIONS WITH A LOW WORKLOAD. WE WONDERED HOW TOUGH IT WOULD BE TO NOTICE THE RESTRS AT NIGHT OR WITH A HIGH WORKLOAD. FOR ME; I LEARNED TO QUERY ABOUT DESCENTS MORE CAREFULLY WHEN THEY OCCUR WHILE I'M OFF FREQUENCY AND TO MORE CAREFULLY REVIEW ALL THE VARIOUS ALT AND SPEED RESTRS ON ARRS AND DEPS TO SEE IF THEY APPLY TO OUR SITUATION. I ALSO NEED TO BRIEF THE PNF THOROUGHLY IF I'M THE PF AND GET A CLRNC WHILE THE PNF IS OFF FREQUENCY; SO HE CAN HELP ME PREVENT THOSE KINDS OF ERRORS. FINALLY; AS A PRACTICAL SUGGESTION TO HELP REDUCE THESE INCIDENTS; WHY CAN'T SOME SORT OF COLOR CODING BE USED ON ARR/DEP PAGES TO MAKE IT EASIER TO SCAN THE PAGE AND SEE APPLICABLE RESTRS AMONG THE MYRIAD OF OTHER NAVAIDS; FIXES; ROUTING; DMES AND NOTES. I WOULD SUGGEST PUTTING ALT RESTRS IN RED AND SPEED RESTRS IN BLUE. THESE COLORS WOULD HELP DRAW THE EYE TO THEM AND MENTALLY FILTER OUT LESS IMPORTANT BLACK COLORED NUMBERS AND WORDS. THIS WOULD BE ESPECIALLY HELPFUL AT NIGHT. THERE ARE MANY PROCS IN OUR ROUTE STRUCTURE WITH THE CHINS 5 COMPLEXITY. THE MITTS 2 ARR INTO LAX IS A GOOD EXAMPLE. THE HUMAN FACTORS THAT GOES INTO PRINTING THEM IS POOR; AS EVIDENCED BY THE TWO OF US COMPLETELY MISSING THIS RESTR IN A DAY WITH A VMC LOW WORKLOAD ENVIRONMENT. ULTIMATELY; IT IS STILL OUR RESPONSIBILITY TO MAKE ALL CROSSING RESTRS AND OUR ERROR WHEN WE FAIL TO DO THAT. BUT I THINK THERE ARE A FEW MINOR CHANGES THAT COULD BE MADE TO HELP PLTS DO 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.