37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 755364 |
Time | |
Date | 200709 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Altitude | msl single value : 32000 |
Environment | |
Flight Conditions | VMC |
Aircraft 1 | |
Controlling Facilities | artcc : zzz.artcc |
Operator | common carrier : air carrier |
Make Model Name | B757-200 |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : intermediate altitude |
Flight Plan | IFR |
Person 1 | |
Function | flight crew : captain oversight : pic |
ASRS Report | 755364 |
Events | |
Anomaly | conflict : airborne critical |
Independent Detector | aircraft equipment : tcas |
Resolutory Action | controller : issued advisory flight crew : took evasive action flight crew : returned to assigned altitude |
Supplementary | |
Problem Areas | ATC Human Performance Aircraft Airspace Structure Company Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Event: I was given a climb to FL330 which I read back and the first officer; who was flying the airplane; acknowledged as I set FL330 into the altitude window. Passing through FL320 the TCAS alerted us to traffic. I looked at the TCAS; saw an aircraft approaching head-on at FL330 and shouted 'leveloff; leveloff.' then I said go back down to FL320 which the first officer complied with immediately. Shortly after; the ATC controller called and said to look for traffic 12 O'clock position ahead x-mi at FL330. I immediately asked the controller 'what altitude did you give us?' he responded by saying 'I gave you FL320; if you are not there maintain FL320 immediately.' I replied that we were now level at FL320. The approaching aircraft flew directly overhead at a closure rate of approximately 900 KTS. We had been within seconds of a disaster. The problem (I think): in hindsight I believe the controller gave us FL320 but I heard and read back FL330 and the first officer acknowledged FL330 and the controller did not catch my incorrect readback. Our flight plan cruise altitude was for FL370. Contributing factor: 45 mins before departure I was informed by the company that after 28 yrs flying for them my recent sick time (I am 2 yrs until retiring at age 60) was under scrutiny. With obvious potential threatening disciplinary actions. This was weighing heavily on my mind during climb out. And I know I was not completely alert to the situation and I could easily have misunderstood the controller. Also; normally if my mind was completely on flying I would have been watching the aircraft on TCAS and possibly seen the potential conflict before the TCAS alert and questioned our assigned altitude. Cas: the TCAS 'traffic' alert was what first brought this potential midair to our attention. Human factors: in my opinion stress; problems at home and work; and distrs are the #1 reason for missing or misunderstanding controller's instructions. In this particular case; there is no doubt in my mind the company's sick time harassment program targeting older capts was the primary cause of this potential disaster. Corrective actions: as much as I tried to put out of my mind the meeting just prior to this flight I could not and did not and it created a distraction with potentially catastrophic results. I know it is imperative to leave all stresses behind and be fully involved in every aspect of the flight.
Original NASA ASRS Text
Title: B757-200 CAPT FEELS THAT DISTR CAUSED BY COMPANY SICK LEAVE MONITORING WARNING RECEIVED PRIOR TO TKOF CAUSED A DISTR WHICH RESULTED IN A MISSET ALT ALERT WINDOW AND A CLOSE ENCOUNTER WITH AN OPPOSITE DIRECTION ACFT.
Narrative: EVENT: I WAS GIVEN A CLB TO FL330 WHICH I READ BACK AND THE FO; WHO WAS FLYING THE AIRPLANE; ACKNOWLEDGED AS I SET FL330 INTO THE ALT WINDOW. PASSING THROUGH FL320 THE TCAS ALERTED US TO TFC. I LOOKED AT THE TCAS; SAW AN ACFT APCHING HEAD-ON AT FL330 AND SHOUTED 'LEVELOFF; LEVELOFF.' THEN I SAID GO BACK DOWN TO FL320 WHICH THE FO COMPLIED WITH IMMEDIATELY. SHORTLY AFTER; THE ATC CTLR CALLED AND SAID TO LOOK FOR TFC 12 O'CLOCK POS AHEAD X-MI AT FL330. I IMMEDIATELY ASKED THE CTLR 'WHAT ALT DID YOU GIVE US?' HE RESPONDED BY SAYING 'I GAVE YOU FL320; IF YOU ARE NOT THERE MAINTAIN FL320 IMMEDIATELY.' I REPLIED THAT WE WERE NOW LEVEL AT FL320. THE APCHING ACFT FLEW DIRECTLY OVERHEAD AT A CLOSURE RATE OF APPROX 900 KTS. WE HAD BEEN WITHIN SECONDS OF A DISASTER. THE PROB (I THINK): IN HINDSIGHT I BELIEVE THE CTLR GAVE US FL320 BUT I HEARD AND READ BACK FL330 AND THE FO ACKNOWLEDGED FL330 AND THE CTLR DID NOT CATCH MY INCORRECT READBACK. OUR FLT PLAN CRUISE ALT WAS FOR FL370. CONTRIBUTING FACTOR: 45 MINS BEFORE DEP I WAS INFORMED BY THE COMPANY THAT AFTER 28 YRS FLYING FOR THEM MY RECENT SICK TIME (I AM 2 YRS UNTIL RETIRING AT AGE 60) WAS UNDER SCRUTINY. WITH OBVIOUS POTENTIAL THREATENING DISCIPLINARY ACTIONS. THIS WAS WEIGHING HEAVILY ON MY MIND DURING CLBOUT. AND I KNOW I WAS NOT COMPLETELY ALERT TO THE SITUATION AND I COULD EASILY HAVE MISUNDERSTOOD THE CTLR. ALSO; NORMALLY IF MY MIND WAS COMPLETELY ON FLYING I WOULD HAVE BEEN WATCHING THE ACFT ON TCAS AND POSSIBLY SEEN THE POTENTIAL CONFLICT BEFORE THE TCAS ALERT AND QUESTIONED OUR ASSIGNED ALT. CAS: THE TCAS 'TFC' ALERT WAS WHAT FIRST BROUGHT THIS POTENTIAL MIDAIR TO OUR ATTN. HUMAN FACTORS: IN MY OPINION STRESS; PROBS AT HOME AND WORK; AND DISTRS ARE THE #1 REASON FOR MISSING OR MISUNDERSTANDING CTLR'S INSTRUCTIONS. IN THIS PARTICULAR CASE; THERE IS NO DOUBT IN MY MIND THE COMPANY'S SICK TIME HARASSMENT PROGRAM TARGETING OLDER CAPTS WAS THE PRIMARY CAUSE OF THIS POTENTIAL DISASTER. CORRECTIVE ACTIONS: AS MUCH AS I TRIED TO PUT OUT OF MY MIND THE MEETING JUST PRIOR TO THIS FLT I COULD NOT AND DID NOT AND IT CREATED A DISTR WITH POTENTIALLY CATASTROPHIC RESULTS. I KNOW IT IS IMPERATIVE TO LEAVE ALL STRESSES BEHIND AND BE FULLY INVOLVED IN EVERY ASPECT OF THE FLT.
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.