37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 783602 |
Time | |
Date | 200804 |
Local Time Of Day | 0001 To 0600 |
Place | |
Locale Reference | navaid : pgy.vortac |
State Reference | CA |
Altitude | msl single value : 4700 |
Environment | |
Flight Conditions | VMC |
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 Plan | IFR |
Aircraft 2 | |
Flight Phase | descent : approach |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : private pilot : instrument pilot : flight engineer pilot : commercial pilot : atp pilot : multi engine |
Experience | flight time last 90 days : 100 flight time total : 9500 flight time type : 3263 |
ASRS Report | 783602 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 17 flight time total : 5195 flight time type : 665 |
ASRS Report | 783945 |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance non adherence : published procedure non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | none taken : detected after the fact |
Supplementary | |
Problem Areas | Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
Clearance was for the baret 4 STAR and localizer runway 27 into san. ATC cleared us to cross baret at or above 5500 ft and actual crossing was at 7000 ft; no problem there. ATC also cleared us for the localizer 27 via a point on the plate called vydda; which wasn't on the STAR. This diverted my attention from the vertical to the horizontal at a critical time as we were in our descent. The baret to ifhej segment of the STAR had a minimum altitude of 5500 ft; but we began descent early for the following segment altitude after ifhej of 4000 ft about 4-5 mi early; crossing ifhej at approximately 4700 ft. Socal approach called and noted this to us that we descended early; no request for a phone call. There were no GPWS or terrain alerts; and I was monitoring terrain on the navigation display as well. Factors: fatigue as this occurred after an all-night flight sequence from ZZZ1-ZZZ2-san with a 3 hour ground time at ZZZ2. I had been flying the previous 4 days with day/night body clock changes as well. The STAR chart altitude was missed and the FMS programming skipped a point (vydda) on our routing which added more confusion with the segment/altitude requirements; thereby diverting my attention at an inopportune time. Lessons learned/corrective personal actions: use anti-fatigue strategies better so as to be as ready and alert as possible; thereby finding; trapping; and correcting errors in a timely manner. Also checking the charts and FMS more carefully so as to note and fix any discrepancies so the 'box' is correctly programmed.
Original NASA ASRS Text
Title: ACR FLT CREW MISINTERPRETED AN ALT RESTRICTION ON THE BARAT4 ARRIVAL INTO SAN. MINIMUM ALT FOR THE SEGMENT WAS VIOLATED.
Narrative: CLRNC WAS FOR THE BARET 4 STAR AND LOC RWY 27 INTO SAN. ATC CLRED US TO CROSS BARET AT OR ABOVE 5500 FT AND ACTUAL XING WAS AT 7000 FT; NO PROB THERE. ATC ALSO CLRED US FOR THE LOC 27 VIA A POINT ON THE PLATE CALLED VYDDA; WHICH WASN'T ON THE STAR. THIS DIVERTED MY ATTN FROM THE VERT TO THE HORIZ AT A CRITICAL TIME AS WE WERE IN OUR DSCNT. THE BARET TO IFHEJ SEGMENT OF THE STAR HAD A MINIMUM ALT OF 5500 FT; BUT WE BEGAN DSCNT EARLY FOR THE FOLLOWING SEGMENT ALT AFTER IFHEJ OF 4000 FT ABOUT 4-5 MI EARLY; XING IFHEJ AT APPROX 4700 FT. SOCAL APCH CALLED AND NOTED THIS TO US THAT WE DSNDED EARLY; NO REQUEST FOR A PHONE CALL. THERE WERE NO GPWS OR TERRAIN ALERTS; AND I WAS MONITORING TERRAIN ON THE NAV DISPLAY AS WELL. FACTORS: FATIGUE AS THIS OCCURRED AFTER AN ALL-NIGHT FLT SEQUENCE FROM ZZZ1-ZZZ2-SAN WITH A 3 HR GND TIME AT ZZZ2. I HAD BEEN FLYING THE PREVIOUS 4 DAYS WITH DAY/NIGHT BODY CLOCK CHANGES AS WELL. THE STAR CHART ALT WAS MISSED AND THE FMS PROGRAMMING SKIPPED A POINT (VYDDA) ON OUR ROUTING WHICH ADDED MORE CONFUSION WITH THE SEGMENT/ALT REQUIREMENTS; THEREBY DIVERTING MY ATTN AT AN INOPPORTUNE TIME. LESSONS LEARNED/CORRECTIVE PERSONAL ACTIONS: USE ANTI-FATIGUE STRATEGIES BETTER SO AS TO BE AS READY AND ALERT AS POSSIBLE; THEREBY FINDING; TRAPPING; AND CORRECTING ERRORS IN A TIMELY MANNER. ALSO CHKING THE CHARTS AND FMS MORE CAREFULLY SO AS TO NOTE AND FIX ANY DISCREPANCIES SO THE 'BOX' IS CORRECTLY PROGRAMMED.
Data retrieved from NASA's ASRS site as of May 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.