37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 788451 |
Time | |
Date | 200805 |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : bwi.airport |
State Reference | MD |
Altitude | msl single value : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | tracon : pct.tracon |
Operator | common carrier : air carrier |
Make Model Name | B737-300 |
Operating Under FAR Part | Part 121 |
Navigation In Use | other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : terpz rnav. |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Experience | flight time last 90 days : 228 flight time type : 2800 |
ASRS Report | 788451 |
Events | |
Anomaly | non adherence : published procedure non adherence : clearance other anomaly |
Independent Detector | other flight crewa |
Resolutory Action | controller : issued new clearance |
Supplementary | |
Problem Areas | Chart Or Publication Flight Crew Human Performance |
Primary Problem | Flight Crew Human Performance |
Narrative:
This may be one of the oddest mistakes I've made. While doing my before start flows; I always use the MCP setup as a physical checklist to ensure SID compliance. I read the SID then (left to right on the MCP) I rechk it for speed restrs; headings; altitudes; and course. This night we were assigned the terpz departure. I read this procedure twice since it was new to me and took note of the crossing restr (can't remember the fix name) at or above 11000 ft. Took off runway 15R and were almost immediately turned direct terpz. Rolled out on the heading and lowered the nose to accelerate from 210 KTS to 250 KTS. I remembered the note on the commercial chart saying not to accelerate until out of 12000 ft for west departures; but I figured since we now had an RNAV departure and were not going down to J149 off of aml; this didn't really apply anymore. Nonetheless; I accelerated very gradually out of 10000 ft. Boy; am I glad I did! The departure controller handed us off and said; 'cancel the speed restr.' I told the captain; 'I don't know what he is talking about.' I looked at the plate and still didn't see the restr. The captain said; 'I meant to remind you about that but I forgot.' I pulled the plate off the clipboard and finally saw it. The note on top about speed 250 KTS until terpz. The reason I didn't see it is the whole time since I had pulled the plate out of the binder; I had it on the yoke clipboard. This is where it was when I reviewed it. The overhead light is almost directly above the yoke and the actual clip casts a shadow about 1/2 inch long with that light on. My chart was on the clipboard in such a way that the note was in the shadow and so I couldn't see it. I would have never thought this was a possibility. Now I do. It should be noted that the handoff from departure was very near terpz and I had truly only accelerated minimally. I doubt the controller canceled the speed restr in a 'wink; wink' kind of way because I had not accelerated much at all. Rest of flight was uneventful. Secondly; and the real reason I am submitting this report; is the lack of standardization among commercial charts for both departures and arrs. On departures alone; along with the terpz referenced here; I can think of gorman out of lax where the speed restr is in 2 places on the plate and the staav out of las where the restrs are located along the departure track at the fixes where they apply. As we move towards more automation and increasingly tighter controling; I think it would make sense for chart maker to standardize the format. If I had known that the speeds would definitely be noted at the top if there were any; I would have pulled the plate off the clipboard to look. Instead; I looked along the track (assuming it would be like the staav) and saw nothing. Luckily we were the only aircraft out there and there was no conflict. In the future; this may not be the case.
Original NASA ASRS Text
Title: AN ACR PILOT MISSED THE 250 KT BWI TERPZ ONE SPD RESTRICTION BECAUSE THE SPD CONSTRAINT IS UNDER THE YOKE CLIPBOARD AND PRINTED ONLY ONCE ON THE CHART.
Narrative: THIS MAY BE ONE OF THE ODDEST MISTAKES I'VE MADE. WHILE DOING MY BEFORE START FLOWS; I ALWAYS USE THE MCP SETUP AS A PHYSICAL CHKLIST TO ENSURE SID COMPLIANCE. I READ THE SID THEN (L TO R ON THE MCP) I RECHK IT FOR SPD RESTRS; HDGS; ALTS; AND COURSE. THIS NIGHT WE WERE ASSIGNED THE TERPZ DEP. I READ THIS PROC TWICE SINCE IT WAS NEW TO ME AND TOOK NOTE OF THE XING RESTR (CAN'T REMEMBER THE FIX NAME) AT OR ABOVE 11000 FT. TOOK OFF RWY 15R AND WERE ALMOST IMMEDIATELY TURNED DIRECT TERPZ. ROLLED OUT ON THE HDG AND LOWERED THE NOSE TO ACCELERATE FROM 210 KTS TO 250 KTS. I REMEMBERED THE NOTE ON THE COMMERCIAL CHART SAYING NOT TO ACCELERATE UNTIL OUT OF 12000 FT FOR W DEPS; BUT I FIGURED SINCE WE NOW HAD AN RNAV DEP AND WERE NOT GOING DOWN TO J149 OFF OF AML; THIS DIDN'T REALLY APPLY ANYMORE. NONETHELESS; I ACCELERATED VERY GRADUALLY OUT OF 10000 FT. BOY; AM I GLAD I DID! THE DEP CTLR HANDED US OFF AND SAID; 'CANCEL THE SPD RESTR.' I TOLD THE CAPT; 'I DON'T KNOW WHAT HE IS TALKING ABOUT.' I LOOKED AT THE PLATE AND STILL DIDN'T SEE THE RESTR. THE CAPT SAID; 'I MEANT TO REMIND YOU ABOUT THAT BUT I FORGOT.' I PULLED THE PLATE OFF THE CLIPBOARD AND FINALLY SAW IT. THE NOTE ON TOP ABOUT SPD 250 KTS UNTIL TERPZ. THE REASON I DIDN'T SEE IT IS THE WHOLE TIME SINCE I HAD PULLED THE PLATE OUT OF THE BINDER; I HAD IT ON THE YOKE CLIPBOARD. THIS IS WHERE IT WAS WHEN I REVIEWED IT. THE OVERHEAD LIGHT IS ALMOST DIRECTLY ABOVE THE YOKE AND THE ACTUAL CLIP CASTS A SHADOW ABOUT 1/2 INCH LONG WITH THAT LIGHT ON. MY CHART WAS ON THE CLIPBOARD IN SUCH A WAY THAT THE NOTE WAS IN THE SHADOW AND SO I COULDN'T SEE IT. I WOULD HAVE NEVER THOUGHT THIS WAS A POSSIBILITY. NOW I DO. IT SHOULD BE NOTED THAT THE HDOF FROM DEP WAS VERY NEAR TERPZ AND I HAD TRULY ONLY ACCELERATED MINIMALLY. I DOUBT THE CTLR CANCELED THE SPD RESTR IN A 'WINK; WINK' KIND OF WAY BECAUSE I HAD NOT ACCELERATED MUCH AT ALL. REST OF FLT WAS UNEVENTFUL. SECONDLY; AND THE REAL REASON I AM SUBMITTING THIS RPT; IS THE LACK OF STANDARDIZATION AMONG COMMERCIAL CHARTS FOR BOTH DEPS AND ARRS. ON DEPS ALONE; ALONG WITH THE TERPZ REFED HERE; I CAN THINK OF GORMAN OUT OF LAX WHERE THE SPD RESTR IS IN 2 PLACES ON THE PLATE AND THE STAAV OUT OF LAS WHERE THE RESTRS ARE LOCATED ALONG THE DEP TRACK AT THE FIXES WHERE THEY APPLY. AS WE MOVE TOWARDS MORE AUTOMATION AND INCREASINGLY TIGHTER CTLING; I THINK IT WOULD MAKE SENSE FOR CHART MAKER TO STANDARDIZE THE FORMAT. IF I HAD KNOWN THAT THE SPDS WOULD DEFINITELY BE NOTED AT THE TOP IF THERE WERE ANY; I WOULD HAVE PULLED THE PLATE OFF THE CLIPBOARD TO LOOK. INSTEAD; I LOOKED ALONG THE TRACK (ASSUMING IT WOULD BE LIKE THE STAAV) AND SAW NOTHING. LUCKILY WE WERE THE ONLY ACFT OUT THERE AND THERE WAS NO CONFLICT. IN THE FUTURE; THIS MAY NOT BE THE CASE.
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.