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|
Attributes | |
ACN | 86151 |
Time | |
Date | 198804 |
Day | Sat |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sjc |
State Reference | CA |
Altitude | msl bound lower : 5000 msl bound upper : 6800 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : oak |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude |
Route In Use | departure sid : sid |
Flight Plan | IFR |
Aircraft 2 | |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 190 flight time total : 9000 flight time type : 2100 |
ASRS Report | 86151 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 130 flight time total : 4650 flight time type : 170 |
ASRS Report | 86426 |
Events | |
Anomaly | altitude deviation : crossing restriction not met conflict : airborne less severe non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | other |
Consequence | faa : reviewed incident with flight crew |
Miss Distance | horizontal : 9000 vertical : 200 |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
Several mistakes came together at one time and as a result a serious altitude incursion resulted. We were departing sjc on a sjc four departure with a clearance to climb to FL230. The sjc 4 has 2 altitude restrictions, the first is a minimum altitude at 2000' MSL before reaching 2 pt 5 DME off sjc for noise and then a maximum of 5000' until crossing the sjc 005 radial eastbound. Today we were flying a medium large transport with higher thrust engines. It was the first officer's leg but it was his first in the series of the medium large transport we briefed the departure in the gate including the altitude restrictions and importance of scanning for traffic, I stated that I would call passage of the 005 radial on my RMI and I set FL230 in the altitude alerter. Departure was normal except that the aircraft was light and climbing in excess of 4000' per min at 210 KTS. As I contacted bay departure climbing to 230 with restrictions we started the turn from 300 degree to 120 degree as stated on the departure, we had no trouble making the 2000' restriction and we were passing 2600' at the start of the turn. First call back from bay was to check transponder code (the x-ponder is located at the rear of the lower center pedestal and its operational switches have no mechanical lock and approach are often knocked out of the on position). I checked the x-ponder was on and so stated, returned my scan to the outside for traffic. Bay called again and had us check for proper code, I again looked back and noticed the second digit was off, it was set at 3 instead of 2. I changed the code and as I returned my scan forward I noticed the aircraft was out of 6000' and climbing at 4500' per min. As bay called to verify our knowledge of the 5000' restriction I began to level aircraft and climb stopped at 6800'. Bay then called IFR traffic which I later learned was within 200' and 1 1/2 min. There were several contributing factors which put together caused this unfortunate incursion, first in my mind was the location of the transponder and my past experience with the power switches, secondly was the inexperience of the first officer with the aircraft and the combination of a light load and cool air produced a very high performance climb profile. Also because of the combination of the previous two I was unaware of the presence of other IFR traffic until we had already busted the altitude, of course our rate of climb was probably exceeding the capacity of the ATC computer to give the controller an accurate update of our altitude. Finally this is an extremely busy departure calling for high performance initial climb, a 180 degree climbing turn, early leveloff all the while scanning for traffic in a very busy VFR area. As pilot in command the operation of the aircraft is of course my responsibility at all times. This incursion has changed the way I will fly and manage my cockpit. With first officer lack of experience with both aircraft and departure procedure the least I should have done is set the alerter for 5000'. With difficult departures I usually fly the first one so the first officer can see the restrictions, however we busted the altitude so fast I never realized what a difficult departure it was with the performance of the aircraft this day. Lastly I am lucky enough to fly some of the latest and best equipment in the sky, but more and more the location of some of the most important radio's in the aircraft are down on the pedestal, taking the non-flying pilot completely out of the forward scan to tune a radio or select a radio or select a new mode on the flight management system while still in the lower and busier altitudes. We were fortunate not to have caused a major catastrophe through the series of actions that led to the altitude bust, lessons learned will make me a safer and more aware pilot and perhaps help in formulating procedures to reduce the risk of this happening again. Supplemental information from acn #86426: one last point I feel a lot of the south californian departures are difficult and with the high VFR traffic detrimental to flight safety.
Original NASA ASRS Text
Title: GROSS ALTITUDE EXCURSION RESULT OF FLT CREW EXPERIENCE, ACFT PERFORMANCE AND COCKPIT MANAGEMENT.
Narrative: SEVERAL MISTAKES CAME TOGETHER AT ONE TIME AND AS A RESULT A SERIOUS ALT INCURSION RESULTED. WE WERE DEPARTING SJC ON A SJC FOUR DEP WITH A CLRNC TO CLIMB TO FL230. THE SJC 4 HAS 2 ALT RESTRICTIONS, THE FIRST IS A MINIMUM ALT AT 2000' MSL BEFORE REACHING 2 PT 5 DME OFF SJC FOR NOISE AND THEN A MAX OF 5000' UNTIL XING THE SJC 005 RADIAL EBOUND. TODAY WE WERE FLYING A MLG WITH HIGHER THRUST ENGINES. IT WAS THE F/O'S LEG BUT IT WAS HIS FIRST IN THE SERIES OF THE MLG WE BRIEFED THE DEP IN THE GATE INCLUDING THE ALT RESTRICTIONS AND IMPORTANCE OF SCANNING FOR TFC, I STATED THAT I WOULD CALL PASSAGE OF THE 005 RADIAL ON MY RMI AND I SET FL230 IN THE ALT ALERTER. DEP WAS NORMAL EXCEPT THAT THE ACFT WAS LIGHT AND CLIMBING IN EXCESS OF 4000' PER MIN AT 210 KTS. AS I CONTACTED BAY DEP CLIMBING TO 230 WITH RESTRICTIONS WE STARTED THE TURN FROM 300 DEG TO 120 DEG AS STATED ON THE DEP, WE HAD NO TROUBLE MAKING THE 2000' RESTRICTION AND WE WERE PASSING 2600' AT THE START OF THE TURN. FIRST CALL BACK FROM BAY WAS TO CHECK TRANSPONDER CODE (THE X-PONDER IS LOCATED AT THE REAR OF THE LOWER CENTER PEDESTAL AND ITS OPERATIONAL SWITCHES HAVE NO MECHANICAL LOCK AND APCH ARE OFTEN KNOCKED OUT OF THE ON POSITION). I CHECKED THE X-PONDER WAS ON AND SO STATED, RETURNED MY SCAN TO THE OUTSIDE FOR TFC. BAY CALLED AGAIN AND HAD US CHECK FOR PROPER CODE, I AGAIN LOOKED BACK AND NOTICED THE SECOND DIGIT WAS OFF, IT WAS SET AT 3 INSTEAD OF 2. I CHANGED THE CODE AND AS I RETURNED MY SCAN FORWARD I NOTICED THE ACFT WAS OUT OF 6000' AND CLIMBING AT 4500' PER MIN. AS BAY CALLED TO VERIFY OUR KNOWLEDGE OF THE 5000' RESTRICTION I BEGAN TO LEVEL ACFT AND CLIMB STOPPED AT 6800'. BAY THEN CALLED IFR TFC WHICH I LATER LEARNED WAS WITHIN 200' AND 1 1/2 MIN. THERE WERE SEVERAL CONTRIBUTING FACTORS WHICH PUT TOGETHER CAUSED THIS UNFORTUNATE INCURSION, FIRST IN MY MIND WAS THE LOCATION OF THE TRANSPONDER AND MY PAST EXPERIENCE WITH THE POWER SWITCHES, SECONDLY WAS THE INEXPERIENCE OF THE F/O WITH THE ACFT AND THE COMBINATION OF A LIGHT LOAD AND COOL AIR PRODUCED A VERY HIGH PERFORMANCE CLIMB PROFILE. ALSO BECAUSE OF THE COMBINATION OF THE PREVIOUS TWO I WAS UNAWARE OF THE PRESENCE OF OTHER IFR TFC UNTIL WE HAD ALREADY BUSTED THE ALT, OF COURSE OUR RATE OF CLIMB WAS PROBABLY EXCEEDING THE CAPACITY OF THE ATC COMPUTER TO GIVE THE CTLR AN ACCURATE UPDATE OF OUR ALT. FINALLY THIS IS AN EXTREMELY BUSY DEP CALLING FOR HIGH PERFORMANCE INITIAL CLIMB, A 180 DEG CLIMBING TURN, EARLY LEVELOFF ALL THE WHILE SCANNING FOR TFC IN A VERY BUSY VFR AREA. AS PLT IN COMMAND THE OPERATION OF THE ACFT IS OF COURSE MY RESPONSIBILITY AT ALL TIMES. THIS INCURSION HAS CHANGED THE WAY I WILL FLY AND MANAGE MY COCKPIT. WITH F/O LACK OF EXPERIENCE WITH BOTH ACFT AND DEP PROCEDURE THE LEAST I SHOULD HAVE DONE IS SET THE ALERTER FOR 5000'. WITH DIFFICULT DEPS I USUALLY FLY THE FIRST ONE SO THE F/O CAN SEE THE RESTRICTIONS, HOWEVER WE BUSTED THE ALT SO FAST I NEVER REALIZED WHAT A DIFFICULT DEP IT WAS WITH THE PERFORMANCE OF THE ACFT THIS DAY. LASTLY I AM LUCKY ENOUGH TO FLY SOME OF THE LATEST AND BEST EQUIPMENT IN THE SKY, BUT MORE AND MORE THE LOCATION OF SOME OF THE MOST IMPORTANT RADIO'S IN THE ACFT ARE DOWN ON THE PEDESTAL, TAKING THE NON-FLYING PLT COMPLETELY OUT OF THE FORWARD SCAN TO TUNE A RADIO OR SELECT A RADIO OR SELECT A NEW MODE ON THE FLT MGMNT SYSTEM WHILE STILL IN THE LOWER AND BUSIER ALTS. WE WERE FORTUNATE NOT TO HAVE CAUSED A MAJOR CATASTROPHE THROUGH THE SERIES OF ACTIONS THAT LED TO THE ALT BUST, LESSONS LEARNED WILL MAKE ME A SAFER AND MORE AWARE PLT AND PERHAPS HELP IN FORMULATING PROCEDURES TO REDUCE THE RISK OF THIS HAPPENING AGAIN. SUPPLEMENTAL INFORMATION FROM ACN #86426: ONE LAST POINT I FEEL A LOT OF THE S CALIFORNIAN DEPS ARE DIFFICULT AND WITH THE HIGH VFR TFC DETRIMENTAL TO FLT SAFETY.
Data retrieved from NASA's ASRS site as of August 2007 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.