37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 86152 |
Time | |
Date | 198804 |
Day | Sat |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sjc |
State Reference | CA |
Altitude | msl bound lower : 5000 msl bound upper : 6000 |
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 |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : flight engineer pilot : cfi pilot : atp |
Experience | flight time last 90 days : 160 flight time total : 7250 flight time type : 2000 |
ASRS Report | 86152 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 160 flight time total : 27000 flight time type : 1500 |
ASRS Report | 86195 |
Events | |
Anomaly | altitude deviation : crossing restriction not met non adherence : clearance non adherence : published procedure |
Independent Detector | other controllera |
Resolutory Action | none taken : insufficient time other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were operating a medium large transport long range aircraft. The departure clearance was the san jose four departure, avenal transition. Climb and maintain FL230. Except FL330 ten minutes after departure. Etc etc. Prior to departure we reviewed the SID. The captain was flying the aircraft. After takeoff upon reaching the 2.5 NM arc of sjc VOR and above 2000'. We initiated a right turn to the 120 degree heading required and continued climb. The next restriction is to cross the 005 degree radial of sjc VOR at or below 5000'. I had selected the fix page of the flight management computer and entered sjc VOR so that a continuous bearing and distance to the VOR could be observed at all times during the departure to meet this next restriction. While concentrating on keeping the turn within 4 NM of departure, we were also scanning for traffic and completing the after takeoff checklist. About that same time departure control asked us our altitude. We were passing 6000' and climbing fast due to a low gross weight. We were still not past the 005 degree radial of sjc VOR. Departure asked us if we were aware of the 5000' or below restriction. Looking down at the SID we realized that we mistakenly and unintentionally misread the 5000' restriction at the sjc 005 degree radial to be at or above instead of at or below. Immediately we began a descent back down to 5000' but passed the 005 degree radial before we could get down to it. We then continued climb. Contributing to the mistake I think was the fact that we set the departure clearance altitude of FL230 in the altitude alert window which helped set the stage for us to misread the 5000' restriction as above instead of below, and also fly through 5000' since we wouldn't receive an altitude alert until 1000' below our set FL230. Also contributing was the after takeoff high workload phase of flight in which oversights are more probable. A low gross weight/high climb rate also contributed because it just accelerated the speed at which the events occurred. One thing I will do from now on is to set the at or below restriction of a SID in the altitude alert window even if departure clearance altitude. Is higher. This way you will at least get an altitude warning before your restriction and be less likely to miss it once you are in the air and the workload is higher.
Original NASA ASRS Text
Title: FAILED TO COMPLY WITH THE ALT CROSSING RESTRICTION.
Narrative: WE WERE OPERATING A MLG LONG RANGE ACFT. THE DEP CLRNC WAS THE SAN JOSE FOUR DEP, AVENAL TRANSITION. CLIMB AND MAINTAIN FL230. EXCEPT FL330 TEN MINUTES AFTER DEP. ETC ETC. PRIOR TO DEP WE REVIEWED THE SID. THE CAPT WAS FLYING THE ACFT. AFTER TKOF UPON REACHING THE 2.5 NM ARC OF SJC VOR AND ABOVE 2000'. WE INITIATED A RIGHT TURN TO THE 120 DEG HEADING REQUIRED AND CONTINUED CLIMB. THE NEXT RESTRICTION IS TO CROSS THE 005 DEG RADIAL OF SJC VOR AT OR BELOW 5000'. I HAD SELECTED THE FIX PAGE OF THE FLT MGMNT COMPUTER AND ENTERED SJC VOR SO THAT A CONTINUOUS BEARING AND DISTANCE TO THE VOR COULD BE OBSERVED AT ALL TIMES DURING THE DEP TO MEET THIS NEXT RESTRICTION. WHILE CONCENTRATING ON KEEPING THE TURN WITHIN 4 NM OF DEP, WE WERE ALSO SCANNING FOR TFC AND COMPLETING THE AFTER TKOF CHECKLIST. ABOUT THAT SAME TIME DEP CTL ASKED US OUR ALT. WE WERE PASSING 6000' AND CLIMBING FAST DUE TO A LOW GROSS WEIGHT. WE WERE STILL NOT PAST THE 005 DEG RADIAL OF SJC VOR. DEP ASKED US IF WE WERE AWARE OF THE 5000' OR BELOW RESTRICTION. LOOKING DOWN AT THE SID WE REALIZED THAT WE MISTAKENLY AND UNINTENTIONALLY MISREAD THE 5000' RESTRICTION AT THE SJC 005 DEG RADIAL TO BE AT OR ABOVE INSTEAD OF AT OR BELOW. IMMEDIATELY WE BEGAN A DESCENT BACK DOWN TO 5000' BUT PASSED THE 005 DEG RADIAL BEFORE WE COULD GET DOWN TO IT. WE THEN CONTINUED CLIMB. CONTRIBUTING TO THE MISTAKE I THINK WAS THE FACT THAT WE SET THE DEP CLRNC ALT OF FL230 IN THE ALT ALERT WINDOW WHICH HELPED SET THE STAGE FOR US TO MISREAD THE 5000' RESTRICTION AS ABOVE INSTEAD OF BELOW, AND ALSO FLY THROUGH 5000' SINCE WE WOULDN'T RECEIVE AN ALT ALERT UNTIL 1000' BELOW OUR SET FL230. ALSO CONTRIBUTING WAS THE AFTER TKOF HIGH WORKLOAD PHASE OF FLT IN WHICH OVERSIGHTS ARE MORE PROBABLE. A LOW GROSS WEIGHT/HIGH CLIMB RATE ALSO CONTRIBUTED BECAUSE IT JUST ACCELERATED THE SPEED AT WHICH THE EVENTS OCCURRED. ONE THING I WILL DO FROM NOW ON IS TO SET THE AT OR BELOW RESTRICTION OF A SID IN THE ALT ALERT WINDOW EVEN IF DEP CLRNC ALT. IS HIGHER. THIS WAY YOU WILL AT LEAST GET AN ALT WARNING BEFORE YOUR RESTRICTION AND BE LESS LIKELY TO MISS IT ONCE YOU ARE IN THE AIR AND THE WORKLOAD IS HIGHER.
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.