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Air carrier large transport altitude deviation overshot during profile descent into czyz, on. States chart depiction problem which has since been resolved.
| Attributes | |
| ACN | 108804 |
| Time | |
| Date | 198904 |
| Day | Thu |
| Local Time Of Day | 1801 To 2400 |
| Place | |
| Locale Reference | airport : czyz |
| State Reference | ON |
| Altitude | msl bound lower : 10000 msl bound upper : 11000 |
| Environment | |
| Flight Conditions | Marginal |
| Light | Night |
| Aircraft 1 | |
| Controlling Facilities | tracon : czyz |
| Operator | common carrier : air carrier |
| Make Model Name | Large Transport, Low Wing, 3 Turbojet Eng |
| Flight Phase | descent other |
| Route In Use | arrival : profile descent |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : instrument pilot : commercial pilot : atp |
| Experience | flight time last 90 days : 210 flight time total : 8000 flight time type : 230 |
| ASRS Report | 108804 |
| Events | |
| Anomaly | altitude deviation : overshoot non adherence : published procedure non adherence : clearance |
| Independent Detector | other controllera |
| Resolutory Action | none taken : anomaly accepted |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
First day of new profile descent to runway 24 at brany intersection toronto. All crew members reviewed and agreed on altitudes at DME fixes. All were wrong. Should have been at 11,000' at 38 DME not 10,000'. Previous aircraft busted same altitude restriction, as told to us by ATC. 10,000' was for 38 DME northwest. All caused by poor depiction on plate. Quadrants not marked in bolder lines.
Original NASA ASRS Text
Title: ACR LGT ALT DEVIATION OVERSHOT DURING PROFILE DESCENT INTO CZYZ, ON. STATES CHART DEPICTION PROBLEM WHICH HAS SINCE BEEN RESOLVED.
Narrative: FIRST DAY OF NEW PROFILE DSCNT TO RWY 24 AT BRANY INTXN TORONTO. ALL CREW MEMBERS REVIEWED AND AGREED ON ALTS AT DME FIXES. ALL WERE WRONG. SHOULD HAVE BEEN AT 11,000' AT 38 DME NOT 10,000'. PREVIOUS ACFT BUSTED SAME ALT RESTRICTION, AS TOLD TO US BY ATC. 10,000' WAS FOR 38 DME NW. ALL CAUSED BY POOR DEPICTION ON PLATE. QUADRANTS NOT MARKED IN BOLDER LINES.
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.