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Widebody transport aircraft. 2 man flight crew. Overshot sjc VOR crossing altitude on loupe departure.
| Attributes | |
| ACN | 194129 |
| Time | |
| Date | 199111 |
| Day | Mon |
| Local Time Of Day | 1201 To 1800 |
| Place | |
| Locale Reference | airport : sjc |
| State Reference | CA |
| Altitude | msl bound lower : 12000 msl bound upper : 15000 |
| Environment | |
| Flight Conditions | VMC |
| Light | Daylight |
| Aircraft 1 | |
| Controlling Facilities | tower : aty |
| Operator | common carrier : air carrier |
| Make Model Name | Widebody, Low Wing, 3 Turbojet Eng |
| Navigation In Use | Other Other |
| Flight Phase | climbout : intermediate altitude |
| Route In Use | departure other departure sid : sid enroute airway : zoa |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : captain oversight : pic |
| Qualification | pilot : instrument pilot : atp pilot : commercial pilot : flight engineer |
| Experience | flight time last 90 days : 68 flight time total : 12000 flight time type : 68 |
| ASRS Report | 194129 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : first officer |
| Qualification | pilot : instrument pilot : commercial pilot : atp |
| Events | |
| Anomaly | aircraft equipment problem : less severe altitude deviation : crossing restriction not met altitude deviation : overshoot non adherence : clearance non adherence : published procedure |
| Independent Detector | other controllera other flight crewa |
| Resolutory Action | controller : issued new clearance none taken : detected after the fact other |
| Consequence | Other |
| Supplementary | |
| Primary Problem | Flight Crew Human Performance |
| Air Traffic Incident | Pilot Deviation |
Narrative:
Inexperienced crew (new to aircraft, low time, very low time with 2 person crew). Myriad aircraft writeups and placards and problems unusual SID. Executing SID (loupe 8) heading 120 degrees, climbing, cleared to turn right, cross sjc VOR at 12000 ft then climb to FL230. Copilot flying, did not hear clearance, I repeated it to him, he began right turn to sjc VOR. At this point flight attendant called that rear lavatory was spewing blue waste water on floor and flooding. I was distracted from supervising first officer. Departure control called and reiterated clearance as we were climbing out of 15000. They coordinated with oak center and we were cleared unrestricted to FL230. Factor: first officer prior experience is on large transport, and he was hand flying, did not fully utilize automatic features. Factor: altitude was set at 23000 ft so no alert was sounded passing 12000. Factor: new equipment widebody transport full of discrepancies, malfunctions, none major, but cumulative effect was distraction at critical time. Factor: little or no experience. First officer on first line trip with 2 person crew. Both had very low time, spread out over months. Factor: not trained to simply ignore situations that involve areas where we had had no schooling or other expertise.
Original NASA ASRS Text
Title: WDB ACFT. 2 MAN FLC. OVERSHOT SJC VOR XING ALT ON LOUPE DEP.
Narrative: INEXPERIENCED CREW (NEW TO ACFT, LOW TIME, VERY LOW TIME WITH 2 PERSON CREW). MYRIAD ACFT WRITEUPS AND PLACARDS AND PROBLEMS UNUSUAL SID. EXECUTING SID (LOUPE 8) HDG 120 DEGS, CLBING, CLRED TO TURN R, CROSS SJC VOR AT 12000 FT THEN CLB TO FL230. COPLT FLYING, DID NOT HEAR CLRNC, I REPEATED IT TO HIM, HE BEGAN R TURN TO SJC VOR. AT THIS POINT FLT ATTENDANT CALLED THAT REAR LAVATORY WAS SPEWING BLUE WASTE WATER ON FLOOR AND FLOODING. I WAS DISTRACTED FROM SUPERVISING FO. DEP CTL CALLED AND REITERATED CLRNC AS WE WERE CLBING OUT OF 15000. THEY COORDINATED WITH OAK CENTER AND WE WERE CLRED UNRESTRICTED TO FL230. FACTOR: FO PRIOR EXPERIENCE IS ON LGT, AND HE WAS HAND FLYING, DID NOT FULLY UTILIZE AUTOMATIC FEATURES. FACTOR: ALT WAS SET AT 23000 FT SO NO ALERT WAS SOUNDED PASSING 12000. FACTOR: NEW EQUIP WDB FULL OF DISCREPANCIES, MALFUNCTIONS, NONE MAJOR, BUT CUMULATIVE EFFECT WAS DISTR AT CRITICAL TIME. FACTOR: LITTLE OR NO EXPERIENCE. FO ON FIRST LINE TRIP WITH 2 PERSON CREW. BOTH HAD VERY LOW TIME, SPREAD OUT OVER MONTHS. FACTOR: NOT TRAINED TO SIMPLY IGNORE SITUATIONS THAT INVOLVE AREAS WHERE WE HAD HAD NO SCHOOLING OR OTHER EXPERTISE.
Data retrieved from NASA's ASRS site as of July 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.