Narrative:

En route to sfo from pdx, unforecasted WX closed the acceptance rate at the airport. 80 mi northwest of pye, ZOA advised us that delay vectors could be anticipated. We received clearance to descend from FL330 and then vectored off the airway. In anticipation of delays, we requested and received slower speeds while descending away from the direction of our destination. Numerous heading and step down altitudes were received during our descent, and the final clearance was for 11000 ft. About 20 northwest of pye, while still descending at 1000 FPM and on vectors, we received clearance to proceed to pye and hold northwest on the 320 degree radial, right turns, maintain 13000 ft, efc XA50Z. I copied the clearance on the flight plan margin while the first officer programmed the FMC to fly direct to the VOR and while doing so he also inserted the 'hold' clearance. With that efc I became concerned about our fuel status and we both reviewed our alternative plan of proceeding to oak. With this preoccupation, plus verifying the FMC depicted hold, an upcoming 50 mi report and relaying the efc time via ACARS, I completely forgot to reset the altitude alert to 13000 ft, as the new clearance canceled the previous 11000 ft clearance. Even though the FMC was programmed correctly, we had been descending with the vertical speed mode at 1000 FPM due to previous vectors. Consequently the autoplt continued through the programmed altitude. We received a TCASII warning and visually sighted an aircraft idented as a 747 at our 12:15 position. Simultaneously oak queried us about our altitude clearance and if we had the 747 in sight. We responded in the affirmative and started a climbing turn eastbound in response to a TCASII climb command and ZOA heading command. Visual identify of our traffic occurred at about 4 NM and was confirmed by TCASII. Oak informed us that our altitude clearance was revised to 13000 ft and during the preceding hectic mins I had forgotten to change the altitude alerter. I estimated our lateral distance from the 747 about 1 mi and vertical separation of 200 ft when we initiated corrective action at 12200 ft. The chain of events leading to this occurrence included numerous heading changes and airspeed changes, all while cleared to 11000 ft. Concern over not making our arrival time, and that I had numerous international connecting passenger, who would miss their flts, should the need arise for going to the alternate, all became part of the equation at the moment I should have reset the altitude alerter. Allowing my attention to divert to double-checking the FMC pattern, fuel concerns and keeping a lookout for traffic in the VMC environment close to the VOR contributed to my oversight. I would recommend that when a controller issues a hold clearance, and especially one in which the cleared altitude is higher than was previously issued, that he first amend the altitude. In this way he is actually issuing 2 clrncs, the most important clearance being the amended altitude. Once that information is passed on and inserted by the pilot, the hold clearance can be issued as a separate part. In my case, the tasks assigned by the clearance was fly to pye, enter a hold with right turns and inbound on the 320 degree radial. Maintain 13000 ft and expect further clearance at XA50. Maintaining 13000 ft was the most important part of that clearance, yet it came third in task accomplishment. As pilots we generally comply with directives in the order given. In the future, I will make it a point to change the altitude alert before anything else is accomplished in the hold clearance sequence. Supplemental information from acn 268658: the trip identify is the most complained about in the domicile. Alpa has complained for 2 months that this is an unsafe trip. The first day is a XX50 report, fly all night, arrive ord at XC15, followed by an XX00 hotel departure that night and fly to the east coast, arriving at XY10. Then a minimum rest layover to fly all day to the west coast (a 3 hour time change), followed by a XA45 wakeup and XB30 departure from the hotel and arrive that night at home at XC00. By the last day both my captain and I were physically and mentally tired and had commented so. To have all night flts followed by early departures and minimum rest periods does not allow yourbody clock to adjust. The captain wrote down the clearance and read back the correct clearance, however he forgot to put the new altitude in the MCP window. I, however, did not hear the altitude clearance and therefore was not looking for it. I asked the captain if the holding page looked good, he said yes, and I executed the program. Within seconds we received a warning light that we were using reserve fuel. Fatigue: both the captain and I were tired. The tendency to lose your concentration is high. As pilots, prioritize the instructions received, be on the alert for heading and altitude changes. Set these first, then take care of the rest. The controller issued 6 instructions with no emphasis on the amended altitude. If the controller had prioritized his commands and said amend altitude to 13000 ft, stop your descent at 13000 ft, this incident may have been prevented.

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Original NASA ASRS Text

Title: POTENTIAL CONFLICT BTWN 2 ACR ACFT IN A HOLDING PATTERN. EVASIVE ACTION CLB TURN.

Narrative: ENRTE TO SFO FROM PDX, UNFORECASTED WX CLOSED THE ACCEPTANCE RATE AT THE ARPT. 80 MI NW OF PYE, ZOA ADVISED US THAT DELAY VECTORS COULD BE ANTICIPATED. WE RECEIVED CLRNC TO DSND FROM FL330 AND THEN VECTORED OFF THE AIRWAY. IN ANTICIPATION OF DELAYS, WE REQUESTED AND RECEIVED SLOWER SPDS WHILE DSNDING AWAY FROM THE DIRECTION OF OUR DEST. NUMEROUS HDG AND STEP DOWN ALTS WERE RECEIVED DURING OUR DSCNT, AND THE FINAL CLRNC WAS FOR 11000 FT. ABOUT 20 NW OF PYE, WHILE STILL DSNDING AT 1000 FPM AND ON VECTORS, WE RECEIVED CLRNC TO PROCEED TO PYE AND HOLD NW ON THE 320 DEG RADIAL, R TURNS, MAINTAIN 13000 FT, EFC XA50Z. I COPIED THE CLRNC ON THE FLT PLAN MARGIN WHILE THE FO PROGRAMMED THE FMC TO FLY DIRECT TO THE VOR AND WHILE DOING SO HE ALSO INSERTED THE 'HOLD' CLRNC. WITH THAT EFC I BECAME CONCERNED ABOUT OUR FUEL STATUS AND WE BOTH REVIEWED OUR ALTERNATIVE PLAN OF PROCEEDING TO OAK. WITH THIS PREOCCUPATION, PLUS VERIFYING THE FMC DEPICTED HOLD, AN UPCOMING 50 MI RPT AND RELAYING THE EFC TIME VIA ACARS, I COMPLETELY FORGOT TO RESET THE ALT ALERT TO 13000 FT, AS THE NEW CLRNC CANCELED THE PREVIOUS 11000 FT CLRNC. EVEN THOUGH THE FMC WAS PROGRAMMED CORRECTLY, WE HAD BEEN DSNDING WITH THE VERT SPD MODE AT 1000 FPM DUE TO PREVIOUS VECTORS. CONSEQUENTLY THE AUTOPLT CONTINUED THROUGH THE PROGRAMMED ALT. WE RECEIVED A TCASII WARNING AND VISUALLY SIGHTED AN ACFT IDENTED AS A 747 AT OUR 12:15 POS. SIMULTANEOUSLY OAK QUERIED US ABOUT OUR ALT CLRNC AND IF WE HAD THE 747 IN SIGHT. WE RESPONDED IN THE AFFIRMATIVE AND STARTED A CLBING TURN EBOUND IN RESPONSE TO A TCASII CLB COMMAND AND ZOA HDG COMMAND. VISUAL IDENT OF OUR TFC OCCURRED AT ABOUT 4 NM AND WAS CONFIRMED BY TCASII. OAK INFORMED US THAT OUR ALT CLRNC WAS REVISED TO 13000 FT AND DURING THE PRECEDING HECTIC MINS I HAD FORGOTTEN TO CHANGE THE ALT ALERTER. I ESTIMATED OUR LATERAL DISTANCE FROM THE 747 ABOUT 1 MI AND VERT SEPARATION OF 200 FT WHEN WE INITIATED CORRECTIVE ACTION AT 12200 FT. THE CHAIN OF EVENTS LEADING TO THIS OCCURRENCE INCLUDED NUMEROUS HDG CHANGES AND AIRSPD CHANGES, ALL WHILE CLRED TO 11000 FT. CONCERN OVER NOT MAKING OUR ARR TIME, AND THAT I HAD NUMEROUS INTL CONNECTING PAX, WHO WOULD MISS THEIR FLTS, SHOULD THE NEED ARISE FOR GOING TO THE ALTERNATE, ALL BECAME PART OF THE EQUATION AT THE MOMENT I SHOULD HAVE RESET THE ALT ALERTER. ALLOWING MY ATTN TO DIVERT TO DOUBLE-CHKING THE FMC PATTERN, FUEL CONCERNS AND KEEPING A LOOKOUT FOR TFC IN THE VMC ENVIRONMENT CLOSE TO THE VOR CONTRIBUTED TO MY OVERSIGHT. I WOULD RECOMMEND THAT WHEN A CTLR ISSUES A HOLD CLRNC, AND ESPECIALLY ONE IN WHICH THE CLRED ALT IS HIGHER THAN WAS PREVIOUSLY ISSUED, THAT HE FIRST AMEND THE ALT. IN THIS WAY HE IS ACTUALLY ISSUING 2 CLRNCS, THE MOST IMPORTANT CLRNC BEING THE AMENDED ALT. ONCE THAT INFO IS PASSED ON AND INSERTED BY THE PLT, THE HOLD CLRNC CAN BE ISSUED AS A SEPARATE PART. IN MY CASE, THE TASKS ASSIGNED BY THE CLRNC WAS FLY TO PYE, ENTER A HOLD WITH R TURNS AND INBOUND ON THE 320 DEG RADIAL. MAINTAIN 13000 FT AND EXPECT FURTHER CLRNC AT XA50. MAINTAINING 13000 FT WAS THE MOST IMPORTANT PART OF THAT CLRNC, YET IT CAME THIRD IN TASK ACCOMPLISHMENT. AS PLTS WE GENERALLY COMPLY WITH DIRECTIVES IN THE ORDER GIVEN. IN THE FUTURE, I WILL MAKE IT A POINT TO CHANGE THE ALT ALERT BEFORE ANYTHING ELSE IS ACCOMPLISHED IN THE HOLD CLRNC SEQUENCE. SUPPLEMENTAL INFO FROM ACN 268658: THE TRIP IDENT IS THE MOST COMPLAINED ABOUT IN THE DOMICILE. ALPA HAS COMPLAINED FOR 2 MONTHS THAT THIS IS AN UNSAFE TRIP. THE FIRST DAY IS A XX50 RPT, FLY ALL NIGHT, ARRIVE ORD AT XC15, FOLLOWED BY AN XX00 HOTEL DEP THAT NIGHT AND FLY TO THE EAST COAST, ARRIVING AT XY10. THEN A MINIMUM REST LAYOVER TO FLY ALL DAY TO THE WEST COAST (A 3 HR TIME CHANGE), FOLLOWED BY A XA45 WAKEUP AND XB30 DEP FROM THE HOTEL AND ARRIVE THAT NIGHT AT HOME AT XC00. BY THE LAST DAY BOTH MY CAPT AND I WERE PHYSICALLY AND MENTALLY TIRED AND HAD COMMENTED SO. TO HAVE ALL NIGHT FLTS FOLLOWED BY EARLY DEPS AND MINIMUM REST PERIODS DOES NOT ALLOW YOURBODY CLOCK TO ADJUST. THE CAPT WROTE DOWN THE CLRNC AND READ BACK THE CORRECT CLRNC, HOWEVER HE FORGOT TO PUT THE NEW ALT IN THE MCP WINDOW. I, HOWEVER, DID NOT HEAR THE ALT CLRNC AND THEREFORE WAS NOT LOOKING FOR IT. I ASKED THE CAPT IF THE HOLDING PAGE LOOKED GOOD, HE SAID YES, AND I EXECUTED THE PROGRAM. WITHIN SECONDS WE RECEIVED A WARNING LIGHT THAT WE WERE USING RESERVE FUEL. FATIGUE: BOTH THE CAPT AND I WERE TIRED. THE TENDENCY TO LOSE YOUR CONCENTRATION IS HIGH. AS PLTS, PRIORITIZE THE INSTRUCTIONS RECEIVED, BE ON THE ALERT FOR HDG AND ALT CHANGES. SET THESE FIRST, THEN TAKE CARE OF THE REST. THE CTLR ISSUED 6 INSTRUCTIONS WITH NO EMPHASIS ON THE AMENDED ALT. IF THE CTLR HAD PRIORITIZED HIS COMMANDS AND SAID AMEND ALT TO 13000 FT, STOP YOUR DSCNT AT 13000 FT, THIS INCIDENT MAY HAVE BEEN PREVENTED.

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.