|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||navaid : pom.vortac|
|Altitude||msl single value : 9500|
|Controlling Facilities||tracon : sct.tracon|
|Operator||common carrier : air taxi|
|Make Model Name||Beechjet 400|
|Operating Under FAR Part||Part 135|
|Flight Phase||climbout : initial|
|Route In Use||departure sid : pom|
|Affiliation||company : air taxi|
|Function||flight crew : first officer|
|Qualification||pilot : atp|
|Experience||flight time total : 9700|
flight time type : 900
|Affiliation||company : air taxi|
|Function||flight crew : captain|
oversight : pic
|Anomaly||altitude deviation : crossing restriction not met|
non adherence : clearance
non adherence : published procedure
|Independent Detector||other controllerb|
|Resolutory Action||controller : issued advisory|
|Consequence||faa : reviewed incident with flight crew|
|Problem Areas||Flight Crew Human Performance|
Chart Or Publication
|Primary Problem||Flight Crew Human Performance|
We exceeded the '8000 ft at or below' over pom VOR altitude restriction leaving ont on the POM6 SID. Departure advised us we did not comply with the SID. We climbed through the altitude restriction; however; no loss of separation occurred and we were to call socal after we landed. The chain of events that led to this situation were; in my opinion; of human factors origin. In order of significance; these factors are 1) our rushing through checklists and specifically the crew departure briefing to meet an ATC wheels-up departure window. 2) our over reliance on our FMS to provide preprogrammed SID/STAR altitude restrictions. 3) our exclusive use of the electronic flight bag (efb) program to review the departure. 4) my unfamiliarity with california airspace and procedures. I have found out 'at or below' altitude restrictions are very common out west. 5) finally; the lack of any additional barriers to errors by the local ATC structure. In regards to the efb; I feel very strongly that I would have seen and briefed the captain on an altitude restriction on our POM6 departure had I been using the paper faxed copy of the chart we had onboard. I have found it takes more time and discipline by pilots to obtain all the information they need from an electronic vs paper chart. This is especially true with large charts that require the user to scroll around the screen to have all the information. Also; use of the efb becomes much more difficult in bright daylight; forcing the pilots to shield the display to accurately read the information. I'm not exactly sure how I read the departure and missed the words on the first fix of 'at or below.' I will guess that because the other altitude restrictions were 'at or above;' I was scrolling around the display to read everything. I was shielding the unit with my free hand to be able to even read it; and we were hurrying through the whole process at an airport we were not familiar with. In addition; because our units are not hard mounted; once I reviewed the chart; by company policy; the efb is stowed; there was no chance I would have picked out my mistake again by a second review as could easily be done had I been using a paper chart attached to my yoke. Until technology advances so efb chart information can be displayed clearly and in its entirety; till it can be in a place that allows for rapid review by both pilots; I will continue to only use paper charts. When we talked with the socal controller via landline; he informed us the call was for pilot education and not FAA enforcement; but he told us crews missing the 8000 ft restriction over pom VOR was becoming too common; the airspace above that point is extremely busy with lax traffic; and we all have been very lucky. He also asked we contact our company safety department to educate our pilots on this SID; which I will do. I mentioned I feel a lack of additional barriers would have also prevented this altitude bust. What I mean by this is while I understand review of a SID is a pilot's responsibility; ATC could provide; purely in the interest of safety; some additional barriers to such errors. For example; ont clearance delivery or control tower could remind pilots there is an altitude restriction below their assigned altitude when they issue or departure aircraft on the POM6 SID. Also; if departure radar controllers responded to initial calls; that may be in question as to the crew's knowledge of the SID; with a reminder of the intermediate altitude restriction. For example; pilot; 'socal N1234 2000 ft climbing to 14000 ft.' ATC; 'roger N1234; radar contact; comply with 8000 ft or below altitude restriction till pom VOR then continue your climb to 14000 ft.' a clearance delivery reminder or clarification by departure controllers could add additional barriers to error and increase safety. Our rushing through critical preflight preparation at an unfamiliar airport using an efb with a poor display and an over reliance that our FMS contained all the SID data; were the causes linked to our human factors failure of not complying with a SID and busting altitude.callback conversation with reporter revealed the following information: reporter stated that the company has two efb's per aircraft.they are not hard mounted to the aircraft and are stowed on takeoff and landing. They have the ability to print any chart that is displayed. He commonly prints the airport diagram and the approach or departure that is to be flown as the efb is not available for the takeoff and landing. He stated that it is difficult to scroll through that chart if it is a large expanded chart with detail instruction and requires time to do it properly. The efb is difficult to see in the bright light. The reporter indicated that it is excellent during night and low visibility periods. The efb is the only source for approach; departure; and airport diagrams. There are no paper charts onboard the aircraft other than en route charts and charts that are printed from the efb. He stated that it is difficult for him to transition to the efb from paper charts and that training is limited. Reporter stated that in his opinion; the following are weak points regarding the efb's: 1) inability to read the plate/chart in bright light. 2) having to stow the efb during critical times in the operations. 3) lack of training on the efb. Company does not give hands on training; only provides a book. 4) time it takes to scroll/drag through a complicated chart. This may cause the operator to miss important information. Reporter stated that in his opinion the pluses for the efb are: 1) ability to quickly pull up any airport/chart with the just the name or identifier. 2) excellent detail regarding the terrain and approach plate. The reporter's company has gotten approval from the FSDO to hard mount one (1) efb in each aircraft and the reporter feels that this may not be a good solution; as the efb is mounted on the copilot's side; leaving the PF to look at the chart from across the cockpit and rely on the PNF for backup.
Original NASA ASRS Text
Title: BE400 BEECHJET FLT CREW HAS AN ALT CROSSING RESTRICTION THAT IS NOT MET DURING THE POM6 DEP. ATC NOTIFIES THE CREW OF THE MISSED RESTRICTION.
Narrative: WE EXCEEDED THE '8000 FT AT OR BELOW' OVER POM VOR ALT RESTRICTION LEAVING ONT ON THE POM6 SID. DEP ADVISED US WE DID NOT COMPLY WITH THE SID. WE CLBED THROUGH THE ALT RESTRICTION; HOWEVER; NO LOSS OF SEPARATION OCCURRED AND WE WERE TO CALL SOCAL AFTER WE LANDED. THE CHAIN OF EVENTS THAT LED TO THIS SITUATION WERE; IN MY OPINION; OF HUMAN FACTORS ORIGIN. IN ORDER OF SIGNIFICANCE; THESE FACTORS ARE 1) OUR RUSHING THROUGH CHKLISTS AND SPECIFICALLY THE CREW DEP BRIEFING TO MEET AN ATC WHEELS-UP DEP WINDOW. 2) OUR OVER RELIANCE ON OUR FMS TO PROVIDE PREPROGRAMMED SID/STAR ALT RESTRICTIONS. 3) OUR EXCLUSIVE USE OF THE ELECTRONIC FLT BAG (EFB) PROGRAM TO REVIEW THE DEP. 4) MY UNFAMILIARITY WITH CALIFORNIA AIRSPACE AND PROCS. I HAVE FOUND OUT 'AT OR BELOW' ALT RESTRICTIONS ARE VERY COMMON OUT WEST. 5) FINALLY; THE LACK OF ANY ADDITIONAL BARRIERS TO ERRORS BY THE LCL ATC STRUCTURE. IN REGARDS TO THE EFB; I FEEL VERY STRONGLY THAT I WOULD HAVE SEEN AND BRIEFED THE CAPT ON AN ALT RESTRICTION ON OUR POM6 DEP HAD I BEEN USING THE PAPER FAXED COPY OF THE CHART WE HAD ONBOARD. I HAVE FOUND IT TAKES MORE TIME AND DISCIPLINE BY PLTS TO OBTAIN ALL THE INFO THEY NEED FROM AN ELECTRONIC VS PAPER CHART. THIS IS ESPECIALLY TRUE WITH LARGE CHARTS THAT REQUIRE THE USER TO SCROLL AROUND THE SCREEN TO HAVE ALL THE INFO. ALSO; USE OF THE EFB BECOMES MUCH MORE DIFFICULT IN BRIGHT DAYLIGHT; FORCING THE PLTS TO SHIELD THE DISPLAY TO ACCURATELY READ THE INFO. I'M NOT EXACTLY SURE HOW I READ THE DEP AND MISSED THE WORDS ON THE FIRST FIX OF 'AT OR BELOW.' I WILL GUESS THAT BECAUSE THE OTHER ALT RESTRICTIONS WERE 'AT OR ABOVE;' I WAS SCROLLING AROUND THE DISPLAY TO READ EVERYTHING. I WAS SHIELDING THE UNIT WITH MY FREE HAND TO BE ABLE TO EVEN READ IT; AND WE WERE HURRYING THROUGH THE WHOLE PROCESS AT AN ARPT WE WERE NOT FAMILIAR WITH. IN ADDITION; BECAUSE OUR UNITS ARE NOT HARD MOUNTED; ONCE I REVIEWED THE CHART; BY COMPANY POLICY; THE EFB IS STOWED; THERE WAS NO CHANCE I WOULD HAVE PICKED OUT MY MISTAKE AGAIN BY A SECOND REVIEW AS COULD EASILY BE DONE HAD I BEEN USING A PAPER CHART ATTACHED TO MY YOKE. UNTIL TECHNOLOGY ADVANCES SO EFB CHART INFO CAN BE DISPLAYED CLEARLY AND IN ITS ENTIRETY; TILL IT CAN BE IN A PLACE THAT ALLOWS FOR RAPID REVIEW BY BOTH PLTS; I WILL CONTINUE TO ONLY USE PAPER CHARTS. WHEN WE TALKED WITH THE SOCAL CTLR VIA LANDLINE; HE INFORMED US THE CALL WAS FOR PLT EDUCATION AND NOT FAA ENFORCEMENT; BUT HE TOLD US CREWS MISSING THE 8000 FT RESTRICTION OVER POM VOR WAS BECOMING TOO COMMON; THE AIRSPACE ABOVE THAT POINT IS EXTREMELY BUSY WITH LAX TFC; AND WE ALL HAVE BEEN VERY LUCKY. HE ALSO ASKED WE CONTACT OUR COMPANY SAFETY DEPARTMENT TO EDUCATE OUR PLTS ON THIS SID; WHICH I WILL DO. I MENTIONED I FEEL A LACK OF ADDITIONAL BARRIERS WOULD HAVE ALSO PREVENTED THIS ALT BUST. WHAT I MEAN BY THIS IS WHILE I UNDERSTAND REVIEW OF A SID IS A PLT'S RESPONSIBILITY; ATC COULD PROVIDE; PURELY IN THE INTEREST OF SAFETY; SOME ADDITIONAL BARRIERS TO SUCH ERRORS. FOR EXAMPLE; ONT CLRNC DELIVERY OR CTL TWR COULD REMIND PLTS THERE IS AN ALT RESTRICTION BELOW THEIR ASSIGNED ALT WHEN THEY ISSUE OR DEP ACFT ON THE POM6 SID. ALSO; IF DEP RADAR CTLRS RESPONDED TO INITIAL CALLS; THAT MAY BE IN QUESTION AS TO THE CREW'S KNOWLEDGE OF THE SID; WITH A REMINDER OF THE INTERMEDIATE ALT RESTRICTION. FOR EXAMPLE; PLT; 'SOCAL N1234 2000 FT CLBING TO 14000 FT.' ATC; 'ROGER N1234; RADAR CONTACT; COMPLY WITH 8000 FT OR BELOW ALT RESTRICTION TILL POM VOR THEN CONTINUE YOUR CLB TO 14000 FT.' A CLRNC DELIVERY REMINDER OR CLARIFICATION BY DEP CTLRS COULD ADD ADDITIONAL BARRIERS TO ERROR AND INCREASE SAFETY. OUR RUSHING THROUGH CRITICAL PREFLT PREPARATION AT AN UNFAMILIAR ARPT USING AN EFB WITH A POOR DISPLAY AND AN OVER RELIANCE THAT OUR FMS CONTAINED ALL THE SID DATA; WERE THE CAUSES LINKED TO OUR HUMAN FACTORS FAILURE OF NOT COMPLYING WITH A SID AND BUSTING ALT.CALLBACK CONVERSATION WITH RPTR REVEALED THE FOLLOWING INFO: RPTR STATED THAT THE COMPANY HAS TWO EFB'S PER ACFT.THEY ARE NOT HARD MOUNTED TO THE ACFT AND ARE STOWED ON TKOF AND LNDG. THEY HAVE THE ABILITY TO PRINT ANY CHART THAT IS DISPLAYED. HE COMMONLY PRINTS THE ARPT DIAGRAM AND THE APCH OR DEP THAT IS TO BE FLOWN AS THE EFB IS NOT AVAILABLE FOR THE TKOF AND LNDG. HE STATED THAT IT IS DIFFICULT TO SCROLL THROUGH THAT CHART IF IT IS A LARGE EXPANDED CHART WITH DETAIL INSTRUCTION AND REQUIRES TIME TO DO IT PROPERLY. THE EFB IS DIFFICULT TO SEE IN THE BRIGHT LIGHT. THE RPTR INDICATED THAT IT IS EXCELLENT DURING NIGHT AND LOW VIS PERIODS. THE EFB IS THE ONLY SOURCE FOR APCH; DEP; AND ARPT DIAGRAMS. THERE ARE NO PAPER CHARTS ONBOARD THE ACFT OTHER THAN ENRTE CHARTS AND CHARTS THAT ARE PRINTED FROM THE EFB. HE STATED THAT IT IS DIFFICULT FOR HIM TO TRANSITION TO THE EFB FROM PAPER CHARTS AND THAT TRAINING IS LIMITED. RPTR STATED THAT IN HIS OPINION; THE FOLLOWING ARE WEAK POINTS REGARDING THE EFB'S: 1) INABILITY TO READ THE PLATE/CHART IN BRIGHT LIGHT. 2) HAVING TO STOW THE EFB DURING CRITICAL TIMES IN THE OPERATIONS. 3) LACK OF TRAINING ON THE EFB. COMPANY DOES NOT GIVE HANDS ON TRAINING; ONLY PROVIDES A BOOK. 4) TIME IT TAKES TO SCROLL/DRAG THROUGH A COMPLICATED CHART. THIS MAY CAUSE THE OPERATOR TO MISS IMPORTANT INFO. RPTR STATED THAT IN HIS OPINION THE PLUSES FOR THE EFB ARE: 1) ABILITY TO QUICKLY PULL UP ANY ARPT/CHART WITH THE JUST THE NAME OR IDENTIFIER. 2) EXCELLENT DETAIL REGARDING THE TERRAIN AND APCH PLATE. THE RPTR'S COMPANY HAS GOTTEN APPROVAL FROM THE FSDO TO HARD MOUNT ONE (1) EFB IN EACH ACFT AND THE RPTR FEELS THAT THIS MAY NOT BE A GOOD SOLUTION; AS THE EFB IS MOUNTED ON THE COPLT'S SIDE; LEAVING THE PF TO LOOK AT THE CHART FROM ACROSS THE COCKPIT AND RELY ON THE PNF FOR BACKUP.
Data retrieved from NASA's ASRS site as of January 2009 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.