|37000 Feet||Browse and search NASA's
Aviation Safety Reporting System
|Local Time Of Day||1201 To 1800|
|Locale Reference||atc facility : rbv|
airport : ewr
|Altitude||msl bound lower : 9500|
msl bound upper : 11000
|Controlling Facilities||artcc : zny|
|Operator||common carrier : air carrier|
|Make Model Name||Medium Large Transport, Low Wing, 2 Turbojet Eng|
|Flight Phase||descent other|
|Affiliation||company : air carrier|
|Function||flight crew : captain|
oversight : pic
|Qualification||pilot : atp|
|Experience||flight time last 90 days : 130|
flight time total : 6500
|Function||flight crew : first officer|
|Qualification||pilot : commercial|
pilot : instrument
|Anomaly||altitude deviation : overshoot|
non adherence : clearance
other spatial deviation
|Independent Detector||other controllera|
|Resolutory Action||flight crew : returned to intended course or assigned course|
|Primary Problem||Flight Crew Human Performance|
|Air Traffic Incident||Pilot Deviation|
I was the captain, the copilot was flying. We are both on reserve. Both of us received a call from scheduling at XA00 am for a C am departure that morning. As a result both of us were tired due to lack of sleep. I am a new captain, (1 1/2 months) the first officer was hired 6 months ago and has been denver assigned until one week ago. (New to ny area) at approximately xm 30 local time, ny center said, cross 15 west of robbinsville at 11000', robbinsville at 8000'. Given two altitudes, I chose to set 8000' in the altitude alert, so we would not forget to descend to our final altitude. I then, (after I made sure the first officer had heard the clearance) proceeded to finish the inrange checklist. The next thing I hear is center calling telling us to climb to 11000'. We were at 9500' at 19 DME, we had descended below 11000' before reaching 15 mi. I dialed in 11000' on the altitude alert and we climbed back up. The first officer said he thought the clearance meant to be below 11000' by 15 west and to be at 8000' by robbinsville VOR. Busting this crossing restriction sent both of us into a semi-state of 'shock' -- thinking, 'are we going to get violated?' a brief discussion between us about the restriction followed, the first officer saying he did not take the clearance to mean that. Center called us back again and said, cross robbinsville at 8000'. I was glad he called us back because if he hadn't I probably would have forgot to cross robbinsville at 8000'. We had plenty of time to meet this restriction, and we did, however, we were both still rather overcome with the fact that we had another call from center saying we were 4 1/2 mi off course (we were about 4 mi from robbinsville) and to turn right and get on course. He mentioned something about conflicting traffic. A few seconds before his call I had gotten my senses back together enough to see we were off course and told the first officer to turn right and get back over on course. I told ATC we were already in the turn. At this point I found the first officer had still had the previous VOR frequency in his radio. We got back on course. By this time we were over the VOR (rbv) the fear that set in when we were told to climb back to 11000' was hard to overcome, the thought of a violation is rather overwhelming. This situation was greatly intensified by the fact that we were both very fatigued by this time of the day, having been awakened by scheduling at xa am. I had previously had 2 days off and had not gotten to bed early. The copilot had exactly the same situation. What we have here is a new captain, with a relatively new copilot, (totally new to the ny area) both of us with little sleep, very fatigued (and as an added note, it is perfectly normal to have 3 brand new F/a's along also. This was a trip that was filled with all 'reserve' people. This happens often, however I'm now wondering whether this trip did have 3 new F/a's) in any event, I've learned not to trust any copilot, regardless of his previous experience, and to watch them like a hawk. I must be more aware of my fatigue level and show extra caution at these times. Also, when a mistake is made, put it behind you and don't let it screw up your next task, which in my case was staying on course and rbv at 8000' (which we did). I also feel a clearance containing 2 altitude restrictions is not safe. It is too easy to confuse the clearance and it is too easy to forget one of the altitudes, especially since we can only dial in one altitude on the alert. You become conditioned to using and relying on the altitude alert. Also concerning 'fatigue,' when a new copilot or captain starts out he is on reserve or on call, it has become standard practice at air carrier to receive a call at xa am or xb am to be given a trip assignment. In my case anyway, this leaves you very tired. The first officer is in the same situation and the F/a's also. The whole crew could be new and very fatigued, not a good situation. The entire crew rest situation needs to be re-evaluated. It is criminal to allow crews to operate on so little rest. Example: 8 1/2 rest from block to block. This leaves you with about 4 hours sleep! If you're lucky. Unacceptable. You hear somuch about the drug testing issue these days, well there is a problem that is 100 times more pressing at hand, crew rest!
Original NASA ASRS Text
Title: FAILED TO COMPLY WITH CLRNC RESTRICTION ON CROSSING ALT.
Narrative: I WAS THE CAPT, THE COPLT WAS FLYING. WE ARE BOTH ON RESERVE. BOTH OF US RECEIVED A CALL FROM SCHEDULING AT XA00 AM FOR A C AM DEP THAT MORNING. AS A RESULT BOTH OF US WERE TIRED DUE TO LACK OF SLEEP. I AM A NEW CAPT, (1 1/2 MONTHS) THE F/O WAS HIRED 6 MONTHS AGO AND HAS BEEN DENVER ASSIGNED UNTIL ONE WEEK AGO. (NEW TO NY AREA) AT APPROX XM 30 LCL TIME, NY CENTER SAID, CROSS 15 W OF ROBBINSVILLE AT 11000', ROBBINSVILLE AT 8000'. GIVEN TWO ALTS, I CHOSE TO SET 8000' IN THE ALT ALERT, SO WE WOULD NOT FORGET TO DSND TO OUR FINAL ALT. I THEN, (AFTER I MADE SURE THE F/O HAD HEARD THE CLRNC) PROCEEDED TO FINISH THE INRANGE CHKLIST. THE NEXT THING I HEAR IS CENTER CALLING TELLING US TO CLB TO 11000'. WE WERE AT 9500' AT 19 DME, WE HAD DSNDED BELOW 11000' BEFORE REACHING 15 MI. I DIALED IN 11000' ON THE ALT ALERT AND WE CLBED BACK UP. THE F/O SAID HE THOUGHT THE CLRNC MEANT TO BE BELOW 11000' BY 15 W AND TO BE AT 8000' BY ROBBINSVILLE VOR. BUSTING THIS XING RESTRICTION SENT BOTH OF US INTO A SEMI-STATE OF 'SHOCK' -- THINKING, 'ARE WE GOING TO GET VIOLATED?' A BRIEF DISCUSSION BTWN US ABOUT THE RESTRICTION FOLLOWED, THE F/O SAYING HE DID NOT TAKE THE CLRNC TO MEAN THAT. CENTER CALLED US BACK AGAIN AND SAID, CROSS ROBBINSVILLE AT 8000'. I WAS GLAD HE CALLED US BACK BECAUSE IF HE HADN'T I PROBABLY WOULD HAVE FORGOT TO CROSS ROBBINSVILLE AT 8000'. WE HAD PLENTY OF TIME TO MEET THIS RESTRICTION, AND WE DID, HOWEVER, WE WERE BOTH STILL RATHER OVERCOME WITH THE FACT THAT WE HAD ANOTHER CALL FROM CENTER SAYING WE WERE 4 1/2 MI OFF COURSE (WE WERE ABOUT 4 MI FROM ROBBINSVILLE) AND TO TURN R AND GET ON COURSE. HE MENTIONED SOMETHING ABOUT CONFLICTING TFC. A FEW SECONDS BEFORE HIS CALL I HAD GOTTEN MY SENSES BACK TOGETHER ENOUGH TO SEE WE WERE OFF COURSE AND TOLD THE F/O TO TURN R AND GET BACK OVER ON COURSE. I TOLD ATC WE WERE ALREADY IN THE TURN. AT THIS POINT I FOUND THE F/O HAD STILL HAD THE PREVIOUS VOR FREQ IN HIS RADIO. WE GOT BACK ON COURSE. BY THIS TIME WE WERE OVER THE VOR (RBV) THE FEAR THAT SET IN WHEN WE WERE TOLD TO CLB BACK TO 11000' WAS HARD TO OVERCOME, THE THOUGHT OF A VIOLATION IS RATHER OVERWHELMING. THIS SITUATION WAS GREATLY INTENSIFIED BY THE FACT THAT WE WERE BOTH VERY fatigueD BY THIS TIME OF THE DAY, HAVING BEEN AWAKENED BY SCHEDULING AT XA AM. I HAD PREVIOUSLY HAD 2 DAYS OFF AND HAD NOT GOTTEN TO BED EARLY. THE COPLT HAD EXACTLY THE SAME SITUATION. WHAT WE HAVE HERE IS A NEW CAPT, WITH A RELATIVELY NEW COPLT, (TOTALLY NEW TO THE NY AREA) BOTH OF US WITH LITTLE SLEEP, VERY FATIGUED (AND AS AN ADDED NOTE, IT IS PERFECTLY NORMAL TO HAVE 3 BRAND NEW F/A'S ALONG ALSO. THIS WAS A TRIP THAT WAS FILLED WITH ALL 'RESERVE' PEOPLE. THIS HAPPENS OFTEN, HOWEVER I'M NOW WONDERING WHETHER THIS TRIP DID HAVE 3 NEW F/A'S) IN ANY EVENT, I'VE LEARNED NOT TO TRUST ANY COPLT, REGARDLESS OF HIS PREVIOUS EXPERIENCE, AND TO WATCH THEM LIKE A HAWK. I MUST BE MORE AWARE OF MY FATIGUE LEVEL AND SHOW EXTRA CAUTION AT THESE TIMES. ALSO, WHEN A MISTAKE IS MADE, PUT IT BEHIND YOU AND DON'T LET IT SCREW UP YOUR NEXT TASK, WHICH IN MY CASE WAS STAYING ON COURSE AND RBV AT 8000' (WHICH WE DID). I ALSO FEEL A CLRNC CONTAINING 2 ALT RESTRICTIONS IS NOT SAFE. IT IS TOO EASY TO CONFUSE THE CLRNC AND IT IS TOO EASY TO FORGET ONE OF THE ALTS, ESPECIALLY SINCE WE CAN ONLY DIAL IN ONE ALT ON THE ALERT. YOU BECOME CONDITIONED TO USING AND RELYING ON THE ALT ALERT. ALSO CONCERNING 'FATIGUE,' WHEN A NEW COPLT OR CAPT STARTS OUT HE IS ON RESERVE OR ON CALL, IT HAS BECOME STANDARD PRACTICE AT ACR TO RECEIVE A CALL AT XA AM OR XB AM TO BE GIVEN A TRIP ASSIGNMENT. IN MY CASE ANYWAY, THIS LEAVES YOU VERY TIRED. THE F/O IS IN THE SAME SITUATION AND THE F/A'S ALSO. THE WHOLE CREW COULD BE NEW AND VERY FATIGUED, NOT A GOOD SITUATION. THE ENTIRE CREW REST SITUATION NEEDS TO BE RE-EVALUATED. IT IS CRIMINAL TO ALLOW CREWS TO OPERATE ON SO LITTLE REST. EXAMPLE: 8 1/2 REST FROM BLOCK TO BLOCK. THIS LEAVES YOU WITH ABOUT 4 HRS SLEEP! IF YOU'RE LUCKY. UNACCEPTABLE. YOU HEAR SOMUCH ABOUT THE DRUG TESTING ISSUE THESE DAYS, WELL THERE IS A PROB THAT IS 100 TIMES MORE PRESSING AT HAND, CREW REST!
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.