UK AAIB Nov 2007 bulletin

[dontpickit]

http://www.aaib.dft.gov.uk/publications/bulletins/november_2007.cfm

[safetypee]

Re TC-JGR. With hindsight, the erroneous interpretation of note 3 could be understandable, but not expected from an experienced crew. However, such is the nature of error and unforeseen or unstated HF contributions.
This is a good lesson identifying the need for clear communications (charts) in an industry that has to accommodate a wide range of understanding from users who do not have English as their first language. If note 3 means do not turn below 850ft, then state it – simplicity, clarity (and avoid the QFE issue).
Furthermore, note 5 could help if written “Do not climb above 5000ft until …”, yet this may not help if alternative altitude clearances were common place – the challenge of standardization (clarity) vs flexibility; - SID - ‘Standard Instrument Departure’.
The chart highlights the 5000ft limit in a warning. The use of this terminology might be questionable; whist there is a hazard it would be mitigated by a clear depiction of the standard profile and crew procedure, i.e. this is not a hazard unique to this SID.
I would have thought that the conclusions from this investigation warranted a recommendation to review this and similar charts with respect to this form of error.

[Pilot Pete]

Couldn't agree more. Having used several different manufacturers charts I must admit to finding Jeppesens the worst for 'dotting' important info all over the place in a non-standard way. Often the SID stop altitude is depicted alongside the SID track, but occassionally it is written in a box at the bottom of the chart well away from the SID track info. It's the unfamiliar pilot that is more likely to fall into this sort of trap and miss something important. Having said that I was suprised that neither of them (on TC-JGR) thought to question a level off at 500' on a SID.....

PP

[Shiny side down]

However.

from the AAIB report.
the commanders experience says 10500hrs TT, 7000hrs on type.

These (jepps) are the airlines charts. Surely with that level of experience there should not be such a complete breakdown of the operation?
I know far worse has happened despite experience, in other places, but it stills begs the question.