Near CFIT because PIC didn't understand FL

[Consol]

SERIOUS INCIDENT: BAe 125-800B, N1310H, Co. Kerry Ireland, 16 June 2015: REPORT 2016-005 | AAIU.ie (http://www.aaiu.ie/node/907)

This individual levelled off in IMC at 2000ft in an area of high terrain with safe altitudes of 4500ft because he thought FL two zero zero meant 2000ft. Saved by ATC intervention. I have flown both corporate jets and large jet transports and find myself troubled by apparent low levels of experience and ability that seems to permeate the corporate sector and repeatedly show up in accident reports. It is also worrying to be flying airliners around the skies shared with some of these guys. I know the airline sector has it's issues with handling of abnormalities of late and I am sure the vast majority of corporate pilots are highly professional, as I said I was one once. I just feel that with events like a previous near CFIT corporate jet in EIKY, the EGSS G4 localiser take out and many others that pop up in accident reports need some highlighting and debate.

[GlobalNav]

But...PIC? Maybe he/she should just be a drone pilot.

[+TSRA]

Or perhaps this is a North American pilot used to a Transition Level of FL180. They fly across the pond where the number of Transition Levels between Ireland and Russia equal the number of aircraft in the sky and they made a simple, albeit serious, mistake.

Rather than specifying a "lowest available flight altitude," Europe seems to favour "lowest Transition Altitude." It's quite a different concept and a very easy mistake to make that has absolutely nothing to do with the professionalism of a crew flying a corporate or airline gig.

[Flap62]

Did you honestly just use "easy mistake to make" and "professionalism of flight crew" in the same sentance in reference to this incident?

[ZOOKER]

"Lowest available flight altitude" + "lowest transition altitude" = "Houston, we have a problem".

[ManaAdaSystem]

That is why it is called FL 200, not 2 0 0.

[GlobalNav]

FL200 is FL200, no matter what the TL/TA.

[HEATHROW DIRECTOR]

Incredible, just incredible.

[+TSRA]

Did you honestly just use "easy mistake to make" and "professionalism of flight crew" in the same sentance in reference to this incident?

Yes I did. Because professionals are allowed to make mistakes. Sometimes they're small, sometimes they're massive (like this example). Note that I'm not condoning their mistake, but rather saying that a mistake does not imply an unprofessional attitude. That would be called negligence...which I don't think happened here.

[Airbubba]

This individual levelled off in IMC at 2000ft in an area of high terrain with safe altitudes of 4500ft because he thought FL two zero zero meant 2000ft.

Many of my U.S. colleagues seem puzzled when I wince at their calls like 'passing flight level twenty-three point six climbing to flight level two seven zero'.

Flying Tigers had a fatal 747 accident on approach to Kuala Lumpur (Subang, not Sepang) years ago where the crew interpreted 'Tiger 66, descend two four zero zero' as 'Tiger 66, descend to four zero zero':

https://en.wikipedia.org/wiki/Flying_Tiger_Line_Flight_66

[+TSRA]

FL200 is FL200, no matter what the TL/TA.

You are 100% correct. I'm not meaning to imply this was not a very serious mistake.

All I said, in different words, was that a pilot who is never used to hearing "Flight Level Zero Two Zero" or "Flight Level Two Hundred" could easily make a mistake for "Flight Level Two Zero Zero" or the other way around (which seems to be the case here).

[GlobalNav]

+TSRA

I agree with you. I could much easier accept that the pilot mis-heard the clearance, rather than confused FL200 for 2,000' QNE. But thinking that the clearance was to 2,000 ft or so still challenges the imagination when the safe altitude was around 4,500 ft. But, it wouldn't be the first time. Where was EGPWS in all this?

[fireflybob]

Surely a safety altitude of 4,500 feet is based on QNH wherever you are?

[+TSRA]

GlobalNav,

You're absolutely right. Challenge the clearance. About 8 hours ago I departed with another Captain from an airport in the Canadian Rockies. The clearance was to 13,000'. MSA is 14,000'. We challenged, they said 13,000' was fine. We departed because we are both very familiar with the area and it was screaming VMC - but agreed between us we would not have departed in IMC or MVMC. Once airborne we called the controller and asked for clarification. He was astounded at his mistake and re-cleared us up to FL250. So you're right, not the first time - and it can happen on both ends of the mic.

In fact, reading through the report that was attached to the website, it seems the pilot did mishear the clearance like you suggest...but then never confirmed what "Flight Level Two Hundred" meant.

As for theEGPWS...yep. It's a great tool when all the conditions are met to use it. I routinely have to remind my co-pilots to turn the weather radar on. In our type the EGPWS is inhibited with the radar off. We only use it 5% of the flying we do, so maybe its the same thing here - it's never used so it was forgotten about???

[GlobalNav]

Makes me wonder if the introduction of CPDLC will reduce misunderstandings such as might have been the case here.

[+TSRA]

Una Due Tfc,

I think the confusing thing for these guys was the clearance was given to them (per the report, page 4, third paragraph) as "Flight Level Two Hundred." So written down that does look a whole lot like Twenty Thousand Feet. But, then the crew has read somewhere that FL050 is the lowest TL; they hear "Two Hundred" so to them that must mean "Two Thousand" because that's a whole lot less than "Twenty Thousand" which, to them, would have been spoken as "Flight Level Two Zero Zero." To GlobalNav's point, why they accepted the clearance below the MSA in unfamiliar territory...only they can answer. But there is a lot of trust in controllers, so they must have thought it OK.

[+TSRA]

CPDLC probably would have reduced the error here. It would be interesting to find out what errors CPDLC introduces.

[Flap62]

+TSRA

I'm not suggesting that profesionals cannot and do not make mistakes. However I certainly do not think this is an "easy mistake to make". The crew did not misread back a clearance, they did not fundamentally understand what FL two hundred meant. For a pic operating international flights that is worrying. They levelled at 2000' IMC flying towards close in and charted terrain going to above their level. It would be interesting to see how thorough their pre-departure brief was with reference to terrain. It was either covered in the brief and they ignored the implications of the level off or it wasn't covered and they didn't know about the terrain. Either way, that level of operational situational awareness is worrying. They then didn't file a report until contacted by their regulatory authority so either they didn't understand how close they had come to CFIT (again worrying) or they did and thought best not to file.

From all of the above, yes, I would certainly say this went way beyond an "easy mistake to make" and I would question the integrity and professionalism of the whole operation.

[Pace]

I read sometime back that EASA were thinking of introducing a standardised transition level for Europe with such a variation throughout Europe that itself can lead to confusion even among our own pilots

There are many airports within Europe where the terrain is much higher than Kerry and it highlights the need for worldwide standardisation of regulations.

Pace

[framer]

they did not fundamentally understand what FL two hundred meant. For a pic operating international flights that is worrying
Is it standard phraseology to say " flight level two hundred" anywhere? I am not being facetious, genuine question as I have only ever been cleared to " flight level two zero zero". Is it a US thing and is it slang or standard phraseology?

[pilotho]

FL TWO HUNDRED tends to be used in UK airspace and as far as I remember it's in the CAP413.

Saying FL two zero zero is an ICAO thing and most other countries use that system.

There are some fundamental errors performed here since we don't fly on FL until passing the transition altitude on climb out. So if I were in the Crew's shoes, levelling off at altitude 2000, alarm bells will be ringing especially if I were PM. Also, did the Crew actually set 1013 at 2000? Just wondering because if the QNH was low say QNH 1000 then they would have been even lower than they thought.

When I was operating in Europe, saying altitude or FL on your read back was very common but the rest of the world doesn't seem to think along the same lines.

[porterhouse]

Frankly I am surprised no one picked on another problem here - I don't know where the boundary in Europe lies but in the US you are not allowed to use flight-level terminology if you are below 18000 feet, I think it makes perfect sense to disallow use of flight levels anywhere except the class A airspace. And frankly I am at 2000 feet sounds a lot shorter than I am at flight level two hundred...

Or perhaps this is a North American pilot used to a Transition Level of FL180.
No, he couldn't have been a North American pilot precisely because of the above. No NA pilot will use flight level for such low altitudes.

[Superpilot]

I sympathise with the crew a little. Not used to the myriad of transition levels where they come from combined with the serious sounding "STOP at FL200" requirement despite the cleared final level of FL340 means they must've thought this to be some kind of low level instrument departure level off. In the US, this clearance would be to INITIALLY climb FL200 and expect FL340 within x minutes.

[SV_741_India_Bravo]

Why isnt this antiquated european system overhauled? for a bunch who tells Americans to "get to know the world", you folks sure prefer to stick to your confusing methods instead of making things simpler.

[HEATHROW DIRECTOR]

<<And frankly I am at 2000 feet sounds a lot shorter than I am at flight level two hundred...>>

Except that those two are approximately 18000 feet apart.

[Pace]

I have to say that I found the ATC response given the situation to have been odd
Seeing that there was a threat and suspecting a confusion over flight levels and altitude ATC Cleared him to climb to FL300 :ugh:
That is almost like saying your departure is fine you are now re cleared to FL300?

The obvious would have been realising the aircraft was at 2000 feet to have instigated an immediate climb to above the SSA in feet and with the QNH given with a request for a read back of both ?

sv_741_india_bravo

Yes EASA had a blank Sheet and should have saved the Eurozone £ Millions by taking the FAA system modifying it to suit Europe and harmonising aviation regulations worldwide but then? When have EASA ever done anything sensible which has not been for their own or their chums benefits

there was talk of EASA standardising a transition Level but that went quiet probably too much time in the bars and restaurants of Brussels on lavish expense accounts

Pace

[Sciolistes]

"flight level two zero zero" is international (ICAO) phraseology.

[safelife]

ICAO Doc 9432:
"All numbers used in the transmission of altitude, cloud height, visibility and runway visual range (RVR) information, which contain whole hundreds and whole thousands, shall be transmitted by pronouncing each digit in the number of hundreds or thousands follow by the word HUNDRED or THOUSAND as appropriate".

Germany does this, "cleared flight level two hundred".

[fox niner]

Hold on. FL 200 is the same in the US as it is in Europe. So it should not be difficult for anyone to understand what is being meant, no matter where you are from. Especially if you had to make a hop across the pond to end up in Ireland, the PIC surely was thouroughly familiar with the TA/TL system.
This was my WTF moment of the day. Thanks.

[Mariner9]

No, he couldn't have been a North American pilot precisely because of the above. No NA pilot will use flight level for such low altitudes.

Not so it would seem. The report states:
The Pilot in Command of N1310H was based in the United States.

[Hawker 800]

No, he couldn't have been a North American pilot precisely because of the above. No NA pilot will use flight level for such low altitudes.

Well, on the grapevine he was indeed an American pilot. Apparently, it was flying a charter so a commercial operation/FAR135.

[IcePack]

& of course over Kashmir Fl is on QNH.
Would be nice if their was some commonality.

[ATC Watcher]

Not sure what was the level of automation on this 125 , but this could also be a ergonomic error in setting the FL in a box or a display of some kind.

Could have been one pilot doing the R/T and the other entering the figures.
so the immediate read back FL200 is correct because done by same individual right after the transmission but if the other enter 020 i.s.o. 200 , and not cross- checked , that could explain the later transmissions : "which level are you climbing to ? : PIC reading the display : FL020 ... ( as in the report page 4 )

Speculating of course.

[Huck]

I learned to fly international in Africa and South America, sitting in Diesel Tens beside fossils from the stone age who had come up in the trash-hauling business.

They always, ALWAYS, knew what their MSA was. And woe be unto you if you didn't.....

[Basil]

They always, ALWAYS, knew what their MSA was. And woe be unto you if you didn't.....
That is so basic and vital that it's worth repeating :ok:

[Journey Man]

I have flown both corporate jets and large jet transports and find myself troubled by apparent low levels of experience and ability that seems to permeate the corporate sector...

I'm not sure this type of generalisation is helpful. You say "the corporate sector", but you fail to clarify whether you're referring to corporate flight departments, or just any non-scheduled aircraft. Of course, the latter includes non-scheduled commercial air transport operators and private operators.

However, in general, I agree with you and there is value in having the conversation. In a multi crew environment, where was the monitoring to trap this error? Discipline is often lacking in non-scheduled operations and I believe this to be from a number of factors. Smaller operators lack the resources to adequately analyse incidents and develop robust defences, whilst also lacking the resources to mine available incident data from other operators. Familiarity breeds poor discipline and relaxing of SOPs, which must be guarded against. A poor understanding of the benefits of a robust SOP culture and cockpit discipline is often accompanied by general disdain for scheduled CAT operations where "they only use the autopilot and can't really fly." Finally, a lack of competitiveness seems to breed less hungry FOs. Having been involved in command training in airlines, FOs were motivated to acquire the relevant regulatory and systems knowledge independently. I don't see that as the default situation in non-scheduled transport, where the environment is less disciplined. Couple this with the many flights consisting of two commanders switching seats between legs and it is an area where groups such as the IBAA or EBAA need to start a discussion.

These are my general observations, and there are exceptions i.e. private operators of one or two aircraft who are well drilled and exceedingly disciplined, or larger corporate operators who must have non-scheduled standard SOPs to cater for frequent different pairings of crew.

Finally, I know certain members here such as Pace favour the FAA system over the EASA system, being a pilot of an N-Reg with only an FAA licence. Do not forget that each ICAO member state has sovereignty over the airspace over their territory. Whatever the regulations and standards, it's our jobs as professionals to be current with applicable regulation, not argue the merits of different systems as though this somehow defends ignorance.

[de facto]

When one flies out of its own state/country,one should be familiar with rules/regulations/phraseology differences along the route.

[Pace]

Journey Man

A well written piece which in principal I agree with but I equally add that there are cockups in CAT too even with all the inbuilt safeguards

It may surprise you to know as it surprised the CAA too but statistically private jets flown by professional crew have a better safety record than equivalent in AOC operations.

I am sure that is nothing to do with better pilots but more to do with private jets being treated like a beloved private car with the same chauffeur

But on the whole I agree with the gist of your sentiments

Yes I went the FAA way with an ATP as that was where historically private jets were in Europe and it was perfectly legitimate to work them in Europe for far longer than the EU has existed. My other sentiments are more political and I firmly believe EASA missed a golden opportunity of harmonising aviation world wide

The FAA system is tried and tested and universally the most used model worldwide. As aviation knows no barriers from a safety angle it makes every sense that we all used the same regulation structure so that there is no room for errors going from one continent to another.
Going forward people are becoming more no barriers in movement for work too and in future pilots should be able to take work simply in different parts of the globe

EASA could have been more forward thinking and developed a system more towards the FAA system with some changes to suit Europe but that would not have secured the longevity of their department size, their lavish pay structures and benefits and so they decided to reinvent the wheel something they were warned about years ago by the commission.

i have been flying 30 accident free years plus so it won't make a massive difference to me other than I will stop flying a few years earlier faced with the costs and time in converting to holding licenses which have no bearing on the reg I fly. That will be a cost /time decision I will need to make depending on how things pan out.
But that doesn't change my opinion on the ridiculousness of the whole thing and taking things off topic ;)

Pace

[Cows getting bigger]

I don't fly IFR below SA. If someone tells/asks me to do so, I ask them why? I did it the other week at a UK airfield which gave me a climb out restriction below SA; I kindly declined and chose to stay on the ground.

[Bergerie1]

Like Cows getting bigger, I have refused a clearance below safety altitude and stayed on the ground until it was changed. I also agree with Journey Man that each sovereign state 'owns' its own airspace and can decided the rules which govern it - therefore, it is our business as pilots to know these rules.

However, I have long been an advocate of a common transition altitude across the whole of Europe, either 18,000ft, as in the States, or 15,000ft (it doesn't really matter which) as a means of reducing yet one more source of error.

[Aluminium shuffler]

Have I read the comments correctly? An abysmal lack of airmanship leads to a very close brush and it turns into a "why the US is so much smarter" thread! Given the number of runway excursions, landings on incorrect runways and airports that occur Stateside and cock ups many Americans make around the rest of the world and at home (ATC to visiting aircraft) due to sloppy RT, please explain why they are seen as the higher standard. As many said, 2000' isn't a FL anywhere, and even then it's irrelevant to the discussion. A clearance to FL200 cannot be interpreted as 2000' by anyone competent, so what the hell has this got to do with nationalities?

[Pace]

AS

Its not got to do with nationalities. Cockups occur in CAT as well as in Private as well as with ATC. As far as I have seen there is no safety benefits over FAA or EASA statistically only harmonisation between the two systems reduces the chance of mistakes

I fail to understand why ATC knowing something was wrong with the understanding of the clearance then recleared the aircraft to FL300 from FL200?

Surely they should have said " Climb immediately to 6000 feet (or whatever) on 1002 (or whatever) Read back
Their reaction was to reclear the aircraft from FL200 to FL300 which hardly indicates anything wrong or urgent

Pace

[Chesty Morgan]

Frankly I am surprised no one picked on another problem here - I don't know where the boundary in Europe lies but in the US you are not allowed to use flight-level terminology if you are below 18000 feet
How do you ever get cleared to a flight level?

[Pace]

I don't know where the boundary in Europe lies but in the US you are not allowed to use flight-level terminology if you are below 18000 feet

All over the place hence a standardisation over Europe is much needed

It could be the very reason that they were not used to FLs at low level that they used that terminology incorrectly

Pace

[Hawker 800]

AS

Its not got to do with nationalities. Cockups occur in CAT as well as in Private as well as with ATC. As far as I have seen there is no safety benefits over FAA or EASA statistically only harmonisation between the two systems reduces the chance of mistakes

I fail to understand why ATC knowing something was wrong with the understanding of the clearance then recleared the aircraft to FL300 from FL200?

Surely they should have said " Climb immediately to 6000 feet (or whatever) on 1002 (or whatever) Read back
Their reaction was to reclear the aircraft from FL200 to FL300 which hardly indicates anything wrong or urgent

Pace


Pace

This was a CAT flight. I agree though (and I fly for a UK AOC on a Hawker in addition to a bit of 'private' BizJet flying in the same type) that private operators generally have very high standards, often better than AOC operators. Don't think that the majority are cowboys...

ATC cleared them to FL300 and expedite. They were trying to salvage the situation, probably understanding the problem.

The Controller was concerned that the aircraft had levelled out at 2,000 ft and was tracking towards high ground in the Slieve Mish area of Co. Kerry. The controller then instructed the Flight Crew to climb to Flight Level Three Zero Zero and to expedite their climb until they were through four thousand feet.

It could be the very reason that they were not used to FLs at low level that they used that terminology incorrectly

No excuse for not being aware of MSA or local procedures. Even if it was their first trip across the pond, you'd think that their company would have a briefing sheet for Europe and the North Atlantic that they would read. I'll guarantee that they've sat through a Simcom, FSI or CAE International Procedures course. If they'd have listened, maybe this wouldn't have happened.


At 14.36:51 hrs the Flight Crew replied "We were cleared only to Flight Level Two Zero Zero". Shannon Low Level Control persisted "Okay sir that’s copied but your passing altitude...your current altitude". At 14.36:59 hrs the Flight Crew replied "And we confirm that we are cleared up to Flight Level Zero Two Zero… Two Thousand feet".


Worrying. Even more worrying is that the crew were self admittedly confused as to the cleared level, and didn't ask....


According to the Pilot’s Report Form "Our altitude climb instruction was "climb level Two Hundred". We read back the clearance and began the departure. As we began to climb we had some confusion as to what the altitude clearance limit was as we were unsure what level Two Hundred meant. We levelled at Two Thousand feet to ensure we didn't exceed any altitude limits. We contacted departure control and informed them we were level, they questioned what altitude we were climbing through and we clarified that we were level. There was some question from ATC regarding what altitude we were cleared up to by Kerry and we informed the controller that we were unsure but were level at Two Thousand. He further cleared us to Flight Level Three Zero Zero and to expedite through Four Thousand Five Hundred, and we immediately began climbing. The flight continued on without incident".

[Bergerie1]

Aluminium shuffler, I wasn't suggesting things in the USA were better, in fact, having flown, there some things are worse (please don't jump down my throat, everyone). The fact is we can always improve air safety by progressively removing those things that incline people more likely to make mistakes. And a uniform Transition Altitude, in my opinion, would help.

[RAT 5]

"Our altitude climb instruction was "climb level Two Hundred". We read back the clearance and began the departure. As we began to climb we had some confusion as to what the altitude clearance limit was as we were unsure what level Two Hundred meant. We levelled at Two Thousand feet to ensure we didn't exceed any altitude limits.

The correct time to solve that conundrum was before the wheels left the ground; i.e. during the read back.

[ROSUN]

Did confusion set in because one of the waypoints was 020?

[Uplinker]

Sorry to shout, but

IF IN DOUBT, CHECK.

If we are ever in doubt about, or mishear a clearance, we must ask for clarification.

I do this and I don't mind if it makes me seem stupid; it's a hell of a lot less stupid than flying into a hill.

[philbky]

I live in Kerry and am well aware of the terrain surrounding the airport. Standing at the airport, many of the mountains are either in full view or partly shrouded in cloud depending on the day. Taken in conjunction with the heights and spot heights on the charts,it should have been blindingly obvious that the mountains are higher than 2000ft in close proximity to the departure end of 26 on a direct track to VENER.

Judging from the statement in the report that the Kerry controller told the Shannon low level controller that "he's just gone into cloud there now", in conjuction with the diagram of the departure, again it should have been blindingly obvious that the mountain tops exceeded the bottom of the clouds which were at circa 2000 feet.

Regardless of any confusion over the delivery of the cleared height, there is a clear lack of planning and situational awareness evidenced in the report.

Equally as worrying is the delay in installing and implementing the operationof ATM equipment in Kerry tower. Unfortunately this is a cultural thing here with examples of projects, both public and private, in many fields of everyday life being started in response to a need and then delayed time after time for no explicable reason.

[Basil]

IF IN DOUBT, CHECK.
Yup, no matter how many 'looks' you get from the captain or, in the past, smartass comments from other crew, don't even ask "Should I clarify that?" JDI!

[Dimitrii]

I bet the mic problem got them out of understanding mode into just get it back to them mode.

There followed three unsuccessful attempts by the EIKY Tower Controller to obtain a read back of the clearance from the Flight Crew. Finally, the Flight Crew transmitted “Ah let me try this mic is this any better” to which the EIKY Tower Controller responded “Affirm initially I got the start of your transmission and then it blanked out just a blank sound dead air so if you can just give the read back again please”.

[+TSRA]

No, he couldn't have been a North American pilot precisely because of the above. No NA pilot will use flight level for such low altitudes.

Porterhouse, a NA pilot would use FL terminology below FL180 in Europe where the transition altitude is as low as 2,000 feet in some locations.


Originally Posted by porterhouse View Post

Frankly I am surprised no one picked on another problem here - I don't know where the boundary in Europe lies but in the US you are not allowed to use flight-level terminology if you are below 18000 feet

How do you ever get cleared to a flight level?

In NA you only get cleared to a Flight Level if operating above 18,000 feet.

From there ATC will nominate the lowest useable flight level based on the local altimeter setting. FL180 for 29.92 and above, FL190 for 29.91 - 28.92, and FL200 for anything below 28.91.

This is why I see part of what this incident crew did wrong. They're used to hearing a Flight Level as being much, much higher. Then they read that a Flight Level can start as low as 2,000 feet in Europe and suddenly they are confused by a clearance.

What they should have done above all else is to slow their process down. Maybe they did check the MSA but in the flurry of everything else, they forgot. Maybe one of them did read somewhere that they could expect to hear "Flight Level Two Hundred," but then forgot what that means. Maybe, just maybe, they put their trust into the controller who (seemingly to the crew) gave them a clearance to below the MSA and below the local transition altitude. But not knowing all the local regulations, they accepted it...then, when being questioned about what altitude they were at, they read the clearance back as it made sense to them, with a quick jab across the cockpit to say "but here that means this." From there, the spiral began.

Frankly, I'm surprised at the number of "super pilots" who obviously have never read back a clearance wrong, have never forgotten the MSA, or who accepted a clearance without fully understanding it. I guess these "sky gods" all work in a part of the industry where they either never leave home or always fly to the same destinations.

I remember my charter flying well; and I remember being utterly confused and bewildered some of the time by the flow of new information I was suddenly expected to be an expert on. Perhaps that's why I'm willing to throw these guys a bone and say that, while it was a serious mistake with fatal implications that I personally would have clarified before leaving the ground, I understand why they did it and it in no way makes them less of a pilot than I.

[His dudeness]

What amazes me, is that I either overread the info on previous flights/sleep patterns/time acclimate to local time or it is not in the report...

THIS is EXACTLY the fukc up one expects when you are out of your comfort zone fatigue wise. Of course, thats just my opinion, however...

The broken mic will certainly not have helped to create a, say, comfortable atmosphere.

And +TSRA is right, the amount of info can overwhelm one, especially in types without APU.

Together with the ever increasing BS "they" (e.g. Eurocontrol and local ATC provider) throw at one (CTOTs, TOBT etc.etc.), this is an accident waiting to happen (not saying it has anything to do with this one...)

[Pace]

We all make mistakes in the heat of the moment! In most cases it's nothing! no big deal just slap each others wrists in other cases that mistake can be very serious or even fatal

Private jets or CAT EASA or FAA we all do it

I remember that Ryanair operated 737 landing at the disused military airfield next to Londonderry an airfield I flew to a lot at that time.

How could both Crew on a RyanAir operated 737 mistake the two airfields ?

Having made an identification mistake to then carry on to a landing on a disused runway with two crew and loads of visual cues was hard to get my head around! But it happened. If it had been a private jet there would be cries of cowboy pilots

All the passengers had to be bussed out and across to the active airport and the aircraft removed empty after the runway had been cleaned and inspected

Pace

[Chesty Morgan]

NA you only get cleared to a Flight Level if operating above 18,000 feet.

From there ATC will nominate the lowest useable flight level based on the local altimeter setting. FL180 for 29.92 and above, FL190 for 29.91 - 28.92, and FL200 for anything below 28.91.

The same everywhere. You missed my point - How would you get cleared to a flight level if you weren't allowed to ever mention flight level below the TA?

It was however, tongue in cheek.

[clunckdriver]

Regardless of the circumstances in this case why cant the EU who mandate what size a cucumber must be can come up with a standard transition level ?{as in Canada, F/L 180, which puts the aircraft above the big rocks} some of the transition levels are simply too low given the rate of climb/descent of many aircraft in service in this day and age, it also prevents the QFE holdouts from trying to remove the top 300 feet of the local lumps. {Well not all the time, but it does reduce the chances of hitting a grain elevator as done by a certain exchange pilot a few years back}

[Pace]

Regardless of the circumstances in this case why cant the EU who mandate what size a cucumber must be can come up with a standard transition level ?{as in Canada, F/L 180, which puts the aircraft above the big rocks} some of the transition levels are simply too low given the rate of climb/descent of many aircraft in service in this day and age, it also prevents the QFE holdouts from trying to remove the top 300 feet of the local lumps. {Well not all the time, but it does reduce the chances of hitting a grain elevator as done by a certain exchange pilot a few years back}

Totally agree, We have the Alps and FL180 would be a good starting point. It is ridiculous that there is so much variation.
There was talk from EASA of having a standard transition level then it died a death :ugh:

Pace

[23c]

Dear Pace. Please get your facts right. The incident you refer to at Ballykelly in 2006 was not operated by Ryanair. They had subbed the flight to Eirjet who operated an A320, not a B738. I am not a fan of RYR but I do take issue with your derisory comments of their crew without bothering to check the facts.

[His dudeness]

Dear Pace. Please get your facts right. The incident you refer to at Ballykelly in 2006 was not operated by Ryanair. They had subbed the flight to Eirjet who operated an A320, not a B738. I am not a fan of RYR but I do take issue with your derisory comments of their crew without bothering to check the facts.

So he talked about Ryan instead of Eirjet, and 320 instead of a 737.

The point he was trying to make was a different one and you know that.

If I were a pompous git, I´d say I take issue with that.

But I´m not.

[ZOOKER]

This is a whole catalogue of 'gotchas', that fortunately, everyone walked away from.
I don't know what plates the crew were looking at prior to departure, but the transition altitude at EIKY is 5000'. On all the cockpit-trips I was privileged to do during 30 years as an operational ATCO, I'm fairly certain TA was mentioned as part of the pre take-off briefing, conducted by the crews. Was this a single-pilot operation? The report makes references to 'the crew'.
If I remember correctly, the 'FL One hundred' phraseology was brought in in the U.K. FIR due to the frequent confusion between FL100 and FL110.
It can be argued that similar confusion is unlikely between FL200 and FL210/300 and 310, etc.
The proposal for a harmonised EASA Europe-wide, transition altitude is also interesting. There is no doubt that some form of 'standardisation' is required. In the U.K. FIRs, we have TA's of 5000, 6000, or 3000', depending on where you are.
My own personal preference would be a TA of 6000' across the UK/Ireland FAB. OK, it doesn't align with the terrain in the rest of the EASA/SESAR region, but if you're flying over the U.K. or Eire, the highest thing you'll be likely to hit is Ben Nevis, at 4414' AMSL.
One of the problems with introducing an 18,000 transition altitude in the UK and Eire is the frequent occurence of steep horizontal pressure gradients, which are related to our position on the edge of a North Atlantic continental land-mass. Descending from FL 200 the QNH at the transition point could easily be 4mb/HPas different from that at the destination airfield. i believe the Met Office have suggested upwards of 40 altimeter-setting-regions, (ASRs), would be required. If 'climate-change' predictions are to be believed, such steep pressure-gradients will become more frequent in the years ahead.
Safe flying Y'all, and as has been already said..."If in doubt, just ask". Anything which prevents 'form-filling' is good news, no matter which side of the mic you're on.

[Pace]

Dear Pace. Please get your facts right. The incident you refer to at Ballykelly in 2006 was not operated by Ryanair. They had subbed the flight to Eirjet who operated an A320, not a B738. I am not a fan of RYR but I do take issue with your derisory comments of their crew without bothering to check the facts.

Operated by was not clear I meant subcontracted by so I stand corrected as I do on the aircraft Type A320

Derisory comment on the Crew? I was making a point that we all make stupid mistakes private, CAT, EU reg or FAA. Most of us get away with it but some at the wrong point can have serious or very embarrassing consequences.

I made that comparison as had this been an FAA reg business jet no doubt there would be derisory comments on FAA cowboy pilots

Even with two crew at close quarters neither noticed and instigated a go around ?

As they had no charts for this disused runway and had no clue where they were landing it was lucky that it was well long enough for them

if Eire Jet were subbed by Ryan air to do the flight there is still a responsibility to meet the standards required ?


http://news.bbc.co.uk/1/hi/northern_ireland/4857962.stm

https://assets.digital.cabinet-office.gov.uk/media/5422f88ae5274a1317000729/Airbus_A320__EI-DIJ_01-07.pdf

Pace

[+TSRA]

The same everywhere. You missed my point - How would you get cleared to a flight level if you weren't allowed to ever mention flight level below the TA?

It was however, tongue in cheek.

That's fair. But these are guys who are used to the term "Flight Level" to mean everything above 18,000'. They're then sent to a location where that term may mean anything down to 5,000' in a (wide) geographic area of the world where it can be as low as 2,000'. Then they hear a clearance they've never heard before ("Flight Level Two Hundred") and it is easy to see how they could confuse that to mean 2,000' instead of 20,000'.

[olasek]

("Flight Level Two Hundred") and it is easy to see how they could confuse that to mean 2,000'
No, it is not easy to understand for me since it one insists on this flight-level "mania" 2000 feet would be flight level twenty, not two hundred. I can't see how you can hear two hundred and translate it in your mind into ... twenty. Also, if they never heard 200 versus 2-0-0 (big deal!!), had slightest doubt they could have asked for clarification, actually it was their duty to do so. These pilots should be grounded and sent for some retraining.

[+TSRA]

Give me a break. Grounded and retraining? So you've never once made a bonehead mistake? Well, I guess in that case you are one of those way better pilots than I. Anyone who makes a mistake in this industry should be shown the door I suppose.

[RAT 5]

Guys: KISS. You are sitting on the ground, warm & cosy. You receive a clearance to leap into the unknown with confusion in your mind. Your warm cosy feeling is disturbed. What would you do? Take a leap of faith that it'll be alright on the night and you'll sort it out with ATC later; or pause, consider and ask again? Then you can leap off and still feel warm & cosy knowing exactly what you re going to do. Let's not use too much energy trying to find excuses for why FL 200 was mistaken for 2000' once airborne. That is too late to be confused.

[Pace]

It would be interesting to know the weather at the time of flight? Did he enter low scud cloud and was on top at 2000 and hence visual with terrain or in between cloud and visual? Or was he at 2000 and solid IMC ?
If he was visual and levelled temporally to get clarity incase ATC had wanted him to stop at 2000 but he could see the mountains that is different to blindly levelling at 2000 in IMC with a CFIT potential.

According to the Pilot’s Report Form “Our altitude climb instruction was “climb level Two Hundred”. We read back the clearance and began the departure. As we began to climb we had some confusion as to what the altitude clearance limit was as we were unsure what level Two Hundred meant. We levelled at Two Thousand feet to ensure we didn't exceed any altitude limits. We contacted departure control and informed them we were level, they questioned what altitude we were climbing through and we clarified that we were level. There was some question from ATC regarding what altitude we were cleared up to by Kerry and we informed the controller that we were unsure but were level at Two Thousand. He further cleared us to Flight Level Three Zero Zero and to expedite through Four Thousand Five Hundred, and we immediately began climbing. The flight continued on without incident”.

From this it looks like he took LEVEL as to be LEVEL not FL On ATC realising he was level at 2000 feet they then give a strange clearance to climb Flight level 300 from level 200 hardly a terrain avoidance clearance? itself a confusing response instead of expedite climb immediately to XYZ feet on 1002 (or whatever) read back with maybe a terrain warning ?

Historically there was confusion over Level with pilots saying " Level at FL270 ( example) and that was changed to " maintaining FL270" so as not to confuse the two and that appears the case in this situation where wrongly the pilot took LEVEL as to be LEVEL

Pace

[Cows getting bigger]

Pace, the METARs. AAIU says the aircraft departed at 1535Z.

EIKY 161630Z 25009KT 220V290 9999 FEW013 BKN021 18/15 Q1023=

EIKY 161600Z 23011KT 9999 SCT015 BKN025 18/15 Q1024=

EIKY 161530Z 19007KT 160V260 9999 SCT017 BKN024 18/15 Q1024=

EIKY 161500Z NIL=

EIKY 161430Z 20007KT 170V240 9999 FEW016 BKN018 OVC024 17/14 Q1024=

EIKY 161400Z 23008KT 9999 SCT016 BKN021 17/14 Q1024=

[Pace]

EIKY 161600Z 23011KT 9999 SCT015 BKN025 18/15 Q1024=
EIKY 161530Z 19007KT 160V260 9999 SCT017 BKN024 18/15 Q1024=

So it appears that at 2000 feet he was below broken cloud and in good visibility with maybe some scattered below and hence visual with the terrain ahead but once climbing into cloud would be on an unknown climb profile re terrain having delayed the climb

[Aluminium shuffler]

If they had been instructed to maintain a lower altitude, that would have been said as such - European ATC units do not ask someone to maintain level at an altitude. That is a poor excuse.

I agree that harmonising EU transition altitudes would be nice, but the explanation about needing a ridiculous amount of ASRs to cover the wildly differing QNHs makes sense - I had never heard that explanation before and it seems entirely logical. All the same, a 6000' TA across Europe must be "doable". I still can't see how uncertainty over TA could be an issue in this incident - if cleared to a FL, then you know you're going up reasonably high, much more than 2000', and nobody would stop at 2000' out of EIKY if they had any situational awareness.

[Steve6443]

I think we can all be thankful for the controller who realised that the pilot was out of his depth because he stated 'cleared to Flight Level 300' and told the PIC to expedite his climb through 4500 feet because otherwise, with all likelihood, the PIC would have levelled off at 3000 feet and smacked into the terrain around the airport......

Having said that, the mind still boggles how ANYONE, irrespective of where they fly, can confuse Flight Level 200 with 2000 feet...... Even if flight levels begin at 18.000 feet in the US, surely he'd have received clearance to Flight Level 240 or similar before and understand that Flight Level 200 and 240 are 4000 feet apart, not 22.000?

[Solidfuel]

I don't find the crew's explanation satisfactory. How can anyone think level 200 means 2000ft? Utter nonsense! Even if they are utterly confused about TA and have no idea what a flight level is. If they thought it was fl200 they should know what that is, if it was an altitude it would be 200ft - which would clearly need to be challenged. Do they also think 2+2=5?

[fireflybob]

Guys: KISS. You are sitting on the ground, warm & cosy. You receive a clearance to leap into the unknown with confusion in your mind. Your warm cosy feeling is disturbed. What would you do? Take a leap of faith that it'll be alright on the night and you'll sort it out with ATC later; or pause, consider and ask again? Then you can leap off and still feel warm & cosy knowing exactly what you re going to do. Let's not use too much energy trying to find excuses for why FL 200 was mistaken for 2000' once airborne. That is too late to be confused.

RAT, I agree 100% - this is where the error chain started.

[neila83]

I am very confused as to how because it was said FL 2-0-0 rather than FL 200 they understandably thought this meant 2000ft?! I know I had a socialist education and may be missing something, but to me FL200 looks remarkably like FL200.

Seems any excuses will be made once it's established the pilots are from a certain perfect nation. How different this thread would be if the pilots were from somewhere further towards where the sunrises. Of course one contributer assured us the pilot couldn't possibly be American :rolleyes:

And I fully agree with whoever suggested some retraining is in order. Is that not the positive safety culture in action? Don't fire them but probably a good idea to make sure they don't play hide and seek in the hills below MSA again.

[captainsmiffy]

For what it is worth in this debate, I have recently had to take up sim training when my medical went sarfff....and I am quite frequently picking younger guys up after I have cleared them to FL60 when they check in "climbing 6000". Altimetry and strict adherance to its conventions was drummed into me in the air force but, clearly, similar emphasis is being missed somewhere along the way. You simply have to be an absolute pedant when it comes to altimetry.....

[chimbu warrior]

No excuse for not being aware of MSA or local procedures. Even if it was their first trip across the pond, you'd think that their company would have a briefing sheet for Europe and the North Atlantic that they would read. I'll guarantee that they've sat through a Simcom, FSI or CAE International Procedures course. If they'd have listened, maybe this wouldn't have happened.

My recollection is that the FAA mandated the completion of an international procedures course before pilots involved in commercial operations could fly internationally; is that not the case for part 135?

[Future Rodney King]

1. Why no observation of TA on departure? Part of brief surely?

2. QNH should have been set on standby until passing the latter of TA or MSA.

3. Looks like SA was very thin on the ground.

4. Believing of clearance to be a FL below TA?

5. Sloppy altimeter setting procedures coupled with poor SOP's.

6. No error trap.

7. Luckily no one died in the process.

To many pilots call passing FL..... climbing FL..... on hand over when still below transition. The correct read back should be passing altitude until you are above the transition using your standby altimeter for reference, a lack of understanding? As for the issue and read back of flight levels, using the terminology "FL Two Zero Zero", "FL Three Zero Zero" etc. is not without confusion. The simple use FL200/ FL300 surely safeguards against this? Why do some pilots feel the need for a Europe wide TA? Surely any transition altitude should form part of your pre departure brief serving to increase awareness of your SSA on departure.

Incorrect altimetry procedures and the potential threats of, require robust SOP's and subsequent adherence to them to mitigate the risk. Its seems that this was not observed on the day. Or maybe there was a genuine lack of understanding by the PIC?

[Uplinker]

........I am quite frequently picking younger guys up after I have cleared them to FL60 when they check in "climbing 6000". Altimetry and strict adherance to its conventions was drummed into me in the air force but, clearly, similar emphasis is being missed somewhere along the way. You simply have to be an absolute pedant when it comes to altimetry.....

Say nothing but give them a TCAS or EGPWS alert. That might wake them up.

Agree about RT pedantry. Many folk seem to think it is 'flashy' or clever to abbreviate RT phraseology, but they completely fail to understand that on a bandwidth limited VHF radio link, with atmospheric interference and less than perfect broadcast quality microphones; What you might say into your microphone does not come out perfectly in the headphones of the person receiving. Also, 'your' abbreviation might be completely misunderstood by the person receiving, so it is really important to only use approved and correct phrases.

Embarrasing as it can seem - we have surely all been there - if you cannot understand a clearance due to a bad microphone or different accent or whatever, please check and clarify. In this case, if the crew had simply asked (on the ground) "Just to clarify; are you clearing us to Altitude 2000 feet or Flight level 2 zero zero?" it would have easily resolved the issue. There can be no shame in double checking in aviation.

[EMIT]

From thee report, as written by the pilot, it seems that they were not under the impression that FL200 would represent 2.000 ft, but they were unsure what their cleared level was and temporarirly levelled off at 2.000 ft to get clarification first. Of course, levelling of below MSA, IF not in VMC, was not a wise decision. Subsequently there was confusion in the communication with the controller, where the controller probably expected the "flying level" would mean that the aircraft had reached its assigned level. This communication mix up prolonged the undesirable situation of flying below MSA.
It is unclear whether the unsure feeling about the cleared level existed on the ground, or whether the pilot(s) had a brain fart once airborne?

[akaSylvia]

That's a very generous reading of the situation.

At 14.36:40 hrs the Flight Crew replied “Ah we are level Flight Level Two Zero Zero and squawking Six Three Zero Four”. Shannon Low Level Control then said “November One Three One Zero Hotel Shannon radar contact and just confirm your passing altitude”. At 14.36:51 hrs the Flight Crew replied “We were cleared only to Flight Level Two Zero Zero”. Shannon Low Level Control persisted “Okay sir that’s copied but your passing altitude...your current altitude”. At 14.36:59 hrs the Flight Crew replied “And we confirm that we are cleared up to Flight Level Zero Two Zero… Two Thousand feet”.


There's really no question in my mind but that they felt that FL200 represented 2,000 feet and thus they were level at their clearance.

Edit: Never mind the fact that they did not ask for clarification.

[Journey Man]

To many pilots call passing FL..... climbing FL..... on hand over when still below transition. The correct read back should be passing altitude until you are above the transition using your standby altimeter for reference, a lack of understanding?

Subtle difference in the UK:

UK AIP ENR 1.7 paragraph 5.1.4 states ‘...when cleared for climb to a Flight Level, vertical position will be expressed in terms of Flight Level...’

https://publicapps.caa.co.uk/docs/33/SafetyNotice2014004.pdf

http://www.ead.eurocontrol.int/eadbasic/pamslight-185C21691017E242A56DF9F904157092/7FE5QZZF3FXUS/EN/AIP/ENR/EG_ENR_1_7_en_2016-03-31.pdf

[mayam13]

+TSRA
May be this pilot needs a quadruple channel computer to handle his 'levelling off'. By the way what is a 'highly professional easy mistake' ?

[Airbubba]

From thee report, as written by the pilot, it seems that they were not under the impression that FL200 would represent 2.000 ft, but they were unsure what their cleared level was and temporarirly levelled off at 2.000 ft to get clarification first.

This points out the additional possibility of numeric confusion over in the written domain. 2.000 ft is two feet where I come from (see: https://docs.oracle.com/cd/E19455-01/806-0169/overview-9/index.html). From context this is obviously not what you meant but it is another example of how ambiguities in expressing numerical quantities can bite us in the international flying business.

For years I've worked with a flight plan that has fuel in hundreds of pounds with no decimal on the flight plan, fuel in thousands of pounds with a decimal on the dispatch release and fuel in pounds on the ACARS performance printout.

I've had a fuel order of 2000 lbs. additional for weather pumped as 20000 lbs.(I purposely left out the numeric separator here ;)) more by a truck that was calibrated in liters. Not a big deal this time, we caught it on the crosscheck and didn't have a full load to begin with. We ended up tankering the extra fuel rather than going through a time consuming defueling process. I suspect the error was generated by decimal format confusion in the updated dispatch release and flight plan.

And, yes, like a lot of us, I've flown with fuel in kilos as well...

[Airbubba]

Subtle difference in the UK:

Excerpted from a list in one of the documents you linked:

The following hazards can and do result in a level bust:

• Low transition altitude particularly where initial Standard Instrument Departure (SID) clearance is to a flight level.

• Periods of high cockpit workload – take-off and climb, SIDs particularly with a stepped climb.

Those low transition altitudes in the UK combined with complex departure procedures are absolutely spring loaded to screw up in my opinion. I know it's a case of NIH, Not Invented Here, but I would hope that someday the UK will raise the transition altitude to something that is more user friendly to large aircraft. And, have more 'maintain runway heading or as assigned, climb to FL200' procedures. We promise we won't level off at 2000 feet next time.

In the U.S. many pilots choose to never fly internationally and often the training is based almost totally on domestic procedures.

Usually, by the time you get to 18,000 feet things have calmed down and its unlikely that you would both miss the transition so what's the problem, right? In recent years the feds seem to have required more realistic sim training for those of us who fly internationally.

Over the years I've seen many procedures for altimetry approaching transition level or altitude.

One procedure is for both pilots to wait until transition altitude to switch to QNE. Another is for both pilots to set QNE when cleared to climb above the transition altitude. And, a third is for one pilot to set QNE when cleared above transition altitude and the other to stay on QNH temporarily just in case ATC asks for altitude passing (and not level passing ;)).

Add the fact that some procedures include the standby altimeter which in the past may or may not have been 'corrected' (I think it means they didn't work well up high). And most autopilots will level on the captain's altimeter but with some procedures it's the pilot flying's indication that the autopilot sees.

And, in the case of a low transition altitude with and initial SID clearance to a flight level, for a while we were able to optionally set QNE before departure as a 'strategy of threat mitigation'. Then someone observed that our performance data and noise profiles were based on QNH altitudes.

Anyway, I'd rather be 400 feet off on the altitude passing call to ATC than on the level off so I tend to be proactive about setting QNE and QNH early.

[Future Rodney King]

Subtle difference in the UK:

Quote:
UK AIP ENR 1.7 paragraph 5.1.4 states ‘...when cleared for climb to a Flight Level, vertical position will be expressed in terms of Flight Level...

Unless... quote ENR 1.7

unless intermediate altitude reports have been specifically requested by Air Traffic Control.


Climbing in controlled airspace pilots will still reference an altimeter set to 1013 and read off a requested "passing altitude". Hope thats clearer?

[captainsmiffy]

I know that earlier I mentioned being an altimetry pedant.....so, airbubba...QNE isnt the standard pressure setting, as you seem to imply. Rather, it is the altitude of the runway that would be read on the altimeter if standard were set....and is used if the pressure was either too low or too high to set on the altimeter.

[captainsmiffy]

In effect, the Flight level of the runway.....used if the actual pressure could not be set on the altimeter, which, if memory serves me is outside of 950 to 1050 mb.

[ZOOKER]

captainsmiffy,
that is how I always understood QNE. I never used it in 30 years of controlling in the U.K.
The first NATS 'fam flight' I ever did, was in the cockpit of a BEA Trident 3, in fact it was the same a/c that is now preserved at EGCC. Sitting behind the captain, as a newly-valid ATCO, I asked him what advice he could give me, to make his job that bit easier?
I remember him mentioning something along the lines of "always use the term 'flight level' when appropriate"........So I did, and passed that advice on to all the u/t ATCOs I met later on.
Much later on, The U.K. introduced the term 'degrees' for heading instructions, and 'altitude' for QHH-based level instructions. Both were initially a pain to keep saying on the R/T, but, hey, they seem to work.
Altimetry took up a fair bit of the ATC Technical Course, back in the 1980s. It still needs to be fully understood today, even with the technology we now have.
As has been stated above, as with every aspect of ATC......"If in doubt, just ask".

[av8r76]

I'm probably going to end up in a crater because karma just plays it so. But I will venture out and say, even the slightest doubt on any radio transmissions and I will without fail ask for clarification in plain English if need be to ensure there is no discrepancy or doubt.

In a globalized world where we mingle with diverse cultures, miscommunication is a distinct and present threat we have to recognize and mitigate.

I have quite evidently annoyed local ATC at the end of a 12 hour duty day at 10am for repeated confirmations just because that particular situation warranted it. It is theirs and my job to ensure we get down safe. No matter what the perceived annoyances.

[Airbubba]

I know that earlier I mentioned being an altimetry pedant.....so, airbubba...QNE isnt the standard pressure setting, as you seem to imply. Rather, it is the altitude of the runway that would be read on the altimeter if standard were set....and is used if the pressure was either too low or too high to set on the altimeter.

Thanks for the correction :ok:, folks have set us straight on this one before here on PPRuNe:

Sorry to be a bit pedantic, but QNE is not in fact an altimeter setting.
QNE is the elevation of the airfield (threshold?) when 1013.2 is set on the altimeter.

http://www.pprune.org/questions/65806-qnh-qne-qnf-altimeter-settings.html#post622468

I was trying to say when the altimeters are set to 'standard', i.e. 29.92 inHg or 1013.2 hPa.

[Flap62]

I struggle to see how the variations in transition altitude make any difference. If ATC tell me to climb to XXXX thousand feet, I climb to xxxx thousand feet on the QNH. If they tell me to climb to FL xxx, I set 1013 above accel altitude and climb to FL xxx. How is that difficult? If you're told to climb to FL xxx and you then level at xxxx feet on the QNH you've almost certainly got it wrong!

[olster]

It is not impressive SA to level off in IMC below MSA because of an altimeter misunderstanding. Correct altimeter protocol is important but so is avoiding CFIT. When in doubt speak up!

[Capn Bloggs]

Why do some pilots feel the need for a Europe wide TA? Surely any transition altitude should form part of your pre departure brief serving to increase awareness of your SSA on departure.

Are you serious? "Keep it simple stupid!". Never flew there, but I couldn't think of anything worse... not only differing TAs but so low. What's the point? Get it up well above where you can at least get the machine cleaned up and comfortable before twiddling BARO settings...

[Airbubba]

Get it up well above where you can at least get the machine cleaned up and comfortable before twiddling BARO settings...

Absolutely. Some of those SID's in the UK have you take off on the local altimeter setting, start turning to several waypoints whilst [sic :)] hitting altitude constraints like 4000 feet. You can't start cleaning up the aircraft other than raising the gear until 3000 feet AGL and just as you are retracting the flaps, leveling at 4000 and accelerating you get a frequency change and a climb unrestricted to a flight level above the transition altitude at, say, 5000 feet. We are professionals, it builds character, 'I used to fly that departure with NDB's on one receiver with raw data' etc., etc., etc...

But, does it really need to be that hard? At least raising the transition altitude would take one possible trap out of the initially busy departure procedure.

[Future Rodney King]

Are you serious? "Keep it simple stupid!

I am serious, and don't call me stupid.

Maybe we should make it easier for the likes of yourself?

At least raising the transition altitude would take one possible trap out of the initially busy departure procedure.

That maybe, but at the cost of a Europe wide redesign of airspace structure. I think not.

[atpcliff]

I fly all over and never heard "Flight Level Two Hundred" (or three hundred). That would be a bit confusing.

I also don't like the "low" flight levels. I think Transition Altitude and/or Level in Dar Es Salam, Tanzania is 2,500'.

[RAT 5]

That maybe, but at the cost of a Europe wide redesign of airspace structure. I think not.

And what did the construction of the 'not quite so successful as it was conceived' Eurocontrol cost? But it's still there and has evolved and improved slowly. Cost investment now for long-term benefit often seems expensive. The amount of dosh swashing around in European aviation would swallow any such structural change if a hiccup.

[galaxy flyer]

atpcliff,

Maybe you fly all over, but you haven't flown in the UK and much of Europe, if you haven't heard "FL Two Hundred".

[Capn Bloggs]

Maybe you fly all over, but you haven't flown in the UK and much of Europe, if you haven't heard "FL Two Hundred".

In the atipodes a few years ago, FL "two hundred" (and I think Heading "two hundred?) was introduced to reduce confusion. We possibly inherited it from some other country? In any case, we then changed back to "two zero zero".

I see that UK CAP 413 (2011 version) says:

d) When transmitting messages containing flight levels each digit shall be
transmitted separately. However, in an endeavour to reduce ‘level busts’ causedby the confusion between some levels (100/110, 200/220 etc.), levels which are whole hundreds e.g. FL100, 200, 300 shall be spoken as “Flight level (number) HUN DRED”. The word hundred must not be used for headings.

I am serious, and don't call me stupid.

Maybe we should make it easier for the likes of yourself?
Rodney, we already have TA/TL as 100/110. It works well. Try it one day. :ok:

[Airbubba]

Are you serious? "Keep it simple stupid!"

I am serious, and don't call me stupid.

As in :ok::

Ted Striker: Surely you can't be serious.

Rumack: I am serious... and don't call me Shirley.


Airplane! (1980) - Quotes - IMDb (http://www.imdb.com/title/tt0080339/quotes)

[Aluminium shuffler]

As per my earlier post, we yet again see the Americans turning this into a peeing contest of how their rules are better and the rest of the world should bow to them. The transition altitude was utterly irrelevant to this incident, as is the debate surrounding it. Two pilots paid insufficient attention to their clearance, and even less to what they set on their MCP. They then levelled off at a stupidly low altitude 2500' below the MSA, showing a stunning lack of awareness of the terrain around them. They were cleared to FL200. They could have changed their altimeter settings at 2000', 5000', 10000', 18000' and still not have had an issue. There is a smokescreen constructed around a lack of attention to clearances, MCP operation and chart details, and evidently there was no briefing or cross checking as both pilots made the error together without any idea about the impending CFIT. Stop turning this into a US vs the world bragging match.

[Icarus2001]

Or perhaps this is a North American pilot used to a Transition Level of FL180.

All I said, in different words, was that a pilot who is never used to hearing "Flight Level Zero Two Zero"

Your posts do not make sense to me. :confused:

If he is used to a TL of FL180 then he must also hear FL200?

[HeartyMeatballs]

Really? The country that gives us classics like "BIGPLANE 123, out of thirty three three for thirty seven...." Or "We descend......... The BIGPLANE 123" is lecturing us about how their system is better?

[Airbubba]

If he is used to a TL of FL180 then he must also hear FL200?

FL200 verbalized as 'flight level two zero zero' is certainly a level that you get in the U.S.

However, it was given to the pilots by the tower controller as 'flight level two hundred', that is not something you will ever hear in a U.S. clearance.

Expressing flight levels in hundreds is a common practice in the UK but it is non-standard in Ireland and most other places in the world as other folks have observed here.

And, Americans are just not good with figuring out flight levels other than round numbered ones above FL180. It's a gotcha and we need to be a lot more careful in my opinion.

As I said earlier in the thread:

Many of my U.S. colleagues seem puzzled when I wince at their calls like 'passing flight level twenty-three point six climbing to flight level two seven zero'.

[4runner]

As per my earlier post, we yet again see the Americans turning this into a peeing contest of how their rules are better and the rest of the world should bow to them. The transition altitude was utterly irrelevant to this incident, as is the debate surrounding it. Two pilots paid insufficient attention to their clearance, and even less to what they set on their MCP. They then levelled off at a stupidly low altitude 2500' below the MSA, showing a stunning lack of awareness of the terrain around them. They were cleared to FL200. They could have changed their altimeter settings at 2000', 5000', 10000', 18000' and still not have had an issue. There is a smokescreen constructed around a lack of attention to clearances, MCP operation and chart details, and evidently there was no briefing or cross checking as both pilots made the error together without any idea about the impending CFIT. Stop turning this into a US vs the world bragging match.


The US has more than double the number of a/c than the rest of the world COMBINED. Just saying....

[4runner]

I fly all over and never heard "Flight Level Two Hundred" (or three hundred). That would be a bit confusing.

I also don't like the "low" flight levels. I think Transition Altitude and/or Level in Dar Es Salam, Tanzania is 2,500'.

That's awesome when you're descending to hold on the ils for 05, waiting for a caravan from Zanzibar and have wx between you and the airport.

[ATC Watcher]

The US has more than double the number of a/c than the rest of the world COMBINED

True and the FAA always resisted changes to ICAO based on that argument. The problem is that for many years only a tiny proportion of those aircraft were travelling outside the continental US , but now things are changing , and when they do go outside , it causes problems. Also the number of foreign aircraft /pilots entering continental US airspace is increasing. Time to wake up, and to be fair I think the FAA do realize they have an issue now,and plan to tackle it. At this this is what I hear.

[Bergerie1]

It has been interesting reading this debate, it reminds me of many I have had in the past, both within the UK, within Europe and within the USA. Clearly, as other have said, the pilots involved should have paid much closer attention to their ATC clearance. If there is one thing you DON'T do, it is to fly below your MSA.

I have long advocated a higher TA in Europe (18,000ft to harmonise with the USA and above Mt Blanc would be a good compromise) not only because of the harmonisation issue but, even more important, to raise it to an altitude where things are less busy. Others on this thread have mentioned the complicated SIDs out of Heathrow - turn here, turn there, level out until past xxx, then climb to yyy, change frequency to zzz, etc, etc. I have always thought to change altimeter setting in the middle of all this is only to invite yet another mistake.

And this brings me round to the subject of standardised terminology. This is not a case of the USA versus Europe or anywhere else in the world for that matter. When I used to fly many years ago, in different parts of the world, different phrases were used to clear aircraft to line up and then take-off (there are others too). And incidents were caused by such things. If we are really interested in safety we should work towards removing as many as possible of these differences.

It is not a case of just saying, 'pilots should take more care' or from a state ANSP's point of view, 'this system is best for our country'. However, professional a person may be, they are human and, as we all now, humans make mistakes.

So, please let us remove yet one more possibility for error and thus make the total system safer.

[Shot Nancy]

Many of my U.S. colleagues seem puzzled when I wince at their calls like 'passing flight level twenty-three point six climbing to flight level two seven zero'

Maybe they say it that way because Angels without Cherubs is clearer. Don't start on Devils. 😏

Regarding transition alt; I always believed it was above the highest MSA. I never understood the need in the UK for different TAs. How about a global TA?

[Pace]

How about a global TA?

Even better how about GLOBAL REGULATIONS full stop :ok:

[fireflybob]

Even better how about GLOBAL REGULATIONS full stop


Good grief! Please NO - I have enough trouble keeping up with all the EASA nonsense.

Don't get me wrong I'm not against better standardisation but you're never going to have a one size fits all. Part of pilot training and operation is management of altimeters etc.

Perhaps we should recall that all of us in the UK now have to suffer the imposition of having to say "Hectopascals" whenever the pressure is 999 or less because a couple of US operated aircraft confused inches with millibars (as they were then) and ended up with at least one potential CFIT at Birmingham (UK). We also have to suffer the nanny State stuff on the NOTAMs when the pressure is low reminding pilots how to set their altimeters.

Be careful when you fix one problem that you don't generate a load more.

When in Rome do as the Romans.

[DirtyProp]

Even better how about GLOBAL REGULATIONS full stop

And deprive many paper-shufflers and chair-warmers of their hard-earned salary?
No no, we can't have that! :=

[Bergerie1]

fireflybob,
I agree - I would prefer more harmonisation, not standard Global Regulations!!

[+TSRA]

+TSRA
May be this pilot needs a quadruple channel computer to handle his 'levelling off'. By the way what is a 'highly professional easy mistake' ?


Hiya mayam13,


My point to that comment was that a mistake, in of itself, does not imply unprofessionalism. Any mistake in the right circumstances can be viewed as easy one to make. What is akin to negligence one day can be dismissed the next depending upon the conditions leading up to the mistake. That's why I don't like throwing people under the bus because I was not there and, while I can put myself in their shoes, I don't know what else was going on. I guess my attitude comes from spending way too much time training in airplanes and simulators are coming to realize there are far more "average" pilots, like me, than there are "natural born" pilots.


If he is used to a TL of FL180 then he must also hear FL200?


Icarus2001,


I'll give you that over the course of my posts I may have had a typo or two. I'm not a fan of editing my posts because they made sense at the time. :)


I meant to say "Flight Level Two Hundred." You're right, they will have heard, and been to, FL200 a lot, but if you never hear it spoken a certain way, then you're bound to make a mistake if you don't ask for clarification. That failure to ask for clarification was a big mistake on their part, but I think we've all been there before.

[Lancelot de boyles]

In airline operations, for almost as long as I can remember now, it has been standard practice for both crew to listen to the clearance as it is received. On so many occasions that I have lost count of, this has resulted in one or other of us querying some aspect of that clearance, whether it is the name (foreign accent and pronunciation) altitude/level, or squawk; the ambiguity has been caught, and resolved.

In corporate operations, I frequently had to 'push' the F/O to clarify the clearance after it had already been received, because he had taken the clearance on his own. Again, this frequently resolved some ambiguity that existed. More than once, the repeated clearance bore no resemblance to the first version.
Too often, even now, clearances issued during push or taxi are recorded when there are other distractions.

Not so very long ago, I was working in North America. The issue of lower transition levels/altitudes frequently caused issue for local crews when around the Caribbean, where the levels are frequently reminiscent of those in Europe.

Standardisation could benefit more areas of operations than just the transition altitude. However, that is unlikely to happen in the short term. Better briefings from companies for crews operating outside of their usual hunting ground would help relieve a great many problems.
That works both ways. You shouldn't go swanning off to the US/Canada without thinking about regional differences and expectations, any more than North American crews should simply arrive in London air space, to suddenly be confronted with strange hitherto unheard of clearances. A frequently heard query over London being a US major querying a level such as descend to FL7-0 as FL7000feet? Crews from both sides of the pond are frequently getting it wrong. Often to comedic effect, until the enormity of the error becomes apparent.

One area frequently mentioned in the previous postings, here, is the clearing up of confusion on the ground. A big problem can often be not realising that there is any confusion until later. That smacks of not briefing properly. I'm not talking about laboriously briefing every single bit of a departure; as a senior training captain once said to me- 'I can read the bloody plate, tell me about the bit that isn't written there'.

Being cleared to quite a high initial flight level on a departure may suddenly seem strange when the norm has been initial levels in the single thousands of feet altitudes. A badly scrawled clearance, taken in isolation, inadequately briefed and understood (I said something, he heard something, but was it the same something?)

The traps are all there, and none of us are immune.

[ZOOKER]

In relation to ' Global standardisation and harmonisation', RTF Phraseology looks like a good place to start.

[pattern_is_full]

As a Yank, I'll be the first to admit the crew in this case made the primary error. "When in Rome, do as the Romans do - however weird." Not dead sure you understand the clearance? STOP - and get it clarified before you take off.

I'm not really thrilled about "fly heading two hundred" or "flight level two hundred" - smacks of contacting aircraft G-GEDY as "Geddy" instead of "Golf Echo Delta Yankee." ;)

But in some places we're already on that path - "United two four six", or "United two forty-six."

[Aluminium shuffler]

Lancelot has the key issue diagnosed. It is the gash nature of most GA pilots that caused this incident. Transition altitude and RT had absolutely nothing to do with it. They paid no attention to the clearance, the charts or terrain and just blasted off in a cavalier fashion. Airline pilots operating from airports with a lot of GA see this sort of crap daily - I saw a biz jet out of a London airport declare an emergency as he got airborne, bringing all departures in the London TMA to a halt for 30 minutes, because of an "FMS malfunction". He was only positioning to Farnborough, FFS! He clearly got airborne with the FMS misset or not set at all, with no raw data back ups and no mental preparation for the SID. London had to bring in the whole "hectopascal" read back because of GA pilots assuming everything is done in inches all over. I would regularly see the biz jets nearly run off the end, and one time actually do so, landing on wet runways with the thrust up to get a greaser.

That is the issue here. Not US/Europe, not transition levels, not RT. GA attitudes.

[Solidfuel]

Yep. Sure, different regional terminology can require a bit of care, but any pilot operating in unfamiliar parts should be conscientious enough to prepare beforehand, intelligent enough to work out obvious things (like fl2-0-0 being the same as fl200, I mean write it down, what does it look like?) and humble enough to ask if unsure. If that isn't you, then you're in the wrong job.

[ice2x01]

My humble opinion is that the root of this was a poor pre-flight briefing.

I recall once flying out of Mumbai, the ground controller kept saying number one at the end of the taxi routing (3 times maybe, I read it back each time). Both the captain and I shrugged it off as it being a silly Indian ATC custom. Until we started approaching november one (the hold short as it was). Yes, our mistake being not fully briefing the entire expected taxi routing.

So being in a foreign place and "when in Rome" is my best guess as to what happened. That being said, the people saying that being American with a TA/L of FL180 so therefore hearing flight level two hundred was new to them.. even as a fairly young F/O I find it hard to mix up two hundred and zero two zero or two zero zero.

It seems like a chain of errors that started with a poor briefing regarding the TA and MSA.

[HighAndFlighty]

The phraseology issue is adequately dealt with in the report:

In this particular event the Shannon Low Level Data Assistant relayed the clearance as “[...] Flight Level Two Zero Zero[...]”, and that is what the EIKY Tower Controller read back. Subsequently, the EIKY Tower Controller gave the clearance as “[...] Flight Level Two Hundred[...]” and that is what the Flight Crew read back. When queried by Shannon Low Level Control as to their passing altitude the Flight Crew Reported “Ah we are level Flight Level Two Zero Zero.” When queried again, the Flight Crew reported “We were cleared only to Flight Level Two Zero Zero”. The fact that these first two replies are both in the single digit form i.e. “Two Zero Zero” leads the Investigation to believe that the Flight Crew had correctly interpreted their initial clearance to “[...] Flight Level Two Hundred[...]”.

Consequently, the Investigation does not believe that non-standard phraseology played a role in the Flight Crew's misinterpretation of their cleared Flight Level.

Evidence that the Flight Crew were confused can be found from the Pilot-in-Command's statement which says “we informed the controller that we were unsure”; however, there is no recording that this actually happened.

In fact, it appears that it was only following three direct inquiries in quick succession from Shannon Low Level Control that the crew identified that they were confused about their cleared level. When the Shannon Low Level Control enquired for a third time the Flight Crew reported “and we confirm that we are cleared up to Flight Level Zero Two Zero... Two Thousand feet”. This was a change from the Flight Crew’s two initial reports that they were level at “Flight Level Two Zero Zero” and probably reflects a realisation of their behalf that they had correctly heard and recorded “Flight Level Two Hundred/Flight Level Two Zero Zero”, but that they had misinterpreted its meaning. This is supported by the fact that the Flight Crew did not at any stage request a clarification of their cleared Flight Level which, if they were confused or concerned, would be good airmanship and is the practice advocated by Eurocontrol.

The Investigation also notes that the Flight Crew’s transmissions featured several instances of single digits being read back in group form e.g. “Two Zero” read back as “Twenty”,“Three Zero” as “Thirty”, “Four Zero” as “Forty”, “Five Zero” as “Fifty”, “One Two Four decimal Seven” as “Twenty Four decimal Seven”. It therefore appears that, although it is not ICAO standard phraseology, the Flight Crew were comfortable working with grouped digits and should not have had a difficulty interpreting “Flight Level Two Hundred".

The whole matter really begins and ends with these extracts direct from the report:

At 14.36:28 hrs, the Flight Crew called Shannon Low Level Control saying “Shanwick good afternoon Hawker November One Three One Zero Hotel Flight Level Two Zero Zero direct Vener”. Shannon acknowledged “November One Three One Zero Hotel Shannon control confirm squawk and passing altitude”. At 14.36:40hrs the Flight Crew replied “Ah we are level Flight Level Two Zero Zero and squawking Six ThreeZero Four”. Shannon Low Level Control then said “November OneThree OneZero Hotel Shannon radar contact and just confirm your passing altitude”. At 14.36:51 hrs the Flight Crew replied “We were cleared only to Flight Level Two Zero Zero”. Shannon Low Level Control persisted “Okay sir that’s copied but your passing altitude...your current altitude”. At 14.36:59 hrs the Flight Crew replied “And we confirm that we are cleared up to Flight Level Zero Two Zero... Two Thousand feet”.And:

The Planning Controller said that when the Tactical Controller cleared N1310H up to Flight Level Three Hundred the introduction of the new Flight Level seemed to snap the Flight Crew out of the Flight Level Two Hundred/Flight Level Zero Two Zero cycle.Conclusions:

1. Cause of incident: Unanimous Flight Deck Brain Fart

2. Good pick-up by ATC

[nats]

Just noting another possible wee chink in the situational awareness chain, the crew were asked to contact 'Shannon' by Kerry tower, and checked in calling 'Shanwick'. They sound similar I agree, but these two centres have a heck of a difference in operating techniques and contact requirements.
Was sending direct to an OEP an issue of doubt as to whom who they were talking to, another distraction?

[Aluminium shuffler]

I still cannot understand people referring to the transition altitude as a factor, or suggesting a poor briefing was the specific cause. Gross incompetence was the problem. They missed a whole load of items, but repeatedly read back 2000' as FL200, and that is just basic lack of knowledge. Neither pilot should be holding a licence on the basis of the stupidity they displayed on that departure. They owe their lives entirely to that Shannon controller.

[His dudeness]

I refrained from answering your previous post AS.

Yes they screwed up royally. But there is always a reason why, if they were just "too stupid" to know the difference between an altitude and a flight level, then they would not have survived so long (the capt has 4000+ hrs)

There has to be more to it. As I mentioned before, the report lacks any info on previous duty and sleep / sleep pattern and other things IMHO.

But of course, they are GA pilots, so lynch them. Which brings me back to your previous post. I ask you to exchange "most" with "some".

[RAT 5]

But there is always a reason why,

To me, and a few others who've agreed with this thought; what is the reason they launched into the unknown when all they had to do was ask? That is where this whole thing started; point. No if's or buts IMHO. They had an escape route and chose not to take it. TWO pilots, not a single crew cowboy.

[Aluminium shuffler]

His Dudeness,

I have flown with some very professional ex GA pilots. However, from what I saw daily in an airport crammed with G, D and N registered Citations, Lears and Gulfstreams was cringeworthy and infuriating. Lining up on busy runways but not ready, causing landing aircraft to go around, taking incorrect taxy routes, taxying without clearance, pushing back without clearance, level busts, altimetry errors, entering controlled airspace VFR without clearances and generally getting in the way with ridiculous speeds downwind or on base or when taxying... yes, some airlines did it too, and no-one is beyond making mistakes, but with less than 20% of the aircraft at that base being GA but causing 90%+ of the problems, I stand by my remark.

Look up the London TMA level bust statistics and you'll see the diabolically disproportionate amount of level busts they have. Look at the amount of runway excursions they have, all because of chasing greasers. Look at how many airlines refuse to recruit GA pilots (several I worked for had that policy).

There are some extremely capable and professional GA pilots. Only a fool would deny that. But that part of the industry is riddled with cowboys.

[His dudeness]

To me, and a few others who've agreed with this thought; what is the reason they launched into the unknown when all they had to do was ask? That is where this whole thing started; point.

Absolutely, BUT when 2 pilots make a mistake that is bordering on the ridiculous, and not being aware that they are in what you call the unknown, then I think there is something underlying that needs to be found. Of course, they just be cowboys as AS puts it, yet I don´t - with the little info that report gives - think this is a real example of cowboy-ism. I have said it before, fatigue is one of the few things I can imagine letting a seasoned crew make such mistakes... I for one have a lot of lamps blinking when cleared to depart outside a SID - cause flying SIDs is my daily business. Not flying a SID when on an IFR plan is the uncommon that lets me check MSAs etc. rather three than two times. (although we often fly to EGLF) If you`re dead tired (can happen even if when operating within the FDT regs as most pilots will know), and you are used to fly non SID flights, then you might drop that defense...because you simply forget it.

AS, I have been on approach at EDDM/MUC/Munich - which is a very busy airfield, let me assure you - when a Lufthansa A310 called in ready, was cleared to line up and takeoff, After a minute or so the ATCO inquired why they are not moving, the Skipper replied something that the he wasn´t ready yet, the Airbus was then asked to leave the runway. Which they plainly refused. (never witnessed something like that before or after!) The ATCO grew agitated, yet the Lufthansa did not give in. Meanwhile I was ordered to go around from about 3 miles final. Then the A310 Skipper demanded a T/O clearance to EDDF as he was ready now whilst I was basically overflying him in my cowboy toy, a Citation 550 SII. The behavior of this crew during the event and afterwards (I followed them up via telephone, after an uneventful second approach and finally a landing) was something I never ever encountered again and certainly not from a "GA" crew. Which could be anyone from a wealthy dude that just added another toy to his stable to people that fly every day to get some bread onto their table, btw...

If your stretch of airfield/airspace produces such an amount of problems, then YOU have to look at what YOU do in terms of rules and regulations. I assume you where at Luton or Stansted ?

Especially the UK reeks of being different. Driving on the wrong side of the road is the most obvious one, naming convention of STARs and SID contrary to the rest of the world is another one, asking for what services one wishes outside controlled airspace and then replying "only able to offer basic service" at the time is another one etc.etc. IFR in uncontrolled airspace is impossible in Germany, even after SERA an employee of the german air traffic control plus a state servant from the department of traffic just cancelled that for the "D-people". Hence this concept is unknown and was not teached in Germany. There is one reason why some don´t cope with that as they should.

My point here (and that of others): we need to get rid of differences that are unnecessary and only serve to confuse.

Look at the amount of runway excursions they have, all because of chasing greasers.

Do I really need to look up on rwy excursions the "pros" have ? I fly from an airfield that offers 3323 ft of LDA on the main runway with no RESA. The only ones that managed to crash their DO328 there were an "Airline", lord praise them Skygods, based there!
Based on that very field are 2 Excels, a Phenom 300, a Lear 35 without T/Rs (!), a Falcon 2000, 2 Challenger 300, a CJ. 2 CJ3s and a Sovereign. Runway overruns within the last 20 years: Airline 1, GA Jets: none.

A tip: if the speed of someone in a control zone / controlled airspace is too high for you as a controller, then ask him to slow down. My father was an ATCO and he managed to do that just fine - he even married a commercial GA pilot and had to answer to her after duty when making her in a Navajo number two to a LH 737. A brave man he was!

[akaSylvia]

My point here (and that of others): we need to get rid of differences that are unnecessary and only serve to confuse.

Oh thank goodness. So we can finally drop feet, inches of mercury, backwards dates and gallons? Because you know, it's mainly the US that reeks of being different.

[OldLurker]

when 2 pilots make a mistake that is bordering on the ridiculous, and not being aware that they are in what you call the unknown, then I think there is something underlying that needs to be found.From my humble point of view far below the gods, I agree, but it's not clear what the underlying something was, or whether we'll ever know. The only substantive reason the PIC gave was "we were unsure what level Two Hundred meant." Fatigue may have been a factor but the report doesn't indicate either way. Basically there was a failure to aviate and navigate, only a few minutes after take-off when at least one of the pilots might surely have been able to understand the lack of digits on the altimeter (or whatever passes for an altimeter) and where they were going. Neither of the pilots seems to have thought or said "Whatever FL Two Hundred means, WTF are we doing down here among the treetops, heading for high ground?"

[ATC Watcher]

His dudeness : when a Lufthansa A310 called in ready,
Let me guess , early 1990's , whit an ex Interflug captain ?
The bad ones did not last long but caused a lot of problems for a while. Not used to go to busy western airports and not being treated as Masters of the Universe as they were in the DDR)
ATC wise , LH is today definitively one of the best to work with.

As to the debate GA vs Airline, again from and ATC perspective , yep, lots of problems with N and flags of convenience registered aircraft but not with the most GA I would say. Some established airline are far worse.

[White Knight]

Absolutely. Some of those SID's in the UK have you take off on the local altimeter setting, start turning to several waypoints whilst [sic ] hitting altitude constraints like 4000 feet. You can't start cleaning up the aircraft other than raising the gear until 3000 feet AGL and just as you are retracting the flaps

I think you'll find that 3,000' AAL is the maximum clean up altitude in UK airspace. 800' to 1,000' is the standard thrust reduction and acceleration. Noise abatement is based on track and not altitude...

[Airbubba]

I think you'll find that 3,000' AAL is the maximum clean up altitude in UK airspace. 800' to 1,000' is the standard thrust reduction and acceleration. Noise abatement is based on track and not altitude...

Actually, I believe most carriers use an NADP 1 profile (the former ICAO A departure profile) in the UK and hold off cleaning up the flaps until 3000 AGL.

Does your outfit do something else?

From a Boeing article on the subject, emphasis mine:

These simplified profiles are based on the International Civil Aviation Organization (ICAO) Procedures for Air Navigation Services Aircraft Operations (PANS-OPS) Noise Abatement Departure Procedures (NADP) NADP 1 and NADP 2 profiles. Profile 1 is a climb with acceleration and flap retraction beginning at 3,000 feet (914 meters) AGL, which is the noise climb-out procedure for close-in noise monitors.

AERO - Fuel Conservation Strategies: Takeoff and Climb (http://www.boeing.com/commercial/aeromagazine/articles/qtr_4_08/article_05_3.html)

[PCTool]

The most important thing to say about this is that the flight crew were sloppy right from the start. They were not ever told to climb to FL020. It was FL200. Add two zeros ....that's 20,000 feet on 1013. It doesn't matter where you're from or where you do most of your flying or whether the controller said "flight level two hundred" or "flight level two zero zero". If the clearance was written down after being read back properly, what's the problem for a commercial pilot? So it was just sloppy, end of story.

[His dudeness]

Let me guess , early 1990's , with an ex Interflug captain ?

No, more like 1999 or 2000 and from the reaction I got when I demanded to speak to the PIC from DLH, he might very well been management. From his dialect I`d guessed he was western German....and he was certainly not willing to apologize nor to see his "error". he had an issue with GND before he switched to TWR.

[White Knight]

Actually, I believe most carriers use an NADP 1 profile (the former ICAO A departure profile) in the UK and hold off cleaning up the flaps until 3000 AGL.

They shouldn't be... NADP 2 if you're going to use a noise abatement profile. But like I said - noise abatement is actually track-based so you need to fly the departure track very accurately.

[Aluminium shuffler]

Most use NADP 2 unless NADP 1 is specified. But hey, lets make up some more rubbish to show how only Americans know how to fly...

[White Knight]

Part I Noise Abatement Procedures
Section 7 Noise Preferential Runways and Routes
Chapter 2 In general, where turns are required shortly after take-off
for noise abatement or other operational purposes, the
2.2.3. nominal track has not been designed in accordance with
the criteria in Volume II Part 2 Chapter 3 para 3.3.
However, no turns are to be commenced below a height
of 500 ft aal. Airport Operators may specify the criteria
used to determine individual Noise Preferential Routes.
These criteria are for guidance only and aircraft operators
should adhere to the routes to the maximum extent
practicable commensurate with the safe operation of the
aircraft.

Part I Aeroplane Operating Procedures
Section 7 Unless otherwise stated, the upper limit for noise abatement
procedures is 3000 ft alt. However, Chapter
3 aircraft operators are expected to operate their aircraft at all times in a
manner calculated to cause the least noise disturbance on the ground

is the exact wording from the UK AIP - sort of our version of your FAR/AIM. Note the UPPER limit - so in fact you can accelerate and clean up nice and low...

[silvertate]

The same everywhere. You missed my point - How would you get cleared to a flight level if you weren't allowed to ever mention flight level below the TA?


Unfortunately ATC do use FLs below the TA. Its happened to me several times in N Ireland. And in XXX we were cleared to FL35 and we agreed this berween ourselves. And then the f/o descended to 3500' without telling me. Luck I caught it, but we still went 200' below cleared altitude. First time I have bust an altitude. This business of FLs below TA does cause confusion.

And I would second a stantard TA across Europe. I have been writing and complaining to the CAA about this for 30 years. But the CAA does not care. All they want is an easy life and fat pension, while safety comes a poor third or fourth.

[RAT 5]

This is a slight thread creep; I admit. London airports have a TA 6000'. Descending into LTN from the north I have often been cleared descend FL60. I queried this with ATC, but they didn't have time for a lengthy explanation. The best I could get was "the lowest level available on the airway was FL60. At this point we were outside the London TMA and thus above the FIR where the TA was 3000'." It it still the case. I trusted NATS, but you'll understand my confusion as I was descending towards the London TMA. Opinions?

[wiggy]

Confusing perhaps but certainly not unknown to the locals ;).

FL 060 (by definition on STD) could have been far enough above 6000' (the TMA TA) QNH to be a usable Flight Level.

[Airbubba]

As per my earlier post, we yet again see the Americans turning this into a peeing contest of how their rules are better and the rest of the world should bow to them.

Most use NADP 2 unless NADP 1 is specified. But hey, lets make up some more rubbish to show how only Americans know how to fly...

No need to feel inferior, you seem to be a little sensitive about Americans for some reason. Lighten up. ;)

Do you ever fly to America? I've been flying to the UK for decades now so I think I can share some thoughts from my perspective. Things are a little different in other countries and the UK has its own peculiarities in ATC just like everywhere else.

NADP 1 has indeed been specified for many international carriers in the UK for a while now as far as I know. Or, maybe I'm just making this up, right? :)

And sometimes those company notes for a departure noise abatement profile on a particular aircraft type stay in our Jepps long after the requirements have been abolished by local ATC.

Anyway, some of us still have to wait until we hit 3000 AGL to start raising the flaps on those wacky convoluted departure procedures with a low transition altitude.

And yes, there is talk about going back to a lower cleanup height to save fuel and enhance sustainability so I'm sure things will change as they always do in this business.

But the low transition altitude, like the old QFE procedures, is a known gotcha that has been remedied elsewhere in the world. :=

I have flown with some very professional ex GA pilots. However, from what I saw daily in an airport crammed with G, D and N registered Citations, Lears and Gulfstreams was cringeworthy and infuriating. Lining up on busy runways but not ready, causing landing aircraft to go around, taking incorrect taxy routes, taxying without clearance, pushing back without clearance, level busts, altimetry errors, entering controlled airspace VFR without clearances and generally getting in the way with ridiculous speeds downwind or on base or when taxying... yes, some airlines did it too, and no-one is beyond making mistakes, but with less than 20% of the aircraft at that base being GA but causing 90%+ of the problems, I stand by my remark.


Your observation is consistent with the Pareto principle:

https://en.wikipedia.org/wiki/Pareto_principle

is the exact wording from the UK AIP - sort of our version of your FAR/AIM. Note the UPPER limit - so in fact you can accelerate and clean up nice and low...

But only if your company procedures permit it. Ours currently do not but as I said, it will probably change, thanks for the cite. :ok:

[RAT 5]

FL 060 (by definition on STD) could have been far enough above 6000' (the TMA TA) QNH to be a usable Flight Level.

That would be dependant on QNH and thus be a variable day by day. This was not the case but a constant.

[wiggy]

Ah OK...some local agreement perhaps?

[Lancelot de boyles]

Airbubba, I'm playing devils advocate, now...

But only if your company procedures permit it. Ours currently do not but as I said, it will probably change...

Dare I say it, but that smacks of a fix-all SOP in the absence of truly understanding the individual local requirements? ie. The most limiting (apparently), would be NADP1, and so let's adopt that as our standard.

I've worked in many places where the company standard became a sort of NADP2, unless NADP1 is specified.
1500'/1500'.
And then others where we used 800'/800'
And in North America, frequently 400'

And in a most refreshing case, with my last two operations, what does it say on the charts? (assuming that they reflect the AIP accurately, which is not always the case) If NADP1, we'll fly that. If NADP2, then that is what we'll do. If nothing is stated, then 400'.

There is a very big case for a rationalisation of the rules. For instance, I recently departed an airport where QNH was 1013, and cleared level was 6000'. On handover, two sectors down, we remained at 6000' but belatedly prompted by ATC that we were now flying on Flight levels, so FL60. Easily missed, because it was a slightly unusual circumstance.

It does not negate the point, however, that as crew, either myself or the FO, we are responsible for taking these into account. That's the professional+airmanship aspect.

Some mention has been made about accepting/declining a departure clearance that includes an altitude below MSA.
For descents and approaches, this will frequently be the case. And with upwards of 20+ different national air spaces over here, within the same geographical area as one national air space in the US, some significant consideration needs to be given to the differences.

I alluded to this earlier. Not far from US airspace, there is a very large arena (the Caribbean) where things are very different and varied from home skies.

The risks aren't limited to the lower levels. Internationally, When you start crossing borders where levels are suddenly metric, and RVSM constraints mean going down, not up, being equally unprepared can have equally worrisome results.
The list can go on, as there are a great many issues that we may either take for granted, or dismiss out of simple naïveté through lack of local knowledge.

One or two things this crew will have gained from this is a very valid lesson about complacency, and a good helping of experience, that hopefully will help them going forwards.

[silvertate]

Confusing perhaps but certainly not unknown to the locals ;).

FL 060 (by definition on STD) could have been far enough above 6000' (the TMA TA) QNH to be a usable Flight Level.

Yes, but I have been given FL 50 in the same situation. The reason given when I queried it, is they had someone at FL60 so we were given FL50 for convenience. Might have been convenient, but it was certainly confusing.

[fireflybob]

Surely much of what is being discussed here comes down to situational awareness?

[Airbubba]

If NADP1, we'll fly that. If NADP2, then that is what we'll do. If nothing is stated, then 400'.

Is that a thrust reduction at 400 feet? Sounds low to me, but I can't remember all that stuff about the fifth segment climb gradient. Maybe 400 feet is the minimum for the thrust reduction in the regs but seems like everywhere I've worked we used something like 800 or 1000 feet for the power reduction on the more fuel efficient (and noisier) takeoff profile.

Dare I say it, but that smacks of a fix-all SOP in the absence of truly understanding the individual local requirements? ie. The most limiting (apparently), would be NADP1, and so let's adopt that as our standard.


We do NADP 1 in the UK and Europe for simplicity. It seems to satisfy the requirements for the noise folks at every airport we go to over there. But there is already talk of changing it to something else to save the whales.

In America we figure that simple procedures are best and the most likely to be performed correctly. I realize that some other cultures seem to thrive on infinite detail.

You can get some idea of the cultural philosophical differences by comparing the airport reference pages at LHR and JFK. ;)

Don't know if you fly to NRT but the NADP 1 takeoff profile is still in the reference pages. It's a lot easier for a country boy like me to understand than the LHR writeup about them dBA's and the 4% climb gradient. :D

[Lancelot de boyles]

Don't get me wrong-

I love the simple, omni departures on vectors. A simplified and consistent transition level would appear to make much more sense. Thumbing through page upon page of arrivals and departures often seems utterly ridiculous. But in the context of this situation, there's little to be gained by not being fully aware that there are big, and subtle/small differences to be taken into account.

[PCTool]

Transition Altitude is 5,000 feet for all airports in Ireland.

[White Knight]

We do NADP 1 in the UK and Europe for simplicity.

The point being that Carriers specifying NADP1 in UK Airspace are incorrect to do so! Country Rules and Regs should not be over ruled by company policies...

I do agree that having a higher TA and TL would be easier ops wise... It doesn't though deflect from this particular crews lack of SA and knowledge of ops in various Euro countries. And possibly the lack of a preflight brief discussing the lower TAs.

I don't remember the Jepp AOI layout which we used to use but the LIDO CRAR, RSI and airport briefings are easy to use and generally well laid out!

[Aluminium shuffler]

Bubba, you ask what my problem is with American pilots. I don't have a problem with most of them, but I do with a lot on here who adamantly refuse to accept that theirs is not the only way and that they should abide with others' rules and stipulations when abroad. You just made the point for me about US arrogance. Why is it that only Americans on here seem to have so much issue with everyone else's regulations, and why do only they seem to think flouting them is perfectly reasonable? As such superior aviators, surely you have the ability to read the charts like everyone else and the mental capacity to fly in accordance with them?

But once again for the cheap seats, the rules had nothing to do with this case - it was two idiots being gash. Of course, why accept that when you can try to apportion blame on procedures or regulations that had nothing to do with it, just because they were foreign.

[vh-foobar]

Notwithstanding the errors the crew made, the North American System (and others) removes or reduces the transposition error, that the crew clearly made. Ironically (perhaps) the Non-ICAO use of FL two hundred is trying to reduce the likelihood of another error.

The North American Flight crew, would be used to FL being tens of thousands. Perhaps worth asking what mental steps your own mind actually performs from hearing a FL to selecting it, and how you are or aren't protected from making the same mistake.

[galaxy flyer]

Stipulated, they screwed up, but why?

First, it's not coincidental in happened to a Hawker crew in Ireland. Charter operator and crew from US, who rarely fly outside of North America. Do we know their training? No. Do we know what they flew in Europe prior to this flight and how they performed before this departure? No. They could have never done a crossing until they picked up the plane at EIKY. OTOH, they could have flown around Europe all week with nary a problem until thrown off by FL Two Hundred.

True, they shouldn't have turned a wheel confused about the airways clearance, but flying a crossing from a foreign country, if you rarely do it, is daunting.

[Aluminium shuffler]

No, VH-Foobar, it does not. FL200 is above US and European transition altitudes alike, so I yet again state the different TAs are irrelevant. The Americans refer to Flight Levels as "Flight Level", just like the rest of the world, not as tens of thousands of feet, which is an altitude, referred to as "altitude x thousand feet in both the US and the rest of the non-metric world, so that too is not contributory.

"FL two hundred" was introduced in the UK because of the number of errors of numerical transposition (in fact, it was FL one hundred instead of one-zero-zero, where many pilots then set 110, and the practice since expanded to all the even hundreds). It was nothing to do with transition from QNH to STD.

So, once more, stop trying to make bs xenophobic excuses for two bad pilots.

[Aluminium shuffler]

Galaxy flyer, it may be daunting flying in an unfamiliar region, but that is more reason to read the charts and brief properly. That this happened to a US GA crew is not coincidental. That it happened abroad is. It is purely down to pilot attitude and training, nothing more.

[RAT 5]

It is purely down to pilot attitude and training, nothing more.

Let's put this to bed and stop spinning in ever decreasing spirals. No pilot, anywhere, in any a/c should launch with confusion about what they are going to do. The time & place to sort it out and be clear in your mind is on the ground, stationary. Case closed, please.

[vh-foobar]

No, VH-Foobar, it does not. FL200 is above US and European transition altitudes alike, so I yet again state the different TAs are irrelevant. The Americans refer to Flight Levels as "Flight Level", just like the rest of the world, not as tens of thousands of feet, which is an altitude, referred to as "altitude x thousand feet in both the US and the rest of the non-metric world, so that too is not contributory.

Thanks for the tips, I think you missed my point completely.

[His dudeness]

Am I the only one thinking that AS hatred of GA pilots is unhealthy ?

[galaxy flyer]

No............

[4runner]

Universal transition altitude and level is now 18,000-fl180. I fixed it. Btw, Johannesburg is the worst. Their transition levels change in the terminal environment depending on what the altimeter setting is, i.e. U gotta use different approach plates for the same approach on different days.

[Uplinker]

The Investigation also notes that the Flight Crew’s transmissions featured several instances of single digits being read back in group form e.g. “Two Zero” read back as “Twenty”,“Three Zero” as “Thirty”, “Four Zero” as “Forty”, “Five Zero” as “Fifty”, “One Two Four decimal Seven” as “Twenty Four decimal Seven”. It therefore appears that, although it is not ICAO standard phraseology, the Flight Crew were comfortable working with grouped digits and should not have had a difficulty interpreting “Flight Level Two Hundred".

This is a classic example of why it is not a good idea to invent one's own RT shorthand, and why it is important to use the correct phraseology - otherwise it could lead to dangerous situations. Another one I hear sometimes is "Runway three" for example. Well, is that three zero, or zero three? It's kind of important.

Correct RT phraseology can be a real ball ache, especially in busy airspace, and it can be tedious to recite every digit. However, it is done for very good reasons - to avoid confusion.

We were once flying to Cancun, I think it was, and were cleared down to an altitude with a QNH of "nine nine two". We queried this several times, but the Mexican ATC guy kept saying "nine nine two". On hand over to the next sector, we queried again and were were told "two nine nine two" (i.e. mmHg, not millibars). The first guy had been using his own RT shorthand, but it would have put us at the wrong altitude.

[aox]

... we queried again and were were told "two nine nine two" (i.e. mmHg, not millibars).

That's 29.92 inches not millimetres.

[atpcliff]

I was just flying and heard "Flight Level Three Hundred". I knew exactly what it meant due to this thread...I had never remembered hearing a "hundred" before. The other pilot had flown extensively in Europe and said he had heard the "hundred" thing a lot.

We used to be NADP2 in the US, and 1 outside it.
But, now we are NADP2 all the time, unless specifically instructed to fly NADP1. NADP 2 is 1000/Flaps 5, and NADP1 is 3000/1500 for us, unless something else specified...I think Stansted is NADP 1, except 5000/1500???

[Obama57]

Having been a military pilot, an airline pilot, a corporate GA pilot, and now instructing at a major corporate training center, it is my observation that corporate pilots paying big money for their recurrent training are not held anywhere near to the same standard as airline or military pilots.