Near CFIT because PIC didn't understand FL

[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-offic...-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

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.