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Near CFIT because PIC didn't understand FL

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Near CFIT because PIC didn't understand FL

Old 27th Apr 2016, 04:48
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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
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Old 27th Apr 2016, 08:45
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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?
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Old 28th Apr 2016, 10:10
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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.
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Old 28th Apr 2016, 20:08
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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".
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Old 28th Apr 2016, 20:43
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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.
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Old 29th Apr 2016, 06:34
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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.
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Old 29th Apr 2016, 07:23
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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 donīt - 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 wasnīt 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 donīt 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!
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Old 29th Apr 2016, 08:12
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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.

Last edited by akaSylvia; 29th Apr 2016 at 08:14. Reason: brain dead for a moment
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Old 29th Apr 2016, 10:15
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Originally Posted by His dudeness
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?"
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Old 29th Apr 2016, 10:17
  #130 (permalink)  
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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.
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Old 29th Apr 2016, 12:55
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Originally Posted by airbubba
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...
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Old 29th Apr 2016, 16:57
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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
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Old 29th Apr 2016, 22:00
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Sloppy

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.
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Old 29th Apr 2016, 22:07
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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.
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Old 30th Apr 2016, 07:16
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Originally Posted by airbubba
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.
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Old 30th Apr 2016, 07:19
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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...
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Old 30th Apr 2016, 07:24
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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...
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Old 30th Apr 2016, 15:58
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Originally Posted by Chesty Morgan
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.
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Old 30th Apr 2016, 16:09
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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?
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Old 30th Apr 2016, 16:14
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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.
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