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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 19th Apr 2016, 20:44
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Near CFIT because PIC didn't understand FL

SERIOUS INCIDENT: BAe 125-800B, N1310H, Co. Kerry Ireland, 16 June 2015: REPORT 2016-005 | AAIU.ie

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.
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Old 19th Apr 2016, 20:46
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But...PIC? Maybe he/she should just be a drone pilot.
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Old 19th Apr 2016, 21:04
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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.
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Old 19th Apr 2016, 21:14
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Did you honestly just use "easy mistake to make" and "professionalism of flight crew" in the same sentance in reference to this incident?
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Old 19th Apr 2016, 21:15
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"Lowest available flight altitude" + "lowest transition altitude" = "Houston, we have a problem".
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Old 19th Apr 2016, 21:47
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That is why it is called FL 200, not 2 0 0.
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Old 19th Apr 2016, 21:49
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FL200 is FL200, no matter what the TL/TA.
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Old 19th Apr 2016, 21:52
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Incredible, just incredible.
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Old 19th Apr 2016, 22:11
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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.
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Old 19th Apr 2016, 22:15
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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...Line_Flight_66
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Old 19th Apr 2016, 22:28
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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).
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Old 19th Apr 2016, 22:34
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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?
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Old 19th Apr 2016, 22:35
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Surely a safety altitude of 4,500 feet is based on QNH wherever you are?
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Old 19th Apr 2016, 22:45
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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???
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Old 19th Apr 2016, 22:52
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Makes me wonder if the introduction of CPDLC will reduce misunderstandings such as might have been the case here.
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Old 19th Apr 2016, 22:55
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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.
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Old 19th Apr 2016, 22:58
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CPDLC probably would have reduced the error here. It would be interesting to find out what errors CPDLC introduces.
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Old 20th Apr 2016, 05:00
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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.
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Old 20th Apr 2016, 05:43
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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.

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Old 20th Apr 2016, 05:45
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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?
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