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-   -   Near CFIT because PIC didn't understand FL (https://www.pprune.org/rumours-news/577810-near-cfit-because-pic-didnt-understand-fl.html)

Journey Man 22nd Apr 2016 13:33

...a lack of understanding?
 

Originally Posted by Future Rodney King
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...ice2014004.pdf

http://www.ead.eurocontrol.int/eadba...2016-03-31.pdf

mayam13 22nd Apr 2016 13:50

+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 22nd Apr 2016 14:01


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...w-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 22nd Apr 2016 15:29


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 22nd Apr 2016 18:07

Absolutely.
 

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 22nd Apr 2016 19:21

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 22nd Apr 2016 19:33

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 22nd Apr 2016 20:18

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 22nd Apr 2016 20:41

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 22nd Apr 2016 20:59


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/6580...tml#post622468

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

Flap62 23rd Apr 2016 10:05

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 23rd Apr 2016 10:10

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 23rd Apr 2016 12:56


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 23rd Apr 2016 15:21


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 23rd Apr 2016 15:54


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 23rd Apr 2016 16:05

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 23rd Apr 2016 18:18

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 23rd Apr 2016 23:18

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 24th Apr 2016 03:43


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.

Originally Posted by Future Rodney King
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 24th Apr 2016 04:04


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

Aluminium shuffler 24th Apr 2016 09:34

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 24th Apr 2016 10:11


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 24th Apr 2016 15:21

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 24th Apr 2016 15:25


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 25th Apr 2016 02:11


Originally Posted by Aluminium shuffler (Post 9354704)
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 25th Apr 2016 02:14


Originally Posted by atpcliff (Post 9353996)
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 25th Apr 2016 06:29


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 25th Apr 2016 08:23

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 25th Apr 2016 12:15


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 25th Apr 2016 12:29


How about a global TA?
Even better how about GLOBAL REGULATIONS full stop :ok:

fireflybob 25th Apr 2016 13:54


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 25th Apr 2016 13:59


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 25th Apr 2016 14:32

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

+TSRA 25th Apr 2016 16:32


+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 25th Apr 2016 17:39

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 25th Apr 2016 20:15

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

pattern_is_full 26th Apr 2016 02:25

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 26th Apr 2016 09:50

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 26th Apr 2016 14:07

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 26th Apr 2016 18:30

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.


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