The phraseology issue is adequately dealt with in the report:

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

And:

Conclusions:

1. Cause of incident: Unanimous Flight Deck Brain Fart

2. Good pick-up by ATC

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?

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.

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".

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.

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.

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.

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!

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.

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?"

His dudeness : 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.

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:

AERO - Fuel Conservation Strategies: Takeoff and Climb

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.

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.

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.

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...

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...

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.

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?

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.

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. :=

Your observation is consistent with the Pareto principle:

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

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:

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.

Ah OK...some local agreement perhaps?

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

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.

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.

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

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.

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

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.

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

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!

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.

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.

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.

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.

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.

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.

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

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

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

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.