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.

But...PIC? Maybe he/she should just be a drone pilot.

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.

Did you honestly just use "easy mistake to make" and "professionalism of flight crew" in the same sentance in reference to this incident?

"Lowest available flight altitude" + "lowest transition altitude" = "Houston, we have a problem".

That is why it is called FL 200, not 2 0 0.

FL200 is FL200, no matter what the TL/TA.

Incredible, just incredible.

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.

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

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).

+TSRA

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?

Surely a safety altitude of 4,500 feet is based on QNH wherever you are?

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???

Makes me wonder if the introduction of CPDLC will reduce misunderstandings such as might have been the case here.

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.

CPDLC probably would have reduced the error here. It would be interesting to find out what errors CPDLC introduces.

+TSRA

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.

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.

Pace

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?

FL TWO HUNDRED tends to be used in UK airspace and as far as I remember it's in the CAP413.

Saying FL two zero zero is an ICAO thing and most other countries use that system.

There are some fundamental errors performed here since we don't fly on FL until passing the transition altitude on climb out. So if I were in the Crew's shoes, levelling off at altitude 2000, alarm bells will be ringing especially if I were PM. Also, did the Crew actually set 1013 at 2000? Just wondering because if the QNH was low say QNH 1000 then they would have been even lower than they thought.

When I was operating in Europe, saying altitude or FL on your read back was very common but the rest of the world doesn't seem to think along the same lines.

Frankly I am surprised no one picked on another problem here - I don't know where the boundary in Europe lies but in the US you are not allowed to use flight-level terminology if you are below 18000 feet, I think it makes perfect sense to disallow use of flight levels anywhere except the class A airspace. And frankly I am at 2000 feet sounds a lot shorter than I am at flight level two hundred...

No, he couldn't have been a North American pilot precisely because of the above. No NA pilot will use flight level for such low altitudes.

I sympathise with the crew a little. Not used to the myriad of transition levels where they come from combined with the serious sounding "STOP at FL200" requirement despite the cleared final level of FL340 means they must've thought this to be some kind of low level instrument departure level off. In the US, this clearance would be to INITIALLY climb FL200 and expect FL340 within x minutes.

Why isnt this antiquated european system overhauled? for a bunch who tells Americans to "get to know the world", you folks sure prefer to stick to your confusing methods instead of making things simpler.

<<And frankly I am at 2000 feet sounds a lot shorter than I am at flight level two hundred...>>

Except that those two are approximately 18000 feet apart.

I have to say that I found the ATC response given the situation to have been odd
Seeing that there was a threat and suspecting a confusion over flight levels and altitude ATC Cleared him to climb to FL300 :ugh:
That is almost like saying your departure is fine you are now re cleared to FL300?

The obvious would have been realising the aircraft was at 2000 feet to have instigated an immediate climb to above the SSA in feet and with the QNH given with a request for a read back of both ?

sv_741_india_bravo

Yes EASA had a blank Sheet and should have saved the Eurozone £ Millions by taking the FAA system modifying it to suit Europe and harmonising aviation regulations worldwide but then? When have EASA ever done anything sensible which has not been for their own or their chums benefits

there was talk of EASA standardising a transition Level but that went quiet probably too much time in the bars and restaurants of Brussels on lavish expense accounts

Pace

"flight level two zero zero" is international (ICAO) phraseology.

ICAO Doc 9432:
"All numbers used in the transmission of altitude, cloud height, visibility and runway visual range (RVR) information, which contain whole hundreds and whole thousands, shall be transmitted by pronouncing each digit in the number of hundreds or thousands follow by the word HUNDRED or THOUSAND as appropriate".

Germany does this, "cleared flight level two hundred".

Hold on. FL 200 is the same in the US as it is in Europe. So it should not be difficult for anyone to understand what is being meant, no matter where you are from. Especially if you had to make a hop across the pond to end up in Ireland, the PIC surely was thouroughly familiar with the TA/TL system.
This was my WTF moment of the day. Thanks.

Not so it would seem. The report states:

Well, on the grapevine he was indeed an American pilot. Apparently, it was flying a charter so a commercial operation/FAR135.

& of course over Kashmir Fl is on QNH.
Would be nice if their was some commonality.

Not sure what was the level of automation on this 125 , but this could also be a ergonomic error in setting the FL in a box or a display of some kind.

Could have been one pilot doing the R/T and the other entering the figures.
so the immediate read back FL200 is correct because done by same individual right after the transmission but if the other enter 020 i.s.o. 200 , and not cross- checked , that could explain the later transmissions : "which level are you climbing to ? : PIC reading the display : FL020 ... ( as in the report page 4 )

Speculating of course.

I learned to fly international in Africa and South America, sitting in Diesel Tens beside fossils from the stone age who had come up in the trash-hauling business.

They always, ALWAYS, knew what their MSA was. And woe be unto you if you didn't.....

That is so basic and vital that it's worth repeating :ok:

I'm not sure this type of generalisation is helpful. You say "the corporate sector", but you fail to clarify whether you're referring to corporate flight departments, or just any non-scheduled aircraft. Of course, the latter includes non-scheduled commercial air transport operators and private operators.

However, in general, I agree with you and there is value in having the conversation. In a multi crew environment, where was the monitoring to trap this error? Discipline is often lacking in non-scheduled operations and I believe this to be from a number of factors. Smaller operators lack the resources to adequately analyse incidents and develop robust defences, whilst also lacking the resources to mine available incident data from other operators. Familiarity breeds poor discipline and relaxing of SOPs, which must be guarded against. A poor understanding of the benefits of a robust SOP culture and cockpit discipline is often accompanied by general disdain for scheduled CAT operations where "they only use the autopilot and can't really fly." Finally, a lack of competitiveness seems to breed less hungry FOs. Having been involved in command training in airlines, FOs were motivated to acquire the relevant regulatory and systems knowledge independently. I don't see that as the default situation in non-scheduled transport, where the environment is less disciplined. Couple this with the many flights consisting of two commanders switching seats between legs and it is an area where groups such as the IBAA or EBAA need to start a discussion.

These are my general observations, and there are exceptions i.e. private operators of one or two aircraft who are well drilled and exceedingly disciplined, or larger corporate operators who must have non-scheduled standard SOPs to cater for frequent different pairings of crew.

Finally, I know certain members here such as Pace favour the FAA system over the EASA system, being a pilot of an N-Reg with only an FAA licence. Do not forget that each ICAO member state has sovereignty over the airspace over their territory. Whatever the regulations and standards, it's our jobs as professionals to be current with applicable regulation, not argue the merits of different systems as though this somehow defends ignorance.

When one flies out of its own state/country,one should be familiar with rules/regulations/phraseology differences along the route.

Journey Man

A well written piece which in principal I agree with but I equally add that there are cockups in CAT too even with all the inbuilt safeguards

It may surprise you to know as it surprised the CAA too but statistically private jets flown by professional crew have a better safety record than equivalent in AOC operations.

I am sure that is nothing to do with better pilots but more to do with private jets being treated like a beloved private car with the same chauffeur

But on the whole I agree with the gist of your sentiments

Yes I went the FAA way with an ATP as that was where historically private jets were in Europe and it was perfectly legitimate to work them in Europe for far longer than the EU has existed. My other sentiments are more political and I firmly believe EASA missed a golden opportunity of harmonising aviation world wide

The FAA system is tried and tested and universally the most used model worldwide. As aviation knows no barriers from a safety angle it makes every sense that we all used the same regulation structure so that there is no room for errors going from one continent to another.
Going forward people are becoming more no barriers in movement for work too and in future pilots should be able to take work simply in different parts of the globe

EASA could have been more forward thinking and developed a system more towards the FAA system with some changes to suit Europe but that would not have secured the longevity of their department size, their lavish pay structures and benefits and so they decided to reinvent the wheel something they were warned about years ago by the commission.

i have been flying 30 accident free years plus so it won't make a massive difference to me other than I will stop flying a few years earlier faced with the costs and time in converting to holding licenses which have no bearing on the reg I fly. That will be a cost /time decision I will need to make depending on how things pan out.
But that doesn't change my opinion on the ridiculousness of the whole thing and taking things off topic ;)

Pace

I don't fly IFR below SA. If someone tells/asks me to do so, I ask them why? I did it the other week at a UK airfield which gave me a climb out restriction below SA; I kindly declined and chose to stay on the ground.

Like Cows getting bigger, I have refused a clearance below safety altitude and stayed on the ground until it was changed. I also agree with Journey Man that each sovereign state 'owns' its own airspace and can decided the rules which govern it - therefore, it is our business as pilots to know these rules.

However, I have long been an advocate of a common transition altitude across the whole of Europe, either 18,000ft, as in the States, or 15,000ft (it doesn't really matter which) as a means of reducing yet one more source of error.