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➣ Operational Issues Bulletins
Y2 Confirm Altitude Assignments
A First Officer’s report of a crossing altitude deviation
illustrates how cockpit procedures may be vulnerable to a
multiple error chain. In this instance, the error chain
included distraction, a common clearance misunderstanding,
and forgetting to confirm the altitude assignment with
ATC.
 The Captain was the Pilot Flying (PF), the autopilot was
engaged, and he was making the FMS entries and
selections on the mode control panel. He had programmed
the FMS VNAV to cross intersection at 250 knots and
11,000 feet altitude, as depicted on the STAR [Standard
Terminal Arrival Route]. I confirmed this entry as correct.
Center cleared us to “cross [fix] at 11,000, 250 knots,”
which is what I read back. At that time the Lead Flight
Attendant (F/A) came forward with 2 cabin discrepancies. I
briefly reviewed them to see if they were considered
“airworthiness items” by our company policy, as those
require a logbook entry. This all took about a minute. I feel
that this distraction broke down my PNF habit patterns of
back-up and confirmation of the PF’s navigation.
Our company promotes an…altitude confirmation
technique [by both PNF and PF] for what altitude is set in
the mode control panel. Because of the F/A call bell, I don’t
recall pointing to the Altitude Window after the Captain
was supposed to enter 11,000... The Captain thought he had
11,000 in and doesn’t know how 10,000 got selected...
I have read that ten and eleven thousand feet are the most
often confused altitudes and I believe it. In the future I
intend to train myself to be extra vigilant with clearances
and setting to those altitudes.
The last chance to break the chain of events came with the
ATC hand-off to Approach Control. Because of congestion
on the frequency Approach Control called us first with a
spacing vector behind a B-747. This is not at all unusual
in a busy terminal environment. The radio chatter is nonstop…
The lesson learned here is that if the controller
initiates communication, read back your…current and
cleared-to altitudes to ATC, even if [you] must tack the info
onto another readback.
In addition to heeding our reporter’s words of wisdom,
readers may want to check out a widely reprinted ASRS
Directline article on the 10,000-11,000 foot clearance
confusion problem. The article, “One Zero Ways to Bust
an Altitude,” is available from the ASRS web site, and was
originally published in Directline Issue No. 2 (1991).
➣ NASA Reporting
Forms in Adobe’s
Acrobat (PDF) format.
➣ Information on ASRS immunity policies, including
Advisory Circular 00-46D, Federal Aviation
Regulation (FAR) 91.25, and Facility Operations and
Administration Handbook (7210.3M), Para. 2-2-9.
➣ ASRS database report sets (in Rich Text Format).
There are currently 27 report sets available for
downloading on topics of broad interest to the aviation
community.
➣ ASRS Program Overview, including a brief overview of
ASRS functions and products, as well as a more
detailed Program description.
➣ Contact information for ASRS services/staff.
➣ Other useful aviation links.
Come visit us soon at http://asrs.arc.nasa.gov.
Number 247 January 2000
Unhappy Landings
Several recent reports to ASRS offer fresh insight into
landing problems on both land and sea. Our first reporter,
a General Aviation pilot, describes how a new type of
headset contributed to a gear-up event:
 Problem: on landing, gear was unlocked but up.
Contributing factors: busy cockpit. [I] did not notice the
gear down-and-locked light was not on.
Discovered: Gear up was discovered on landing.
Corrective action: [I] was unable to hear gear warning
horn because of new noise canceling headsets. I recommend
removal of one earpiece in landing phase of flight to allow
audible warning devices to be heard by pilot. The noise
canceling headsets were tested by three people on the
ground and all three noted that with the headsets active
that the gear warning horn was completely masked by the
headsets.
Splash!
The First Officer of an air carrier float plane operating in
the South Atlantic relates how missing the landing spot led
to a rough ride for crew and passengers:
 I was the First Officer [on the air carrier flight]. It was
my flying leg and the Captain and I both agreed to land in
the protected waters on the leeward side of bay by
　
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