ACR LGT ALTDEV OVERSHOT ALT XING RESTRICTION NOT MET.

Date: 1991-10 · Aircraft: Large Transport; Low Wing; 3 Turbojet Eng

Anomalies: deviation-altitude-overshoot|deviation-altitude-crossing-restriction-not-met|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-published-material-policy

Synopsis

ACR LGT ALTDEV OVERSHOT ALT XING RESTRICTION NOT MET.

Narrative

FLT WAS CLRED FOR THE 24/25 PROFILE DSCNT (FMI.FIM6) INTO LAX WHERE THE WX WAS APPROX 3X1/2 F AND THE RVR FOR RWYS 24 AND 25 WAS 6000 PLUS. SPD WAS AT OUR DISCRETION. A DSCNT FROM FL310 WAS INITIATED TO 12000 FT ENRTE TO THE FILMORE VOR (FIM). THE ALT ALERT WAS SET TO 12000 FT. THE PROFILE DSCNT CALLED FOR XING FIM AT OR BELOW FL190 AND AT OR ABOVE 15000 FT. THE NEXT FIX WAS 12 DME ON THE 148 DEG RADIAL (SYMON) CALLING FOR A XING AT OR BELOW 15000 FT AND AT OR ABOVE 12000 FT AND 280 KTS. PASSING APPROX 13500 FT; I DISCOVERED THE FACT THAT I HAD MISREAD THE PROFILE DSCNT PLATE COINCIDENT WITH A CALL FROM ATC REQUESTING OUR PRESENT ALT. THE FLT WAS RECLRED TO CROSS FIM AT 12000 FT; BAYST AT 10000; SANTA MONICA AT OR ABOVE 7000 AND TO DSND TO AND MAINTAIN 2500 FT. DEPART SANTA MONICA ON A 070 DEG HDG; EXPECT THE ILS 25L AT LOS ANGELES (WE WERE APPROX 15 NM NW OF FIM AT 13500 FT AND THE PROFILE DSCNT CALLED FOR US TO CROSS FIM BTWN FL190 AND 15000 FT. THE FIM XING RESTRICTION WAS OVERLOOKED AND A DSCNT WAS ESTABLISHED SO AS TO COMPLY WITH THE SYMON XING RESTRICTION AT OR BELOW 15000 FT AND AT OR ABOVE 12000 FT). HUMAN PERFORMANCE FACTORS: FATIGUE. THIS WAS THE 8TH DAY OF A 9 DAY TRIP SEQUENCE AND THE THIRD CONSECUTIVE TIME THIS IDENTICAL TRIP SEQUENCE HAD BEEN FLOWN. ALL TRIP SEQUENCES WERE FLOWN BTWN THE HRS OF XX00 PM AND AA00 AM. EMPLOYEE/EMPLOYER RELATIONS. RECENT ORGANIZING EFFORTS AND ANTI-ORGANIZING EFFORTS BY THE COMPANY PRECIPITATED AN ELECTION THAT FAILED BY 15 VOTES (LESS THAN 1 PERCENT) AND CAUSED OBJECTIONS TO BE FILED. THIS EFFORT CAUSED EACH PLT TO RECEIVE AN OVERNIGHT LETTER WITH PROPAGANDA FROM THE COMPANY ON A DAILY BASIS FOR 45 CONSECUTIVE DAYS. IT HAS BEEN UNSETTLING AND HAS CAUSED FRICTION AMONG CREW MEMBERS AS THEY HAVE BEEN FORCED TO TAKE SIDES. THE STRESS LEVELS HAVE BEEN SUBSTANTIAL.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.