WDB ACFT. 2 MAN FLC. OVERSHOT SJC VOR XING ALT ON LOUPE DEP.

Date: 1991-11 · Aircraft: Widebody; Low Wing; 3 Turbojet Eng · Phase: climb

Anomalies: aircraft-equipment-problem-less-severe|deviation-altitude-overshoot|deviation-altitude-crossing-restriction-not-met|deviation-discrepancy-procedural-clearance|deviation-discrepancy-procedural-published-material-policy

Synopsis

WDB ACFT. 2 MAN FLC. OVERSHOT SJC VOR XING ALT ON LOUPE DEP.

Narrative

INEXPERIENCED CREW (NEW TO ACFT; LOW TIME; VERY LOW TIME WITH 2 PERSON CREW). MYRIAD ACFT WRITEUPS AND PLACARDS AND PROBLEMS UNUSUAL SID. EXECUTING SID (LOUPE 8) HDG 120 DEGS; CLBING; CLRED TO TURN R; CROSS SJC VOR AT 12000 FT THEN CLB TO FL230. COPLT FLYING; DID NOT HEAR CLRNC; I REPEATED IT TO HIM; HE BEGAN R TURN TO SJC VOR. AT THIS POINT FLT ATTENDANT CALLED THAT REAR LAVATORY WAS SPEWING BLUE WASTE WATER ON FLOOR AND FLOODING. I WAS DISTRACTED FROM SUPERVISING FO. DEP CTL CALLED AND REITERATED CLRNC AS WE WERE CLBING OUT OF 15000. THEY COORDINATED WITH OAK CENTER AND WE WERE CLRED UNRESTRICTED TO FL230. FACTOR: FO PRIOR EXPERIENCE IS ON LGT; AND HE WAS HAND FLYING; DID NOT FULLY UTILIZE AUTOMATIC FEATURES. FACTOR: ALT WAS SET AT 23000 FT SO NO ALERT WAS SOUNDED PASSING 12000. FACTOR: NEW EQUIP WDB FULL OF DISCREPANCIES; MALFUNCTIONS; NONE MAJOR; BUT CUMULATIVE EFFECT WAS DISTR AT CRITICAL TIME. FACTOR: LITTLE OR NO EXPERIENCE. FO ON FIRST LINE TRIP WITH 2 PERSON CREW. BOTH HAD VERY LOW TIME; SPREAD OUT OVER MONTHS. FACTOR: NOT TRAINED TO SIMPLY IGNORE SITUATIONS THAT INVOLVE AREAS WHERE WE HAD HAD NO SCHOOLING OR OTHER EXPERTISE.

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