B737-700 FLIGHT CREW MISREAD CROSSING RESTRICTIONS ON THE DELTA 2 RNAV STAR AT SLC.
Synopsis
B737-700 FLIGHT CREW MISREAD CROSSING RESTRICTIONS ON THE DELTA 2 RNAV STAR AT SLC.
Narrative
ON FLIGHT TO SLC; FLYING INBOUND ON THE DELTA 2 ARRIVAL. CLEARED FROM APPROACH CONTROL TO DESCEND VIA THE DELTA 2 ARRIVAL; WHILE DESCENDING AT EACH BOXED FIX; STARTING WITH 'JAMMN' - 17000 FT; THEN 'DRAPR' -14000 FT; 'SPIEK' - 13000 FT; 'HEIRY' - 12000 FT; AND 'PITTT' - 11000 FT. AS I LOOKED DOWN AT THE ARRIVAL PLATE; I MISREAD THE 'MAGNE' FIX TO READ 10;000 FT INSTEAD OF 11;000 FT (SINCE THE ARRIVAL ALREADY HAD THE CROSSING RESTRICTION OF 11000 FT AT 'PITTT' INTERSECTION). I MISREAD THE NEXT BOXED FIX 'MAGNA' AS 10;000 FT; NOT EXPECTING THE SAME CROSSING RESTRICTION TWICE ALONG THE ROUTE. I THOUGHT IT READ 10000 FT FOLLOWING THE PATTERN; 14000 FT; 13000 FT; 12000 FT; 11000 FT; THEN 10000 FT WHEN I LOOKED AT THE CHART. I SIMPLY MISREAD IT AND WAS THINKING I HAD TO START DOWN TO CROSS THE 'MAGNA' FIX AT 10000 FT. WITHIN A COUPLE HUNDRED FT AS I LOOKED AT THE CHART AGAIN TO FOLLOW MY PROGRESS; I REALIZED MY MISTAKE -- IT WAS THE SAME ALTITUDE OF 11000 FT PRINTED A SECOND TIME AND NOT 10000 FT. I IMMEDIATELY STARTED TO CORRECT MY ALTITUDE (AT THE SAME TIME MY FIRST OFFICER SAW MY MISTAKE AND WAS VERBALLY BRINGING IT TO MY ATTENTION). AS I WAS IN THE PROCESS OF TRYING TO QUICKLY CORRECT THE ATTITUDE; APPROACH CONTROL CAME OVER THE RADIO AND REQUESTED US TO CLIMB BACK TO 11000 FT AND ANNOUNCED TRAFFIC CLIMBING OUT BELOW AND TO THE RIGHT OF US AND ASKED IF WE HAD THE TRAFFIC IN SIGHT. MY FIRST OFFICER CONFIRMED TO APPROACH CONTROL THAT WE HAD THE TRAFFIC IN SIGHT AND INFORMED THE CONTROLLER THAT THE TRAFFIC WAS NO FACTOR. (THE TRAFFIC APPEARED TO BE A FEW THOUSAND FT BELOW AND TO THE RIGHT OF US.) THE AIRCRAFT WAS NEVER CLOSE ENOUGH TO RECEIVE ANY TCAS ALERTS OR WARNINGS. WE THEN CONFIRMED TO APPROACH CONTROL THAT WE WERE LEVEL AT 11000 FT. DURING THE TIME I NOTICED MY MISTAKE AND REVERSED THE AIRCRAFT'S DESCENT RATE TO QUICKLY CLIMB BACK TO 11000 FT; I HAD LOST APPROX 400-500 FT. WE ASKED APPROACH FOR THEIR PHONE NUMBER SO I COULD CONTACT THEM ON THE GROUND. SPEAKING WITH THE ATC FACILITY; I WAS TOLD THERE WAS NEVER ANY LOSS OF TRAFFIC SEPARATION. I WAS THINKING IT WAS FOLLOWING THE SAME 1000 FT DESCENT PATTERN AND THOUGHT I WAS DOING EXACTLY WHAT I WAS SUPPOSED TO DO AND STARTED DOWN I REALIZED I MISREAD THE ATTITUDE CROSSING AND I TRIED TO CORRECT MY MISTAKE AS QUICK AS POSSIBLE; BUT IT APPEARS I WAS TOO LATE. IN THE FUTURE; I WILL DOUBLE-CHECK ALL ATTITUDES LONG BEFORE I BEGIN THE ARRIVAL TO SEE IF THERE ARE ANY REPEATED ALTITUDES; AND AS I DID WITH THE PREVIOUS ALTITUDES; CONFIRM WITH MY FIRST OFFICER BEFORE CHANGING ANY ALTITUDE -- DOWN OR UP! I ALSO FEEL THAT THIS ARRIVAL (DELTA 2); HAVING THE SAME BOXED ATTITUDE RESTRICTION OF 11000 FT REPEATED TWICE WITHIN A SHORT DISTANCE AND WITH A 1000 FOOT DESCENT PATTERN; WAS THE MAIN CONTRIBUTING FACTOR TO MY MISTAKENLY READING AND THINKING I NEEDED TO DESCEND QUICKLY TO MAKE THE NEXT ALTITUDE CROSSING; WHICH I INCORRECTLY MISREAD AS 10000 FT. SUPPLEMENTAL INFORMATION FROM ACN 814119: AS THE PILOT MONITORING; I SET THE 'FINAL' ALTITUDE FOR THE PITTT INTERSECTION AT 11000 FT. THE AIRPLANE CAPTURED AND LEVELED AT 11000 FT AS EXPECTED. THE FIX AFTER PITTT IS MAGNE AND IS ALSO BOXED WITH THE SAME ALTITUDE AS PITTT; WITH THE ADDITION OF A SPEED OF 210 KTS. WHILE I WAS BUSY ON THE RADIO; THE PILOT FLYING MISTAKENLY INTERPRETED THE BOXED ALTITUDE AT MAGNE AS 10000 FT AND THINKING THAT A TIMELY DESCENT WAS NECESSARY; PUT 10000 FT IN THE MCP; AND STARTED TO DESCEND. POSSIBLY A DIFFERENT BOX OR ONLY PUTTING THE SPEED AT MAGNE MIGHT HAVE HELPED THE PILOT FLYING TO INTERPRET THE INFORMATION MORE QUICKLY AND ACCURATELY.
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Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.