2011-05 · NASA ASRS report 946638
A Corporate Jet crew exceeded the 10;000 FT WITLA constraint on the LAS BOACH4.TNP departure because of poor CRM and a misunderstanding about the word ATC next to the altitude.
While executing the Boach 4 RNAV departure from Runway 1L; we failed to stop at an intermediate altitude (10;000 FT) as depicted at WITLA Intersection; on the departure chart in a climb to FL190. I was the Captain flying on this flight. Upon climbing through approximately 11;500 FT we were asked to 'descend to 10;000 FT immediately' at which time I initiated a 2;000 FPM descent back to 10;000 FT. There was no loss of required separation during this incident. We operate a two captain crew on this aircraft for Part 91 corporate operations. We were in the eighth hour of our duty day. We have also recently switched to the use of NOS approach procedures from commercial charts. Upon a review of the situation; there were several opportunities for both the crew and Air Traffic Control to catch this situation before it occurred. We failed to apply CRM (Crew Resource Management) principals on this particular incident. The Captain not flying filed the flight plans for the entire day from our starting point. The Captain not flying obtained the clearance and set the plane up for the incident departure. We always operate with two captains. Normally; regardless of which Captain will be flying we have one Captain file the flight plan and the other will obtain the clearance and set up the plane for departure. We then discuss the clearance and any limitations. After obtaining the clearance the Captain not flying queried the clearance Controller because no initial altitude was given. The clearance Controller said the initial altitude was FL190 which was consistent with previous departures from the same runway. This was the first missed opportunity to correct the error. At this point we were distracted by the arrival of our passengers and the standard luggage fiasco. We did not properly brief the departure; missing the second opportunity to catch the error. On the taxi out I asked to review the departure procedures. Because I was taxiing the plane I misread the restriction and missed a third chance to catch the error. After take off we were handed off to departure. The Captain not flying called Departure with our current altitude and climbing to FL190. The Departure Controller replied with no correction; missing a fourth opportunity to correct the error. In the end this incident occurred because of a breakdown of CRM; aided by a breakdown of the Air Traffic Control System and a poorly depicted procedure.
We had mistakenly thought that the words ATC next to the 10;000 FT restriction meant that this restriction would be called out by ATC if it was necessary. The other contributing factor was that we had always been cleared to a higher altitude prior to reaching the WITLA RNAV fix on previous flights using the BOACH departure off Runway 1L.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.
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