Altitude+Excursion+Risk+Management+ Rev.02 PDF

USING THE ETIHAD RISK MANAGEMENT MODEL TO REDUCE THE RISK OF
ALTITUDE EXCURSIONS
A TRAINING MANUAL
Altitude Excursion Risk Reduction Page: 2
Revision: 2
Training Manual Date: 10.07.2016
Foreword
Foreword
This Manual is intended to be used as self-study material on all fleets.
It is issued on the authority of the VP Operations Training and is intended to be used in the initial and
recurrent training of Etihad Airways Pilots. It also serves as a reference for Instructors to reinforce the
application of risk reduction tactics when demonstrating and discussing the threats and errors
associated with Altitude Excursions.
The information in this document must be used in conjunction with Etihad Airways Policies and
Procedures contained in the following documents:
• OM-A,
• FCOM, and
• FCTM
In the event of contradictions between the information contained in this publication and the manuals
above, the latter take precedence.
Please send all comments, corrections and suggestions to the content of this manual via email to
TSFormsHelp@Etihad.ae
ALL INFORMATION CONTAINED IN THIS REPORT IS STRICTLY CONFIDENTIAL AND CIRCULATED TO

IMPROVE SAFETY AWARENESS AMONGST ETIHAD PILOTS. UNDER NO CIRCUMSTANCES SHOULD IT
BE DISCLOSED TO, OR DISCUSSED WITH NON-ETIHAD EMPLOYEES WITHOUT PRIOR WRITTEN
PERMISSION BY ETIHAD CORPORATE SAFETY & QUALITY, LEGAL AFFAIRS, AND CORPORATE
COMMUNICATIONS.
© ETD Foreword ALL

Revision: 2
Contents
Contents
Foreword 2
Introduction 4
Statistical Data 4
Threats, Errors and Undesired Aircraft States 11
Threats .......................................................................................................................................... 11
Errors ............................................................................................................................................. 11
Undesired Aircraft States (UAS) .................................................................................................... 11
Threat and Error Analysis using the Etihad Risk Management Model 13
Threat – Workload ........................................................................................................................ 13
Threat – Additive Factors .............................................................................................................. 14
Pilot-Controller Communications .................................................................................................. 15
Human Factors .............................................................................................................................. 15
Mastering the Language ............................................................................................................... 16
Threat – Change ............................................................................................................................ 24
Threat – Crew Factors ................................................................................................................... 24
Threat – Weather .......................................................................................................................... 25
Analysis of Crew Errors ................................................................................................................. 27
Mishandled TCAS events............................................................................................................... 30
The Pilot Competencies Required to Avoid an Altitude Excursion 33
Situation Awareness (SAW) .......................................................................................................... 34
Flight Path Management – Automation (FPA).............................................................................. 34
Flight Path Management – Manual Control (FPM) ...................................................................... 34
Communication (COM).................................................................................................................. 35
Knowledge (KNO) and Application of Procedures (APK) ............................................................... 36
OM-A Altitude Excursion Risk Reduction Policies and Procedures............................................... 37
Using the Etihad Risk Management Model to reduce the risk of Altitude Excursions ..................... 46
Assess ............................................................................................................................................ 46
Balance .......................................................................................................................................... 47
Communicate ................................................................................................................................ 47
© ETD TOC ALL

Revision: 2
Statistical Data
Introduction
An “Altitude Excursion” or “Level Bust” is defined as any deviation from an assigned level in excess of
300 feet, or 200 feet within RVSM airspace.
Altitude deviations may result in:
• A loss of separation;
• A mid-air collision; or The Etihad Risk Management Model:
• A CFIT event. 3 Levels of Risk:
Low – Medium – High
Whilst the majority of level bust incidents do not involve any
loss of separation, it is not difficult to imagine the
3 Tactics to reduce risk:
• Buy Time
catastrophic outcome and significant loss of life should a mid- • Reduce Workload
air collision occur due to such an occurrence. Indeed, the • Change the Mission
tragic mid-air collision that occurred in 1996 near New Delhi
and claimed 349 lives was the result of a level bust by one of 9 Competencies you need to stay
the aircraft involved. The immediate cause of the accident has safe:
been documented as poor flight deck communication and
lack of co-ordination, but there were a number of additional
contributory factors.
This document addresses the Threats and Errors related to
Altitude Excursion accidents and incidents. It also provides
mitigating strategies using the Etihad Risk Management
Model. For a detailed description of the Risk Management
Model, refer to the CRM Training Guide.
Statistical Data
To learn from Altitude Excursion events, this document uses data from multiple sources including the
IATA Safety Trend Evaluation, Analysis and Data Exchange System reports (STEADES) and the UK CAA
Statistics. Lessons are also drawn from the Etihad Altitude Awareness Program (EAAP) and Etihad
Airways Altitude Excursion ASR data.
Figure 1, depicts the worldwide altitude deviation rates between 2009 and 2013 of airlines participating
in the IATA STEADES program. It implies an average rate of 1 altitude deviation per 7,353 sectors.
© ETD Threats, Errors and UAS ALL

Revision: 2
Statistical Data
Figure 1: Altitude Deviations, Year trend. (Source IATA STEADES report 2014)
Use CAUTION when comparing these figures against Etihad’s data, as the rate is dependent on the reporting culture of
participating airlines.
Figure 2 shows a breakdown of reported altitude deviations by phase of flight. While the majority of
deviations occur during the climb and descent phases, a surprising number of deviations also occur
during cruise and are caused primarily by weather conditions and responses to TCAS RAs.
Figure 2: Altitude Deviation by Phase of Flight (Source IATA STEADES report 2014)

Revision: 2
Statistical Data
Figure 3 shows a breakdown of the contributing factors for Altitude Deviations, the major contributing
factors being Flight Management (82%), ATM (50%), Weather (14%), TCAS (4%) and Documentation
(3%).
Figure 3: Altitude Deviation by Contributing Factor (Source IATA STEADES report 2014)
The following figures provide a detailed breakdown of the major contributing factors for
Altitude Deviations:
FLIGHT MANAGEMENT:
 41% Flight Management - Other
 15% Flight Crew Mis-Selection *
 14% Flight Crew Fatigue/Stress
 13% Flight Crew Auto Handling
 5% Checklist/SOP Use
Figure 4A: Altitude Deviation by Flight Management Contributing Factor (Source IATA STEADES report 2014)
* Flight Crew Mis-Selection refers to:

 Incorrect altimeter setting
 Incorrect altitude input
 FMC/MCDU programming or mode selection error

Revision: 2
Statistical Data
AIR TRAFFIC MANAGEMENT:

 45% ATM – Other
 40% ATC Service Standard
 4% ATC Congestion
 4% Callsign Confusion
 2% Airprox
 ATM Service Standard:
 Confusing clearances
 Late changes to clearances
Figure 4B: Altitude Deviation by Air Traffic Management Contributing Factor (Source IATA STEADES report 2014)
WEATHER
 41% Turbulence
 37% Weather - Other
 5% Windshear
 5% Crosswind
 4% Tailwind
Figure 4C: Altitude Deviation by Weather Contributing Factor (Source IATA STEADES report 2014)
EFFECTS ON OPERATIONS:
 68% Flight Path Deviation - Lateral
 7% Avoidance Maneuver
 5% Temporary Loss of Control
 Contributing Events
 14% Go Around
 12% Aircraft Systems Inhibited
Figure 4D: Other Effect (Source IATA STEADES report 2014)
Etihad statistics for the period January 2013 to December 2015 are quite different from those in the
IATA report, with the majority of deviations occurring in the cruise. In most cases, this was directly
attributable to weather related factors.

Revision: 2
Statistical Data
Total Number of Occurences

70
60
50
40
30
20
10
0
2008 2009 2010 2011 2012 2013 2014 2015
Figure 5: Etihad Airways Altitude Deviation Events (2008 till 2015)
Fleet Flight Phase

A320 (319/320) 106 Cruise 102
A330 84 Descent 67
A340 26 Climb 62
A380 5 Cruise Climb 14
B777 52 Go Around 8
B787 1
Figure 6A: Breakdown of Etihad Airways Altitude Deviation Events from January 2011 to December 2015
Region
Middle East 80
Asia / Pacific 50
Europe 13
CIS 5
Africa 4
North America 3
North Asia 3
Figure 6B: Breakdown of Etihad Airways Altitude Deviation Events from January 2011 to December 2013

Revision: 2
Statistical Data
More recent statistics from Etihad’s Flight Safety department reveal a marked increase in the number of
altitude excursion events involving company aircraft. A total of 27 events were recorded during the
period January-March 2016, of which 15 were classified as “Etihad-induced” (i.e. the events were
directly attributable to pilot actions rather than external factors such as weather). This compares with
just 11 events in the same period during 2015 (with just 5 of these events being classified as Etihad-
induced). Figure 7A gives the distribution of these events by fleet type:
Level Busts per Aircraft Type
44%
TOTAL NUMBER OF EVENTS (Jan-Mar 2016) = 27
26%
11%
7% 7%
4%
A320 A330 A340 B787 B777 A380
Figure 7A: Etihad Airways Altitude Deviation Events (Jan to Mar 2016) – By Fleet Type
The distribution of these events by phase-of-flight (see Figure 7B) is unusual in comparison to Etihad’s
historical experience. The majority of the events (59%) occurred during descent and approach, which is
more in line with industry figures. However, the proportion of events occurring in cruise or cruise-climb
was still significant (29%).
Events per Phase of Flight

33%
26%
22%
7%
4% 4% 4%
Descent Approach Cruise Cruise Climb Takeoff Holding

Climb
Figure 7B: Etihad Airways Altitude Deviation Events (Jan to Mar 2016) – By Phase-of-Flight
Root-cause analysis of the altitude excursion events for the period Jan-Mar 2016 (see Figure 7C) reveal
that the majority of them (60%) were attributable to pilot handling (automatic and manual) and
communication errors. However, weather-related factors were also significant (34%).

Revision: 2
Statistical Data
Root Causes
Pilot/ATC Communication Error 22%

Aircraft Handling 19%
Clear Air Turbulence 19%
Turbulence 11%
Automation Handling 11%
Wrong Altimeter Setting 4%
Windshear 4%
Automation Error/Wrong GS Capture 4%
Late Change of QNH at TL 4%
Compliance with SID Procedure 4%
0% 5% 10% 15% 20% 25%
Figure 7C: Etihad Airways Altitude Deviation Events (Jan to Mar 2016) – Root Causes
For events that involved aircraft handling errors, the most common causes were:
• Lack of awareness of aircraft status, often due to inadequate cross-checking of FMA modes;
• Incorrect or late selection of QNH when passing the Transition Level; and
• Miscommunication between pilots and ATC (the use of conditional clearances by ATC, and
errors arising from pilots’ misunderstanding or misapplication of these clearances, were a causal
factor in the majority of these events).
This latest information serves to reinforce the fact that altitude excursion events are a recognized
hazard for Etihad flights, and that pilots need to remain vigilant in order to manage the threats and
errors that can cause them. It is the objective of this manual to identify these threats and errors, and
provide recommendations that can assist in the avoidance or mitigation of the risks associated with
altitude excursions.

Revision: 2
Threats, Errors and UAS
Threats, Errors and Undesired Aircraft States

Threats
Threats are defined as elements or factors present in the operational environment that affect or
complicate the performance of a task, or compliance with applicable procedures or standards. Threats
usually originate from sources outside the pilots’ immediate sphere of influence, but nevertheless
require active management to prevent them from adversely affecting flight safety.
Figure 8 shows a breakdown of the major threats identified during the STEADES analysis. Please note
that threats are not mutually exclusive, therefore one event can be coded with multiple threats.
Major Threats (%)

Auto Flight Systems 82%
Air Traffic Management / Control 50%
Weather 14%
Figure 8: Breakdown of Major Threats associated with Altitude Excursions (Source IATA STEADES report 2014)
Errors
Errors are defined as crew actions or inactions that lead to deviations from intentions or expectations.
Errors may potentially lead to Undesired Aircraft States (UAS); (see definition below).
Figure 1 identifies the flight crew errors most frequently contributing to altitude deviations:
Flight Management Errors (%)

Flight Management - Other 41%
Flight Crew Mis-Selections 15%
Flight Crew Fatigue/Stress 14%
Flight Crew Automation Handling 13%
Checklist/SOP Use 5%
Figure 9: Breakdown of Flight Crew Management Errors (Source IATA STEADES report 2014)
Undesired Aircraft States (UAS)
Ineffective Threat and Error Management may lead to an Undesired Aircraft State (UAS). An UAS is
defined as a position, condition or attitude of an aircraft that clearly reduces safety margins. These
include failures to capture a cleared level or deviations from an assigned cruise level or altitude.

Revision: 2
Threats, Errors and UAS
EY ASR 1: Unrealistic Climb Performance Expectation
AUH – DARAX: “UAE ATC asked us what will be our flight level at DARAX (FIR boundary waypoint
between UAE and Tehran). During the climb in managed speed, the MCDU was showing FL 327
at DARAX. The Captain (PNF) estimated possible DARAX at FL 350. The FO suggested FL330. The
Captain (PNF) told UAE ATC that DARAX will be flown at FL350. At that time we were level flight
maintaining FL250 for nearly one minute before we were cleared to climb to FL 350.The Captain
discussed the possibility to increase speed from 300 managed to 325 selected while maintaining
level to help building altitude later in climb. The Mach speed technic to optimize the climb was
discussed to make the constraint at DARAX. The UAE controller called us when he realized we
were passing FL340 approaching DARAX telling us that we will not make 350 at DARAX and why
we did not let him know as it is too late to re-coordinate with Tehran. The Captain PNF took
control reducing the speed to green dot, then further down between GD and VLS. We reached
FL 350 about 5-6 nautical miles after DARAX.”

Revision: 2
Risk Management Model
Threat and Error Analysis

THE SOURCES OF RISK
1. THREATS
M ALFUNCTION / CDL ITEM TIME PRESSURE TERRAIN ATC MISSED APPROACH
using the Etihad Risk
Management Model
OR DIVERSION
AUTOMATION ANOMALY
DISTRACTIONS
WEATHER
ADDITIVE
ORGANIZATIONAL ANOM ALY FACTORS
AIRPORT HAZARDS
A more detailed look at Threats and Errors
UNFAMILIAR AIRPORT WORKLOAD CHANGE
that were mismanaged by the flight crew
and resulted in an Altitude Excursion are
PERSONAL ISSUES
CREW
presented below, using the taxonomy of
LOW EXPERIENCE FATIGUE / BOREDOM
FACTORS
the Etihad Airways Risk Management

HEALTH / STRESS COMPLACENCY
LACK OF
Model.
LACK OF KNOWLEDGE / SKILL ASSERTIVENESS HAZARDOUS ATTITUDES
THREATS INCREASE THE POSSIBILITY OF ERROR

In the Etihad Risk Management Model, the
2. UNMANAGED ERRORS
4 broad categories of threats are
Workload, Additive Factors, Crew Factors
and Change. In a high threat environment, the frequency of crew error is usually increased.
Threat – Workload
Data provided in Figure 6A (Breakdown of Etihad Airways Altitude Deviation Events) indicate that
altitude deviations are more likely to occur during the cruise phase of the flight. This may come as a
surprise to most pilots, since the climb and descent phases are usually associated with higher workload
levels that can contribute to a higher error rate. In contrast to the Etihad Airways data, the IATA
STEADES data provided in Figure 2 suggests that the climb is the phase where there is a greater risk for
altitude deviation events, with workload and TCAS RA’s representing the major factors. This data
outlines a very significant fact, which is that the level of risk during low workload phases of flight can be
just as significant as the risk level during high workload phases. Low workload, and any resultant
complacency, are threats that can lead to errors during the cruise phase. However, it is worth noting
that altitude excursion events are rarely due to just one threat, and that these events are often caused
by a combination of several threats and errors (e.g. weather or CAT, combined with low workload
levels).
EY ASR 2: High workload on departure without automation
CGK: “During initial climb out hand flying we over shot the initial climb restriction (by tower)
by about 350 ft. When cleared for take-off by TWR we received additional instructions to
maintain RWY HDG and altitude of 2000 ft. During climb out right after switching to control
frequency, we received additional heading instructions and I asked for speed intervention
180 kts to diminish turn radius. The resulting high workload, compounded by light A/C, high
power thrust, take-off (due to software of the engine required, full take-off thrust) plus high
rate of climb, all contributed to the altitude bust even realizing that we were approaching
the target altitude.”
© ETD Risk Management Model ALL

Revision: 2
Threat – Additive Factors
Additive Factors - ATC

Air Traffic Management - Other 45%
ATC Service Standard 40%
ATC Congestion 4%
Callsign Confusion 4%
Airprox 2%
Figure 10: Breakdown of ATC Factors (Source IATA STEADES report 2014)
EY ASR 3: ATC late change of cleared altitude
“Climbing out of DOH, ATC cleared us to 6,000’. When passing around 3,600’ asked us to
level off at 4,000’. The First Officer (PF) set 4,000’ on the FCU, however the aircraft went to a
mode reversion (V/S) and kept climbing past 4,000’. At around 4,400’ I took over controls
and pushed V/S 0 and the aircraft started slowly to level off. The autopilot reaction being too
slow I disconnected the autopilot and started a gradual descent to 4,000’. In the process ATC
called back and apologized for the late clearance change and asked us to continue climb to
6,000’. Autopilot was engaged again and climb was continued to 6,000’.”
EY ASR 4: ATC conflicting clearance
“In Tehran airspace, we were cleared to avoid CB's to south of track between PAPAR and SYZ
on a free heading when about 25nm south of the airway, TCAS showed an aircraft at 12
o'clock descending out of FL390. It came closer and descended through our level FL 360. After
we challenged ATC, he was ordered to climb back to FL370 after reaching about FL355.
Apparently he was cleared originally to FL270 TCAS delivered traffic advisory; the aircraft
came within 4nm at same level. Aircraft was Falcon 2000/callsign N467P. ATC informed that a

Revision: 2
Pilot-Controller Communications
An analysis of level busts by the US Federal Aviation Administration (FAA) and by USAir (now American
Airlines) showed that:
(a) Approximately 70% of level busts were the

result of a breakdown in pilot-controller Pilot-Controller Communication Loop
communications.
(b) Nearly 40% of level busts occurred when air ATC Clearance
traffic control (ATC) assigned 10000 feet and
the flight crew set 11000 feet in the selected Transmit
altitude window, or vice versa. Acknowledge or
Correct
Listen
The responsibilities of the pilot and controller
overlap in many areas and provide mutual
backup. To be effective, the pilot-controller
communication process must be a “loop” (see
Figure 10). Whenever adverse factors are likely to Controllers
Pilots Readback
Readback
affect communication, proper confirmation and
correction is necessary to prevent communication Transmit
errors.
Listen
As discussed previously, pilots and controllers
share an equal responsibility in air traffic Figure 10: Breakdown of Crew Flight Management Errors
management (ATM) systems. Achieving effective
radio communication involves many factors that
should not be considered in isolation; more than one factor is usually involved in a breakdown of the
communication loop.
Human Factors
Effective communication is achieved when the message transmitted by one party is correctly
interpreted and understood by the other party.
Perception is a key factor in communication. In a multi-pilot cockpit environment, the level of

perception of the crew is only equal to that of the crew member with the lowest level of perception.
The process can be summarised as follows:
a) How do we perceive the message?

b) How do we re-construct the information contained in the message?
c) How do we link the information to an objective or to an expectation (e.g. route, altitude or
time)?
d) What bias or error is introduced in the process?

Revision: 2
Crew Resource Management (CRM) training for pilots and Team Resource Management (TRM) training
for controllers highlight the importance of the context and
expectation in communication. Expectations may introduce
either a positive or negative bias in the effectiveness of the Non Standard Phraseology used
communication. within the UK
High workload, fatigue, distractions, interruptions, and The UK CAA has adopted certain
conflict are amongst the factors that may adversely affect non-standard phraseology designed
pilot-controller communications and result in: to reduce the chance of mishearing
or misunderstanding RTF
(a) Incomplete communication, communications. The phraseology is
(b) Omission of callsign or use of an incorrect callsign, not in accordance with ICAO
(c) Use of non-standard phraseology, standards but is based on careful
(d) Failure to hear and respond to a clearance, and study and breakdown of
(e) Failure to implement effectively a confirmation or pilot/controller communications. The
correction following paragraph taken from
CAP413 summarises the main
EY ASR 5: Incorrect Level Selection differences:
(a) The word “to” is to be omitted

PVG-AUH: Capt. was taking controlled rest. ATC from messages relating to
cleared the flight to climb from FL320 to FL340. FO FLIGHT LEVELS;
made an incorrect selection to FL360. Corrective
(b) All messages related to an
action was taken by the FO upon intervention by aircraft’s climb or descent to a
Kolkata ATC. Max Excursion picked by FDM was HEIGHT or ALTITUDE employ the
700 ft. Aircraft descended to FL340. Causal factors word “to”, followed immediately
included the distraction caused to the FO, who by the word HEIGHT or
was reviewing the next area chart at that moment ALTITUDE. Furthermore, the
and the failure of the FO to wake up the Captain initial message in any such RTF
exchange will also include the
before starting the climb (as agreed between the
appropriate QNH.
crew)
(c) When transmitting messages
containing flight levels each digit
shall be transmitted separately.
Mastering the Language However, in an endeavour to
reduce “level busts” caused by
CRM studies show that language differences on the flight confusion between some levels
deck are a greater obstacle to safety than cultural (100/110, 200/220 etc.), levels
differences. which are whole hundreds e.g. FL
100, 200, 300 shall be spoken as
English is the shared language in aviation and because of this “Flight Level (number)
an effort has been initiated to improve the English-language HUNDRED”. The word Hundred
skills of pilots and controllers worldwide. must not be used for headings.
Nevertheless, even pilots and controllers for whom English is

their native language may still not understand all words spoken in English because of regional accents
and dialogues.

Revision: 2
In many regions of the world language differences generate other communication difficulties.
For example, controllers using both English (for communication with international flights) and the native
language (for communication with domestic flights) can reduce the flight crew level of situation
awareness (loss of party-line communications).
Non-standard Phraseology
Non-standard phraseology is a major obstacle to effective communication.
The use of standard phraseology in pilot-controller communication is intended to maximize mutual

understanding and minimize confusion.
Standard phraseology helps lessen the ambiguities that can be present in spoken language, and thus
facilitates a common understanding among speakers:
(a) Of different native languages, or
(b) Of the same native language, but who pronounce or understand words differently.
Non-standard phraseology, or the omission of key words, may completely change the meaning of the
intended message, resulting in errors that can lead to traffic conflicts.
For example, any message containing a number should indicate what the number refers to (e.g. a flight
level, a heading, or airspeed). Including key words prevents erroneous interpretation and allows an
effective readback/hearback to occur.
Particular care is necessary when certain levels are included in transmissions, because of the high
incidence of confusion between, for example, FL100 and FL110.
Non-standard phraseology is sometimes adopted unilaterally by national or local air traffic services, or is
used by pilots or controllers in an attempt to alleviate these problems; however, standard phraseology
minimises the potential for misunderstanding.
Frequency Congestion
Frequency congestion and interference significantly affects the flow of communications, especially
during the approach and landing phases at high-density airports, and demands enhanced vigilance by
pilots and by controllers.
Good RTF discipline is essential for operating safely in such environments.

Revision: 2
EY ASR 6: Poor Radio Reception
AUH-CGK. Climbing to FL210 on course to KANIP as cleared by UAE. Approaching KANIP,

frequency change to Muscat 124.7. Initially no contact - level off at FL210.
Then contact with Muscat reading 2 while suppressing squelch. Understood clearance to
climb FL350 direct to LABRI. FL350 selected on MCP and climb resumed in VNAV. PM seek
confirmation of clearance to climb FL350 now or after LABRI and request FL330 for cruise as
there was a doubt about the clearance. Autopilot was disconnected to initiate level off and
descent back to FL210 - max FL was 217. No traffic in the vicinity Muscat confirmed
clearance to climb after LABRI, but as PM replied we were already at FL215, Muscat cleared
us to continue climb to FL330 with no restriction.
Failure to Correct Readback
The absence of an acknowledgement or a correction following a clearance readback is perceived by

most flight crews as an implicit confirmation of the readback. The absence of acknowledgement by the
controller may be due to frequency congestion and/or the need for the controller to issue clearances to
several aircraft in succession.
An uncorrected erroneous readback (known as a hearback error) may lead to a deviation from the
cleared altitude, or non-compliance with an altitude restriction or with a radar vector.
Under these circumstances, the deviation from the intended clearance may not be detected until the
controller observes the deviation on his/her radar.
Less than required vertical or horizontal separation (and a near mid-air collision) can be the result of
hearback errors.
EY ASR 7: Clearance Confusion
ORD-AUH. During descent we were cleared by Tehran ATC to FL270 by 'ORSAR' and changed
us over to UAE center. We requested for RNAV APP, communication by UAE Center ended
with '150' which was understood as descend clearance to FL150. As we descended below
FL270 ATC, queried our intentions. When we informed that we were descending to FL150,
we were told no clearance for descend had been given. They asked to stop descend at
FL250. It appears misunderstanding between call sign EY150 and FL150 may have led us to
belief that descend clearance had been given.

Revision: 2
Expectations
Bias can affect the understanding of communications between

pilots and controllers.
Building Situation Awareness
For example, an expectation bias can lead to:
Radio communications should
(a) Transposing the numbers contained in a clearance contribute to the pilot’s and the
(e.g. a flight level) to what was expected, based on controller’s situation awareness,
experience or routine and, which may be enhanced if they
(b) Shifting a clearance or instruction from one parameter provide each other with advance
to another (e.g. perceiving a clearance to maintain a information.
280 degree heading as a clearance to climb/descend
and maintain flight level 280.
Omission of Callsign
Language and Communication Omitting the callsign or using an

incorrect callsign jeopardises an
Even native speakers may not speak their own language effective readback/hearback.
correctly. The standard phraseology specified for RTF
communication is intended to overcome this basic Omission of Readback or
shortcoming.
Inadequate Readback
The first priority of any communication is to establish an
operational context that defines the following elements. The term “Roger” is often misused as
in the following situations:
(a) Purpose: Clearance, instruction, conditional
statement, or a request, or request for confirmation. (a) A pilot says “Roger” (instead of
(b) When: Immediately, anticipate, expect. providing a readback) to
(c) What and How: Altitude (climb, descend, maintain), acknowledge a message
heading (left, right), airspeed; containing numbers , thus
(d) Where: At [….] waypoint. preventing effective hearback
and correction by the controller;
The construction of the initial and subsequent message(s) or,
should support this operational context by:
(b) A controller says “roger” to
(a) Following the chronological order of the actions. acknowledge a message
(b) Grouping instructions and numbers related to each requiring a definite answer (e.g.
action; and a positive confirmation or
(c) Limiting the number of instructions in the correction, such as
transmission. acknowledging a pilots
statement that an altitude or
The intonation, the speed of speaking, and the placement and speed restriction cannot be
duration of pauses, may affect the understanding of a met); this decreases both the
communication. pilots and the controllers’
situation awareness.
Filtering Communications
Due to flight deck workload demands, pilots tend to filter communications, listening primarily for
communications that begin with their aircraft call sign and not listening to most other communications.
For workload reasons, controllers may also filter communications (e.g. not hearing or responding to a

Revision: 2
pilot readback while engaged in issuing clearances/instructions to other aircraft or ensuring internal co-
ordination).
To maintain situation awareness, this filtering process should be adapted, according to the flight phase,
for more effective listening. For example, when operating in congested airspace the pilots should listen
and give attention to all communications related to clearances to climb or descend to, or through, their
levels.
Timeliness of Communications
Deviating from an ATC clearance may be required for operational reasons (e.g. a heading deviation or
altitude deviation due to weather avoidance, or an inability to meet a restriction). Both the pilot and the
controller need time to accommodate this deviation; therefore ATC should be notified as early as
possible to obtain a timely acknowledgement.
Similarly, when about to enter an FIR with non-radar controlled airspace, the pilot should contact the
appropriate ATC facility approximately 10 minutes before reaching the FIR boundary, to ensure
communications are established in time to prevent misunderstandings or potential traffic conflicts.
Blocked or Simultaneous Transmissions
Blocked transmissions are a contributing factor in many altitude deviation incidents. Blocked
transmissions are usually the result or two callsigns transmitting simultaneously, although there are a
number of other possible causes. The absence of a readback from the pilot or controller should be
treated as a blocked transmission and prompt a request to repeat or confirm the message.
Depending on the circumstances, it might be worth alerting controllers and other pilots regarding an
apparent blocked or garbled transmission by saying “blocked” immediately afterwards.
Conditional Clearances
Conditional clearances issued by ATC usually involve a requirement to climb above or descend below the
previously assigned altitude or flight level after crossing a certain waypoint or fix. This type of clearance
is well-recognized as a threat that can lead to errors in the pilot’s understanding and/or compliance with
the clearance.
Although conditional clearances are used by ATC in many parts of the Etihad network, recent statistics
indicate that these have been a causal factor for a significant number of altitude excursion incidents
involving Etihad aircraft operating in UAE airspace. Analysis has shown that conditional clearances at
waypoint LABRI during climbout from Abu Dhabi, and at waypoints SODEX, RESAR, ORSAR and ORSIS
during descent into Abu Dhabi, were frequently cited as contributing to these events.
Pilots need to be aware of the greater potential for errors to occur when receiving a conditional
clearance from ATC, and to be prepared to seek clarification if any uncertainty exists regarding their
understanding of the terms of the clearance.

Revision: 2
EY ASR 8: Conditional Clearance
BNE-AUH: We were on en-route descent FL160 to waypoint SODEX and NOBTO with
Muscat CTL. Muscat gave speed restrictions on the descent as the aircraft was descended
on VNAV profile. On hand-off to UAE CTL, descent clearance was given to 10,000ft on QNH
after SODEX, as was anticipated. Attempting to maintain a continuous descent profile, VS
(vertical speed) descent was selected and controlled to cross SODEX at FL160, then to
10,000ft as cleared. While the green descent arc predicted the aircraft crossing SODEX at
FL160, the aircraft descended below FL160 about one mile short of SODEX. ALT HOLD was
selected to stop the descent and the aircraft leveled off 300 feet below FL160 0.5 mile
short of SODEX. ATC called the level and we explained the inadvertent bust, as we crossed
SODEX. Aircraft descended to 10,000 feet crossing SODEX. No other aircraft was in the
vicinity below. In retrospect I should have: 1. Entered a ‘hard altitude’ restriction of FL160
on the Legs page, as this is a known crossing altitude, although not published (Would it be
a good idea to publish it?) 2. Maintain VNAV descent rather than VS descent for altitude
protection. Lessons learnt from above, during crew de-brief with rest of the crew.
AUH-MEL: 10 miles to position LABRI UAE handover us to MUSCAT with clearance to FL210.
MUSCAT clearance was to continue climb to FL310 after position LABRI. The F/O understood
to continue the climb to FL310. We were trying to confirm the clearance but the frequency
was very busy and I called more than four times to confirm. At the meantime the F/O
continued the climb and we cross position LABRI at about FL230. At Muscat FIR I called again
to confirm the clearance and he confirm that it was climb FL310 after position LABRI.
RUH-AUH: Level bust during descent approaching 10NM before ORSIS. ATC cleared us to
descend after position ORSIS from FL290 to FL250 at the same time as issuing an additional
‘direct to’ clearance. This was understood by the PF as “cleared to descend now” and
initiated a descent down to FL250 from FL290. This was spotted and ‘Push to Level Off’ was
used. The aircraft stopped descent at FL286 and a climb was initiated back to FL290. Flight
continued without further issue to AUH. ATC did not say anything.

Revision: 2
Call Sign Confusion

Statistical Data
The use of similar callsigns by aircraft operating in the same
area and especially on the same RTF frequency often gives The UK CAA reported that of a total
rise to potential and actual flight safety incidents. This hazard of 5,625 safety occurrences notified
is usually referred to as “callsign confusion” to them during 1997, 175 of them
involved callsign confusion. This
The danger of an aircraft taking and acting on a clearance number has been steadily growing
intended for another is obvious. The following are some of since then. In the same year ACCESS
the potential outcomes of such a situation. initiative collected a total of 482
reports of callsign similarity filed by
(a) The aircraft takes up a heading or routing intended pilots and air traffic controllers in the
for another; UK. 217 of these involved actual
(b) The aircraft commences a climb or descent to a level confusion, including 99 where ATC
to which it has not been cleared; were actually confused. 353 involved
(c) The aircraft changes to an incorrect ATC frequency; increased reported controllers
(d) In responding to a message, the aircraft blocks a thinking time, and increasing RTF
transmission from the intended recipient; usage time.
(e) The intended recipient does not receive the
clearance, and fails to take up the desired heading or During 2003, about 800 safety
routing, or fails to climb or descend to the desired occurrence reports concerning
level; similar callsigns were collected by air
(f) The workload of controllers and pilots is increased traffic management services in
due to the necessity to resolve the confusion. France. These include 100 or so
incidents having a direct impact on
Any of the above situations could result in a loss of air traffic safety and leading to very
separation, a level bust or mid-air collision, and so should be unsafe situations.
avoided at all costs.
In cooperation with the Netherlands
Note: Pilots should be ready to adapt to the “group form” Research Laboratory (NRL),
callsign format used in some countries (e.g. Australia, USA) in EUROCONTROL studied 444
order to prevent possible confusion. occurrences in which there were
Example: “Etihad four fifty four, contact departures”. problems with communication
between the controller and the pilot.
All these occurrences were classified
as incidents. These incidents were
Block Level Clearances classified by their consequences. 70
were classified as “wrong aircraft
Block Level Clearances are normally issued within Australian accepting clearance” and 92 as
administered airspace and allow pilots to change levels freely “altitude deviation”. In 19 cases
within the block, provided that the upper and lower limits are there was a combination resulting in
not exceeded. them both.
As most altitude alerting systems do not provide protection

for both upper and lower assigned levels, flight crews are
reminded to be vigilant in monitoring the aircraft altitude
when operating within a Block Level.
Pilots must be aware that Block Level clearances are a

frequent contributing factor for altitude deviations and
Revision: 2
therefore, a high level of vigilance and awareness is required when conducting such operations.
The following Etihad ASRs illustrate the risks associated with Block Level clearances:
EY ASR 11: EY 484 AUH-BNE. Block Level Clearance Altitude Excursion
CPDLC communications were established with Melbourne Center.

The flight was cleared to operate within the block of FL370 to FL390.
At 02:42Z and while cruising at FL375, the following ATC clearance was received and
acknowledged by the crew: "When ready, climb to and maintain block FL380 to FL390.
Reach FL380 by 03:10Z".
The crew continued to maintain FL375, and at 03:12Z ATC instructed the pilots to climb to
and maintain block FL380 to FL390.
The crew acknowledged the clearance and performed an immediate climb to FL380.
EY ASR 12: EY 462 AUH-MEL. Block Level Clearance Altitude Excursion
CPDLC communications were established with Melbourne Center.

The aircraft was cruising at FL330 and a previous request to operate within the block of
FL330 to FL350 was denied by ATC due to a conflicting traffic.
While conducting the handover briefing with the relief crew, ATC cleared the flight to climb
to and maintain block FL330 to FL340.
PF started the climb to FL340, which was subsequently increased to FL345 (FMC Optimum
Altitude) without confirmation, since he had understood that the block level clearance was
from FL330 to FL350.
The distraction caused by the crew changeover prevented the PM to notice this error and
led to a Level Bust

Revision: 2
Caution:
Block Level clearances are a great tool to maximize fuel savings and/or to modify the flight level as
necessary in order to avoid significant weather or turbulence. However, pilots must bear in mind that
these clearances may increase the potential for a Level Bust, especially when the flight has been
cleared to maintain a designated Flight Level or Block Flight Level by a specific position or time
(conditional ATC clearances).
Pilots must exercise extreme caution in these circumstances, and ensure that robust measures are put
in place to ensure that all ATC clearances are strictly understood and followed, including timely
clarification of any uncertainty or ambiguity concerning the content of such a clearance.
Pilots must also avoid any interruptions or distractions whenever they are about to, or while they are
conducting, a level change.
Threat – Change
Last minute changes in a clearance, routing or cleared level can cause high workload within the
flightdeck which may lead to a loss of situation awareness.
The flightdeck crew have no control over this factor but can project their plan forward to cover such
eventualities. The lack of thorough briefing and identifying contingencies for this change can result in
errors due to high work load and distraction.
EY ASR 13: Threat – Change!
FRA-AUH: “We were ready for a NOMBO 2F departure from RWY 25R with an initial climb
clearance to 5000' as per Jeppesen 10-3T7. Change for RWY 18 with a NOMBO 3S. We stopped
the climb at 5000' versus 4000'. After ATC called no further problem, no conflicting traffic.”
Threat – Crew Factors

It can be assumed that a pilot under training is more prone to error since he/she is still familiarizing
himself/herself with the aircraft. This crew factor obviously reduces synergy and increases the workload
of the other pilot.
Flight crews should recognize that a lack of alertness on a multiple leg schedule can easily lead to a
breakdown in prioritization, and errors during task saturation. Fatigue-induced haste, often results in
critical omissions or inappropriate decisions.

Revision: 2
EY ASR 14: Training flight, late engagement of auto-pilot
AMM-AUH. Clearance: climb RWY Hdg 5000', contact departure 128.9. Training flight, due to
confusion with frequency change, assisting trainee F/O, AP1 was not engaged in time, and
cleared ALT 5000' was exceeded momentarily up to 5300'. At the same time, ATC cleared us
to FL250, as soon as frequency was established. There was neither effect on other traffic nor
ATC reaction due to the following clearance.
Threat – Weather
From the data collected from Etihad Airways over the past few years, it becomes apparent that many of
the incidents have taken place during the cruise phase of flight. Low workload might represent just as
much of a threat as high workload does. This phase of low workload makes it more difficult to
concentrate and project ahead, and thereby anticipate and avoid areas of bad weather, turbulence and
wake turbulence from other aircraft.
Events in cruise according to the IATA STEADES report account for 15 – 20% of all altitude excursions.
Etihad data, as shown below, confirms this threat has a bigger impact on our operations during cruise.
Flight crews should be aware that the risk for an altitude deviation is significantly increased when one or
more of the following factors are present:
• Significant temperature changes along the route.
• Areas of forecast CAT and the presence of jetstreams.
• Thunderstorm areas.
• Situations where the flight is conducted through or within the proximity of the tropopause.
Therefore, it is paramount that pilots are able to correctly identify these threats based on the analysis
of the available weather information:
Crew Related Weather Related ATC Related
Figure 11: Etihad Airways 320/330 Altitude Excursion events 2011 - 2112 (Etihad Airways Flight Safety Dept.)

Revision: 2
EY ASR 15: Threat – Weather
Etihad ASR Cruise: “During cruise at FL410 light to moderate turbulence encountered so
speed reduced to M0.80 and seat belts sign on, then temp variation occurred +/- 5 deg which
caused the speed to exceed mmo, auto pilot was manually disconnected and pitch up was
introduced so we gain about 300ft. Later speed loss encountered then pitch down was
introduced to regain the speed.
EY ASR 16: Threat – Weather
SYD-AUH: “Flying at M0.82 at FL360 we encountered unforeseen clear air turbulence at

1434UTC. Turned fasten seat belt on and engine start selector to ignition/start. Autopilot
kept engaged, reduced Mach number. Altitude excursion of +/- 400ft. Then recover normal
speed and altitude within 4 minutes. Cabin crew at mid galley suffered bruises but no
reported injuries. Unable to contact ATC but reported deviation to 118.6 in good

Revision: 2
Analysis of Crew Errors

Flight crew errors can be grouped into categories that include
The “On the Level” project
aircraft handling, procedural or communication errors. These
conducted by the UK CAA during
categories are not mutually exclusive; therefore one event 1999 found that of 626 level bust
can be caused by multiple errors. The predominant errors are incidents reported, the top six causal
linked with communications, followed by procedural and factors involved in more than 70% of
handling errors. all incidents were;
• SID confusions;
Crew Communication Errors • Autopilot problems;
• Failure to follow ATC
Failure to Request Confirmation or instructions;
Clarification • Altimeter mis-setting;
• Pilot handling;
Misunderstandings can arise whenever words or numbers are • Confusion over cleared level.
not clearly heard, and which may then be “guessed” by
expectation.
The potential for misunderstanding numbers increases when

an ATC clearance contains more than two instructions.
Failing to request clarification may cause flight crew to

believe erroneously that they have received an expected
clearance (e.g. clearance to climb to requested level).
Failing to question an instruction can cause a crew to accept an altitude clearance below the minimum
safe altitude (MSA) or a heading that places the aircraft on collision course with another.
If there is any doubt as to the content of a clearance, or its meaning is not clearly understood, pilots
must obtain clarification or confirmation. In this case, pilots must refrain from repeating what they
thought they heard when asking to confirm the clearance. For example “London – confirm the cleared
flight level for Etihad 162” and NOT “London – confirm the cleared flight level for Etihad 162 is FL190”.
This procedure should also be followed if any doubt exists between the crew members and when an
altitude/level change has been received by only one pilot.
EY ASR 17: Communication Error
LHR-AUH: “On climb out EX LHR, we were given instructions: speed restriction cancelled, fly
heading 145º and, we thought, climb FL320. Thru 6700' ATC queried our altitude and then
issued an immediate descend clearance to 6000'. AP was disconnected and descend
maneuver manually flown. There seemed to have been a conflicting traffic above us and
moving right to left; we had this aircraft on TCAS and visually. ATC was advised of this fact
and that there was no conflict. TA or RA were not activated and safety of the aircraft not
compromised.”

Revision: 2
Accepting Another Aircraft’s Clearance

or Instruction
Level busts often occur because an aircraft accidently

accepts a clearance intended for another aircraft. This
usually occurs when two aircraft with similar sounding
callsigns are on the same RTF channel and are likely to
receive similar instructions, or the callsign is blocked by
another transmission. When pilots of different aircraft
with similar sounding callsigns omit the callsign on
readback, or when simultaneous readbacks are made by
both pilots, the error may go unnoticed by the pilots and
the controller.
Some national authorities have implemented programmes to counter callsign confusion. Etihad
currently participates in callsign de-confliction trials being conducted in several FIR’s in the European
and Middle East regions that aim to eliminate similar callsigns and hence reduce the possibility of errors
arising from such confusion. Example:
EY ASR 18: Callsign confusion
Etihad ASR: With Beijing Control on 134.250. At FL321/9800m. Requested to climb to

FL361/11000m. Request approved, and ‘Leaving 9800m climbing 11000m Etihad 889’ was
read back. No correction from ATC. Climb initiated, and when crossing FL329, ATC came back
and asked us to maintain FL321/9800m. Descent was initiated. Qatar 889 was on the same
frequency as well as another airline with c/s 885, and one more with c/s 8899.
Aircraft Handling Errors

Handling the aircraft correctly and applying the correct use of automation are integral to avoid Altitude
excursions. There are many reasons for mishandling an aircraft; however the major reasons are still as
simple as over confidence or distraction at a critical phase of flight.
EY ASR 19: Conditional clearance & automation error
Etihad ASR: While descending to FL150, new clearance was given to descent 13,000’ QNH
1012 after passing BOPIT. PF selected 13,000 on FCU and inserted a constraint in FMGC. PF
however inadvertently inserted +13000 instead of +15000 at BOPIT.
By the time PM cross-checked PF’s action, aircraft had already passed FL150 before BOPIT and
UAE controller had called to verify our level maintaining and position.

Revision: 2
Altimeter Setting Errors
Diagram 1: QNH is 1003 hPa, but the altimeter was mistakenly set to the standard pressure setting,
1013 hPa, resulting in the actual altitude being different from the altimeter by 300 feet.
Diagram 2: QNH is an unusually low 28.90in.Hg, but the altimeter was mistakenly set to a more usual
29.90. This would result in a discrepancy of 1000 feet.
Diagram 3, a QNH of 29.91 in.Hg was mistakenly set on the altimeter as 991 hPa. This would result in a
discrepancy of 650 feet.

Revision: 2
Mishandled TCAS events

EY ASR 20: Multiple Resolution Advisories in cruise
ETD 008 Airbus A330 was the scheduled flight from Frankfurt (FRA) to Abu Dhabi (AUH).
The crew was operating a single sector from FRA to AUH following a layover.
In the cruise at FL390 50nm South/East of Erbil and cruising at M0.84 the aircraft
encountered light turbulence which led to the Captain reducing the managed speed to
M0.83. Shortly afterwards there was speed trend increase which led to a MMO
exceedance. The autopilot was disconnected and through the Captain’s Side Stick input
command the aircraft pitched up leading to both an altitude increase in excess of 300ft
plus a TCAS RA with an aircraft cruising at 1000ft above. This opposite traffic was forced to
climb in reacting to the RA. The Captain in response to the RA commanded a pitch down
and through the ensuing rate of descent instigated a further TCAS RA with another aircraft
below. The autopilot was reengaged but due to the continuing TCAS resolution commands
it was further disengaged and reengaged twice before the flight was continued. The First
Officer was in controlled rest at the time of the incident and awoke when the Master
Warning aural alert for the over speed was activated.
(Source material: European Action Plan for Air Ground Communication Safety May 2006.)

Revision: 2

Revision: 2

Revision: 2
The Pilot Competencies Required to Avoid an Altitude Excursion
P
K
The following competencies are particularly important in the context of avoiding Altitude Excursions:
Workload Management (WLM):

• Plans, prepares, prioritizes and schedules tasks effectively. For example:
o Crew ensures briefings / programming completed prior to high workload periods
o Crew prioritizes & concentrates on primary tasks first
o Crew "Buys time" when necessary
• Manages interruptions, distractions, variations and failures effectively. For example:
o Crew ensures distractions do not detract from monitoring flight level capture.
o The Captain ensures that Sterile Cockpit rules are enforced.
o Social climate & activities are appropriate to operational circumstances, and do not
interfere with primary duties.
• Reviews, monitors and cross-checks actions conscientiously. For example:
o The SID and initial clearance level are discussed during the departure briefing, and then
o The actual initial clearance is verbalized on receipt with both crew members listening to
the actual clearance.
o Crewmember employs active monitoring / cross checking.
Problem Solving & Decision-Making (PSD)

• Identifies and verifies why things have gone wrong and does not jump to conclusions or make
uninformed assumptions. For example:
o Asks questions to clarify uncertainties / resolve concerns.
o Ensures all crew concerns are resolved.
o Takes nothing for granted.
Situation Awareness (SAW)

• Is aware of where the aircraft is and its environment. For example:
o Crewmembers monitor / cross-check cleared altitude.

Revision: 2
o Crewmembers question / resolve ambiguities with respect to aircraft position.

o Crew members update each other on proximate traffic
• Identifies threats to the safety of the aircraft and people, and takes appropriate action.
o Enroute hazards are identified / discussed / resolved
o Checks the OFP weather information to determine areas with significant wind or
temperature changes.
Actions that Enhance Situation Awareness

The following procedures can serve to mitigate the factors involved in Altitude Excursions due to a loss
of situation awareness:
Situation Awareness (SAW)

• Follow normal SOPs – they are the first line of defence against a level bust.
• Increase vigilance, particularly in the TMAs and where traffic density is high.
• If in doubt about a clearance, confirm on the R/T, as well as with your colleague.
• Avoid non-essential tasks (e.g. passenger announcements) which remove a crew member
from the R/T communications loop, especially during climb and descent.
• Report your cleared level on first contact on a new frequency, unless specifically requested
not to.
• Pay special attention to SID charts, particularly at airports where the SID involves a stepped
climb. Brief thoroughly.
Flight Path Management – Automation (FPA)

• Effectively monitors automation, including engagement and automatic mode transitions
o Crewmember always reads FMA after a change
o Crew members monitor capture of cleared altitude or level
• Selects appropriate level and mode of automation in a timely manner considering phase of flight
and workload
o Uses appropriate automation modes to manage rate of climb and descent when
approaching cleared altitude or level.
o Reduces level of automation when situation requires this.
Flight Path Management – Manual Control (FPM)

• Maintains the desired flight path during manual flight whilst managing other tasks and
distractions
o Decides to fly manually only when this is appropriate to the conditions and workload.
Revision: 2
• Detects deviations from the desired aircraft trajectory and takes appropriate action
o Recovers from an overspeed condition in accordance with FCOM procedure
Communication (COM)
• Conveys messages and information clearly, accurately, timely and adequately
o Adheres to standard ICAO radio phraseology
o Reads back ATC clearances in full
• Confirms that the recipient correctly understands important information
o When in doubt about an ATC instruction or clearance, actively seeks clarification and
confirmation.
Actions that Enhance Communication

The following communication guidelines can serve to mitigate the factors commonly involved in Altitude
Excursions:
1) Use of English language and adherence to established standard ICAO phraseologies in order
to maintain effective communication and situation awareness for all participants associated
with flight operations.
2) Advise ATC if any of the following situations occur:

 Two or more aircraft with similar call signs are on the RTF frequency;
 It is suspected that an aircraft has taken a clearance not intended for it;
 It is suspected that another aircraft has misinterpreted an instruction;
 A blocked transmission is observed.
3) After a flight where an actual or potential call sign confusion incident is observed, file a
report using the national mandatory incident reporting system or voluntary incident
reporting system as appropriate.
4) Always use headsets during times of high RTF loading.
5) Always wear a headset when members of the flight crew are involved in other tasks and
may not be monitoring the RTF.
6) If in doubt about an ATC instruction, ask the controller to re-confirm the clearance rather
than saying what you thought you heard i.e. “London, confirm the cleared flight level for
Etihad 162” NOT “London, confirm the cleared flight level for Etihad 162 is FL190”. This
procedure should also be followed if any doubt exists between flight crew members and
when an altitude/level change has been received by only one pilot.
7) Be alert to the possibility of loss of communication, and always follow standard procedures
for copying, setting and cross-checking RTF frequencies. As soon as a loss of communication
is suspected, check radio equipment settings and carry out a radio check.
8) If any part of a message transmitted to your flight is distorted, request repetition i.e. “say
again…”

Revision: 2
9) On observing any radio interference, note the nature and effect of the interference, time
and position of commencement and cessation of the interference, and any other factors
that would help the authorities to identify the source.
10) If in your opinion safe aircraft operation is affected by radio interference, request a
frequency change. If the interference prevents satisfactory communication with your
assigned ATC unit, request instructions using another listed frequency.
11) If the squelch control is adjusted to reduce the effect of interference, take care to ensure
that transmissions from ATC or other aircraft are not cut out.
12) If unable to establish contact on a newly-assigned frequency, check all equipment settings
(including volume) and return to previous frequency if contact is not quickly established.
13) Make use of other aircraft to relay messages when operating at extreme range or when
poor radio signal propagation is suspected.
14) Inform cabin crew of any suspected “sleeping receiver” occurrence and ask for any relevant
information (e.g. recent use of cabin address or portable electronic equipment).
15) Follow company procedures for the monitoring of 121.5 MHz. If loss of communications is
suspected, monitor 121.5 MHz and listen out for any transmission from intercepting aircraft.
16) Do not switch immediately to the next sector frequency following read back of controller’s
instruction. Ensure any necessary correction of your read back can be received.
17) Check the audio panel settings after using the passenger address system, and when
returning to the active ATC frequency after using another frequency (e.g. communications
with the next ATC centre, company frequency, etc.).
Knowledge (KNO) and Application of Procedures (APK)

• Demonstrates practical and applicable knowledge of limitations and systems and their
interraction
o Understands how the automation operates and reacts (enhances PSD)
o Able to detect deviations from normal operation in a timely manner (enhances FPA)
• Demonstrates required knowledge of published operating instructions
o Able to apply procedures intended to minimize risk of altitude excursion

Revision: 2
OM-A Altitude Excursion Risk Reduction Policies & Procedures
OM-A Altitude Excursion Risk Reduction Policies and Procedures
The examples provided below ilustrate actual altitude deviation events where, in the majority of cases,
the crew failed to effectively apply the policies and procedures specified in the OM-A. These policies and
procedures originate from aviation regulations and industry best practices that have been developed to
reduce the likelihood for an altitude deviation to occur.
Pilots must familiarise themselves with these policies and procedures in order to minimise the
potential for them to be involved in a “level bust”
OM-A 8.3.3: Altimeter Setting Procedures

The policies in this section that can serve to prevent an altitude excursion are:
• Changing the Altimeter Setting in Climb or Descent
“Whenever altimeter-setting value is required to be changed, a crosscheck is required by the flight crew
in accordance with the standard operating procedures...
Aircraft operations at or below TA must be based on area/local QNH reference altimeter setting, until
passing through TA, even if the ATS has issued climb clearance to a Flight Level (FL).
Aircraft operations at or above TL must be based on STD reference altimeter setting, until passing
through TL, even if the ATS has issued descend clearance to an altitude…”
• Landing at an Airport in a Metric Altimetry Region

“If a landing is to be made at an airport in a metric altimetry region, the following procedure shall be
adopted:
1. Set up the approach in the FMS using standard operating procedures;
a) For metric operations, DH/DA/MDA are depicted in feet on the Jeppesen chart. A table
giving ALT / HEIGHT CONVERSION IN QNH or QFE is displayed on the chart.
2. Descend from cruising level in accordance with policy in the table above;
a) Transition level is displayed on the Jeppesen chart in both metres and in feet. Change to
QNH approaching the Transition Level;
3. For airports where the ATC standard is to issue clearances to heights in metres QFE, e.g Almaty,
depicted on the Jepessen chart, (Alt Set: QNH on Request (QFE)), the metric altimeter function
shall not to be used;
a) To avoid all ambiguity, “request QFE approach” and use the ALT / HEIGHT conversion
tables on the appropriate Jeppesen terminal chart to set the altitude in feet;
b) Refer to the relevant Jeppesen chart, plan and brief the approach, paying particular
attention to brief that, although the initial part of the approach may be flown with
reference to the metric system, all the minima entered in the FMS are in feet, and all call-
outs are based on altitude indications in feet;
4. For airports where ATC issues clearances to altitudes in metres QNH, e.g. Beijing,the metric
altimeter function should be used to set the cleared metric altitude directly. Where this is not
possible because the metric altimeter function is not fitted, the meters to feet conversion table on
the Jeppesen terminal chart shall be used to set the corresponding altitude in feet;
5. Fly the approach down to the minimums as indicated in feet (QNH) and land or go-around as
appropriate;
a) Missed approach altitudes are given in feet on the Jeppesen approach charts”

Revision: 2
OM-A 8.3.20.14: Cross Check of Critical Actions by the Flight Crew

“ETIHAD policy on the execution of abnormal/non-normal and emergency procedures, is to ensure that a
crosscheck and verbal confirmation by two flight crew members, (dual response), occurs before the
actuation of any critical aircraft system controls as a minimum the following items. Etihad flight crew
shall crosscheck and confirm critical actions the following items:
…
viii) Altimeter subscale settings;
ix) Altitude (window) selections;…”
The non-adherence to the previous OM-A policies and procedures was a contributing factor in the
following 3 events:
EY ASR 21: Incorrect altimeter setting source.
The aircraft departed DOH on time and the clearance was given to FL 210 passing 9000FT
(QNH 996). The Captain under training was PF and the Nominated Commander was PNF.
Both crew missed the transition altitude at 13.000’. Subsequently the aircraft levelled at
21.000’, autopilot one and auto thrust were engaged. The crew immediately recognized
the error on level off and set 1013 (standard). The altimeter read FL 214. ATC were
informed and the aircraft was descended FL 210. There was no other traffic in the
vicinity.
EY ASR 22: Incorrect altitude selection in metric altimetry airspace.
During the descent to Almaty, ATC gave us radar vectors to intercept the ILS 05L. Ask us
to descend to 900 m = 5190 ft and set on the FCU. The final vector was given to intercept
the localizer and further descend to 600 m. Where the mistake took place, and 2000 ft
(height) instead of 4200 ft (altitude). During configuration for the approach and
communicating with ATC, I realized we are not on profile and I said "GO-AROUND" at
1000 ft RA. At the same time the FO realized as well and the Glide Slope alert came on.
We executed a Go around to come for a second approach and land on runway 05L
EY ASR 23: Incorrect flight level selection in metric altimetry airspace.
In stepped descent F/O PF radar cleared to descend to FL 10100 m. PM read back

clearance and read equivalent FL (FT) from chart China H/L 1,2 as FL 33100 PF x-checked
and says he saw 31100 on the chart. 31100 set in alt window PM was then distracted and
missed seeing the wrong "alt" set. On descent passing 33100 radar queried assigned
altitude and as we passed around FL 32500 ATC re-cleared us to FL 31100 (9500 m) and
handed the flight over to the next ACC Flight continued with no further events.

Revision: 2
OM-A 8.3.6: Policy and Procedures for the Use of TCAS

“…Satisfy RA's using prompt, positive control inputs to fly away from the outline pitch avoidance area.
For TCAS to provide safe vertical separation, initial pitch change response is expected within 5 seconds of
when the RA is first displayed. Excursions from the assigned altitude, when responding to an RA, typically
should be no more than 300 to 500 ft to satisfy the conflict. All responses should be flown accurately to
the outlined pitch avoidance area. For detailed operating procedures, system depiction and aural
announcements refer to OM B for the appropriate aircraft type”
OM-A 8.3.20.16: Maximum Permissible Rates of Climb/Descent

“During Climb or Descent the maximum vertical speed shall not exceed:
• 2000 ft/min when within 2000 feet of the cleared flight level/altitude
• 1000 ft/min when within 1000 feet of the cleared flight level/altitude”
EY ASR 24: High rate of descent followed by a TCAS RA.
BOM: “During descent to Bombay, we were cleared to FL350, the descent was managed and we
were on the path at a normal rate (approx. 2000ft/min) when we received a traffic advisory
followed by a message "adjust vertical speed". This message occurred out of FL351 and we were
already in the ALT* mode (altitude capture) at approximately 1200ft/min. The other A/C was
clearly in sight at FL340 and never complained about us. The situation was clear to us, separation
was sufficient at all times so we did not mention it to ATC and continued to destination”
OM-A 8.3.20.5: Altitude Awareness

“Altitude awareness is achieved by the active attention of the Flight Crew. This awareness with
associated continuous monitoring is the primary means of ensuring that cleared altitudes are adhered to
and clearances are not infringed. As a matter of policy, the following mandatory altitude checks and
callouts during climb and descent phases of flight shall be made:
• “10000’ Above airport Level”
• Every 10000’ (FL 200 and above, in climb and descent): Passing ALT/FL _,
Climbing/Descending FL/ALT_,
• 1000’ before reaching the cleared Altitude or Flight Level “one thousand to go”
These calls shall be made by the PM and checked and acknowledged by the PF. The altitude alert system
should only be considered as a back-up aid. Its operation must not be permitted to replace the
requirement to make the standard altitude calls.”
EY ASR 25: Level deviation due to reduced altitude awareness.
Both (my FO) and I had recently returned from our rest (around 10-15 minutes ago).We were
cruising at FL340. The recommended level had just changed to FL360. We requested to Edmonton
via CPDLC FL360. Edmonton cleared us to FL350 which I thought it was FL360 and I selected FL360
in the FCU and started climbing. FO did not notice I selected the wrong level as he thought he read
FL350 instead of FL360 on the FCU. He only realized that it was taking too long to climb only
1000ft. By the time we realized our mistake, we were at FL357. I changed the FCU down to FL350

Revision: 2
OM-A 8.3.20.4: Sterile Cockpit Policy

“Adhering to the Sterile Cockpit Policy can largely reduce interruptions and distractions, therefore flight
crew shall not engage in, nor may any Commander permit any activity during a critical phase of flight
which could distract any flight crew member from the performance of his duties or which could interfere
in any way with the proper conduct of those duties. For the purpose of this requirement, an "activity"
includes: engaging in non-essential conversation within the cockpit and non-essential communication
between the cabin and cockpit crew.
The Commander shall ensure that the ‘Sterile Cockpit Policy’ is in force as follows:
1. From commencement of push back (or engine start when no push back is required), to Top of
Climb (TOC), and
2. From Top of Descent (TOD) until engine shutdown on stand.
No paperwork including non-essential ACARS shall be accomplished during sterile cockpit operations.
Headsets must be worn for communication with ATC during these phases of flight. Flight Crew shall avoid
conversation not directly related to the safe operation of the aircraft.
The "Sterile Cockpit Policy" comprises the following:
• Cockpit door closed and locked;
• No access to the flight deck is permitted unless operationally necessary;
• P.A.’s are prohibited during sterile cockpit operations unless operationally necessary;
• Cabin Crew shall address active flight crew members only when necessary for the safe conduct of
the flight.
• Restrict to all activities except to flight operational matters”
OM-A 8.3.20.8.2: ATC Clearance / Instructions

“It is recognised that certain events preclude both pilots being in the cockpit or from hearing a clearance
(ATIS, company call, PA). In such situations it is mandatory that when returning to frequency he/she
verifies new clearance/instruction with ATC.”
(Refer to the Failure to Request Confirmation or Clarification section on page 24 of this manual).
EY ASR 26: Non-adherence to the Sterile Cockpit and ATC Clearance/Instructions policies.
The Captain started his PA announcement before the TOD. In the meantime, and while cruising at
FL370, Bahrain ATC cleared us to descend to FL250 to be level by RESAR. First officer read back the
clearance. When passing FL285 ATC said that clearance had been given to descend to FL290. A V/S
of +1000 fpm was selected to regain FL290 immediately.
OM-A 8.1.1: Minimum Flight Altitudes

“Except during take off and landing, the minimum altitude/flight level shall be that specified on the
relevant charts. During any phase of take off or landing, the minimum altitude to be flown is that shown
for the leg of the procedure being flown, or, the sector/segment safe altitude as depicted on the relevant
terminal chart when not following the procedure. When under positive radar control, the minimum
vectoring altitude (MRVA) to be flown is that cleared by the radar controller and verified by the pilots on
the MRVA chart if available.”

Revision: 2
EY ASR 27: Descent below the minimum flight altitude.
On approach to Rwy 18R, we were cleared by ATC to descend to 2200ft, on a heading to

intercept the localizer. On the PF's instruction, I extended the centreline of the ILS as we were
on radar vectors. After the fact, we were then told to proceed to MOLOP and cleared for the
ILS approach. As we had already been cleared to intercept, MOLOP had been removed from
the FMS. I went heads down trying to find the waypoint, with the correct spelling to reinsert it
into the FMS, I was distracted because it wasn't on the ILS chart, but on the STAR, and I had to
scroll through the charts to find it. As I went heads down, the First Officer lost situational
awareness, and focusing on the Glideslope indication, descended to maintain 1600ft, the
check height at 4.6 DME from the ILS, while we were still approximately 12 miles from
touchdown where the MSA was 2200ft. When I realised what had happened and the reason, I
notified ATC. We also got a false localizer capture, shortly after. As we were VMC, and could
clearly see where we were, the airport and the landing runway, and given the unreliability of
the ILS indication, we elected to continue the approach and land visually. There were a
number of factors that contributed to this incident, including fatigue, late night/early morning
departure with a delay that put us into discretion. Confusing and late ATC instructions poorly
communicated, which created some distraction. Unreliable ILS Glideslope and Localizer. Our
own complacency, VMC, runway in sight, we let our guard down.
OM-A 8.3.4: Altitude Alerting Systems Procedures

“The purpose of the altitude alerting system is to alert the flight crew by the automatic activation of a
visual and/or an aural signal when the aircraft is about to reach or is leaving the pre-selected altitude /
flight level. The system and its operation shall ensure an accurate altitude adherence during all phases of
the flight.”
EY ASR 28: Incorrect altitude selection followed by a failure to react to the altitude alerting
system warning.
CM1 was taking controlled rest and CM2 was PF/PM using headset as per company procedure.
Ankara advised to climb initially from FL380 to FL390 (non-standard). Shortly after Ankara
advised to climb FL400 and also simultaneously change to Sofia control. At this moment CM1
was woken up by the sound of Altitude alert (c-chord) and immediately woke and asked what
was happening. FO advised that we had been cleared from FL390 to FL400 and I could see that
we were passing FL396 with VS selected 600 so it seemed correct although I was not clear at this
stage why the C-chord had sounded. By the time I sat up correctly in my seat and regained my
surroundings I noticed that we had passed through FL400 and were passing FL404, I realized that
the FCU was still set at FL390 and immediately instructed FO to push to level off and pull open
descent/set FL400 to regain our altitude.

Revision: 2
Caution: Pilots must be aware of the risk of “flying away” from the FCU/MCP selected altitude when
using the V/S mode.
OM-A 8.3.8: Adverse and Potentially Hazardous Atmospheric Conditions

“The latest meteorological forecasts and actual weather reports should be used to plan routes, where
possible, along which the risk of a thunderstorm encounter is low. If an area of thunderstorm activity is
encountered en-route, consider a route deviation to avoid the area and do not attempt to fly under a
thunderstorm even if you can see through to the other side or to fly over thunderstorms unless a
minimum of 5,000 ft clearance above the storm top is ensured.
When possible, detour between the storm cells of a squall line rather than fly directly above them and
avoid any thunderstorm identified as severe or giving an intense radar echo by at least 20 nautical miles.
When it is necessary to fly parallel to a line of cells, the safest path is on the upwind side (i.e. the side
away from the direction of storm travel). Although severe turbulence and hail can be encountered in any
direction outside a thunderstorm, strong drafts and hail are more often encountered outside the body of
the cell on the downwind side.
Avoid flight under the anvil. The greatest possibility of encountering hail is downwind of the cell, where
hail falls from the anvil or is tossed out from the side of the storm. Hail has been encountered as much as
20 nm downwind from large thunderstorms. Avoid cirrus and cirrostratus layers downwind from the
storm tops. Such layers may be formed by cumulonimbus tops and may contain hail, even though the
radar scope shows little or no return echoes.”
OM-A 8.3.8.1.2: Use of Weather Radar
EY ASR 29: Thunderstorm penetration.
Heavy spread of weather around Chennai FIR (south west coast of India till Sri Lanka). We had
cleared some weather by requesting climb to FL350 (which we could only maintain for a short
while due traffic). We were given descent to FL330 as we were unable to climb to FL370. In spite
of significant weather deviation, some weather could not be avoided. We had used the weather
radar's gain function to assess the areas of possible penetration with least turbulence. However,
we encountered sudden turbulence and a down draft which caused an altitude loss of around
400ft. No injuries to passengers or crew. The rest of the flight was un-eventful.

Revision: 2
OM-A 8.3.8.5: Jet Streams

“Near the tropopause there can be narrow bands of wind with extremely high speeds, up to 300 kts
called Jet stream. The extent in length is up to several thousand miles, the width can be several miles.
The main direction is south-west to north.
In mid-latitudes there is a common area for clear air turbulence (CAT) around the jet stream, below the
jet core and to the polar side. Taking a cross section of a jet stream looking downwind, the turbulence
region would be to the left of the core in the Northern Hemisphere and to the right in the Southern
Hemisphere.
To avoid or leave the area of CAT the following procedures should be applied:
• Reduce speed, to reduce acceleration due to wind shears
• When flying parallel with the jet stream changing altitude up to 1000 ft
• When flying perpendicular to the jet stream, changing altitude by 1000 ft from the warm side to
the cold side downwards, from the cold side to the warm side upwards
• If the temperature is changing in the CAT area the flight should be continued on course; the CAT
area is likely to be crossed in a short time
• If the temperature remains constant the course should be altered in order to leave the CAT area.”
EY ASR 30: Altitude deviation due to CAT.
Routine Ankara-Tehran UT36, FL410 when temp changes due tropopause changes fluctuations in
speed. PF selected speed and worked to mitigate effects. Crew were seated and turbulence was
light. Aircraft in ALT CRZ pitched to cope with speed changes. Resulted in attaining 41300 FT.
During this we were aware of an aircraft below us and were working with ATC to clear us to a
lower level ATC assigned direct SNJ and descend nonstandard FL400. Once past the mountains
and the tropopause was higher we worked with ATC and climbed back to FL410. Where we
continued no problem.
OM-A 8.3.20.8.2: ATC Clearance / Instructions

“All ATC instructions shall be read-back in full using standard R/T phraseology and callsign as follows;
1. Always report CLEARED flight level on first contact with ATC unless specifically asked not to
e.g. (callsign only)
2. Always readback all cleared altitudes, flight levels, QNH and ATC clearances in full
Both Flight Crew members shall monitor ATC clearances and have a responsibility to query any clearance
that is not understood, incorrectly received, or incomplete. Any uncertainty must be resolved by asking
ATC to repeat the clearance. It is recognised that certain events preclude both pilots being in the cockpit
or from hearing a clearance (ATIS, company call, PA). In such situations it is mandatory that when
returning to frequency he/she verifies new clearance/instruction with ATC.
With regard to altitude awareness and aircraft separation it is mandatory that, when one pilot is absent
from frequency no request for lateral or vertical change of the flight path is made.”

Revision: 2
EY ASR 31: Late ATC clearance confirmation.
10 miles to position LABRI UAE handover us to MUSCAT with clearance to FL 210 , MUSCAT
clearance was to continue climb to FL 310 after position LABRI the FO understood to continue the
climb to FL 310 , we were trying to confirm the clearance but the frequency was very busy and I
called more than four times to confirm at the mean time the FO continue the climb and we cross
position LABRI at about FL 230 . At Muscat FIR I called again to confirm the clearance and he
confirm that it was climb FL 310 after position LABRI
OM-A 8.3.20.7: Task Sharing and Crew coordination in the Cockpit

“The task sharing in the cockpit requires a clearly defined assignment of tasks to PF and PM with the aim
to guarantee that the full attention of PF is concentrated on the primary task of piloting the aircraft.
The division of duties for all operational tasks during manual and automatic flight shall be observed
according to the philosophy in the appropriate OM B…”
EY ASR 32: Altitude Deviation during Go-around.
We were cleared for the VOR 27 in LKO with Tower reported of Wind Calm! Once fully
configured and. established on Final Approach for RWY 27 with the A/P disconnected being
established and stabilized, passing 500' AGL we noticed that the tailwind increased from 9 kts
to 19 kts. (090 / 09) while descending around 900' / min. Maximum as not to go over 1,000 ft /
min R.O. D. Below 1,000 ft. At around 300' AGL we noticed that the tailwind got the better of
us and that we were ending up too high, 1 red and 3 white becoming 4 white, we executed a
Go Around following the published missed approach. The Captain was PF focused on following
the flight path after reading the FMA (missing out on the A/P window on the FMA)
approaching the missed approach altitude I selected the V/S to + 1,000 ft / min. In order to
avoid busting the Altitude. Realizing that the selection did not display on the FMA I noticed the
A/P was not engaged as we flew the approach manual including the G.A. Plus the attempt to
instinctively disconnect the A/P manually I heard PRIORITY LEFT (other indication that the A/P
was not on ) So I turned on the the A/P at that stage and immediately pulled the ALT. knob in
order for the aircraft to descend in THR IDLE & OPEN DES, to the Missed Approach Altitude of
3,500 ft.
OM-A 8.3.20.23.1: Callsign Confusion Policy

“All crew members must be certain that an ATC instruction was for their aircraft. If there is any doubt at
all about callsign flight crew shall request clarification from ATC. In particular, cleared altitudes, flight
levels, headings and runway crossing clearances are critical. Always listen out before transmitting…”

Revision: 2
EY ASR 33: Altitude deviation due to Callsign confusion.
Maintaining FL300 and standing by higher as instructed by Yangon 128.75, we have been cleared
to climb FL340 by the same frequency. We confirmed the clearance twice and start the climb.
Approaching FL310 and hearing Sri Lankan 403 inquiring about his clearance to climb to FL340 and
the controller stating that he already cleared him. We advised Yangon that we have been cleared
that level, confirmed twice the clearance and started the climb. The controller then instructed us
to descend and maintain FL300 which we did promptly. There was no further claim or comment
OM-A 8.3.20.4.1: No Contact Period

“In addition to the sterile cockpit procedure described above, the following no-contact period is enforced.
During this period, there shall be no contact with the flight deck from the cabin crew.
The no-contact period is from:
• the application of take off power until the undercarriage is retracted and,
• from the extension of the undercarriage prior to landing, until the aircraft has vacated the
runway.”
OM-A 8.3.13.3.1: Flight Crew Absence from the Flight Deck

“On flights operated by only two pilots, when a pilot needs to leave the flight deck for physiological
reasons or otherwise, a member of the cabin crew shall be present on the flight deck before that pilot
exits the flight deck.
Flight crew are reminded that:
• The flight deck door must be locked whilst the pilot is absent.
• Absence from the flight deck is restricted to the minimum time necessary.
• Sterile cockpit rules apply and that the remaining pilot at the controls should be wearing
head phones and have the full seat harness securely fastened.
• Both pilots will cross check that the radio panels are configured with the active frequency on
set 1 and the guard frequency (121.5 MHz) on set 2 including appropriate volume setting.
• The flight crew member returning to the flight deck follows the flight deck entry request
procedure”

Revision: 2
Etihad’s Risk Management Model: A-B-C
Using the Etihad Risk Management Model to reduce the risk of Altitude
Excursions – It’s as simple as ABC....
Assess
Each crewmember must individually assess current or future Threats and Errors that increase the
potential for an altitude excursion. In particular each crewmember must:
• Be aware of conflicting information and cross check all cleared altitudes.

• Be aware of the threat of high traffic density and the effect this can have on ATC error rates.
• Be aware that the threats of non-standard phraseology, similar call signs and multiple languages
increase the potential for Altitude Excursions.
• Be aware that ATC will not pick up all errors in readback.
• Be aware of the importance of checking and cross checking and to obtain clarification whenever
there is uncertainty or ambiguity about a clearance.
• Be aware of the correct way to challenge ambiguity.
• Be aware of the risks associated with similar callsigns.
• Be aware of the risks associated with QFE (metric altimetry).
• Be aware of the importance of monitoring TCAS display to maintain awareness of proximate
traffic.

Revision: 2
Balance
Following the Assessment above, when the level of risk is identified as anything but low, ensure you stay
in or return to the ‘Green’ by applying one or more of the following tactics, as appropriate to your
particular situation:
Buy Time:
• Reduce rate of climb or descent – (use required values specified in OM-A.)
• Negotiate with ATC to reduce workload (e.g. request holding/lower speed).
Reduce Workload:
• Negotiate with ATC if their clearance imposes unreasonable or unachievable requirements.

• Adhere to the sterile cockpit policy.
• Monitor all altitude captures without distraction.
• Minimise / avoid distractions (e.g. paperwork / cabin crew)
Change the Mission:
• If you have any doubt at any time concerning the cleared level, contact ATC in the correct manner
and clarify the situation.
Communicate
Communicate your risk assessment and balancing tactic, irrespective of your rank or experience level:
• “Captain, I have not understood the cleared level, please reduce the v/s while I ask ATC.”
• “I am not sure whether we were cleared to FL100 or FL110, let us ask ATC.”
- END -

Revision: 2
INTENTIONALLY LEFT BLANK

Altitude+Excursion+Risk+Management+ Rev.02 PDF

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Altitude+Excursion+Risk+Management+ Rev.02 PDF

Загружено:

Авторское право:

Доступные форматы

USING THE ETIHAD RISK MANAGEMENT MODEL TO REDUCE THE RISK OF

ALL INFORMATION CONTAINED IN THIS REPORT IS STRICTLY CONFIDENTIAL AND CIRCULATED TO

© ETD Foreword ALL

© ETD TOC ALL

© ETD Threats, Errors and UAS ALL

© ETD Threats, Errors and UAS ALL

* Flight Crew Mis-Selection refers to:

© ETD Threats, Errors and UAS ALL

AIR TRAFFIC MANAGEMENT:

Figure 4D: Other Effect (Source IATA STEADES report 2014)

© ETD Threats, Errors and UAS ALL

Total Number of Occurences

Figure 5: Etihad Airways Altitude Deviation Events (2008 till 2015)

Fleet Flight Phase

© ETD Threats, Errors and UAS ALL

Level Busts per Aircraft Type

TOTAL NUMBER OF EVENTS (Jan-Mar 2016) = 27

A320 A330 A340 B787 B777 A380

Events per Phase of Flight

Descent Approach Cruise Cruise Climb Takeoff Holding

© ETD Threats, Errors and UAS ALL

Pilot/ATC Communication Error 22%

0% 5% 10% 15% 20% 25%

© ETD Threats, Errors and UAS ALL

Threats, Errors and Undesired Aircraft States

Major Threats (%)

Flight Management Errors (%)

Undesired Aircraft States (UAS)

© ETD Threats, Errors and UAS ALL

EY ASR 1: Unrealistic Climb Performance Expectation

© ETD Threats, Errors and UAS ALL

Threat and Error Analysis

the Etihad Airways Risk Management

THREATS INCREASE THE POSSIBILITY OF ERROR

EY ASR 2: High workload on departure without automation

© ETD Risk Management Model ALL

Threat – Additive Factors

Additive Factors - ATC

EY ASR 3: ATC late change of cleared altitude

EY ASR 4: ATC conflicting clearance

© ETD Risk Management Model ALL

(a) Approximately 70% of level busts were the

Perception is a key factor in communication. In a multi-pilot cockpit environment, the level of

The process can be summarised as follows:

a) How do we perceive the message?

© ETD Risk Management Model ALL

(a) The word “to” is to be omitted

Nevertheless, even pilots and controllers for whom English is

© ETD Risk Management Model ALL

Non-standard phraseology is a major obstacle to effective communication.

The use of standard phraseology in pilot-controller communication is intended to maximize mutual

(a) Of different native languages, or

Good RTF discipline is essential for operating safely in such environments.

© ETD Risk Management Model ALL

EY ASR 6: Poor Radio Reception

AUH-CGK. Climbing to FL210 on course to KANIP as cleared by UAE. Approaching KANIP,

Failure to Correct Readback

The absence of an acknowledgement or a correction following a clearance readback is perceived by

EY ASR 7: Clearance Confusion

© ETD Risk Management Model ALL

Bias can affect the understanding of communications between

Language and Communication Omitting the callsign or using an

© ETD Risk Management Model ALL