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Fatigued Flight Crew Misses Two Altitude Restrictions On Departure

Missing even just one crossing restriction can have ramifications for your pilot certificate. Here's how to avoid a similar mistake...


Report: Corporate Flight Crew Departs Unprepared

The following NASA ASRS report details an event in which an inexperienced First Officer misreads a departure procedure and the Captain (pilot-flying) doesn't catch the mistake. It's easy to misread instructions and this could happen to any crew.

We departed OAK on an IFR flight plan which included the Skyline Six departure procedure. My First Officer was a low time pilot with 500 hours total time and 125 hours in the Learjet. He read the departure procedure to me as "fly heading 278 to 3,000 then left heading 200 to intercept the 135 radial from PYE." He failed to read the proper departure route description which was to "Climb on heading 278 for vectors to PYE R-135 to cross 4 DME northwest of OAK VOR/DME at or above 1400 and at or below 2000."

I did not verify the routing on my iPad and assumed what he told me was correct. After turning to heading 200 at 3,000 feet, ATC quickly vectored me back to heading 270. We were then vectored and assigned higher altitudes. As we were assigned FL190 ATC said we needed to copy a phone number for NORCAL. In the process of copying the phone number we flew through FL190 by about 1,500 feet.

It was a long day and by the time we departed OAK we had been up for 12 hours. I discovered that my First Officer did not get any sleep the night before. My First Officer was very inexperienced and didn't have much instrument procedure time other than what he received to get his ratings. As Captain, I failed to verify the departure procedure with my FO. I tried to multi-task by flying the airplane and copying a phone number from ATC instead of using appropriate automation to lighten my work load.

Wikipedia / Adrian Pingstone

Review: Flying Departure Procedures

You typically find departure procedures in major terminal areas, like Denver, Houston, or San Francisco. They're only flown by aircraft on an IFR flight plan, and they're used even if the weather is clear. By far most of the charted departure procedures are published to manage traffic. They're called "Standard Instrument Departures", but you'll usually hear the called "SIDs." There are three types: vector, pilot navigated, and RNAV.

The Skyline SID, which we'll detail below, is a pilot-nav SID. It uses ground based navaids, like VORs to help you navigate a course out of the terminal area. With these procedures, you can also fly them with a GPS or RNAV system if they're in your database. SIDs usually aren't all that complicated to fly. But when you have lots of restrictions with a "climb via", you need to stay ahead of the airplane so you don't miss an altitude restriction. Brief the SID on the ground, and in the air as you approached each fix, making sure you're at the right altitude for each crossing restriction. Flying by memory, or a verbal briefing from a crewmember just isn't adequate.

SKYLINE Departure Procedure (KOAK)

When you were reading the report above, you might've thought the SKYLINE Departure sounds confusing, and that's because it is! This is one of the tougher SIDs we've seen, including multiple crossing restrictions at low altitudes, multiple headings, and even VOR tracking. All within a few miles.

Oakland International (KOAK) is a busy Class C airport, and departing Runway 28L/R will fly your directly towards San Francisco International Airport (KSFO) and its arrival/departure routes. That's why you'll find so many crossing restrictions and quick turns to keep you well clear. Here's a screenshot of the graphical departure procedure. Remember, the First Officer failed to note the DME-based crossing restriction.


On page two of the SKYLINE SID, you'll find the written description of the SID procedure. This clarifies one massively confusing graphic that caught this crew. The graphically depicted minimum 3000-foot altitude requirement on page 1 before turning to heading 200 is ONLY performed in the event of a communication loss. You do not make this turn yourself. Instead, you fly straight ahead on heading 278 until receiving a vector from ATC.


Stress And Fatigue + Yet Another Altitude Busted

In the report, the Captain mentioned he was fatigued and that the First Officer didn't receive sleep the night before. This should've been mentioned in the preflight brief. Flying while fatigued is equivalent in many cases to flying under the influence of alcohol. Fortunately, new FAA regulations are a step in the right direction, giving airline pilots longer rest periods. However, the FAA's Part 121 rest rules don't apply to flights like this, which was likely flown under Part 91.

As this crew continued to fly by hand to FL190, ATC called them with a "possible pilot deviation" call and requested they copy down a phone number. Instead of engaging the autopilot, the Captain elected to continue flying by hand. This led them to break another altitude assignment by climbing 1,500 higher than cleared, all the way to 20,500 feet. That's certainly not what you want happening when you're already getting called for a pilot deviation.


While there's nothing wrong with flying by hand, you need to have a solid idea of exactly what you'll be doing before takeoff. It's much harder to verify a chart when you're hand flying. It's likely this high-workload SID could've been better managed with the autopilot engaged. The First Officer obviously should've read the departure correctly, but ultimately it was the Captain's responsibility to ensure accuracy and check the plate.

How would you avoid making a mistake like this? Tell us in the comments below.

Swayne Martin

Swayne is an editor at Boldmethod, certified flight instructor, and an Embraer 145 First Officer for a regional airline. He graduated as an aviation major from the University of North Dakota in 2018, holds a PIC Type Rating for Cessna Citation Jets (CE-525), and is a former pilot for Mokulele Airlines. He's the author of articles, quizzes and lists on Boldmethod every week. You can reach Swayne at, and follow his flying adventures on his YouTube Channel.

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