B737 Undifferentiated or Other Model
Flight Crew Air Transport Pilot (ATP); Flight Crew Flight Engineer
Flight Crew Last 90 Days 160; Flight Crew Total 13870; Flight Crew Type 7125
Confusion; Fatigue; Situational Awareness
Deviation - Altitude Undershoot; Deviation - Track / Heading All Types; Deviation / Discrepancy - Procedural Clearance; Deviation / Discrepancy - Procedural Published Material / Policy
Air Traffic Control Issued New Clearance; Air Traffic Control Issued Advisory / Alert; Flight Crew Became Reoriented; Flight Crew Returned To Clearance
Human Factors
Before dispatch; cockpit procedures were standard. We reviewed weather; formulated an air-return plan; discussed the green pages and the terrain. I would depart with terrain selected on the ND. Followed standard checklist procedures when the PDC was received; PM read the PDC and I verified the information. (Note that PDC contained no 'climb to' altitude; we were simply 'Cleared NSIGN3 Departure. Climb via SID. Expect 350 10 Minutes after departure'. Taxi out at night; good visibility; via Taxiway H to Runway 34R. Smooth uneventful dispatch. Loaded takeoff data while waiting at spot 5. Taxiing on H; accomplished remaining checklists; including before takeoff checklist. While accomplishing this checklist; we were both attentive to the newly finished taxiways and lighting; and also were distracted by ATC repeated attempts to contact aircraft at #1 position. At some point the altitude in the MCP was set at 10;000; I must have also briefed 10;000 feet on departure while doing this checklist; though I don't recall. Takeoff uneventful. I was hand-flying. Approaching RATTO I commented we would make the 8;400 restriction. Moments later we were cleared direct CHEDO. I saw the fix on the NAV display and started a turn right. FO entered clearance in MCDU; verified LNAV engaged. (Unfortunately; direct CHE was executed before I had a chance to verify it.) While FO was doing this; my FD commanded a level-off at 10;000. I went into alert mode -- I'm thinking something is not right. I had briefed the 'climb quick to 12;000' that's in the Green Page. I decide to level; then verify altitude. As I roll out on LNAV path; I realize ND has a track direct CHE; not direct CHEDO. Before I can address altitude concern or fix concern; SLC called and asked 'Where are you going?' I already realize the error; turn farther right (still level at 10;000) while FO works to enter CHEDO. This takes time; and ultimately direct CHEDO is almost due south. While I'm in the turn to CHEDO; SLC calls and tells us to go direct HERTS instead; as CHEDO is due south. I turn back to the left; and before I can address the altitude; ATC calls and asks if we have the mountains in sight. (I have terrain selected on my ND; and green terrain is ahead of us -- no yellow; no red). ATC then directs us to expedite our climb through 12;000 and climb to FL230. I start the climb. ATC asks if we were given a clearance to climb to 10;000. We respond yes; though we are now clearly understanding an error has happened. About an hour later; we were directed to contact SLC Tracon after landing. On contact I was advised we were below MVA due to our 10;000 foot error.Pre push; I normally put a 'strange' altitude in the MCP until the PDC is reviewed. This did not happen. The before takeoff checklist was interrupted and distracted. It may have been fatigue (late hour); or night; or some other distraction but we did not realize 10;000 was set and wrong. Make time; verify; verify; verify. I should have engaged the autopilot soon after takeoff given the high workload and threats on this departure routing. The PDC should always have a numeric altitude; no more 'Climb via SID' or 'Descend via STAR'. Jeppesen should increase the font size of climb to and descend to altitudes.
B737 Captain reports not setting the correct top altitude in the FMC departing SLC on the NSIGN3; setting 10;000 feet instead. On departure; as the Captain is leveling at 10;000 feet ATC issues a clearance direct CHEDO; but the First Officer enters direct CHE. ATC detects and corrects both errors.