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|
Attributes | |
ACN | 125079 |
Time | |
Date | 198910 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | msl bound lower : 4000 msl bound upper : 4400 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tracon : oak |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | climbout : intermediate altitude cruise other |
Route In Use | departure other departure sid : sid enroute : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : instrument pilot : flight engineer |
Experience | flight time last 90 days : 100 flight time total : 3500 flight time type : 40 |
ASRS Report | 125079 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation other |
Narrative:
Departed sfo on runway 01L and tracked sfo 350 degree right per SID. Checked in with departure control per tower. Departure control cleared us to 210 degree heading and 4000'. First officer (PNF) misunderstood heading and a few seconds attention over the correct heading was taken by both pilots, the captain (PF) did not hear the new altitude and did not notice first officer reset altitude in mode control panel from previous cleared altitude of FL230. The aircraft was climbing at approximately 4000 FPM and by the time altitude deviation was noticed by first officer an altitude of 4400' was momentarily attained before return to 4000'. 2 factors, I believe, underlie this deviation. The first is that this was my first trip in the aircraft since 'shotgun'. I am also new to the 'glass cockpit' and feel that a certain amount of my attention is occupied in interpreting the glass cockpit instrument presentation, in this respect, I feel that having only had 4 simulator rides in training with the glass cockpit is insufficient, although it is FAA approved. This does not develop enough proficiency to apply in the real world with the multiplicity of contingencies that can and do occur. The second factor is that just prior to the altitude and heading clearance, I had called for an infrequently used but SOP autoflt function. This caused the first officer to stop and consider his response and thereby interrupt his 'flow' during this busy time of aircraft confign cleanup, frequency changes and reception of communications. My last remaining thought is that I should be more decisive during my preflight and brief the first officer more thoroughly on what to expect from me in the way of post takeoff procedures.
Original NASA ASRS Text
Title: DEVIATION FROM ALT ON DEP VECTOR.
Narrative: DEPARTED SFO ON RWY 01L AND TRACKED SFO 350 DEG R PER SID. CHECKED IN WITH DEP CTL PER TWR. DEP CTL CLRED US TO 210 DEG HDG AND 4000'. F/O (PNF) MISUNDERSTOOD HDG AND A FEW SECONDS ATTN OVER THE CORRECT HDG WAS TAKEN BY BOTH PLTS, THE CAPT (PF) DID NOT HEAR THE NEW ALT AND DID NOT NOTICE F/O RESET ALT IN MODE CTL PANEL FROM PREVIOUS CLRED ALT OF FL230. THE ACFT WAS CLIMBING AT APPROX 4000 FPM AND BY THE TIME ALT DEVIATION WAS NOTICED BY F/O AN ALT OF 4400' WAS MOMENTARILY ATTAINED BEFORE RETURN TO 4000'. 2 FACTORS, I BELIEVE, UNDERLIE THIS DEVIATION. THE FIRST IS THAT THIS WAS MY FIRST TRIP IN THE ACFT SINCE 'SHOTGUN'. I AM ALSO NEW TO THE 'GLASS COCKPIT' AND FEEL THAT A CERTAIN AMOUNT OF MY ATTN IS OCCUPIED IN INTERPRETING THE GLASS COCKPIT INSTRUMENT PRESENTATION, IN THIS RESPECT, I FEEL THAT HAVING ONLY HAD 4 SIMULATOR RIDES IN TRAINING WITH THE GLASS COCKPIT IS INSUFFICIENT, ALTHOUGH IT IS FAA APPROVED. THIS DOES NOT DEVELOP ENOUGH PROFICIENCY TO APPLY IN THE REAL WORLD WITH THE MULTIPLICITY OF CONTINGENCIES THAT CAN AND DO OCCUR. THE SECOND FACTOR IS THAT JUST PRIOR TO THE ALT AND HDG CLRNC, I HAD CALLED FOR AN INFREQUENTLY USED BUT SOP AUTOFLT FUNCTION. THIS CAUSED THE F/O TO STOP AND CONSIDER HIS RESPONSE AND THEREBY INTERRUPT HIS 'FLOW' DURING THIS BUSY TIME OF ACFT CONFIGN CLEANUP, FREQ CHANGES AND RECEPTION OF COMS. MY LAST REMAINING THOUGHT IS THAT I SHOULD BE MORE DECISIVE DURING MY PREFLT AND BRIEF THE F/O MORE THOROUGHLY ON WHAT TO EXPECT FROM ME IN THE WAY OF POST TKOF PROCS.
Data retrieved from NASA's ASRS site as of August 2007 and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.