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|
Attributes | |
ACN | 129369 |
Time | |
Date | 198911 |
Day | Mon |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | atc facility : mod |
State Reference | CA |
Altitude | msl bound lower : 23300 msl bound upper : 24000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | artcc : zoa |
Operator | common carrier : air taxi |
Make Model Name | Light Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent other |
Route In Use | arrival other |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air taxi |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp pilot : cfi |
Experience | flight time last 90 days : 175 flight time total : 2500 flight time type : 700 |
ASRS Report | 129369 |
Person 2 | |
Affiliation | company : air taxi |
Function | flight crew : first officer |
Qualification | pilot : commercial pilot : instrument |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance |
Independent Detector | other flight crewa |
Resolutory Action | flight crew : returned to intended course or assigned course none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were a lifeguard flight inbound to sfo with a clearance to descend to FL240. We were also given clearance to proceed direct mod for the modesto 1 arrival to sfo. Approximately 20 mi northeast of mod and descending through approximately R260, we were given a new clearance to proceed direct to a fix defined by a VOR radial/DME. I believe it may have been cedes intersection. I then instructed the first officer to set up the fix in the LORAN. He then informed me she was not familiar with that fix function and requested assistance. I told her I would program it and began to do so. Apparently her attention was directed on what I was doing, because before I finished she said that she could finish setting up the LORAN. I then looked up to xchk my instruments and discovered we had descended about 700' below our assigned altitude. I immediately took corrective action and climbed back to FL240. Factors contributing to this incident include: first officer's unfamiliarity with a particular operation which led to the inability to satisfy the captain's request. She had received training in our aircraft by the chief pilot. The patient we were transporting was very unstable requiring a lot of activity and noise from the medical attendants. Captain's lack of delegation of duties. I should have specifically commanded the first officer to fly the aircraft with her attention on the instruments while I programmed the LORAN. It was also one of those stressful days where absolutely nothing was routine (i.e., deice aircraft at XA00 am, dead batteries preventing normal engine start, patient's unstable condition, etc).
Original NASA ASRS Text
Title: AIR AMBULANCE FLT CREW PROGRAMMING LORAN DESCENDS BELOW ASSIGNED ALT.
Narrative: WE WERE A LIFEGUARD FLT INBND TO SFO WITH A CLRNC TO DSND TO FL240. WE WERE ALSO GIVEN CLRNC TO PROCEED DIRECT MOD FOR THE MODESTO 1 ARR TO SFO. APPROX 20 MI NE OF MOD AND DESCENDING THROUGH APPROX R260, WE WERE GIVEN A NEW CLRNC TO PROCEED DIRECT TO A FIX DEFINED BY A VOR RADIAL/DME. I BELIEVE IT MAY HAVE BEEN CEDES INTXN. I THEN INSTRUCTED THE F/O TO SET UP THE FIX IN THE LORAN. HE THEN INFORMED ME SHE WAS NOT FAMILIAR WITH THAT FIX FUNCTION AND REQUESTED ASSISTANCE. I TOLD HER I WOULD PROGRAM IT AND BEGAN TO DO SO. APPARENTLY HER ATTN WAS DIRECTED ON WHAT I WAS DOING, BECAUSE BEFORE I FINISHED SHE SAID THAT SHE COULD FINISH SETTING UP THE LORAN. I THEN LOOKED UP TO XCHK MY INSTRUMENTS AND DISCOVERED WE HAD DESCENDED ABOUT 700' BELOW OUR ASSIGNED ALT. I IMMEDIATELY TOOK CORRECTIVE ACTION AND CLIMBED BACK TO FL240. FACTORS CONTRIBUTING TO THIS INCIDENT INCLUDE: F/O'S UNFAMILIARITY WITH A PARTICULAR OPERATION WHICH LED TO THE INABILITY TO SATISFY THE CAPT'S REQUEST. SHE HAD RECEIVED TRAINING IN OUR ACFT BY THE CHIEF PLT. THE PATIENT WE WERE TRANSPORTING WAS VERY UNSTABLE REQUIRING A LOT OF ACTIVITY AND NOISE FROM THE MEDICAL ATTENDANTS. CAPT'S LACK OF DELEGATION OF DUTIES. I SHOULD HAVE SPECIFICALLY COMMANDED THE F/O TO FLY THE ACFT WITH HER ATTN ON THE INSTRUMENTS WHILE I PROGRAMMED THE LORAN. IT WAS ALSO ONE OF THOSE STRESSFUL DAYS WHERE ABSOLUTELY NOTHING WAS ROUTINE (I.E., DEICE ACFT AT XA00 AM, DEAD BATTERIES PREVENTING NORMAL ENGINE START, PATIENT'S UNSTABLE CONDITION, ETC).
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.