37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 135102 |
Time | |
Date | 199001 |
Day | Sun |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : dtw |
State Reference | MI |
Altitude | msl bound lower : 10000 msl bound upper : 11000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other |
Flight Phase | cruise other descent other |
Route In Use | enroute : on vectors enroute airway : v26 |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 140 flight time total : 13000 flight time type : 400 |
ASRS Report | 135102 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 8000 flight time type : 350 |
ASRS Report | 135276 |
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 |
Narrative:
Just before cetus intersection on V-26 we were cleared to 11,000' from 12,000'. '11,000'' was acknowledged, set and verified per company procedure. Pilot flying (autoflt mode) actuated level change control. Over cetus intersection we were given a radar vector turn to 360 degree. During turn a discussion of correct assigned altitude ensued as the aircraft descended below 11,000' for the 10,000' which was now observed in the altitude window. About this time controller issued 10,000' traffic at 9 1/2 - 10 mi. PNF, confirmed cleared altitude of 11,000' and aircraft was promptly flown back to 11,000'. Traffic was sighted in the distance and no actual conflict ever existed. I have seen the set altitude inadvertently changed by 1000' upon activation of the level change control (pulling) which is also the altitude cranking control (turning). An errant minute twist of control while pulling for activation of level change can change the displayed altitude either 1000' or 100' depending on selected mode. I believe this incident occurred as described above and will insure that any possible future error of this type will not be in excess of 100'.
Original NASA ASRS Text
Title: ACR MLG ALT DEVIATION OVERSHOT. FLT CREW INADVERTENTLY CHANGED ALT ALERT SETTING WHILE ARMING AUTO LEVEL OFF.
Narrative: JUST BEFORE CETUS INTXN ON V-26 WE WERE CLRED TO 11,000' FROM 12,000'. '11,000'' WAS ACKNOWLEDGED, SET AND VERIFIED PER COMPANY PROC. PLT FLYING (AUTOFLT MODE) ACTUATED LEVEL CHANGE CONTROL. OVER CETUS INTXN WE WERE GIVEN A RADAR VECTOR TURN TO 360 DEG. DURING TURN A DISCUSSION OF CORRECT ASSIGNED ALT ENSUED AS THE ACFT DESCENDED BELOW 11,000' FOR THE 10,000' WHICH WAS NOW OBSERVED IN THE ALT WINDOW. ABOUT THIS TIME CTLR ISSUED 10,000' TFC AT 9 1/2 - 10 MI. PNF, CONFIRMED CLRED ALT OF 11,000' AND ACFT WAS PROMPTLY FLOWN BACK TO 11,000'. TFC WAS SIGHTED IN THE DISTANCE AND NO ACTUAL CONFLICT EVER EXISTED. I HAVE SEEN THE SET ALT INADVERTENTLY CHANGED BY 1000' UPON ACTIVATION OF THE LEVEL CHANGE CONTROL (PULLING) WHICH IS ALSO THE ALT CRANKING CONTROL (TURNING). AN ERRANT MINUTE TWIST OF CONTROL WHILE PULLING FOR ACTIVATION OF LEVEL CHANGE CAN CHANGE THE DISPLAYED ALT EITHER 1000' OR 100' DEPENDING ON SELECTED MODE. I BELIEVE THIS INCIDENT OCCURRED AS DESCRIBED ABOVE AND WILL INSURE THAT ANY POSSIBLE FUTURE ERROR OF THIS TYPE WILL NOT BE IN EXCESS OF 100'.
Data retrieved from NASA's ASRS site as of July 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.