37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 139801 |
Time | |
Date | 199003 |
Day | Thu |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | airport : ont |
State Reference | CA |
Altitude | msl bound lower : 8000 msl bound upper : 8940 |
Environment | |
Flight Conditions | VMC |
Light | Night |
Aircraft 1 | |
Controlling Facilities | artcc : zla tracon : n90 |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Navigation In Use | Other Other |
Flight Phase | climbout : intermediate altitude cruise other cruise other |
Route In Use | departure other departure sid : sid |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Experience | flight time last 90 days : 120 flight time total : 2500 flight time type : 120 |
ASRS Report | 139801 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot altitude deviation : crossing restriction not met non adherence : published procedure non adherence : clearance |
Independent Detector | other controllera |
Resolutory Action | controller : issued new clearance flight crew : returned to intended course or assigned course other |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
We were cleared for the pomona 4 departure, maintaining 12000'. 12000' was set and armed in the flight guidance panel, but the SID had a crossing restriction at pom of at or above 3800', at or below 8000'. We departed runway 8R. The aircraft was very light, resulting in a rate of climb of around 400 FPM. The SID requires a right 180 degree turn after takeoff. We made this turn flaps down for minimum maneuvering speed considerations, thus delaying the after takeoff/climb checklists and interrupting the normal after takeoff flow where the altimeters are usually reset). The turn was completed and the flaps/slats retracted at around 5000'. I reset my altimeter to qnh, but I did not xchk the captain's. I began the after takeoff/climb checks, including the air conditioning pack reinstatement as departure gave us direct pom and a frequency change. I confirmed the aircraft was pressurizing and called ZLA as the captain leveled the aircraft at 8000' on his altimeter (which was still set to QFE). My altimeter read 8940' on his altimeter (which was still set to QFE). My altimeter read 8940', and being the single pointer/drum type caused me a moment of confusion. ZLA responded to my initial call by requesting our assigned altitude, at which time we both realized what had happened and quickly descended to 8000'. Conclusions: I believe we were both more fatigued than we realized. While my duty day began at mid-afternoon, I had been up since early a.M. I had intended to sleep longer, but couldn't. We were scheduled to finish by late P.M., but were rescheduled for an additional flight which, due to delays, didn't depart until very early a.M. I had been up for 18 hours at that time. I knew we had the 8000' crossing restriction, but since we were cleared to 12000', I didn't think to set 8000' in the flight guidance panel. I should have crosschecked the captain's altimeter when I reset my own. The flaps down turn disrupted our normal flow at a time we were most susceptible to error (busy departure, tired crew). I let the after takeoff/climb checks distract me from monitoring the departure. The single pointer/drum type altimeter is easily misread when within 100' below 1000'. We could have climbed in speed select/vertical speed mode instead of EPR limit/IAS hold. This would have reduced the rate of climb and slowed things down.
Original NASA ASRS Text
Title: ALT DEVIATION.
Narrative: WE WERE CLRED FOR THE POMONA 4 DEP, MAINTAINING 12000'. 12000' WAS SET AND ARMED IN THE FLT GUIDANCE PANEL, BUT THE SID HAD A XING RESTRICTION AT POM OF AT OR ABOVE 3800', AT OR BELOW 8000'. WE DEPARTED RWY 8R. THE ACFT WAS VERY LIGHT, RESULTING IN A RATE OF CLB OF AROUND 400 FPM. THE SID REQUIRES A RIGHT 180 DEG TURN AFTER TKOF. WE MADE THIS TURN FLAPS DOWN FOR MINIMUM MANEUVERING SPD CONSIDERATIONS, THUS DELAYING THE AFTER TKOF/CLB CHKLISTS AND INTERRUPTING THE NORMAL AFTER TKOF FLOW WHERE THE ALTIMETERS ARE USUALLY RESET). THE TURN WAS COMPLETED AND THE FLAPS/SLATS RETRACTED AT AROUND 5000'. I RESET MY ALTIMETER TO QNH, BUT I DID NOT XCHK THE CAPT'S. I BEGAN THE AFTER TKOF/CLB CHKS, INCLUDING THE AIR CONDITIONING PACK REINSTATEMENT AS DEP GAVE US DIRECT POM AND A FREQ CHANGE. I CONFIRMED THE ACFT WAS PRESSURIZING AND CALLED ZLA AS THE CAPT LEVELED THE ACFT AT 8000' ON HIS ALTIMETER (WHICH WAS STILL SET TO QFE). MY ALTIMETER READ 8940' ON HIS ALTIMETER (WHICH WAS STILL SET TO QFE). MY ALTIMETER READ 8940', AND BEING THE SINGLE POINTER/DRUM TYPE CAUSED ME A MOMENT OF CONFUSION. ZLA RESPONDED TO MY INITIAL CALL BY REQUESTING OUR ASSIGNED ALT, AT WHICH TIME WE BOTH REALIZED WHAT HAD HAPPENED AND QUICKLY DSNDED TO 8000'. CONCLUSIONS: I BELIEVE WE WERE BOTH MORE FATIGUED THAN WE REALIZED. WHILE MY DUTY DAY BEGAN AT MID-AFTERNOON, I HAD BEEN UP SINCE EARLY A.M. I HAD INTENDED TO SLEEP LONGER, BUT COULDN'T. WE WERE SCHEDULED TO FINISH BY LATE P.M., BUT WERE RESCHEDULED FOR AN ADDITIONAL FLT WHICH, DUE TO DELAYS, DIDN'T DEPART UNTIL VERY EARLY A.M. I HAD BEEN UP FOR 18 HRS AT THAT TIME. I KNEW WE HAD THE 8000' XING RESTRICTION, BUT SINCE WE WERE CLRED TO 12000', I DIDN'T THINK TO SET 8000' IN THE FLT GUIDANCE PANEL. I SHOULD HAVE XCHKED THE CAPT'S ALTIMETER WHEN I RESET MY OWN. THE FLAPS DOWN TURN DISRUPTED OUR NORMAL FLOW AT A TIME WE WERE MOST SUSCEPTIBLE TO ERROR (BUSY DEP, TIRED CREW). I LET THE AFTER TKOF/CLB CHKS DISTRACT ME FROM MONITORING THE DEP. THE SINGLE POINTER/DRUM TYPE ALTIMETER IS EASILY MISREAD WHEN WITHIN 100' BELOW 1000'. WE COULD HAVE CLBED IN SPD SELECT/VERT SPD MODE INSTEAD OF EPR LIMIT/IAS HOLD. THIS WOULD HAVE REDUCED THE RATE OF CLB AND SLOWED THINGS DOWN.
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.