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|
Attributes | |
ACN | 140177 |
Time | |
Date | 199003 |
Day | Mon |
Local Time Of Day | 1801 To 2400 |
Place | |
Locale Reference | atc facility : vwv |
State Reference | OH |
Altitude | msl bound lower : 7000 msl bound upper : 10000 |
Environment | |
Flight Conditions | IMC |
Light | Night |
Aircraft 1 | |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | descent other |
Route In Use | enroute airway : zob |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Experience | flight time last 90 days : 240 flight time total : 11500 flight time type : 240 |
ASRS Report | 140177 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : atp |
Events | |
Anomaly | altitude deviation : overshoot non adherence : clearance other anomaly other |
Independent Detector | other controllera other flight crewa |
Resolutory Action | controller : issued new clearance none taken : detected after the fact |
Consequence | Other |
Supplementary | |
Primary Problem | Flight Crew Human Performance |
Air Traffic Incident | Pilot Deviation |
Narrative:
En route from ind to det we were proceeding on the vwv 064 degree right at 10000' in an medium large transport. Received clearance to 8000'. During this time the first officer was attempting to update the det ATIS and was essentially out of the loop. I set 8000' in the altitude alert and began descent at 1000 FPM. While descending, engine anti-ice was placed on and left wing fuel boost pumps were turned on and fuel xfeed valve closed to complete fuel balancing. A smooth level off was made at 7000'. Altitude alert was never heard, although it had been functioning all day and continued to subsequently function properly. ATC continued our clearance to 5000' as there was no conflict, and we profusely apologized. It is hard to imagine that the seemingly minor cockpit tasks were enough distraction to miss the altitude and actually misread the altimeter, but it happened and that seems to be the only explanation. This incident reemphasized the importance of the other guy as a backup, for at the time, the first officer was completely out of the loop. It also reiterated the need for continued diligence, as murphy is alive and well. Another possible contributing factor was fatigue. I had worked 11 of the past 13 days, and although I did not feel tired, my alertness and concentration were obviously lacking.
Original NASA ASRS Text
Title: ALT DEVIATION OVERSHOOT IN DESCENT.
Narrative: ENRTE FROM IND TO DET WE WERE PROCEEDING ON THE VWV 064 DEG R AT 10000' IN AN MLG. RECEIVED CLRNC TO 8000'. DURING THIS TIME THE F/O WAS ATTEMPTING TO UPDATE THE DET ATIS AND WAS ESSENTIALLY OUT OF THE LOOP. I SET 8000' IN THE ALT ALERT AND BEGAN DSCNT AT 1000 FPM. WHILE DSNDING, ENG ANTI-ICE WAS PLACED ON AND LEFT WING FUEL BOOST PUMPS WERE TURNED ON AND FUEL XFEED VALVE CLOSED TO COMPLETE FUEL BALANCING. A SMOOTH LEVEL OFF WAS MADE AT 7000'. ALT ALERT WAS NEVER HEARD, ALTHOUGH IT HAD BEEN FUNCTIONING ALL DAY AND CONTINUED TO SUBSEQUENTLY FUNCTION PROPERLY. ATC CONTINUED OUR CLRNC TO 5000' AS THERE WAS NO CONFLICT, AND WE PROFUSELY APOLOGIZED. IT IS HARD TO IMAGINE THAT THE SEEMINGLY MINOR COCKPIT TASKS WERE ENOUGH DISTR TO MISS THE ALT AND ACTUALLY MISREAD THE ALTIMETER, BUT IT HAPPENED AND THAT SEEMS TO BE THE ONLY EXPLANATION. THIS INCIDENT REEMPHASIZED THE IMPORTANCE OF THE OTHER GUY AS A BACKUP, FOR AT THE TIME, THE F/O WAS COMPLETELY OUT OF THE LOOP. IT ALSO REITERATED THE NEED FOR CONTINUED DILIGENCE, AS MURPHY IS ALIVE AND WELL. ANOTHER POSSIBLE CONTRIBUTING FACTOR WAS FATIGUE. I HAD WORKED 11 OF THE PAST 13 DAYS, AND ALTHOUGH I DID NOT FEEL TIRED, MY ALERTNESS AND CONCENTRATION WERE OBVIOUSLY LACKING.
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.